meta dict | text stringlengths 0 55.8k |
|---|---|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8300
} | Medical Text: Admission Date: [**2165-4-14**] Discharge Date: [**2165-4-16**]
Date of Birth: [**2165-4-14**] Sex: M
Service: Neonatology
HISTORY: [**First Name8 (NamePattern2) 1790**] [**First Name8 (NamePattern2) **] [**Known lastname 47766**] was born at 36 weeks
gestation by a repeat cesarean section for spontaneous
rupture of membranes and a planned repeat cesarean section.
The mother is a 37-year-old gravida 2, para 1 now 2 woman.
Prenatal screens are blood type O-, antibody negative,
rubella immune, RPR nonreactive, hepatitis surface antigen
negative, and group B Strep negative. The pregnancy was
previously uncomplicated. Rupture of membranes 7 hours prior
to delivery. No antepartum fever or other sepsis risk
factors are present.
This infant emerged vigorous. Apgars were eight at one
minute and eight at five minutes. NICU team was called at 10
minutes for grunting and retracting. The infant was found in
the OR to be vigorous, but was grunting and retracting, and
brought to the Newborn Intensive Care Unit on blowby oxygen.
Birth weight was 2,585 grams, birth length 47 cm, and birth
head circumference 34.5 cm.
Admission physical exam reveals a vigorous nondysmorphic
premature infant. Anterior fontanel is soft and flat which
is approximated. Positive bilateral red reflexes. Palate
intact. Neck is supple and without masses. Clavicles
intact. Mild subcostal retractions. Respiratory rate in the
60s, intermittent and grunting. Breath sounds are equal with
scattered rhonchi. Heart was regular, rate, and rhythm, no
murmur. Pink on room air, well perfused. Femoral pulses
present. Abdomen is soft, active bowel sounds, liver edge of
the costal margin. Three vessel umbilical cord, hip laxed
but stable. Sacrum without dimple. Normal digits and
creases. Testes are descended bilaterally. Positive suck,
weak, but equal grasp and an incomplete morrow.
His NICU stay by systems:
Respiratory: Infant developed increasing tachypnea 80-100
breaths per minute, but always remained in room air except
for initially requiring some blowby oxygen. His symptoms
resolved by approximately 12 hours of life, and on
examination at the time of transfer, his respirations are
comfortable. Lung sounds are clear and equal. He remains
with O2 saturations greater than 95 on room air and has had
no apnea or bradycardia.
Cardiovascular: He has remained normotensive throughout his
NICU stay. Blood pressure means have always been within
normal limits. There are no cardiovascular issues. On
examination, he has a regular, rate, and rhythm, and no
murmur.
Fluids, electrolytes, and nutrition: His weight at the time
of transfer is 2,635 grams. Enteral feeds were begun at
approximately 12 hours of life and they advanced without
difficulty to full volume feedings of Enfamil 20 calories per
ounce on an adlib schedule. Mother plans to bottle feed. He
has maintained euglycemia with his last blood glucose being
96.
Gastrointestinal: The infant past meconium stools, and there
are no gastrointestinal issues.
Hematology: The patient's blood type is O+, DAT negative.
He has received no blood product transfusions. His
hematocrit on admission was 44.6 with a platelet count of
350,000.
Infectious disease: At the time of admission, he had a blood
culture drawn and a complete blood count which had a white
count of 19.7 with a differential of 50 polys and 0 bands.
Blood culture remains negative at the time of transfer, and
he was never started on any antibiotics.
Audiology: Hearing screening has not yet been done. It was
recommended prior to discharge.
Psychosocial: Parents have been visiting in the NICU and has
been involved in his care. He has a 14 month old sibling at
home.
The infant is discharged in good condition.
The infant is discharged to the Newborn Nursery.
Primary pediatric care will be provided by Dr. [**First Name8 (NamePattern2) 1743**]
[**Last Name (NamePattern1) 37517**] of [**Location (un) 1887**].
CARE AND RECOMMENDATIONS AT DISCHARGE:
1. Feedings: Enfamil 20 calories/ounce on an adlib schedule.
The infant is discharged on no medications.
Car seat position screening test should be done prior to
discharge as per the American Academy of Pediatrics
Guidelines. State newborn screen should be sent on day of
life three.
The infant has not yet received any immunization, but meets
the criteria for his first hepatitis B vaccine.
DISCHARGE DIAGNOSES:
1. Prematurity 36 weeks gestation.
2. Transitional respiratory distress now resolved.
3. Sepsis ruled out.
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2165-4-16**] 02:41
T: [**2165-4-16**] 06:58
JOB#: [**Job Number 47767**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8301
} | Medical Text: Admission Date: [**2178-11-19**] Discharge Date: [**2178-11-26**]
Date of Birth: [**2127-2-26**] 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:
[**2178-11-19**] Coronary artery bypass grafting times three(left
internal mammary to left anterior descending with vein grafts to
diagonal and PDA)
History of Present Illness:
This is a 51 year old male with CAD s/p PCI at [**Hospital1 112**] in [**2170**].
Recently presented with a few months of chest pain, slowly
getting worse. Catheterization on [**11-12**] revealed an
occluded RCA, significant stenoses proximal and distal to a
previously placed proximal LAD stent and moderate disease
otherwise. He underwent preoperative evaluation and was cleared
for surgery.
Past Medical History:
Coronary Artery Disease s/p stents [**2170**]
Hyperlipidemia
Hypertension
Social History:
He workes in the deli department at the Stop and Shop.
-Tobacco history: denies any smoking.
-ETOH: denies any alcohol use.
-Illicit drugs: denies any drug use.
Family History:
He states his father died at the age of 54 of an MI. Denies any
other family history.
Physical Exam:
General: NAD, WGWN, appears stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
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 x
Pulses:
Femoral Right: cath site Left: 2+
DP Right: 2+ Left: 1+
PT [**Name (NI) 167**]: 2+ Left: NP
Radial Right: 2+ Left: 2+
Carotid Bruit: none
Pertinent Results:
[**2178-11-19**] Intraop TEE:
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is mildly dilated. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The descending thoracic aorta is mildly
dilated. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) are mildly thickened. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen.
POSTBYPASS
LV systolic function is normal EF-55%. RV systolic function
remains normal. The study is otherwise unchanged from the
prebypass period.
Brief Hospital Course:
Admitted and underwent coronary artery bypass grafting surgery
by Dr. [**First Name (STitle) **]. For surgical details, please see operative note.
Following the operation, he was brought to the CVICU for
invasive monitoring. Within 24 hours, he awoke neurologically
intact and was extubated. On postoperative day one, he showed
signs of ETOH withdrawal. He became increasingly tachypneic,
tachycardic and hypertensive. He concomitantly became more
impulsive and confused/agitated requiring Ativan and Haldol prn.
Due to delirium tremens and agitation, he was reintubated for
safety on postoperative day three. On postoperative day four,
patient self extubated. His mental status seemed improved on
Valium three times daily. On postoperative day five, he
transferred to the cardiac SDU. Valium was titrated down
accordingly. Mental status and signs of ETOH withdrawal improved
dramatically. He remained in a normal sinus rhythm. Beta
blockade was advanced as tolerated and ACEI was added for
hypertension. Over several days, he continued to make clinical
improvements and was eventually cleared for discharge to [**Hospital1 38437**] for the Aged - MACU
Medications on Admission:
Aspirin
Discharge Medications:
1. Zantac 150 mg Tablet Sig: One (1) Tablet PO once a day.
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
4. potassium chloride 10 mEq Capsule, Sustained Release Sig: One
(1) Capsule, Sustained Release PO once a day for 5 days.
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
6. aspirin, buffered 81 mg Tablet Sig: One (1) Tablet PO once a
day.
7. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Transdermal
qsunday .
8. Lopressor 100 mg Tablet Sig: One (1) Tablet PO three times a
day.
9. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
10. Wellbutrin SR 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
11. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a
day.
12. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
13. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Coronary artery disease, s/p CABG
Postop ETOH Withdrawal, Altered Mental Status
Hyperlipidemia
Hypertension
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain well controlled
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage
Edema trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] [**2178-12-21**] @ 1 PM
Cardiologist: Dr. [**First Name (STitle) **] [**Name (STitle) **] [**2178-12-15**] @ 140 PM
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1726**] on [**2178-12-1**] @ 145 PM
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2178-11-26**]
ICD9 Codes: 2851, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8302
} | Medical Text: Admission Date: [**2137-6-9**] Discharge Date: [**2137-6-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Anterior ST segment myocardial infarction
Major Surgical or Invasive Procedure:
Coronary artery catheterization and angioplasty of left anterior
descending artery to the right coronary artery
Intraaortic Balloon Pump support
Swan-Ganz catheterization
Catherization results:
.
1. Selective coronary angiography demonstrated two vessel
coronary artery disease in this left dominant circulation. The
LMCA was severely calcified. The proximal LAD was severely
calcified and was completely occluded after the takeoff of a
large D1 branch. The LCX had a distal tubular stenosis. The OM
branches were without angiographically apparent flow limiting
disease. The RCA had a proximal 80% stenosis and was a
non-dominant vessel.
.
2. Resting hemodynamics from right heart catheterization
demonstrated severely elevated right and left sided filling
pressures (RVEDP=17mmHg and mean PCWP=33mmHg). Cardiac output
and index were severely depressed at 2.5 L/min and 1.3 L/min/m2
respectively. Severe pulmonary arterial hypertension was present
(64/31).
.
3. Left ventriculogram was not performed to reduce contrast
load.
.
4. PCI of the LAD and diagonal complicated by distal
embolization into the diagonal. The LAD had a 20% residual
stenosis with distal TIMI 2 flow and poor myocardial perfusion
at the end of the procedure.
.
5. Successful placement of an 8 French 40 cc IABP via the RFA.
<br><br>
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
.
2. Anterior ST segment elevation myocardial infarction.
.
3. Severely elevated right and left sided filling pressures.
.
4. Cardiogenic shock with placement of intra-aortic balloon
assist device.
.
5. PCI of the LAD/Diagonal.
History of Present Illness:
This is an 83 male with a history of hypertension, atrial
fibrillation, subdural hematoma ('[**30**] on coumadin), who presented
to an outside hospital 20 hours after the onset of substernal
chest pain. An EKG performed at the time showed ST segment
elevation in V4-V5, Q waves in leads II, III, avF, and atrial
fibrillation. The patient received sublingual nitroglycerin X3
with no alleviation of chest pain. A nitroglycerin drip was then
started and brought the patient some relief with 2/10 chest
pain. Cardiac enzymes at the time showed an elevated CK of 2519.
The patient was transferred to [**Hospital1 18**] for a cath. A PTCA was
performed to the left anterior descemding artery to the right
coronary (10% residual stenosis). A stent was not placed due to
low residual flow.
At the time the patient was found to have a low cardiac index of
1.3. An intra-aortic balloon pump was placed. The patient
received Lasix 40mg IV and 300mg bolus of Plavix. Integrillin,
ASA, and Lipitor were also started.
Past Medical History:
- CAD (unclear history)
- Atrial fibrillation
- Hypertension
- Subdural Hematoma (s/p trauma on coumadin '[**30**])
Social History:
Lives with wife, quit tobacco
Family History:
Non-contributory
Physical Exam:
Physical Exam on Admission
VS: 93 144/71 (PA 58/26) 14 96% 2L
Gen: NAD, lying in bed
HEENT: neck supple, 7cm JVD
Heart: nl rate, irreg rhythm (Atrial fibrillation), S1S2, no
G/M/R
Lungs: crackles at the bases
Abdomen: soft, non-tender, non-distended, +BS; slight discomfort
due to IABP
R Groin: femoral pulse present, no bruits, no ecchymosis
Extremities: feet cold, DP appreciated bilaterally with doppler;
no c/c/e
Neuro: II-XII grossly intact
Pertinent Results:
Cardiac Enzymes
.
[**2137-6-9**] 02:18PM BLOOD CK(CPK)-3071*
[**2137-6-9**] 07:40PM BLOOD CK(CPK)-4538*
[**2137-6-11**] 07:45AM BLOOD CK(CPK)-686*
.
[**2137-6-9**] 02:18PM BLOOD CK-MB->500 cTropnT-9.33*
[**2137-6-10**] 01:58AM BLOOD CK-MB-486* MB Indx-14.5* cTropnT-22.87*
[**2137-6-11**] 07:45AM BLOOD CK-MB-47* MB Indx-6.9* cTropnT-14.51*
.
Chemistry
.
[**2137-6-9**] 02:18PM BLOOD Glucose-168* UreaN-32* Creat-1.1 Na-132*
K-4.5 Cl-98 HCO3-24 AnGap-15
[**2137-6-14**] 06:25AM BLOOD Glucose-87 UreaN-46* Creat-1.5* Na-135
K-4.3 Cl-100 HCO3-25 AnGap-14
.
[**2137-6-9**] 02:18PM BLOOD Calcium-8.2* Phos-3.7 Mg-1.9
[**2137-6-14**] 06:25AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.2
.
CBC
[**2137-6-14**] 06:25AM BLOOD WBC-9.5 RBC-4.20* Hgb-12.4* Hct-37.3*
MCV-89 MCH-29.5 MCHC-33.2 RDW-13.6 Plt Ct-198
[**2137-6-9**] 02:18PM BLOOD WBC-15.3* RBC-4.87 Hgb-14.4 Hct-42.5
MCV-87 MCH-29.6 MCHC-33.9 RDW-13.5 Plt Ct-199
Brief Hospital Course:
83M s/p STEMI of LAD and RCA territory, loss of D1 [**1-2**]
embolization, transferred to CCU for optimization of
hemodynamics in the setting of cardiogenic shock.
* Pump: Given cardiac index of 1.3 in cath lab, IABP was placed
for optimization of systolic and diastolic pressures. On IABP,
cardiac index improved to 1.7, and although patient diuresed
successfully with 40mg IV Lasix, nesiritide gtt was started to
further improve hemodynamics. On hospital day two, cardiac
index improved to 2.3 on nesiritide and IABP, and both were
discontinued on hospital day three as patient continued to do
improve in function with excellent diuresis on lasix alone (PAP
43/21). Echocardiogram revealed EF<20%, 1+ MR, 1+ TR and global
hypokinesis. Lisinopril was initiated for afterload reduction,
and at the time of discharge, was uptitrated to 7.5mg QD.
Patient was instructed to return for echocardiogram in one month
following discharge. Digoxin was continued for additional rate
control and to also further improve inotropy as outpatient.
Despite poor ejection fraction, patient was considered extremely
poor candidate for anticoagulation given history of subdural
hematoma.
* Rhythm: Atrial fibrillation. Stable throughout
hospitalization. Given history of subdural hematoma, patient
was not candidate for long-term anticoagulation. Patient did
require one dose of IV metoprolol for stable Afib with RVR to
improve rate control.
* STEMI: Given patient's late presentation (infarct may have
begun as early was 3 days before presentation), flow in LAD and
RCA despite PTCA were extremely poor, making stent placement
impossible. CK peaked at 4538, MB >500 on the evening of
hospital day one consistent with transmural infarction. Patient
was started on medical management regimen of ASA 325, Plavix 75,
Atovastatin 80, with Integrilin for 18 hours post
catheterization. Patient tolerated these medications without
evidence of intracranial hemorrhage or other site of bleeding.
To improve rate control post MI, metoprolol 25 [**Hospital1 **] was
initiated. To improve afterload reduction, patient was started
on lisinopril as above and titrated to 7.5mg QD. Patient
remained chest pain free throughout hospitalization.
* Urinary Tract Infection: Patient had a low grade fever (100.5)
on hospital day four, and urinalysis revealed sm leuk esterase
w/ few bacteria. However, given the fact that this was in the
setting of indwelling foley, patient was initiated on bactrim
for treatment with an intent to complete a 7 day course as an
outpatient.
* Dehydration: Patient was initially diuresed aggressively given
cardiogenic shock, however, near the time of discharge, patient
had mild bump in creatinine (chronic renal insufficiency Cr
1.1-1.2) to 1.5, and urine lytes revealed prerenal (UOsm [**Telephone/Fax (1) 63454**] mg/dL UCreat 86 mg/dL USodium 15 mEq/L). Patient was given
250cc NS for hydration and encouraged to take more PO fluids.
At the time of discharge, patient continued to have mild
ambulatory desaturations and exhaustion after minimal exertion,
and was therefore referred to short term inpatient
rehabilitation. Patient was instructed to followup with primary
care physician and cardiologist one week and one month
respectively following discharge from rehab.
Medications on Admission:
Digoxin
Diltiazem
Diovan
Lasix
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Anterior ST segment elevation myocardial infarction.
Discharge Condition:
Good
Discharge Instructions:
You must call 911 first if you experience any chest pain or
chest pressure, if you become short of breath, or if you
experience any numbness, tingling or pain radiating to your jaw
or arms/hands.
You can resume normal activities, but you are not to assume any
strenous activity such as lifting or pulling until you are
cleared by rehabilitation services.
Followup Instructions:
Draw blood for digoxin level in one week following discharge.
Repeat echocardiogram in one month following discharge.
ICD9 Codes: 5990, 2765, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8303
} | Medical Text: Admission Date: [**2127-12-31**] Discharge Date: [**2128-1-8**]
Date of Birth: [**2044-6-29**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
change in mental status
Major Surgical or Invasive Procedure:
Intubation
PEG placement
History of Present Illness:
Pt is an 83 yo gentleman with PMHx sig for HTN, skin cancer NOS,
and sleep apnea who fell down four stairs at home today. EMS was
called and the patient was intubated due to combativeness. He
was brought to an OSH where a head CT showed a
large L temporal ICH, intraventricular hemorrhage, L SDH, and
SAH. The patient was transferred to [**Hospital1 18**] for further
management. Mechanism of fall unclear.
Past Medical History:
HTN, skin cancer, and sleep apnea
Social History:
non-contributory
Family History:
non-contributory
Physical Exam:
Exam upon admission:
Vitals: T 98.2; BP 140/75; P 71; RR 13; O2 sat 99%
General: intubated
HEENT: NCAT, moist mucous membranes
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: no c/c/e.
Neurological Exam:
Mental status: intubated. Does not open eyes and did not
squeeze hands to command.
Cranial Nerves: PERRL, 3-->2mm with light, + corneal, + VOR,
face
symmetric.
Motor/[**Last Name (un) **]: Normal tone. withdraws legs to painful stimuli,
also withdrawal of arm to painful stimuli.
Reflexes: 1+ in UEs and patella, absent ankle jerks.
Toes downgoing bilaterally.
Pertinent Results:
CT head [**2127-12-31**]:
FINDINGS:There is a acute subdural hematoma which surrounds the
left
cerebral hemisphere which measures up to 9 mm in thickness.
Subdural blood
layers along the left tentorium. Blood is noted in the left
quadrigeminal
cistern and surrounding the left cerebral peduncle and within
left portion
of the suprasellar cistern. There is subarachnoid hemorrhage
along the left
cerebral hemisphere spanning the frontal and temporal lobes
primarily. There is also subarachnoid blood on the right noted
in the right sylvian fissure specifically. There is increase in
parenchymal contusion in the left temporal lobe with surrounding
edema and sulcal effacement noted. Areas of pneumocephalus are
again noted in the left middle cranial fossa.
Intraventricular hemorrhage is noted primarily in the left
lateral ventricle and a small amount is noted to layer in the
right lateral ventricle occipital [**Doctor Last Name 534**]. There is no increase in
ventricular size when compared with prior study hough there is
now approximately 4 mm of rightward subfalcine herniation which
may be increased. There is no evidence of downward
transtentorial herniation though there is some relative
hypodensity in the left cerebral peduncle which may reflect
edema. Overall, the most notable difference since the prior
study is the increase in left temporal lobe hemorrhagic
contusion and the surrounding edema.
Impression:
1. Increased hemorrhagic contusion in left temporal lobe with
resultant surrounding edema. No significant change in left
cerebral subdural hematoma and extensive subarachnoid
hemorrhage.
2. Partial opacification of left mastoid air cells and the left
middle ear cavity raising concern for left temporal bone fx. The
presence of pneumocephalus in the left middle cranial fossa also
suggests an underlying fracture.
HEAD AND NECK CTA [**1-1**]: The carotid and vertebral arteries and
their major
branches are patent. In particular, the left MCA is patent
without evidence
of stenosis, but this does not exclude ischemia. There is a mild
narrowing ofthe basilar artery, most likely secondary to
atherosclerotic plaque. The
diamter of The distal cervical internal carotid arteries
measures 7 mm on the right and 4 mm on the left. There is no
evidence of aneurysm formation or other vascular abnormality.
MPRESSION:
1. No interval change of the multiple intracranial hemorrhage
and hematomas. Persistent mass effect with a rightward shift of
midline structures.
2. No evidence of aneurysm. Mild narrowing of basilar artery.
Left MCA
patent, but this does not exclude ischemia.
3. Persistent hypodensity extending to the cortex, approximating
the left MCA distribution. Question remains if parenchymal edema
is secondary to
infarction or contusion.
Brief Hospital Course:
83 yo gentleman with PMHx sig for HTN, skin cancer NOS, and
sleep apnea who fell down four stairs at home. EMS was called
and the patient was intubated due to combativeness. He was
brought to an OSH where a head CT showed a large L temporal ICH,
intraventricular hemorrhage, L SDH, and SAH. The patient was in
SICU during most of the hospital course. The patient's poor
prognosis for a meaningful recovery was discussed with the
family and no brain intervention was performed. Patient was made
DNR. He was not improving and the family decided to make the
patient comfort measures only on [**1-7**]. He was extubated and
later transferred to the floor. He was placed on a morphine
drip. Palliative care recommended a changed in the pain regimen
and also recommended giving him medication for his secretions.
The patient was kept comfortable. His family was with him on
[**1-8**] when he expired at 5 pm. They did not want an autopsy.
Medications on Admission:
ASA 81 mg po q day
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Left temporal intraparenchimal hemorrhage, left subdural
hemorrhage and intraventricular hemorrhage
Discharge Condition:
expired
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2128-1-8**]
ICD9 Codes: 486, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8304
} | Medical Text: Admission Date: [**2172-9-16**] Discharge Date: [**2172-10-24**]
Date of Birth: [**2124-2-26**] Sex: M
Service: SURGERY
Allergies:
Ambien
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Re-opening of Laparotomy
Open Cholecystectomy
Small Bowel Resection
Roux-en-Y Duodeno-jejunosotmy
Small Bowel Stricture-plasty x 10
J-tube Placement
History of Present Illness:
This is a 45 year old male who presented from [**Hospital1 14360**] with a 12 hour history of abdominal pain, nausea and
vomitting and diarrhea. A CT revealed free fluid and free air
with perforation of the duodenum. He was transfered via
med-flight and intubated just prior to departure. Hisa O2 sats
were in the low 80's. He was started on Dopamine for pressure
support and received 7.5 liters of crystalloid.
Past Medical History:
s/p Bilroth II '[**58**], Crohn's, Anemia, Depression, PUD
Physical Exam:
VS: 99.3, 141 sinus tach, 112/57, 14, 92% intubated
Gen: Intubated, PERRL, mucous membrane dry
CV: tachy, regular
Pulm: diffusely coarse BS
Abd: distended, firm, reducable umbilical and right groin
hernia, guaic negative
Ext: no edema
Pertinent Results:
Cardiology Report ECHO Study Date of [**2172-10-7**]
PATIENT/TEST INFORMATION:
Indication: Endocarditis. ?
Height: (in) 70
Weight (lb): 165
BSA (m2): 1.93 m2
BP (mm Hg): 128/69
HR (bpm): 88
Status: Inpatient
Date/Time: [**2172-10-7**] at 16:21
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W031-0:13
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.6 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 5.1 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.6 cm (nl <= 5.0 cm)
Left Ventricle - Ejection Fraction: >= 75% (nl >=55%)
Aorta - Valve Level: 3.5 cm (nl <= 3.6 cm)
Aorta - Arch: *3.2 cm (nl <= 3.0 cm)
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.4 m/sec
Mitral Valve - E/A Ratio: 2.00
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thicknesses and cavity size.
Normal regional LV
systolic function. Hyperdynamic LVEF. TVI E/e' < 8, suggesting
normal PCWP
(<12mmHg). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Based on [**2163**] AHA endocarditis prophylaxis
recommendations,
the echo findings indicate a low risk (prophylaxis not
recommended). Clinical
decisions regarding the need for prophylaxis should be based on
clinical and
echocardiographic data.
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. Regional left ventricular wall motion is
normal. Left
ventricular systolic function is hyperdynamic (EF>75%). Tissue
velocity
imaging demonstrates an E/e' <8 suggesting a normal left
ventricular filling
pressure (<12mmHg). 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
appears
structurally normal with trivial mitral regurgitation. There is
no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be
determined. There is no pericardial effusion.
IMPRESSION: No valvular pathology or pathologic flow identified.
Hyperdynamic
left ventricular systolic function.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2172-10-6**] 8:47 AM
US HEPATOTOMY DRAIN ABSCESS/CY; GUIDANCE FOR ABSCESS ([**Numeric Identifier 10268**])
Reason: Please perform an ultrasound guided percutaneous
drainage of
[**Hospital 93**] MEDICAL CONDITION:
48 year old man with Crohn's s/p BII reconstruction (92) c/b
jejunal perforation, enterectomy and now s/p Roux-en_y
duodenojejunostomy and stricturoplasty x10 with post0operative
fevers and leukocytosis
REASON FOR THIS EXAMINATION:
Please perform an ultrasound guided percutaneous drainage of the
gallbladder fossae abscess and possible drainage of the left
paracolic gutter collection on [**2172-10-6**]
EXAMINATION: Ultrasound-guided abscess drainage, [**2172-10-6**]
COMPARISON: CT of the abdomen and pelvis dated [**2172-10-5**].
INDICATION: History of Crohn's disease and multiple surgeries
with postoperative fluid collections suspicious for abscess.
PROCEDURE AND FINDINGS: Ultrasonography of the gallbladder fossa
demonstrates a complex fluid collection with echogenic foci
within it consistent with fluid collection containing foci of
gas as seen on prior CT scan. Imaging of the left pericolic
gutter demonstrates a complex heterogeneous fluid collection
with multiple septations, which also corresponds to the fluid
collection seen on CT along the left pericolic gutter.
The procedure was explained along with risks and benefits to the
patient's wife via telephone consent and informed consent was
obtained. Throughout the procedure, the patient received 2.5 mg
of Versed and 50 mcg of fentanyl. In addition, after the patient
was prepped and draped in usual sterile fashion. Approximately
10 mL of lidocaine was used to provide local anesthesia. The
left lower quadrant fluid collection was marked under ultrasound
guidance and after the lidocaine was placed skin [**Doctor Last Name **] was made
using a scalpel. Using ultrasound guidance, an 8-French pigtail
drainage catheter was placed into the left lower quadrant fluid
collection. A total of 300 mL of serosanguinous fluid was
aspirated into a drainage bag and the cavity was flushed with
approximately 150 mL of saline which was also aspirated into the
drainage bag. The pigtail catheter was left to gravity drainage.
The fluid and gas collection within the gallbladder fossa was
then approached using ultrasound guidance. Using a transhepatic
approach after the skin was numb, with lidocaine and a skin [**Doctor Last Name **]
was performed, an 8-French pigtail catheter was inserted
transhepatically into the complex fluid collection in the
gallbladder fossa and the catheter was secured in place.
Approximately 160 mL of reddish purulent material was aspirated
and the cavity was flushed with 80 mL of saline. The pigtail
catheter was left to gravity drainage.
The patient tolerated the procedure well and there were no
immediate post- procedural complications.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4401**] is present for placement of the pigtail
catheter in in the gallbladder fossa collection and Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] and [**Doctor First Name **] [**Doctor Last Name 9835**] were present for placement of the
catheter into the left lower quadrant fluid collection
IMPRESSION:.
Successful ultraound guided drain placement into the gallbladder
fossa fluid collection and left pericolic gutter fluid. A
portion of the aspirated fluid from each collection was sent for
gram stain and culture and bilirubin levels which are pending.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 94624**],[**Known firstname 251**] [**2124-2-26**] 48 Male [**-7/3321**] [**Numeric Identifier 94625**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 63180**]/dif
SPECIMEN SUBMITTED: GALLBLADDER, JEJUNUM AFFERENT PORTION.
CT ABDOMEN W/CONTRAST [**2172-10-5**] 4:28 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: ANASTOMOTIC LEAKS POST SURGERY
Field of view: 37 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
48 year old man with crohns s/p Bilroth II (remotely) c/b recent
jejunal perforation (near L.O. Trietz), small bowel resection w/
duodenostomy, now s/p Roux-En-Y duodenojejunostomy and
stricturoplasty of different small bowel stritures (due to his
Crohns) and a feeding J-tube and drain placement near his
pancreaticobiliary limb
REASON FOR THIS EXAMINATION:
Please give po and iv contrast Please use gastrograffin for po
contrast and please put contrast via j-tube. We are looking for
anastomotic leaks above and below the level of the j-tube
CONTRAINDICATIONS for IV CONTRAST: None.
CT ABDOMEN
INDICATION: Status post Billroth II and extensive surgery for
Crohn disease.
TECHNIQUE:
A CT of abdomen was performed with axial images taken from the
lung bases to the symphysis pubis.
Oral and IV contrast was administered.
FINDINGS
There are bilateral pleural effusions with associated
compressive atelectasis and consolidation.
The effusions have reduced in size when compared with the
previous CT from [**9-26**].
In the gallbladder fossa, note is made of a fluid collection
that measures 6 x 5.7 cm and contains air. The appearances are
consistent with an abscess. Just inferior to this, note is made
of an area of mixed attenuation in the right lower quadrant. No
contrast-filled bowel loops are seen in this area, and it may
represent some organizing hematoma.
The surgical patient is post Roux en Y duodeno-jejunostomy and
the draining duodenal catheter has been removed.The exact site
of the anastomosis is difficult to appreciate, but there is a
small amount of layering contrast within the third part of the
duodenum suggesting communication between this loops and the
opacified Jejunum. There are several loops of mildly dilated
small bowel, but contrast flows freely to the rectum and there
is no evidence of obstruction .There is also no evidence of
intraabdominal spilage of oral contrast. A feeding tube has been
placed in the jejunum.
A JP-drain is also noted in the right lower quadrant.
In relation to the liver, a collection which measures
approximately 6 x 3 cm is seen in the left lobe just deep to the
anterior abdominal wall at the site of recent abdominal wall
closure. This collection contains air and likely represents an
abscess.A tract extending from this collection to the superior
extent of the suture line can be seen.
In the liver, there is some minimal intrahepatic biliary
dilatation which is .
The spleen is identified and is normal.
The adrenals, kidneys, and pancreas are unremarkable.
There is significant free fluid throughout the abdomen, and this
has increased since the previous CT. In the left paracolic
gutter, fluid is identified which also contains some air. This
fluid collection is relatively contained. The air may be
postoperative or represent an abscess.
In the pelvis, the bladder is normal and a flatus tube is seen
in the rectum.
CONCLUSION:
Bilateral pleural effusions with atelectasis and consolidation.
Probable abscess in the gallbladder fossa.
Probable abscess in the left lobe of the liver just deep to the
recent abdominal wall closure.
Fluid collection in left paracolic gutter which contains air.
Probable hematoma in right flank at the site of recent surgery.
Minimal intrahepatic biliary dilatation.
Jejunostomy tube.
Right lower quadrant drain.
Findings discussed with Surgical Service
Procedure date Tissue received Report Date Diagnosed
by
[**2172-9-29**] [**2172-9-30**] [**2172-10-3**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cma??????
Previous biopsies: [**-7/3151**] JEJUNUM AND GALLSTONE (1).
[**Numeric Identifier 94626**] GI BIOPSIES.
[**-2/3020**] GI BX'S/da/lp.
DIAGNOSIS
I. Gallbladder:
Chronic cholecystitis; cholelithiasis.
II. Jejunum, afferent portion:
1. Chronic active enteritis extending to margin resection (on
side of stitch); consistent with Crohn's disease.
2. Organizing fibrinous serositis.
CT ABDOMEN W/CONTRAST [**2172-9-26**] 1:37 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: CT Pelvis and Abdomen w/ oral Contrast Through
Nasogastric T
[**Hospital 93**] MEDICAL CONDITION:
48 year old man with crohns s/p small bowel resection w/
duodostomy
REASON FOR THIS EXAMINATION:
CT Pelvis and Abdomen w/ oral Contrast Through Nasogastric Tube
CONTRAINDICATIONS for IV CONTRAST: None.
CT ABDOMEN
REASON FOR EXAM: 48-year-old man with Crohn's disease s/p small
bowel resection
TECHNIQUE: Multidetector CT through the abdomen obtained after
administration of oral contrast through the nasogastric tube and
IV contrast. Axial contiguous images were obtained from the
bases of the lungs through the symphysis pubis. Coronal and
sagittal reformations are also provided.
Comparison is made with prior study dated [**2172-9-16**].
FINDINGS: Small bilateral pleural effusions with adjacent
relaxation atelectasis are mildlely larger.
The liver, spleen, pancreas, adrenal glands and kidneys are
unremarkable.
The aorta is normal in caliber. The celiac, SMA, [**Female First Name (un) 899**] are patent
as is the portal, splenic and superior mesenteric vein
Innumerable enlarged lymph nodes present throughout the
mesentery are enlarged.
The patient has had oral contrast administered via his NG tube
and is status post Billroth II procedure. There is extensive
thickening of the jejunal bowel loops. Oral contrast proceeds
through the Gastrojejunostomy, but there is then a long segment
of bowel which has essentiazlly no oral contrast within its
lumen.The bowel can be traced throughout its length, however,
and this non-opacified segment apppears to then become contigous
with opacified loops of bowel. The appearances are likely due to
intermittent administration of oral contrast via the NG tube,
but fistulization could also have a similar appearance. There
does not appear, on this exam hwever to be evidence of fistula
formation. There is no free contrast within the abdomen. Tiny
pockets of air in the mesentery likely relate to recent surgery.
Patient is s/p gastrojejunostomy(old) and small bowel resection.
Two drain catheters are seen in the left flank and one catheter
is in the subhepatic region. NG tube with tip is in the stomach.
Jejunostomy tube in the right lower quadrant is folded within
the jejunal loop.Also seen on the right side is an intraduodenal
drainage catheter:Reference to the operative notes describes
creation of a duodenal biliary reservoir with external drainage
and a blind ending loop of duodenum with drainage
catheter-corresponding to the described surgical procedure is
seen. No overt evidence of complications are seen in this area.
Several pockets of fluid are seen within the abdomen, the
largest one in the right lower quadrant. There are no organized
complicated fluid collections.
PELVIC CT. The rectum and sigmoid colon are unremarkable. There
is free fluid. Foley catheter is within the bladder lumen. There
is no lymphadenopathy.
There is and open wound in the anterior abdominal wall. There
are bilateral fat-containing inguinal hernias.
BONE WINDOWS: There are no concerning bone lesions.
Coronal and sagittal reformations were essential in the
interpretation of the bowel findings.
IMPRESSION:
1. Status post extensive surgical repair, There is no evidence
of significant intrabdominal fluid collection or free contrast
within the abdomen
2. 3 surgical drains, One draining duodenal reservoir catheter
and a feeding Jejunostomy tube appear in good position. The
feeding tube is probably coiled within a loop of Jejunum
3. Moderate amount of fluid within the abdomen without
complicated organized collections.
4. Reasonably long segment of nonopacified proximal Jejunum is
though likely to reflect bolus administration of oral contrast.
No evidence of Jejuno- Jejunal/ileal fistula is seen .
5. Thickening of bowel loops may reflect underlying Crohns
versus Post- operative edema/change
6.Bilateral fat-containing inguinal hernias.
CHEST (PORTABLE AP) [**2172-9-19**] 1:52 AM
CHEST (PORTABLE AP)
Reason: eval infil
[**Hospital 93**] MEDICAL CONDITION:
48 year old man with acute abdomen, s/p intubation by med flight
s/p left subclavian swan placement
REASON FOR THIS EXAMINATION:
eval infil
AP CHEST.
INDICATION: Status post line placement.
A single AP view of the chest is obtained [**2172-9-19**] at 02:16 hours
and is compared with the prior day's radiograph performed at
06:24 hours. Tubes and lines appear unchanged. Mild increase in
density in the right base may represent a small layering pleural
effusion as has been previously reported. No acute airspace
disease is visualized.
IMPRESSION:
Stable radiograph.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 94624**],[**Known firstname 251**] [**2124-2-26**] 48 Male [**-7/3151**] [**Numeric Identifier 94625**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif
SPECIMEN SUBMITTED: JEJUNUM AND GALLSTONE (1).
Procedure date Tissue received Report Date Diagnosed
by
[**2172-9-17**] [**2172-9-17**] [**2172-9-21**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/lo??????
Previous biopsies: [**Numeric Identifier 94626**] GI BIOPSIES.
[**-2/3020**] GI BX'S/da/lp.
DIAGNOSIS:
Jejunum and Gallstone:
1. Gallstone, cholesterol type.
2. Acute perforation of jejunum, with marked mural inflammation
and acute peritonitis.
3. No tumor.
CHEST (PORTABLE AP) [**2172-9-16**] 11:21 PM
CHEST (PORTABLE AP)
Reason: eval ett position
[**Hospital 93**] MEDICAL CONDITION:
48 year old man with acute abdomen, s/p intubation by med flight
REASON FOR THIS EXAMINATION:
eval ett position
SINGLE AP PORTABLE VIEW CHEST.
REASON FOR EXAM: Evaluate ETT position.
COMPARISON: None.
FINDINGS: ET tube tip is located 5 cm above the carina. NG tube
with tip in the stomach, side hole projected over the GE
junction. Mild pulmonary edema. Allowing supine position, the
cardiac size is normal. Widened mediastinum warrants evaluation
with CT. Bilateral small pleural effusions.
Brief Hospital Course:
He was med-flighted immediately to us and within an hour, he was
taken to the operating room for findings of free air on his
outside hospital CAT scan.
Mr. [**Known lastname 7594**] [**Last Name (Titles) 94627**] the storm of postoperative sepsis quite
well and returned to the operating room for abdominal wash-out
and graduated midline closure using the mesh on [**2172-9-22**].
Then on [**2172-9-29**] he presented for a definitive closure of the
abdomen, if not a definitive operation to reconstitute his bowel
continuity. He had a reopening of a recent laparotomy, open
cholecystectomy, small bowel resection, Roux-en-Y
duodenojejunostomy, small-bowel stricturoplasty x10, and J tube
placement.
CV: Post-operatively he was on Neo and Levophed for pressure
support and was getting aggressive volume repletion. On [**2172-9-20**]
he came off of pressors/inotropes.
Resp: He was intubated and on protective ventilatory support.
Once extubated, he did well and was stable.
GI: His abdomen was open with multiple JP drains. The plan was
to reexplore in a couple days. He had a Duodenal [**Last Name (un) 10045**] drain
tube and J-tube. His drains were working appropriately. The
Right sided drain was D/C'd on [**2172-10-19**]. The left sided drain
continued to put out thick tan fluid. Due to fevers and
increased abdominal pain a CT was ordered on [**2172-10-20**]. A CT scan
showed a 13 cm subhepatic fluid collection is contiguous with
the previously identified gallbladder fossa collection. A new
drain was placed under ultra sound guidance and drained 600 cc
of fluid. He was discharged with drains in place on both sides
and given instructions on drain care.
Renal: Increased creatinine likely secondary to pre-renal. With
hydration, he had improving creatinine
ID: Ampicillin, Gentamycin, Flagyl, Fluconazole were started
empirically. He was pancultured on [**2172-9-17**]. Blood and sputum
cultures and urine cultures were negative from [**9-17**] and [**9-18**]. A
Swab culture showed perfringes, aeromonas (pan-S), viridans
strep. He was changed to Zosyn, Vanc, Flagyl, and Fluc. He had a
temperature the morning of [**2172-10-20**]. A CT scan was done (see
above).
Heme: He received several units of PRBC for drifting HCT while
in the SICU. On [**2172-10-14**] his HCT dipped to 19. He received 2 Units
of RBC and his HCT responded appropriately to 25.6.
FEN: He was on TPN after the OR for nutritional support. He was
also started on tubefeedings. HD #30 ([**2172-10-15**]) his TPN was
decreased and he was on a regular diet. He continued to increase
his PO intake and had calorie counts of 1500+ kcal. His tube
feedings were stopped and he did not require tube feedings
nutrition at home.
Pertinent Microbiology: [**10-20**] Peritoneal fluid - GRAM NEGATIVE
ROD. [**10-11**] C.diff Neg; [**10-7**] BlCx P UCx NG; [**10-6**] Abscess-ecoli
s:levo,; [**10-5**] Abd fluid-E. Coli levo S, BlCx- P, Line tip- Neg,
MRSA- Neg, VRE- Neg; [**10-5**] UCx: Neg; [**10-4**]: UCx NG, BCx: P. [**9-29**]
C.Diff neg; [**9-28**] tip- Neg, MRSA/VRE screens NEG, BCx P, UCx NEG;
[**9-26**] BCx NEG, UCx: NEG, [**9-25**] BCx NEG, UCx NEG. 8
Pertinent Radiology: [**2172-10-20**] CT Abd: 13 cm subhepatic fluid
collection. [**10-10**] CXR- PICC in RA, no acute dz [**10-7**] Echo- EF > 75,
no abnormalities; [**10-6**] Pigtails placed in LLQ and gallbladder
fossa; [**10-5**] CT A/P showed lg fluid collection in gallbladder
fossa and L paracolic gutter [**9-30**] CXR: tubes and lines in good
position, LLL atelectasis; [**9-26**] CT Abd/Pelv: free fluid w/o
collections [**9-26**] CXR: LLL infiltrate.[**9-21**] CXR stable
retrocardiac opacity/atelectasis; [**9-19**] CXR: unchanged; [**9-16**] CXR
b/l pleural effusions; [**9-17**] CXR b/l pleural effusions stable;
[**9-19**] CXR stable.
Physical Therapy: He was seen by PT and made great progress and
was able to walk the halls with assistance. He will receive PT
at home.
Medications on Admission:
pentasa 750qam, Paxil 20', Folate 2'
Discharge Disposition:
Home With Service
Facility:
Interim Home Care
Discharge Diagnosis:
Crohn's Disease s/p Multiple operations for perforated duodenum,
spesis, shock
Discharge Condition:
Fair
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Inability to eat or persistent vomiting
* Inability to pass gas or stool
* Other symptoms concerning to you
You may resume your normal home medications and take all new
medications as ordered.
You may shower and wash incision with soap and water. Pat area
dry. Leave open to air. The staples ..... will be removed at
your follow-up appointment.
Monitor your incision for redness, swelling, or discharge.
No lifting >10 lbs for 4 weeks.
Walk several times every day and increase activity as tolerated.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. Call ([**Telephone/Fax (1) 15807**] to schedule an appointment.
ICD9 Codes: 0389, 5185, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8305
} | Medical Text: Admission Date: [**2198-2-13**] Discharge Date: [**2198-2-20**]
Date of Birth: [**2140-10-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Asymptomatic, positive stress test
Major Surgical or Invasive Procedure:
[**2198-2-15**] Three Vessel Coronary Artery Bypass Grafting(left
internal mammary to left anterior descending, vein grafts to
diagonal and obtuse marginal)
[**2198-2-13**] Cardiac Catheterization
History of Present Illness:
Mr. [**Known lastname 8430**] is a 57 yo Spanish speaking man with DM2, known CAD,
ESRD on HD who presents to [**Hospital1 18**] for elective catheterization
after a positive stress test. His stress test was notable for ST
depressions in the inferolateral leads while imaging showed
moderate reversible anterior and septal defects. He has never
experienced any cardiac symptoms.
Past Medical History:
Coronary artery disease - s/p PCI in [**2197-1-31**], History of
NSTEMI, ESRD - on hemodialysis and s/p AVF, Nephrotic Syndrome
with hypoalbuminemia, Diabetes mellitus, Hypertension,
Hypercholesterolemia, Retinopathy, Iron Deficiency Anemia, Bells
Palsy, History of Rhabdomyolysis, History of left [**Doctor Last Name **] lobe
pneumonia, s/p Hydrocele repair
Social History:
He is from El [**Country 19118**], and was a former sheet metal worker. He
now works as an electrician. He smoked previously, about 1
[**12-4**]-packs-per-day for 10 years, but quit about 15 years ago. He
stopped using alcohol on [**2195-12-3**]. Previously he drank
approximately 2 beers/week. He lives with his wife.
Family History:
Notable for diabetes in both his mother and father. His father
also had hypertension. There is no history of kidney disease in
his family.
Physical Exam:
T 96.8, BP 161/73, P 60, R 16, SAT 98% RA
Gen: NAD, pleasant, conversant
HEENT: NCAT, PERRL
Neck: could not assess JVD given lying flat post-cath
Cor: s1s2, rrr, no r/g/m
pulm: CTAB anteriorly (could not assess posterior given lying
flat post cath
ABD: soft, nt, nd, obese, +bs, R groin c/d/i, nt, no hematoma or
bruit
Ext: no c/c/e, 2+ PT pulses bilaterally
GU: foley catheter in place with no urine in bag.
Pertinent Results:
[**2198-2-20**] 07:10AM BLOOD Hct-29.3*
[**2198-2-18**] 09:10AM BLOOD WBC-7.3 RBC-3.19* Hgb-9.8* Hct-29.3*
MCV-92 MCH-30.6 MCHC-33.3 RDW-16.1* Plt Ct-104*
[**2198-2-20**] 07:10AM BLOOD UreaN-26* Creat-5.9* Na-141 K-4.4
[**2198-2-18**] 09:10AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.0
[**2198-2-14**] 06:00AM BLOOD calTIBC-182* Ferritn-817* TRF-140*
[**2198-2-13**] 10:00AM BLOOD %HbA1c-5.4 [Hgb]-DONE [A1c]-DONE
Brief Hospital Course:
Mr. [**Known lastname 8430**] was admitted and underwent cardiac catheterization.
Angiography showed a right dominant system revealed and two
vessel CAD. The LMCA had a 30% stenosis. The LAD had an 80% mid
lesion and a long 70% lesion on both ends of previosuly placed
stent. The first diagonal had an 80% ostial stenosis and second
diagonal had an 80% ostial stenosis. The LCX had a 70% distal
stenosis. The RCA was a dominant vessel with a 30% mid vessel
stenosis. Left ventriculography revealed a normal EF of 60%.
There was no transaortic gradient upon pullback of the catheter
from the LV to the aorta. Based on the above results, cardiac
surgery was consulted and further evaluation was performed.
Plavix was discontinued in anticipation of surgery. Preoperative
workup was essentially unremarkable and he was eventually
cleared for surgery. He remained pain free on medical therapy.
On [**2-15**], Dr. [**Last Name (STitle) **] performed three vessel coronary
artery bypass grafting. The operation was uneventful and he was
brought to the CSRU for invasive monitoring. Within 24 hours, he
awoke neurologically intact and was extubated. He was transfused
to maintain hematocrit near 30%. He successfully weaned from
inotropic support and transferred to the SDU on postoperative
day two. He remained on his regular dialysis schedule and
continued to be followed closely by the renal service. He
tolerated beta blockade and remained in a normal sinus rhythm
throughout his hospital stay. He experienced no atrial or
ventricular arrhythmias. Over several days, medical therapy was
optimized and he continued to make clinical improvements. His
hospital course was rather routine and he was cleared for
discharge to home on postoperative day five. At discharge, his
BP was 112/60 with a HR of 73. His oxygen sat was 96% on room
air. All surgical wounds were clean dry and intact. His
discharge chest x-ray was notable for bilateral pleural
effusions, left greater than right associated with bibasilar
atelectasis.
Medications on Admission:
ASA 325
renagel 800mg x 4 tabs TID
avandia 4mg po bid
atenolol 100mg po qday
norvasc 5mg po qday
plavix 75mg po qday
pravachol 20mg po qday
Discharge Medications:
1. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
7. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Caregroup
Discharge Diagnosis:
Coronary artery disease - s/p CABG, Post op Pleural Effusion,
ESRD - on hemodialysis, Nephrotic Syndrome, Diabetes mellitus,
Hypertension, Hypercholesterolemia, Retinopathy, Anemia, Bells
Palsy, s/p PCI, s/p AVF, s/p Hydrocele repair
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**3-7**] weeks - call for appt.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**1-5**] weeks - call for appt.
Local cardiologist, Dr. [**Last Name (STitle) **] in [**1-5**] weeks - call for appt.
Completed by:[**2198-2-20**]
ICD9 Codes: 5856, 5119, 2859, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8306
} | Medical Text: Admission Date: [**2153-12-13**] Discharge Date: [**2153-12-19**]
Date of Birth: [**2081-7-17**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: A 72 year-old female
experiencing exertional angina for approximately one year.
She experiences chest pain after walking for about 10
minutes. She denies shortness of breath and any chest pain
at rest. A stress echo done in [**2152-10-20**] showed T
wave inversion. It was decided a cardiac catheterization
should be performed on [**2153-12-13**].
PAST MEDICAL HISTORY:
1. Hypercholesterolemia.
PAST SURGICAL HISTORY: Noncontributory.
ALLERGIES: Question cholesterol medication, question name.
MEDICATIONS:
1. Cholesterol medications question name.
PHYSICAL EXAMINATION: Afebrile. Vital signs are stable. HEENT
- no adenopathy, no masses. COR - regular rate and rhythm.
Lungs are clear to auscultation. Abdomen is soft, nontender,
nondistended. Extremities - no edema, no varicosity.
The patient was brought to the cardiac catheterization lab on
[**2153-12-13**]. See report for full details. In brief
LAD at 99%, ostial lesion with a left circumflex normal. The
RCA noncritical with collaterals to the LAD. The left
ventricular systolic function was normal.
During the procedure an attempted catheterization of the LAD,
the patient developed ST elevation anteriorly and chest pain.
She then went into asystole and a code was called.
Epinephrine and Atropine were given. The pulse and pressure
were zero. After CPR and ventilation, the patient had an
episode of V tach and rapid SVT with hypotension.
Intra-aortic balloon pump was placed and IV Amiodarone was
given and she converted to sinus rhythm.
Cardiothoracic surgery was paged and the patient was brought
to the operating room on an Intra-aortic balloon pump with
Dopamine and Levo. In the operating room she had a CABG
times two with SVG to the LAD and OM. Postoperatively she
was AD paced on Epinephrine drip and brought to the Intensive
Care Unit.
On postoperative day one the patient stabilized and her
Intra-aortic balloon pump was removed.
On postoperative day two all pressers were appropriately
weaned and she was extubated.
Pain on postoperative day three minimal, operative chest
tubes were removed. A portable chest x-ray revealed no
pneumothorax. Also on postoperative day three the patient's
wires were capped.
On postoperative day four the patient had an episode of acute
hypotension on the floor when she was transferred out. Her
blood pressure was in the 80s. A stat echo obtained at this
time revealed no effusions, no evidence of dissection, normal
left ventricular function. She was ruled out by cardiac
enzymes. A chest x-ray obtained at that time showed
increased vascular markings for which she was given multiple
doses of IV Lasix.
On postoperative day five her pacing wires were removed. It
was noted that her creatinine increased to 2.1. At that
point the Lasix, Captopril and Toradol were all held.
On postoperative day six her creatinine was stable and the
patient was in stable condition.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Lopressor 50 milligrams [**Hospital1 **].
2. Aspirin 325 milligrams q day.
3. Protonix 50 milligrams q day.
4. Plavix 75 milligrams q day.
5. Percocet one to two tablets po four to six hours prn
pain.
6. Colace 100 milligrams po bid.
DISCHARGE STATUS: The patient will go to a rehabilitation
facility, follow up with her primary care physician or
cardiologist in three weeks. Follow up with Dr. [**Last Name (STitle) **] in
four weeks.
DISCHARGE LABORATORY DATA: White count 8.9, hematocrit 35.3,
platelet count 100,000. Sodium 138, potassium 4.4, chloride
98, bicarbonate 30, BUN 21, creatinine 2.1, glucose 124.
Calcium 1.09, magnesium 2.1, phosphorus 4.4.
DISCHARGE PHYSICAL EXAMINATION: Heart was regular rate and
rhythm. Abdomen is soft, nontender, nondistended. Lungs are
clear to auscultation bilaterally. Sternum stable with no
drainage. SVG site clean, dry and intact.
DISCHARGE DIAGNOSIS:
1. Status post CABG times two.
2. Hypercholesterolemia.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2153-12-19**] 09:56
T: [**2153-12-19**] 10:05
JOB#: [**Job Number 20075**]
ICD9 Codes: 4111, 9971, 4275, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8307
} | Medical Text: Admission Date: [**2170-8-1**] Discharge Date: [**2170-8-14**]
Date of Birth: [**2125-3-16**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p 18 ft fall
Major Surgical or Invasive Procedure:
Splenectomy
VATS procedure with empyema tube placement
History of Present Illness:
45 year-old gentleman s/p fall approx 18 ft onto a large post
which snapped in half who broke several left sided ribs and also
ruptured his spleen. +EtOH He was transported to [**Hospital1 18**] where he
was takne to the operating and underwent a splenectomy.
Social History:
+EtOH
Family History:
Noncontributory
Pertinent Results:
[**2170-8-1**] 11:58PM GLUCOSE-159* LACTATE-2.4* NA+-137 K+-4.6
CL--105
[**2170-8-1**] 03:22AM GLUCOSE-116* UREA N-19 CREAT-0.9 SODIUM-138
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-20* ANION GAP-17
[**2170-8-1**] 03:22AM CALCIUM-7.9* PHOSPHATE-3.3 MAGNESIUM-2.1
[**2170-8-1**] 03:22AM WBC-10.8 RBC-4.19* HGB-14.0 HCT-40.4 MCV-97
MCH-33.5* MCHC-34.7 RDW-13.2
[**2170-8-1**] 03:22AM PLT COUNT-230
[**2170-8-1**] 12:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
CT CHEST W/CONTRAST
IMPRESSION:
1. Resolving contusion in right apex and basal segment of right
lower lobe.
2. Interval resolution of loculated effusion in left apex
anteriorly.
3. Chest tube in situ with left pleural effusion noted.
4. The patient is status post splenectomy.
5. Multiple rib fractures on the left.
6. Small fluid collection in intercostal muscles on the left
side at the site of a rib fracture.
CT HEAD W/O CONTRAST
IMPRESSION: No intracranial hemorrhage or fracture.
CT C-SPINE W/O CONTRAST
IMPRESSION:
1. No acute alignment abnormality or fracture.
2. Partial demonstration of patient's left pneumothorax.
Brief Hospital Course:
He was admitted to the Trauma service. Once stabilized in the
trauma bay he was taken to the operating room for an exploratory
laparotomy and splenectomy. There were no intraoperative
complications. He remained in the Trauma ICU for several days
for close monitoring given his injuries. He was noted to have
dyspnea and increased oxygen requirements; chest imaging
revealed a loculated left sided effusion. Thoracic surgery was
consulted and he was taken to the operating room on [**8-6**] for left
VATS decortication.
Cultures of the pleural fluid and of his chest wound were sent
which revealed a staphylococcal infection. It was recommended by
Infectious Disease that he be treated with a 6 week course of
Nafcillin. A PICC line was placed and plans were made or
discharge home with IV antibiotics.
He was given the appropriate vaccinations due to the splenectomy
prior to his discharge. Follow up is needed in both Trauma and
Thoracic clinic.
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) as needed for constipation.
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
5. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) GM
Intravenous Q6H (every 6 hours) for 6 weeks.
Disp:*qs GM* Refills:*0*
6. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ML
Injection DAILY (Daily): Flush PICC line before and after use
and PRN.
Disp:*qs ML(s)* Refills:*2*
7. Central line dressing kit
Change PICC line dressing as directed
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
s/p 18 ft fall
Left pneumothorax
Multiple left sided rib fractures
Grade III splenic laceration
Wound staphylococcal infection
Discharge Condition:
Stable
Discharge Instructions:
You will need to continue with the IV antibiotics for a total of
6 weeks.
Return to the Emergency room if you develop any fevers, chills,
shortness of breath, chest discomfort, redness or thick drainage
from PICC lie site, abdominal pain, nausea, vomiting, diarrhea
and/or any other symptoms that are concerning to you.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in 1 week; call [**Telephone/Fax (1) 600**] for an
appointment.
Follow up in [**Hospital 16814**] clinic in [**2-6**] weeks, call [**Telephone/Fax (1) 170**]
for an appointment.
Completed by:[**2170-8-14**]
ICD9 Codes: 5185, 7907, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8308
} | Medical Text: Admission Date: [**2181-5-6**] Discharge Date: [**2181-5-11**]
Date of Birth: [**2103-9-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3266**]
Chief Complaint:
mental status change
Major Surgical or Invasive Procedure:
endoscopy
History of Present Illness:
77 M with pmhx of pulmonary fibrosis, CHF, presents with one
week history of altered mental status, increasing lethargy, and
confused speech. He was brought to his PCP (Dr. [**Last Name (STitle) 3267**] for
evaluation and was referred for a Head CT on 2 days PTA,
negative. On the DOA, he was found by his son to be slumped in
bed, minimally responsive, confused, with bowel incontinence,
and brought to the ED. No report of LOC, trauma, fevers, chills,
has had continued good PO intake, no diarrhea per report, or
cp/sob
In ED, VS 97.8 57 184/40 100% 2L, given levaquin, NS, lactulose,
head CT was negative. NGL was negative.
He was taken to MICU for closer monitoring. TBili was elevated
and ammonia was 114. RUQ U/S revealed chronic liver disease
changes and hepatology was consulted.
Upon improvement of mental status with lactulose, he was
transferred back to the floor. On the floor, he has no
compliants of pain. He denies any F/C/N/V, abd pain. He does
note feeling very thirsty.
Past Medical History:
Interstitial Fibrosis
CHF
Social History:
Lives with wife (with alzheimers), son lives 3 blocks away,
independant own ADLs, was driving up to 1 week ago, DC'd Etoh 5
yrs ago, was told to stop, o/w [**2-3**] drinks/day, quit smoking 25
yrs ago, but o/w 1-2ppd smoker.
Family History:
Brother died 40s, CAD
Father died 40s, CAD
1 Sister healthy
Physical Exam:
VS 98.9 98.9 154-187/71-76 68 18 99%2L
GEN: slightly agitated
HEENT: PERRL, EOMI, icteric sclera, dry MM, OP with thrush
CV: RRR, SEM III/VI, radiating R carotid
ABD: +BS, NT, distended, splenomegaly, no hepatomegaly, no
stigmata, trace guaiac positive
Neuro: awake, oriented X 3, no asterixis
Pertinent Results:
Head CT Head: neg
.
CXray [**2181-5-6**]
- New airspace opacities in left mid and both lower lungs, which
may be due to asymmetrical edema or aspiration pneumonia.
- Diffuse irregular interstitial opacities consistent with
patient's history of fibrosis.
- Multiple calcific densities projecting over the right upper
quadrant likely gallstones.
.
Abd USG [**2181-5-6**]
- findings consistent with chronic liver disease
- no evidence of ascites
- portal vein is patent with antegrade flow.
- Cholelithiasis without cholecystitis.
.
ECHO [**2181-5-7**]
- EF 55%
- left atrium is dilated
- mild symmetric LVH Right ventricular chamber
- mild aortic valve stenosis (area 1.2-1.9cm2)
- Mild (1+) aortic regurgitation
- Mild (1+) mitral regurgitation is seen.
- Mod pulmonary artery systolic hypertension
- no pericardial effusion
Endoscopy:
Erythema and mosaic appearance in the stomach body and fundus
compatible with portal gastropathy
Varices at the lower third of the esophagus and middle third of
the esophagus
Varices at the lower third of the esophagus and middle third of
the esophagus
Erythema in the gastroesophageal junction compatible with
esophagitis
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
77 y/o M with pmhx of idiopathic pulmonary fibrosis, CHF p/w
altered MS and found to have hepatic encephalopathy
.
# Chronic liver disease: The etiology for his liver disease is
unclear. [**Name2 (NI) **] does drink alcohol but not excessively per patient
and family report. Hepatitis serologies, hemachromatosis, A1AT,
and [**Doctor First Name **] were sent and unremarkable. EGD revealed large varices,
and he was started on nadolol and [**Hospital1 **] PPI.
# Altered Mental Status: This was felt to be secondary to
hepatic encephalopathy as well as a UTI. His mental status
improved with lactulose and levaquin for UTI. It remained
unclear what precipitated the hepatic encephalopathy, but may be
infection. Patient remained afebrile, but with mild
leukocytosis. Ultrasound revealed no ascites and thus no SBP. He
continued lactulose, MVI, thiamine, folate.
# Infectious: Patient noted to have urinary tract infection and
possible radiographic evidence of PNA (although no cough,
fever). He was started on levaquin on [**2181-5-6**]. He should continue
for total of 14 day course.
# Anemia: Patient noted to have macrocytic anemia felt likely
from liver disease. B12 and folate were high. Although
haptoglobin low and LDH high and fibrinogen 100, he was not felt
to to be in DIC because no schistocytes on smear and he was
hemodynamically stable with stable hematocrit. Low haptoglobin
was attributed to cirrhosis. He did have guaiac positive stools
and will need outpatient GI follow-up. EGD revealed ulcerations
and Barrett's, and he was started on [**Hospital1 **] PPI.
# Thrombocytopenia: Baseline in [**2171**] was 150's. Now lower
possibly due to splenic sequestration. No evidence to suggest
TTP/HUS.
# Mild Coagulopathy: Felt likely from chronic liver failure.
# HTN: Patient was found hypertensive on admission with elevated
BP during MICU stay. He was initially on lopressor, but then
switched to nadolol given varices.
# Aspiration: NGT placed in MICU for possible aspiration and
inability to swallow [**2-2**] delirium. Speech and swallow eval
cleared him for ground solids. He will need further speech and
swallow therapy at rehab.
# CODE: Full
.
# Contacts: Son
[**Telephone/Fax (3) 3268**]
Medications on Admission:
1. Prednisone, 10 mg daily.
2. Spironolactone, 50 mg daily.
3. Atenolol, 50 mg daily.
4. Aspirin, 81 mg daily.
5. Ativan as needed for sleep.
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q2-3HRS ()
as needed for Titrate to 3 BMs/Day.
Disp:*2700 ML(s)* Refills:*5*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
Primary:
cirrhosis
esophageal varices
urinary tract infection
Secondary:
idiopathic pulmonary fibrosis
Discharge Condition:
stable, mental status at baseline
Discharge Instructions:
You have several new diagnosis:
1) You have chronic liver disease of unclear cause. Your liver
disease may have contributed to your confusion.
2) You also have esophageal varices, which are distended blood
vessels inside your esophagus.
3) You had a urinary tract infection being treated with an
antibiotic
You will need to take several new medications due to your new
diagnosis:
1) Lactulose: You can adjust your daily dose until your have
three soft formed bowel movements every day. This medication is
very important and will help prevent your from becoming
confused.
2) Nadolol: This medication will help with your esophageal
varices
3) Please STOP taking your metoprolol
4) Protonix: This is an acid suppressors for your stomach.
Please take all medications as prescribed.
Please attend all follow-up appointments.
Please call your primary doctor or go to the emergency room if
you have any increased confusion, yellowish tinge to your eyes
or skin, increased itchyness, fever, chills, abdominal pain,
bloody vomit or stools, black and tarry stools, or any other
concerning symptoms.
Followup Instructions:
You have an appointment to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
your new liver doctor [**First Name (Titles) **] [**2181-5-29**] at 3:00 PM in the [**Hospital Unit Name 3269**] [**Location (un) **], Deth [**Country **] [**Hospital Ward Name 517**].
Please attend the following appointments:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2181-5-24**] 2:00
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2181-5-24**] 2:00
Provider: [**Name Initial (NameIs) **]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2181-5-24**] 3:00
ICD9 Codes: 5990, 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8309
} | Medical Text: Admission Date: [**2129-11-2**] Discharge Date: [**2129-11-19**]
Date of Birth: [**2055-12-1**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Enterocutaneous fistula x2 and ventral incisional hernia
Major Surgical or Invasive Procedure:
[**2129-11-3**]:
1. Takedown of abdominal wall fistulae x2.
2. Enteroenterostomy with primary small bowel closure.
3. Repair of multiple enterotomies.
4. Ventral hernia repair with mesh inlay consisting of AlloDerm.
5. Extended adhesiolysis greater than half of the operation.
History of Present Illness:
This 73-year-old gentleman has had an unfortunate course with
abdominal adhesions in the past and this led to an operation 8
months ago which led to an
enterocutaneous fistula. Multiple operations were undertaken
after that to try and repair this and ultimately the patient was
transferred to my care with an enterocutaneous fistula. We
temporized him and improved his nutrition and after that was
stabilized after a couple of months here in our hospital, he was
sent to a local rehab hospital for further conditioning. The
plan would be to take down his fistula in greater than 6 months
from the time of the original
operation.
Past Medical History:
PMH: COPD, TIAs, Nephrolithiasis, BPH, Osteoporosis, Sarcoma L
scapula s/p resect [**7-15**]
PSH: Appendectomy, short of breath diversion and anastomosis to
transverse colon
Social History:
Lives in [**Location **]
Married with 4 kids
Army Lt. General
Quit tob 25 years ago
No EtOH
Family History:
Non-contributory
Physical Exam:
On admission:
99.1, 74, 132/772, 16, 97% RA
Gen: A+O x 3, NAD
NCAT, PERRL
Lungs clear
CV: IRIR
Abd: soft, NTND, +BS, large 25x15cm defect midline with ostomy
appliance in place and 2 segments of prolapsed bowel, no CVA
Ext: no C/C/E
Pertinent Results:
[**2129-11-10**] 01:46AM BLOOD WBC-8.6 RBC-2.97* Hgb-8.1* Hct-25.1*
MCV-84 MCH-27.3 MCHC-32.3 RDW-14.5 Plt Ct-532*
[**2129-11-9**] 03:35AM BLOOD WBC-9.1 RBC-2.90* Hgb-7.8* Hct-24.5*
MCV-84 MCH-27.0 MCHC-32.1 RDW-14.5 Plt Ct-491*
[**2129-11-8**] 01:00AM BLOOD WBC-11.6* RBC-3.11* Hgb-8.9* Hct-26.3*
MCV-84 MCH-28.5 MCHC-33.8 RDW-14.1 Plt Ct-564*
[**2129-11-7**] 11:33PM BLOOD WBC-11.9*# RBC-3.07* Hgb-8.3* Hct-25.9*
MCV-84 MCH-27.1 MCHC-32.2 RDW-14.1 Plt Ct-558*
[**2129-11-7**] 02:30AM BLOOD WBC-7.9 RBC-3.01* Hgb-8.3* Hct-25.4*
MCV-84 MCH-27.6 MCHC-32.7 RDW-14.0 Plt Ct-511*
[**2129-11-6**] 02:08AM BLOOD WBC-8.9 RBC-2.99* Hgb-8.2* Hct-25.2*
MCV-84 MCH-27.4 MCHC-32.6 RDW-13.9 Plt Ct-430
[**2129-11-5**] 02:37AM BLOOD WBC-10.3 RBC-3.06* Hgb-8.5* Hct-25.5*
MCV-83 MCH-27.6 MCHC-33.2 RDW-14.6 Plt Ct-456*
[**2129-11-4**] 03:36AM BLOOD WBC-11.8* RBC-3.34* Hgb-9.0* Hct-27.8*
MCV-83 MCH-27.0 MCHC-32.3 RDW-14.2 Plt Ct-451*
[**2129-11-3**] 04:58PM BLOOD WBC-12.6*# RBC-3.37* Hgb-9.2* Hct-28.2*
MCV-84 MCH-27.3 MCHC-32.5 RDW-14.0 Plt Ct-489*
[**2129-11-3**] 12:16AM BLOOD WBC-6.8 RBC-3.24* Hgb-8.9* Hct-27.7*
MCV-86 MCH-27.5 MCHC-32.2 RDW-13.7 Plt Ct-377
[**2129-11-10**] 01:46AM BLOOD PT-17.2* INR(PT)-1.6*
[**2129-11-8**] 01:00AM BLOOD PT-15.4* PTT-33.8 INR(PT)-1.4*
[**2129-11-7**] 02:30AM BLOOD PT-15.1* PTT-34.3 INR(PT)-1.3*
[**2129-11-6**] 02:08AM BLOOD PT-15.2* PTT-32.9 INR(PT)-1.3*
[**2129-11-3**] 12:16AM BLOOD PT-14.7* PTT-34.4 INR(PT)-1.3*
[**2129-11-18**] 05:13AM BLOOD Glucose-121* UreaN-13 Creat-0.8 Na-139
K-3.7 Cl-103 HCO3-28 AnGap-12
[**2129-11-15**] 05:02AM BLOOD Glucose-120* UreaN-26* Creat-0.8 Na-136
K-4.3 Cl-107 HCO3-24 AnGap-9
[**2129-11-14**] 08:15AM BLOOD Glucose-145* UreaN-27* Creat-0.8 Na-135
K-4.9 Cl-106 HCO3-23 AnGap-11
[**2129-11-13**] 03:48AM BLOOD Glucose-121* UreaN-22* Creat-0.7 Na-136
K-4.1 Cl-106 HCO3-25 AnGap-9
[**2129-11-12**] 04:04AM BLOOD Glucose-125* UreaN-26* Creat-0.8 Na-136
K-4.5 Cl-107 HCO3-25 AnGap-9
[**2129-11-11**] 04:00AM BLOOD Glucose-127* UreaN-22* Creat-0.7 Na-138
K-4.1 Cl-106 HCO3-27 AnGap-9
[**2129-11-10**] 01:46AM BLOOD Glucose-123* UreaN-22* Creat-0.7 Na-140
K-3.8 Cl-106 HCO3-26 AnGap-12
[**2129-11-9**] 03:35AM BLOOD Glucose-153* UreaN-21* Creat-0.7 Na-137
K-4.1 Cl-103 HCO3-28 AnGap-10
[**2129-11-8**] 01:00AM BLOOD Glucose-122* UreaN-16 Creat-0.7 Na-136
K-4.2 Cl-103 HCO3-28 AnGap-9
[**2129-11-7**] 11:33PM BLOOD Glucose-138* UreaN-17 Creat-0.7 Na-136
K-4.3 Cl-103 HCO3-28 AnGap-9
[**2129-11-7**] 02:30AM BLOOD Glucose-122* UreaN-15 Creat-0.6 Na-135
K-4.4 Cl-102 HCO3-27 AnGap-10
[**2129-11-6**] 07:02AM BLOOD Glucose-129* UreaN-13 Creat-0.7 Na-135
K-4.3 Cl-102 HCO3-28 AnGap-9
[**2129-11-6**] 02:08AM BLOOD Glucose-124* UreaN-14 Creat-0.7 Na-133
K-4.3 Cl-101 HCO3-28 AnGap-8
[**2129-11-5**] 02:37AM BLOOD Glucose-152* UreaN-13 Creat-0.7 Na-133
K-4.6 Cl-102 HCO3-28 AnGap-8
[**2129-11-4**] 08:31PM BLOOD K-4.8
[**2129-11-4**] 03:36AM BLOOD Glucose-151* UreaN-14 Creat-0.8 Na-136
K-4.1 Cl-103 HCO3-25 AnGap-12
[**2129-11-3**] 04:58PM BLOOD Glucose-228* UreaN-15 Creat-0.9 Na-133
K-4.9 Cl-102 HCO3-24 AnGap-12
[**2129-11-3**] 12:16AM BLOOD Glucose-106* UreaN-19 Creat-0.9 Na-134
K-4.5 Cl-99 HCO3-29 AnGap-11
[**2129-11-5**] 02:37AM BLOOD ALT-21 AST-18 LD(LDH)-137 AlkPhos-209*
TotBili-1.1
[**2129-11-18**] Transesophageal echocardiogram:
The left atrium is normal in size. A patent foramen ovale is
present. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the aortic arch. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. No masses or vegetations are seen on the
aortic valve. Trace aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. No vegetation/mass is seen on the pulmonic valve. There
is no pericardial effusion.
Impression: No echocardiographic signs of endocarditis. Normal
biventricular function, no significant valvular pathology.
Brief Hospital Course:
The patient was admitted to the West 2A surgery service on
[**2129-11-2**] for enterocutaneous fistula x2, ventral incisional
hernia, and dense adhesions of the small bowel and large bowel
to the abdominal wall. On [**2129-11-3**], he had a takedown of
abdominal wall fistulae x2, enteroenterostomy with primary small
bowel closure, repair of multiple enterotomies, ventral hernia
repair with mesh inlay consisting of
AlloDerm, and extended adhesiolysis greater than half of the
operation. Postoperatively, he was admitted to the SICU
intubated and on phenylephrine. He was kept sedated on propofol
and fentanyl while intubated. On POD#1, he was extubated and
started on Dilaudid PCA. On POD#4, the patient was stable to be
transferred to the floor, but had an episode of desaturations in
the 80s and was transferred back to the SICU. He was put on NRB
with aggressive pulmonary toilet and chest PT, after which his
O2 sats improved. By POD#7, he was stable enough to be
transferred to the floor.
Neuro: While on the floor, the patient was on Dilaudid PCA with
good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications.
CV: Postoperatively, the patient was kept on metoprolol for rate
control given his atrial fibrillation. During his hospital stay,
he had occasional runs of asymptomatic V-tach and was monitored
on telemetry. He was otherwise stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: While on the floor, he was stable from a pulmonary
standpoint; vital signs were routinely monitored.
GI: Postoperatively, the patient's abdomen (fascia closed,
subcutaneous layer open) was covered with wet-to-dry dressings.
On POD#4, an abdominal wound vac was placed with a binder. Wound
vac changes were done every 3-4 days.
FEN/GU: Post-operatively, the patient was started on TPN. He was
also given IV fluids until tolerating oral intake. His diet was
advanced when appropriate, which was tolerated well. He was also
started on a bowel regimen to encourage bowel movement. Foley
was removed on POD#9. Intake and output were closely monitored.
ID: Post-operatively, the patient was started on IV
Vanc/Cipro/Flagyl. POD#4 blood cultures revealed Enterococcus
faecalis that was sensitive to vanc. On POD#7, Flagyl was d/c'd.
On POD#11, Flagyl was d/c'd. On POD#13, ID was consulted for
discharge antibiotic coverage recommendations given his BCx.
They initially recommended a TEE, which was done on POD#15 and
revealed no vegetations. The patient's temperature was closely
watched for signs of infection.
Prophylaxis: Postoperatively, coumadin was never restarted.
Instead, the patient received subcutaneous heparin and pneumatic
boots. However, heparin was discontinued on POD#3, and patient
was only kept on pneumatic boots. On POD#13, he was started on
Aspirin 81mg. He was also encouraged to get up and ambulate as
early as possible.
At the time of discharge on POD#16, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
Meds at Rehab: albuterol 90mcg (2puff q4h prn), fent
100mcg/72hr, fluticasone 110mcg(2puff q12h), furosemide 40',
ativan 1' qhs, lopressor 75 [**Hospital1 **], montelukast 10', protonix 40',
salmeterol 50mcg(1puff q12h), sertraline 75', flomax 4'',
trazodone 25' qhs, coumadin, tylenol 325 (2tab q6h prn), ferrous
sulfate 300', BenGay to neck prn TID, [**Last Name (un) **] protein supp (1 scoop
daily), Eucerin cream (to legs daily), theophylline 600'',
pulmicort inh 200mcg (2 puffs AM, 1 puff PM), actonel 35mg
weekly, Calcium+VitD 250'', glucosamine chondrotine (2 tabs
daily), slo-phyllin
Discharge Medications:
1. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
2. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*5*
3. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
Disp:*5 5* Refills:*2*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*50 Tablet, Chewable(s)* Refills:*2*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**2-9**]
Puffs Inhalation Q4H (every 4 hours) as needed.
Disp:*5 qs* Refills:*0*
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO BID (2 times a day).
Disp:*60 Capsule, Sust. Release 24 hr(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
9. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation three times a day as needed for shortness of breath
or wheezing.
Disp:*1 inhaler* Refills:*2*
10. Methyl Salicylate-Menthol 15-15 % Ointment Sig: One (1) Appl
Topical TID (3 times a day) as needed for neck pain.
11. Theophylline 200 mg Tablet Sustained Release 12 hr Sig:
Three (3) Tablet Sustained Release 12 hr PO BID (2 times a day).
Disp:*180 Tablet Sustained Release 12 hr(s)* Refills:*2*
12. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*75 Tablet(s)* Refills:*2*
13. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
14. 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*
15. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Disp:*30 Tablet(s)* Refills:*0*
17. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q 12H (Every 12 Hours).
Disp:*1 inhaler* Refills:*2*
18. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
Disp:*60 Disk with Device(s)* Refills:*2*
19. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*1 Tablet(s)* Refills:*2*
20. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
21. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)
sliding scale Subcutaneous every six (6) hours: sliding scale.
Disp:*10 insulin pens* Refills:*2*
22. One Touch Basic System Kit Sig: One (1) kit
Miscellaneous every 4-6 hours: check finger sticks every [**5-15**]
hours and record.
Disp:*1 kit* Refills:*2*
23. Lancets Misc Sig: One (1) qs Miscellaneous every [**5-15**]
hours: check fingersticks every 4-6 hours and record.
Disp:*1 qs* Refills:*2*
24. Insulin Syringe 1 mL 28 x [**2-9**] Syringe Sig: One (1) qs
Miscellaneous as directed: use 1 syringe as directed per sliding
scale.
Disp:*1 syringe* Refills:*2*
25. insulin sliding scale
Insulin SC Sliding Scale
Q6H
Regular
Glucose Insulin Dose
0-60 mg/dL [**2-9**] amp D50
61-120 mg/dL 0 Units
121-140 mg/dL 2 Units
141-160 mg/dL 4 Units
161-180 mg/dL 6 Units
181-200 mg/dL 8 Units
201-220 mg/dL 10 Units
221-240 mg/dL 12 Units
241-260 mg/dL 14 Units
261-280 mg/dL 16 Units
281-300 mg/dL 18 Units
> 300 mg/dL Notify M.D.
26. Vancomycin 1,000 mg Recon Soln Sig: 1.25 grams Intravenous
every twelve (12) hours for 10 days: Give 1.25 grams .
Disp:*15 soln* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Doctor First Name **] hospital homecare
Discharge Diagnosis:
1. Enterocutaneous fistula x2.
2. Ventral incisional hernia.
3. Dense adhesions of the small bowel, large bowel to the
abdominal wall.
Discharge Condition:
good
Discharge Instructions:
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* 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.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2129-12-9**] 11:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2129-12-9**] 12:00
Please follow-up with your primary care physician on the week of
[**2129-11-21**].
Completed by:[**2129-11-22**]
ICD9 Codes: 5185, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8310
} | Medical Text: Admission Date: [**2107-9-1**] Discharge Date: [**2107-9-1**]
Date of Birth: [**2031-3-28**] Sex: M
Service: NEUROLOGY
Allergies:
No Allergies/ADRs on File
Attending:[**Last Name (NamePattern1) 11784**]
Chief Complaint:
patient found unresponsive at home
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
The pt is a 76 year old , RHM , with a history of stroke in
the past, presents after being found unresponsive.
On the night of admission at approximately 5 pm the patiemt was
in his usual stat of health. He went upstairs as he normally
does. The patients wife became concerned when the patient did
not come down for dinner.
At approxilately 830 to 9 pm the wife went upstairs and found
the
patiemt unconscious and snoring. He was unarrousable and had
vomited as per the wife.
Th [**Name2 (NI) 105968**] has been in his usual satte of health.
He was not complaining of headache. There was no nausea or
vomiting noted.
Past Medical History:
polio
stroke in the past (thought to be cerebellar)
Social History:
Lives at home with his wife and has three daughters
Family History:
N/C
Physical Exam:
ADMISSION PHYSICAL EXAM:
Physical Exam:
Vitals: Intubated T:afebrile BP:183/125 SaO2:
General: Patient intubated.
HEENT: NC/AT, no scleral icterus noted, Dry mucous membranes.
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: 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: Intubated. Not responsive to sternal rub. Does
not grimace to painful stimuli.
Does not open eyes to command.
Does not follow commands.
-Cranial Nerves:
I: Olfaction not tested.
III, IV, VI: Pupils are midlne on primary gaze.
The left pupil in 2 mm and minimally reactive. The left pupil is
2.5 mm and minimally reactive.
No corneal reflex.
-Motor:
No spontaneous movement.
Th epatient does withdraw from pain , more so on teh left than
the right.
-Sensory: Withdraws to pain.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 1 1
R 1 1 1 1 1
Left upgoing toe.
-Coordination: Unable to assess.
-Gait: Unable to assess.
EXAM ON PRONOUNCIATION OF DEATH
GEN: patient lying in bed, unresponsive
HEENT: no breath felt at mouth, pupils fixed and dilated
bilaterally
CV: no heart beat auscultated
PULM: no breath sounds auscultated
EXT: cool
Pertinent Results:
ADMISSION LABS:
[**2107-8-31**] 09:25PM BLOOD WBC-11.6* RBC-4.69 Hgb-14.5 Hct-43.1
MCV-92 MCH-31.0 MCHC-33.8 RDW-14.3 Plt Ct-256
[**2107-8-31**] 09:25PM BLOOD PT-12.2 PTT-21.7* INR(PT)-1.0
[**2107-8-31**] 09:25PM BLOOD Fibrino-592*
[**2107-9-1**] 02:18AM BLOOD Glucose-124* UreaN-14 Creat-0.5 Na-140
K-4.7 Cl-103 HCO3-26 AnGap-16
[**2107-9-1**] 02:18AM BLOOD ALT-18 AST-34 CK(CPK)-262
[**2107-9-1**] 02:18AM BLOOD CK-MB-10 MB Indx-3.8
[**2107-8-31**] 09:25PM BLOOD Calcium-8.4 Phos-2.9 Mg-1.8
[**2107-9-1**] 03:22AM BLOOD Osmolal-294
[**2107-9-1**] 02:18AM BLOOD TSH-0.62
[**2107-8-31**] 09:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2107-8-31**] 09:32PM BLOOD Glucose-146* Lactate-2.1* Na-140 K-3.6
Cl-100 calHCO3-26
Patient made CMO on the day he expired so he did not have labs
drawn at that time.
Imaging:
CT HEAD [**2107-8-31**]: IMPRESSION: Large left-sided intraparenchymal
hemorrhage with resultant subfalcine and uncal herniation. There
is intraventricular hemorrhage, with associated hydrocephalus.
CXR [**2107-8-31**]: IMPRESSION: Endotracheal tube tip terminates at the
level of thoracic inlet, and could be slightly advanced, as it
terminates 9 cm from the carina. Mild bibasilar atelectasis.
Evaluation of the costophrenic angles is limited on this study.
Brief Hospital Course:
The pt is a 76 year old RHM with a history of stroke in the past
who presented after being found unresponsive, with CT scan
showing a large left sided intraparenchymal hemmorhage. Etiology
was likely hypertensive in nature given the lobar distribution,
but should also consider amyloid angiopathy given the patient's
age. Per family discussion, patient was made CMO on [**9-1**].
.
# NEURO: patient's bleed was considered devastating, and it was
unlikely he would recover any meaningful neurological function.
Prior to family decision, he was loaded with mannitol in order
to allow family members enough time to gather at the bedside.
He was pthen laced on a morphine gtt and ativan gtt once
discussion was had with family to make him CMO. He was
terminally extubated. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] was called to the
bedside to pronounce the patient's death at 3:03pm on [**9-1**].
Patient had no pupillary response, no heart beat and no breath
sounds, and was determined to have expired. His family and
friends were at the bedside. They declined autopsy as did the
ME.
Medications on Admission:
Aspirin
Simvastatin
Discharge Medications:
N/A pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
large intraparenchymal hemorrhage
Discharge Condition:
Pt expired.
Discharge Instructions:
Patient expired on [**9-1**] at 3:03pm surrounded by family and
friends.
Followup Instructions:
N/A, pt expired
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8311
} | Medical Text: Admission Date: [**2166-10-16**] Discharge Date: [**2166-10-24**]
Date of Birth: [**2100-6-16**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
male with a significant history of coronary artery disease
who presented to the [**Hospital1 69**]
with a positive stress test on [**10-3**] for cardiac
catheterization. His cardiac catheterization revealed
3-vessel disease and a right-dominant system. Left main
coronary appeared angiographically normal. The left anterior
descending artery had 90% stenosis, the left circumflex had a
90% proximal stenosis, the right coronary artery was
completely occluded proximally with distal collateral filling
from the conus branch and left-to-right collaterals.
Hemodynamics showed elevated left ventricular end-diastolic
pressure and systolic arterial hypertension.
He was subsequently referred for a coronary artery bypass
graft which was performed on [**2166-10-6**] with left
internal mammary artery to left anterior descending artery,
saphenous vein graft to first obtuse marginal, saphenous vein
graft to first diagonal. His left circumflex was not grafted
because of poor touchdown sites; therefore, he was taken to
the catheterization laboratory where they performed a
successful percutaneous transluminal coronary
angioplasty/stenting of the proximal and middle circumflex.
His postoperative course was complicated by atrial
fibrillation which was originally treated with amiodarone but
switched to procainamide due to transaminitis. Thereafter he
converted to normal sinus rhythm. He was treated with
aspirin and Plavix and discharged on [**10-16**].
After discharge, the patient was home for a few hours and
developed shortness of breath and bradycardia and was brought
back to the Emergency Room. Upon arrival to the Emergency
Room he was intubated secondary to poor oxygenation from
congestive heart failure. He was admitted to the
Cardiothoracic Surgery Service, and his cardiac enzymes were
cycled. A.m. enzymes revealed a creatine kinase of 310. He
was then taken to the catheterization laboratory where he was
found to have a thrombosed left circumflex stent distal to
the obtuse marginal graft. The lesion received Angio-Jet and
an intra-aortic balloon pump was placed, and the patient was
transferred to the Coronary Care Unit.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Coronary artery disease.
3. Status post hip fracture.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Procainamide 750 mg and 500 mg
alternating doses p.o. q.i.d., Plavix 75 mg p.o. q.d.,
Lasix 20 mg p.o. q.d. times five days, Lipitor 20 mg p.o.
q.d., Lopressor 12.5 mg p.o. b.i.d., Percocet p.r.n., [**First Name5 (NamePattern1) 233**]
[**Last Name (NamePattern1) 1002**] 20 mEq p.o. b.i.d. times five days.
PHYSICAL EXAMINATION ON PRESENTATION: On admission
temperature was 99.3, pulse of 109, blood pressure 102/42,
oxygen saturation 100% on CPAP with pressure support of 10,
PEEP of 5, FIO2 50%, tidal volume 450 cc with a respiratory
rate of 19 on propofol and dopamine and Integrilin drips. In
general, the patient was intubated and sedated. Head, ears,
nose, eyes and throat revealed pupils were equal and reactive
to light. No jugular venous distention. Sclerae were
anicteric. Bilateral carotid bruits. Heart had sinus
tachycardia, a [**2-11**] holosystolic murmur radiating to the
axilla. Lungs were clear to auscultation anteriorly. The
abdomen was soft, hyperactive bowel sounds. Extremities
revealed pulses by Doppler, surgical incision on the lower
extremities healing well. Lines: A right arterial and
venous sheaths, left arch sheath.
LABORATORY DATA ON PRESENTATION: White blood cell
count 15.4, hematocrit 25.8, platelets 358. Sodium 137,
potassium 4, chloride 101, bicarbonate 11, creatinine 0.9,
BUN 11. INR 1.4, PTT 32.6, PT 14.3. Magnesium 1.5.
Creatine phosphokinase 310, MB 20. Urinalysis had positive
nitrites, moderate bacteria.
RADIOLOGY/IMAGING: Electrocardiogram from [**2166-10-16**]
revealed sinus bradycardia with normal axis and intervals,
new T wave inversions in I, aVL, II, III, and aVF, V2 through
V6 with ST depressions in V4.
[**2166-10-16**], post intervention revealed normal sinus
rhythm at 102 with no changes from prior electrocardiograms.
HOSPITAL COURSE: While on the Coronary Care Unit the
patient was successfully extubated and intra-aortic balloon
pump was removed. The patient's course in the Coronary Care
Unit was complicated by two episodes of paroxysmal atrial
fibrillation which was converted with intravenous
procainamide and DC cardioversion. He was eventually
switched to oral procainamide and remained in normal sinus
rhythm throughout the rest of his stay in the Coronary Care
Unit. He will need to be reassessed for potential
anticoagulation if he were to convert to atrial fibrillation.
Additionally, he had episodes of chest pain which were not
associated with any electrocardiogram changes and relieved by
sublingual nitroglycerin. He was noted to have a pericardial
friction rub and was treated with indomethacin. Once his
vitals stabilized he was resumed on Lopressor and captopril.
At the time of discharge he remained free of chest pain.
His urinary tract infection was treated with 7-day course of
ciprofloxacin; [**1-9**] blood culture bottles grew
coagulase-negative Staphylococcus. He was treated with
vancomycin for four days, but that was discontinued in light
of no fever spikes and other culture bottles showing no
growth. Surveillance cultures were drawn 48 hours after
discontinuing vancomycin. They had not grown anything at the
time of discharge. It was likely that the one positive blood
culture was due to a skin contaminant. Per Interventional
Cardiology recommendation, the patient was to be continued on
Plavix 150 mg p.o. for two month.
From and Endocrine standpoint the patient continued to have
elevated serum glucose levels. He was put on an insulin
sliding-scale while in the hospital. However, he will need
to be evaluated for diabetes on an outpatient basis since he
has clearly demonstrated fasting blood sugars greater than
126 on several occasions.
The patient was seen by Physical Therapy, and they evaluated
him as having good potential for returning to baseline
functional status. He will need to be enrolled in a cardiac
rehabilitation program upon return to his home in Bermuda.
MEDICATIONS ON DISCHARGE:
1. Lopressor 100 mg p.o. b.i.d.
2. Procainamide 500 mg p.o. q.i.d.
3. Plavix 150 mg p.o. q.d.
4. Aspirin 325 mg p.o. q.d.
5. Captopril 37.5 mg p.o. t.i.d.
DISCHARGE DIAGNOSES:
1. Myocardial infarction secondary to in-stent thrombosis of
left circumflex stent, status post Angio-Jet and restenting.
2. Paroxysmal atrial fibrillation.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Home.
[**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**]
Dictated By:[**Name8 (MD) 5753**]
MEDQUIST36
D: [**2166-11-29**] 21:23
T: [**2166-12-3**] 07:28
JOB#: [**Job Number 35987**]
(cclist)
ICD9 Codes: 4280, 5990, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8312
} | Medical Text: Admission Date: [**2114-4-11**] Discharge Date: [**2114-4-15**]
Date of Birth: [**2037-1-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Iodine
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Dr. [**Known lastname 102490**] is a 77yo physician w/hx of alcoholic cirrhosis,
HCC s/p ablation, CHF (EF 55-60%), chronic afib not on coumadin,
portal vein thrombus, who was transferred from [**Hospital 3278**] Medical
Center for SOB. He initially presented to to his PCP [**Name Initial (PRE) 151**] 1
month of SOB and fatigue as well as syncope and was found to
have a HR of 25. He reports syncope on [**2114-4-1**] and struck his
head but did not seek medical attension. He was sent to the
[**Hospital **] Hospital ED [**4-4**] and was found to have afib with HR in
the 30s and SBPs in the 130s. An echo showed nl EF, 2+MR, mild
AS, severe TR, septal HK, RV dysfunction. He was transferred to
[**Hospital1 3278**] for a pacemaker insertion which was placed on [**4-6**] with
single chamber pacemaker (VVI). He received no contrast with
the PPM placement. His creatinine rose to 4.0 after the
procedure and his urine output dropped. Renal was consulted and
thought that this was HRS vs. ATN vs. pre-renal. Renal U/S was
normal. His T bili rose to 7.0. RUQ U/S showed portal vein
thrombus and ascites with no clear fluid pocket for
paracentesis. Potassium was 5.8 prior to transfer, he got
kayexalate yesterday. ABG 7.36/34/98 on 3L prior to transfer.
INR 1.7. He was started on Vanc and Meropenem for possible
sepsis as a cause for his decompensation.
.
He was to be transferred to the [**Hospital1 3278**] MICU today and family
requested transfer to [**Hospital1 18**].
.
On the floor, his primary complaint is SOB. He denies chest
pain, palpitations, abdominal pain, nausea, vomiting, fevers,
chills, night sweats. He has been having diarrhea after getting
lactulose at [**Hospital1 3278**]
Past Medical History:
# alcoholic cirrhosis complicated by ascites (1x)
# hepatocellular carcinoma s/p radiofrequency ablation in [**4-5**].
Recurrence in [**6-5**] with second radiofrequency ablation in [**8-5**].
# atrial fibrillation
# partial portal vein thrombosis s/p short course of coumadin
Social History:
Patient is former heavy drinker consuming [**12-30**] pint of whiskey
per day and approximately 2 bottles of wine per day. Has not
drank in 15 years. Patient has never smoked cigarretes. Denies
any illicit drug use. Patient is retired physician living alone
in [**Location (un) 2624**]. Daugther lives nearby in [**Location (un) 538**].
Family History:
Extensive family history of alcoholism on father's side. Brother
died of bladder cancer. Sister died of unknown cause, but
suffered from alcoholism. Father died of complications from a
ruptured appendix in the Phillipines, also suffered from
alcoholism. Mother died at age [**Age over 90 **] from old age.
Physical Exam:
Exam on admission:
General: Alert, oriented, increased work of breathing
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated to jaw, no LAD
Lungs: Bilateral crackles throughout
CV: Regular rate and rhythm, [**3-3**] holosystolic murmur at apex
Abdomen: soft, non-tender, distended with appreciable ascites
on exam, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: + foley with minimal yellow urine
Ext: warm, well perfused, 2+ pulses, 2+ peripheral edema to
thighs bilaterally
.
Pertinent Results:
CXR ([**2114-4-11**]): Silhouette is markedly enlarged, and is
accompanied by pulmonary vascular engorgement, perihilar
haziness, and mild interstitial edema. Chronic blunting of
right costophrenic sulcus could reflect small pleural effusion
and/or pleural thickening. Permanent pacemaker lead terminates
in right ventricle.
.
[**2114-4-11**] 09:46PM BLOOD WBC-12.7*# RBC-3.55* Hgb-9.9* Hct-30.2*
MCV-85 MCH-27.9 MCHC-32.8 RDW-19.2* Plt Ct-75*
[**2114-4-11**] 09:46PM BLOOD Glucose-114* UreaN-115* Creat-4.2*#
Na-125* K-5.2* Cl-88* HCO3-20* AnGap-22*
[**2114-4-11**] 09:46PM BLOOD ALT-115* AST-110* LD(LDH)-374*
AlkPhos-104 TotBili-7.0*
[**2114-4-11**] 09:46PM BLOOD Calcium-8.7 Phos-7.7*# Mg-2.8*
Brief Hospital Course:
Mr. [**Known lastname 102490**] is a 77M with a history of alcoholic cirrhosis, HCC
s/p ablation, CHF, presents as a transfer from [**Hospital1 3278**] with
worsening liver failure, oliguric acute on chronic renal
failure, volume overload and respiratory distress. The acute
renal failure may be due to hepatorenal syndrome or possibly ATN
but given his minimal urine output and significant volume
overload and electrolyte abnormalities the corrective option
would be dialysis, which would likely be a longterm need. A
discussion took place between the medicine ICU team, the
daughter [**Name (NI) **] [**Name (NI) 102490**] (HCP) and the patient regariding
dialysis, intubation, and resuscitation. The decision was made
to focus on patient comfort and to not pursue dialysis, which
was thought to be reasonable. He was placed on supplemental
oxygen, given morphine or dilaudid as needed for dyspnea, and
started on a scopolamine patch. The palliative care service was
consulted and coordinated this care plan with the primary team.
He was transitioned to the regular floor from the ICU where he
received comfort care and eventually died on [**2114-4-14**] from acute
renal failure, which was a consequence of his alcoholic
cirrhosis and liver failure, also with underlying hepatocellular
carcinoma.
Medications on Admission:
Home Medications:
Lasix 40mg PO qday
Lactulose 30ml PO BID - not taking
Spironolactone 200mg PO qday
Rifaximin 400mg PO TID - not taking due to cost
Testosterone 1% gel apply to skin once a day
.
Medications on Transfer:
Pantoprazole 40mg PO qday
Lactulose 800mg PO TID
Lasix 40mg IV x 1 [**2114-4-11**]
Lasix 80mg IV x 1 [**2114-4-11**]
Kayexalate 30gm PO x 1 [**2114-4-11**]
Ipratropium/Albuterol q4H
Vancomycin 1gm IV x 1
Meropenem 500mg IV q12H
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary
Acute on chronic renal failure
.
Secondary
alcoholic cirrhosis complicated by ascites
- atrial fibrillation
- COPD
Discharge Condition:
comfort measures only
Discharge Instructions:
(pt died in-house)
Followup Instructions:
none
[**Name6 (MD) **] [**Name8 (MD) **] [**Known lastname **] [**MD Number(2) 2158**]
ICD9 Codes: 5849, 5185, 5859, 2767, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8313
} | Medical Text: Admission Date: [**2117-2-6**] Discharge Date: [**2117-2-10**]
Date of Birth: [**2041-7-25**] Sex: F
Service: SURGERY
Allergies:
Metrogel / Desipramine / Sanctura
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
R IJ central venous line placement
History of Present Illness:
The patient is a 75-year-old female who complains of
progressively worsening rectal and buttock pain over the past 2
weeks. Upon presenting to the [**Hospital1 18**] ED today, she initially had
a
HR of 77 with a BP of 105/69, but quickly became hypotensive to
56/40 with a heart rate of 98. Sepsis protocol was initiated. A
central line was placed with great difficulty due to
near-complete IVC collapse. She was placed on a norepinephrine
drip and underwent a CT scan when she was somewhat stable. The
scan shows a large pre-sarcal abscess with rim enhancement, and
air and fat stranding tracking to a R hip prosthesis.
On [**2116-12-20**], she underwent a diverting loop colostomy by Dr.
[**Last Name (STitle) **] for a large rectovaginal fistula. Intra-operatively, she
was noted to have stool in the rectum, vaginal and presacral
space, and the posterior/presacral space was cleaned out. She
was
discharged on POD#6. It is noteworthy that prior to her
operation, she did manifest fever and hypotension to SBP of 75.
An echocardiogram was reassuring, with an EF of 65% with trace
valvular disease.
She was evaluated in clinic about two weeks ago by Dr. [**Last Name (STitle) **],
who was not reassured by her progress at that time. She
appeared to be slowly declining with a pelvic choleca situation
which was not amenable to repair due to the prior radiation
damage and poor vascular supply.
Past Medical History:
CAD s/p MI in 94
PVD (s/p aorto-fem bypass and L femoral endarterectomy)
L Breast CA s/p mastectomy in early 90's
Colon adenocarcinoma '[**08**] s/p LAR with Chemo and XRT
SBO s/p XLap with LOA in [**3-20**]
Asthma
Hypothyroidism
Hyperlipidemia
Osteoporosis
ORIF R tibia
Bilateral THR [**2110**]
PAF
Social History:
She lives in [**Location 4288**] with her husband. She is a former smoker
but quit 15 years ago. She reports drinking vodka and fruit
juice "most days." She has worked various jobs throughout her
life and cared for her four children
Family History:
he is unable to give much specific history but reports "everyone
is dead" of different things.
Physical Exam:
Gen: elderly female, NAD, no icterus
HEENT: NC/AT, EOMI, PERRLA bilat., dry MM, without cervical LAD
on my exam
Cor: RRR without m/g/r, no JVD, no bruits
Lungs: CTA bilat.
[**Last Name (un) **]: +BS, soft, ND, NT, no masses
Rectal: large communicating fistula palpable between rectum and
vagina anteriorly. Tender on vaginal and ++ tender on rectal
exam. No perineal erythema
Ext: warm feet, 2+ pitting edema to knees
Pertinent Results:
Labs:
| 138 | 108 | 14 / 83 AGap=13
| 3.7 | 21 | 0.9 \
Ca: 7.1 Mg: 1.7 P: 3.5
ALT: 11 AP: 145 Tbili: 0.4
AST: 15 Lip: 6
Cortsol: 34.3
CRP: Pnd
7.4
25.8 >--< 622
23.5
N:88 Band:4 L:4 M:3 E:0 Bas:1
PT: 19.0 PTT: 54.0 INR: 1.8
lactate 2.8 -> 3.1 -> 3.4
Imaging:
CT [**Last Name (un) 103**]/pelvis with IV contrast:
* 65 x 34 mm collection posterior to the rectum highly
suggestive
of an abscess
* Pockets of air in the fascial planes of the right thigh and
around the right hip joint suggestive of either a fistula or a
developing abscess
* Stable severe compression of L1
* distal limbs of aortobifemoral graft not in continuity with
iliac/femoral vessels
Brief Hospital Course:
Patient admitted to SICU. Started on antibiotics, resuscitated
with fluids, intubated, and placed on pressors. She quickly
deteriorated and had worsening acidosis with a ph as low as 6.9
and lactate greater than 20. She was requiring multiple
pressors and her due to her age and prognosis, it was decided to
speak with the family regarding comfort measures, as there was
no effective long term treatment for the pelvic source of
sepsis. The family agreed. It took about 24 hours to get all
the family members to the hospital to say their goodbyes. Once
they arrived the ETT was removed, pressors and IVFs were
stopped. The patient continued to breath spontaneous and
maintain a blood pressure in the low 80s. After many hours it
appeared that the dying process may take a while longer.
Therefore she was transferred to the floor and treated with an
infusion of morphine for pain control. On [**2117-2-10**] at 0405 am the
patient expired, immedicate cause of death being cardiopulmonary
failure secondary to sepsis. The family was present at the time
of death, and declined an autopsy. The attending physician of
record, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] was [**Name (NI) 653**], as well as the chief
surgical resident of the service, Dr. [**First Name8 (NamePattern2) 429**] [**Last Name (NamePattern1) **].
Medications on Admission:
Amiodarone 200 [**Last Name (LF) 6222**], [**First Name3 (LF) **] 81', Vit B 12, Advair, Folic acid
1', Imdur 30', Combivent, Levoxyl 112, MVI, Toprol 25',
Singulair 10', Nitro 0.3', Omeprazole 40', Oxytol, Oxycodone
10", Plavix 75', Ranitidine 150", Simvastatin 20', Trazadone 50
Discharge Disposition:
Expired
Discharge Diagnosis:
sepsis
multiorgan failure
Discharge Condition:
expired
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
Completed by:[**2117-2-10**]
ICD9 Codes: 0389, 5849, 5990, 2762, 4241, 4280, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8314
} | Medical Text: Admission Date: [**2130-3-31**] Discharge Date: [**2130-4-11**]
Date of Birth: [**2052-7-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Ace Inhibitors /
Angiotensin Recp Antg&Calcium Chanl Blkr / Meloxicam
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
anemia
Major Surgical or Invasive Procedure:
Transfusions with packed red blood cells and fresh frozen plasma
History of Present Illness:
77 yo female with HTN, DM, CRI, on prednisone for RA, open
laparotomy for perforated dudenal ulcer at [**Hospital3 **] on
[**2130-3-10**], and recently hosp from [**Date range (1) 104274**] for high INR who was
sent to the ED from [**Hospital3 **] for high INR and HCT of 16.9.
She was seen in ED on [**2130-3-29**] and found to have UTI yeast >
100,000. She was started on ciprofloxacin 500mh [**Hospital1 **] on [**3-29**].
Per [**Hospital3 **] she has had no bloody/black stool or bleeding
from her coccyx wound site. She has had no n/v. She has
received 2.5mg po vit K on [**2130-3-29**]. WBC today at [**Hospital3 **]
was 11. Given increasing creatinine they were holding lasix on
[**2-24**], and [**3-31**] and giving 500ml po TID. VS prior to
transfer to [**Hospital1 **] were 97/64 P103 100% RA.
.
In the ED, initial vs were T95.6 P98 (HR 77-92) BP108/77
(103-115/54-68) R22 (18-28) O2 sat 100%. In the ED HCT was noted
to be 16.9 (HCT 25.7 2 days ago). INR was 5.3. Patient was
given 10mg po vit K and 1.5 units of blood. She was guaiac
negative and NG lavage was not done given high INR and no
evidence of GI bleed. She reported back pain and CT abd was
negative for RP bleed. Initially only had 25cc of pus looking
UOP. She received 80mg IV lasix and had made 250cc of urine by
the time she arrived to the floor. Her urine cx from [**2130-3-29**]
grew >100,000 yeast. Her UA from today had >50 WBC, moderate
bacteria, and [**12-24**] WBC. She was given IV ceftriaxone. Her lung
exam was notable for crackles at the bases. She was difficult
to obtain access on and a right IJ was placed. Max HR in the ED
was 92 and lowest BP was 103. Vitals prior to transfer were T98
HR 78 BP 124/68 RR18 100% on 2L. CXR showed small bilateral
pleural effusions.
.
On the floor, pt reports [**11-13**] back pain worse this AM than
previously. However, she has been having the back pain since
earlier this month after her abdominal surgery.
.
Review of systems:
(-) 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:
#. Left deep venous thrombosis involving the internal jugular
and brachial veins [**2-14**] on coumadin
#. Hypertension - TTE [**3-14**] - EF >55%. Mild AR
#. DM2 - diagnosed [**2118**], has been on insulin in the past but no
longer takes any diabetes medications
#. CKD - baseline creatinine 3.0
#. Rheumatoid arthritis - diagnosed at age 50; [**Doctor First Name **] 1:1280 -
followed by Dr. [**Last Name (STitle) 6426**]; on chronic steroids
#. Hypothyroidism
#. Osteoarthritis
#. Possible SLE, discoid lupus since [**2121**] with a positive right
sided lymph node biopsy
#. Left renal mass detected in [**2121-8-4**] - pt doesn't want
further w/u
#. Anemia - Normocytic in past
#. Asthma
#. History of low back pain
#. C. diff colitis with recurrence 8 and [**10-9**]
#. ?Cecal Mass on CT - [**Last Name (un) **] [**6-10**] negative. CEA 5.7
#. L renal mass
#. ?Coronary atherosclerosis
#. h/o PNA
#. Dysphagia
#. UTIs- multiple recent UTIs + for yeast
.
Allergies:
Ace Inhibitors
Angiotensin Recp Antg&Calcium Chanl Blkr
Meloxicam
Penicillins
Sulfa (Sulfonamide Antibiotics)
Social History:
.
Social History:
Drugs: None
Tobacco: None
Alcohol: None
Other: The patient currently at [**Hospital3 2558**] Nursing
Center, previously living in a home one floor above her
daughters
.
Family History:
Family History: Father had DM, CAD, HTN. No cancer or stroke in
family.
.
Physical Exam:
Physical Exam on ICU admission:
Vitals: T: 97.1 BP:152/58 P: 87-97 R:12 18 O2: 100% 1L
Gen: NAD, AAOx2-3
HEENT: moist mm, EOMI grossly, OP clear
Neck: Supple
CV: +s1+s2 RRR, II/VI SEM
Resp: Mild crackles at bases bilaterally, no rales/wheezes
Abd: +bs, well-healing midline incision, soft, NTND, no rebound
or guarding, no palpable masses.
Ext: 2+ pitting edema bilaterally to knees, chronic venous
statis
changes, LE warm and well perfused, faint DP pulses bilaterally.
GU: foley in place and urine with gross pus
Neuro: CN: II-XII, grossly intact. Moving all extremities.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Pertinent Results:
Labs from [**Hospital3 **]:
HCT 25.4
INR 4.4
BUN 59
creatinine 3.4
K 5.4 (? given kayexelate).
note that was holding lasix x 3 days and giving 500ml po fluid
per shift.
.
[**Hospital1 **] labs:
.
[**2130-3-31**] 10:02PM WBC-11.7* RBC-2.88*# HGB-8.7*# HCT-26.5*#
MCV-92 MCH-30.3 MCHC-32.9 RDW-15.6*
[**2130-3-31**] 10:02PM NEUTS-86.2* LYMPHS-9.0* MONOS-4.3 EOS-0.3
BASOS-0.3
[**2130-3-31**] 10:02PM PLT COUNT-189
[**2130-3-31**] 04:10PM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014
[**2130-3-31**] 04:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2130-3-31**] 04:10PM URINE RBC-[**12-24**]* WBC->50 BACTERIA-MOD
YEAST-NONE EPI-0
[**2130-3-31**] 12:56PM PH-7.48* COMMENTS-GREEN TOP
[**2130-3-31**] 12:56PM GLUCOSE-92 LACTATE-1.2 NA+-137 K+-4.7
CL--113* TCO2-18*
[**2130-3-31**] 12:56PM HGB-5.3* calcHCT-16
[**2130-3-31**] 12:56PM freeCa-1.02*
[**2130-3-31**] 12:45PM GLUCOSE-94 UREA N-68* CREAT-3.6* SODIUM-139
POTASSIUM-4.8 CHLORIDE-112* TOTAL CO2-17* ANION GAP-15
[**2130-3-31**] 12:45PM ALT(SGPT)-19 AST(SGOT)-27 LD(LDH)-280*
CK(CPK)-100 ALK PHOS-397* TOT BILI-0.4
[**2130-3-31**] 12:45PM CK-MB-5
[**2130-3-31**] 12:45PM cTropnT-0.10*
[**2130-3-31**] 12:45PM ALBUMIN-1.8* CALCIUM-7.1* PHOSPHATE-6.0*
MAGNESIUM-1.8 IRON-30
[**2130-3-31**] 12:45PM calTIBC-108* VIT B12-1095* FOLATE-4.0
HAPTOGLOB-248* FERRITIN-645* TRF-83*
[**2130-3-31**] 12:45PM NEUTS-89.5* BANDS-0 LYMPHS-7.1* MONOS-3.0
EOS-0.2 BASOS-0.2
[**2130-3-31**] 12:45PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL
SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL
[**2130-3-31**] 12:45PM PLT COUNT-269
[**2130-3-31**] 12:45PM PT-48.6* PTT-46.2* INR(PT)-5.3*
[**2130-3-31**] 12:45PM RET AUT-3.3*
.
Micro:
Urine cx [**2130-3-29**]:
URINE CULTURE (Final [**2130-3-31**]):
YEAST. >100,000 ORGANISMS/ML.
urine culture [**4-1**]: 10,000-100,000 yeast
Images:
[**2130-3-31**] CXR Pa/lat:
UPRIGHT AP AND LATERAL VIEWS OF THE CHEST: There are low
inspiratory lung volumes. Heart size remains enlarged but
unchanged. Pulmonary vascularity is not engorged. Bibasilar
opacities are noted, slightly worse on the right compared to the
prior study, which may reflect atelectasis. There are small
bilateral pleural effusions which are stable. Clips from prior
thyroidectomy are present. S-shaped scoliosis of the thoracic
spine is again noted.
IMPRESSION: Bibasilar airspace opacities, slightly worse on the
right, likely reflective of atelectasis. Infection is not fully
excluded. Small bilateral pleural effusions, unchanged.
.
CT abd/pelvis without contrast [**2130-3-31**]:
Evaluation of visceral organs is limited due to lack of
intravenous contrast.
Small bilateral pleural effusions with adjacent areas of
compressive
atelectasis are unchanged. Pleural based hyperdensity within the
right lung base is unchanged. Extensive coronary calcifications
are noted.
There is no evidence of retroperitoneal hematoma. Moderate
amount of ascitesis unchanged from [**2130-3-21**] exam. Focal
calcifications of the liver and spleen, likely represent prior
granulomatous disease. Tiny calcified gallstones are noted
within the gallbladder. The pancreas and adrenal glands appear
unremarkable. Bilateral renal hypodensities, most likely renal
cysts, unchanged. There is no evidence of mesenteric or
retroperitoneal lymphadenopathy. Intra-abdominal aorta is
notable for calcified atherosclerotic disease without aneurysmal
changes. There is no free air within the abdomen.
.
CT OF THE PELVIS [**2130-3-31**]:
Moderate amount of fluid within the pelvis is unchanged. The
rectum, bladder, and sigmoid colon appear unremarkable. Moderate
sized fat-containing right inguinal hernia appears unchanged.
There is no free air within the pelvis. Generalized anasarca is
noted.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are
identified. Grade 1 anterolisthesis involving L4-L5 is
unchanged.
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. In comparison to [**2130-3-21**] exam, there are no significant
change in moderate amount of ascites within the abdomen and
pelvis.
3. Small bilateral pleural effusions with adjacent areas of
compressive atelectasis, unchanged.
4. Cholelithiasis.
.
Echo [**2130-2-14**]:
The left atrium is elongated. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Doppler
parameters are most consistent with Grade I (mild) left
ventricular diastolic dysfunction. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are moderately thickened. There is mild aortic valve stenosis
(valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a very small pericardial
effusion.
IMPRESSION: Moderate symmetric LVH with normal global and
regional biventricular systolic function. Calcific aortic valve
disease with mild stenosis/mild regurgitation. Mild mitral
regurgitation. Moderate pulmonary hypertension. Very small
pericardial effusion.
.
Lower extremity dopplers - negative DVT
.
Venous ultrasound [**2130-2-15**]:
FINDINGS: Waveforms of the subclavian veins are symmetric
bilaterally. On the left, the internal jugular vein is notable
for isoechoic endoluminal contents and that vessel is
incompletely compressible and shows only partial flow on color
Doppler analysis, consistent with non-occlusive thrombus. The
left axillary, basilic and one of the left brachial veins are
normal with appropriate compressibility and wall-to-wall flow on
color analysis. The
second left brachial vein shows absent compressibility and no
flow on color Doppler analysis. The cephalic vein is not
identified, though note is made of subcutaneous edema in the
expected region of the cephalic vein.
IMPRESSION: Left deep venous thrombosis involving the internal
jugular and brachial veins. Cephalic vein not identified.
.
.
EKG: Old t wave inversion in I and AVL
Brief Hospital Course:
77 year old woman who presented from [**Hospital3 **] for high INR
(5.3), HCT of 16.9, and no clear source of bleeding. The HCT
drop was from 25.7 to 16.9 in 2 days. She had no clear GI
bleeding. She had Guaiac negative stools in ED and in ICU. She
had recent laparotomy for perforation of duodenal ulcer at OSH
on [**2130-3-10**] so initially there was concern for possible
intraabdominal bleed. CT torso showed no evidence of internal
bleeding. Folate and B12 levels were normal. With normal
bilirubin, elevated hapto and only marginally elevated LDH
hemolysis seemed unlikely. Both ASA and coumadin were held. She
was admitted to the ICU for close observation, although her
hemodynamics were stable. She received 4 units of blood and 3
units of FFP. HCT increased appropriately and have remained
stable in the mid 30s. The exact cause of her presenting anemia
remained unclear. She did not undergo endoscopy. She received
one dose of coumadin 2.5 mg on [**4-2**] while in the ICU for history
of DVT. Subsequently her INR continued to rise significantly to
6.8. We sought the input of our hematology consult service. They
felt that the increase was due to coumadin, given recent
antibiotics use and poor nutritional status. In regards to her
upper extremity DVT, it was line-associated and has been
anticoagulated since then. Hematology advised that the
risk/benefit ratio favors discontinuing anticoagulation. She had
persistent pyuria in urine and several cultures showed yeast. Of
note, several days prior to admission she was initiated on cipro
for pyuria, although this proved not to be a bacterial
infection. This admission our ICU initiated fluconazole, but we
have since discontinued it due to above INR issues. She remained
asymptomatic. The patient had stage IV renal failure and
hyperkalemia from Losartan. Losartan was discontinued and
received several doses of kayexalate. Her discharge was delayed
because of hyperkalemia and her discharge potassium was 5.0. Her
home lasix was held at nursing facility but we increased the
dose as she had severe edema up to the chest wall and
hypoalbuminemia (anasarca; bilateral pleural efusions and
ascites). Because of her low GFR, lower doses of Lasix are
usually ineffective. We found no portal hypertesnion or
thrombosis on ultrasound and no liver cirrhosis. The patient has
a recent history of pancreatitis/pancreatic head enlargement on
ultrasound from prior admission 1/[**2130**]. Ultrasound mentions
multiple pancreatic cystic structures which may be related to
pseudocyst formation and/or previously characterized side branch
IPMN. Given these findings we have recommended GI follow-up in
clinic. Her PCP was also notified of these findings although she
has been unable to see him lately because of her stays in rehab.
We also diagnosed her with stage III decubitus ulcer upon
admission. She had no clinical wound infection. We stopped the
Losartan, Clonidine and Hydralazine and increased the Metoprolol
and she remained normotensive. Her avarage in hospital BP in
fact was low (124/76). If she becomes hypertensive hydralazine
50 mg Tablet every 8 hours can be restarted. She was DNR/DNI but
family needs to consider comfort measures only. She was
disharged back to [**Hospital3 **] but to a different floor per
family request. PCP can reconsider starting aspirin only.
Potassium should be monitored with her low potassium diet.
Medications on Admission:
-amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
-metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO q 8 hrs ??????? daily
-hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
-omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO daily
-acetaminophen 650mg q6hrs prn
- sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID
-humalog sliding scale
-tylenol 650mg every q 6 hrs
-aspirin 81mg daily
-Wellbutrin 100mg daily
-clonidine 0.2 mg/24 hr 1 patch QFRI
-levothyroxine 50 mcg po daily
-hydralazine 50mg q 8hrs
-warfarin being held
-lasix 40mg daily (holding since [**3-29**])
-losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
-prednisone 5 mg daily
.
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
3. bupropion HCl 100 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO DAILY (Daily).
4. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO QID (4 times a day) as needed for GI
upset.
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO three
times a day.
10. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**2-5**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
12. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
13. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
coolige house
Discharge Diagnosis:
coagulopathy from coumadin
anemia, blood loss?
deep venous thrombosis of upper extremity
Type II DM without treatment
pancreatic lesion
stage III decubitus ulcer
hyperkalemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with anemia (low red blood count) and abnormal
labs that showed your blood was too thin. The exact cause is not
clear, but we do believe that you are very sensitive to blood
thinning medicines. You received several transfusions in the
ICU, where you stayed for close monitoring. A CT scan showed no
sign of bleeding in your abdomen, and your stool was also
negative for blood.
The blood thinner (that you were previously taking for the clot
in your arm) has been stopped.
A review of your prior imaging studies from your [**2130-2-4**]
admission for pancreatitis also showed an ultrasound with some
cystic changes and enlargement in an area of your pancreas. You
should see a GI specialist to further evaluate and follow-up
these findings.
Your potassium was elevated and you were placed on a low
potassium diet. Some of your BP medications were stopped
including a medication that elevates the potassium level
(losartan). Please follow up with your PCP in regards to your
potassium, Losartan, need for Aspirin, and anemia
Followup Instructions:
The patient needs GI follow-up for pancreatic changes with
possible IPMN (tumor) mentioned on ultrasound [**2-/2130**] if family
and patient want to pursue it further.
Department: RHEUMATOLOGY
When: THURSDAY [**2130-5-11**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14465**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 2449, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8315
} | Medical Text: Admission Date: [**2114-5-7**] Discharge Date: [**2114-5-11**]
Date of Birth: [**2062-4-28**] Sex: M
Service: ENT
ADMISSION DIAGNOSIS: Tongue cancer.
DISCHARGE DIAGNOSIS: Tongue cancer.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 32496**] is a 52 year old
male with a history of squamous cell carcinoma of the right
tongue who underwent a tracheostomy and placement of
brachytherapy catheters on [**2114-5-7**]. He has plans to
undergo chemotherapy in the future. He underwent
brachytherapy during this hospital stay.
PAST MEDICAL HISTORY: Hypertension, cardiomyopathy with
diastolic dysfunction, home oxygen, pulmonary hypertension,
mitral and tricuspid valve regurgitation, chronic renal
insufficiency with a baseline creatinine of 2.5.
MEDICATIONS AT HOME: Norvasc 10 mg po qd, Lasix 40 mg po
bid, Coreg 12.5 mg po bid and lisinopril 5 mg po qd.
HOSPITAL COURSE: Mr. [**Known lastname 32496**] [**Last Name (Titles) 8337**] his operative
procedure well. For the full details of this procedure,
please see the dictated operative report. He spent two nights
in the ICU and then was transferred to the Step-down Unit. He
had brachytherapy in house. By system, his hospital course is
as follows:
Neuro: His pain was well controlled on subcutaneous
morphine. He is going to be transitioned to Roxicet elixir.
His mental status has been within normal limits.
Cardiovascular: His postoperative EKG was normal. He has
similar right bundle branch block to his previous EKGs. He
was on continuous monitoring. He had some infrequent PVCs.
His electrolytes were repleted prn. He was hemodynamically
stable throughout his hospital stay.
Respiratory: He was maintained on continuous O2 sat
monitoring. His trach was down-sized to a Portex No. 6
nonfenestrated, noncuffed trach on postoperative Day 4 before
discharge. He [**Last Name (Titles) 8337**] this procedure well. He is to have
trach care prn and to be taught to care for his trach. He
will likely be decannulated in one week. He is breathing
comfortably with his new trach.
GI: He was tolerating Nepro tube feeds at 45 with 30 gm of
protein qd. He was seen by Nutrition and this was determined
to be his goal. He was also seen by Speech and Swallow. He
had a video swallow on [**2114-5-11**] which showed a very small
amount of aspiration which was easily expelled with cough.
His PO diet was recommended to be thin liquids with
advancement to puree diet. If he tolerates this, he can
advance to soft solids only if he wears his dentures. With
every bite, he must do swallow, cough, swallow. His abdomen
is soft, nontender and nondistended. His G tube is in place.
GU: Mr. [**Known lastname 32496**] is making good urine. His creatinine is his
baseline 2.3-2.5. His electrolytes were repleted prn.
ID: He was kept on Ancef and Flagyl while brachytherapy
catheters were in place. These catheters were removed on
postoperative Day 3. He is currently on no antibiotics. His
white blood cell count is normal and he is afebrile.
Oncology: He is to follow up with his radiation oncologist.
He has an appointment. He did get brachytherapy treatment
while in house. The brachytherapy catheters were removed, as
mentioned, on postoperative Day 3.
PT: [**Name (NI) **] was seen by PT and OT while in house and he will
continue while in Rehab.
DISPOSITION: Mr. [**Known lastname 32496**] was discharged to Rehab in stable
condition on [**2114-5-11**].
DISCHARGE MEDICATIONS: Amlodipine 5 mg and 10 mg po qd,
carvedilol 12.5 mg po bid, lisinopril 5 mg po qd,
lansoprazole 30 mg po qd, furosemide 40 mg po bid, subcu
heparin 5000 units [**Hospital1 **] and Roxicet prn for pain.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 25181**]
Dictated By:[**Last Name (NamePattern1) 54593**]
MEDQUIST36
D: [**2114-5-11**] 20:48:15
T: [**2114-5-11**] 22:54:57
Job#: [**Job Number **]
ICD9 Codes: 4254, 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8316
} | Medical Text: Admission Date: [**2151-11-21**] Discharge Date: [**2151-12-2**]
Date of Birth: [**2084-11-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ambien
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
s/p redo sternotomy OPCABGx1 (SVG to PDA) on [**11-22**], MVR (#29
Medtroinc Mosaic), TV repair (#32 CE ring) via right thoracotomy
[**11-23**]
History of Present Illness:
Mr. [**Known firstname **] [**Known lastname **] is a 67 year old gentleman who has had
multiple recent hospital admissions for congestive heart
failure. A subsequent work-up revealed severe mitral
regurgitation, severe tricuspid regurgitation, and 90% occlusion
of left main. He was therefore recommended for surgical
correction of his cardiac pathologies.
Past Medical History:
- CHF, EF 20%
- Hyperlipidemia
- Hypertension
- Severe Mitral valve disease.
- Severe Tricuspid valve disease.
- Chronic renal failure.
- Idiopathic thrombocytopenic purpura (ITP).
- Cholestatic jaundice.
- Pancreatic cysts s/p biopsy.
- Renal artery stenosis.
- Bilateral EEA approximately [**2147**].
- Coronary artery bypass graft (CABG) x 5.
- Pulmonary hypertension.
- Left inguinal hernia repair in [**2149**].
- Knee surgery.
- Cardiomyopathy.
- Atrial fibrillation.
- Congestive heart failure.
- Hypothyroidism.
Social History:
He used to drink alcohol excessively, but had his last drink
several months ago. He smoked a half pack to one pack per day
for 15 years until he quit in [**2113**]. He lives with his wife.
.
Family History:
His mother died of a heart attack. His brother died of a heart
attack at age 33. His father died with [**Name (NI) 2481**] disease. Pt's
maternal side of the family has marked hyperlipidemia. He has no
known family history of cancer.
Physical Exam:
On physical exam Mr. [**Name13 (STitle) **] was found to be awake, alert, and
oriented. On auscultation of his lungs, he was found to have
scattered rales. His heart was of regular rate and rhythm. His
sternum was stable and his incision was clean, dry, and intact
with no erythema or drainage. His abdomen was soft, non-tender,
and non-distended. His extremities were warm with no edema.
His lower extremity harvest site was clean and dry.
Pertinent Results:
[**2151-12-2**] 07:40AM BLOOD WBC-8.3# RBC-3.82* Hgb-11.4* Hct-36.5*#
MCV-96 MCH-29.9 MCHC-31.3 RDW-17.9* Plt Ct-195#
[**2151-12-2**] 07:40AM BLOOD Plt Ct-195#
[**2151-12-2**] 07:40AM BLOOD Glucose-76 UreaN-48* Creat-1.8* Na-147*
K-4.1 Cl-109* HCO3-28 AnGap-14
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] is a 67 year old gentleman who has had multiple
recent hospital admissions for congestive heart failure. A
subsequent work-up revealed severe mitral regurgitation, severe
tricuspid regurgitation, and 90% occlusion of left main. He was
therefore recommended for surgical correction of his cardiac
pathologies.
He was taken to the operating room on [**2151-11-22**] with [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] for a redo sternotomy and off pump CABGx1. He
tolerated the procedure well and transferred to the surgical
intensive care unit in critical but stable condition. On the
following day on [**2151-11-23**] he underwent the second stage of his
intervention, a mirtal valvereplacement with a #29 [**Company 1543**]
mosaic valve and a tricuspid valve repair with a 32 CE ring via
a right thoracotomy. He tolerated this procedure well and was
transferred in critcal but stable condition to the surgical
intensive care unit.
He was extubated on post-operative day 7 after multiple failed
attempts. He was weaned from his pressors, his chest tubes were
removed. His LFTs were found to be elevated early in his
post-operative course, but these lab values were trending toward
normal by the end of his stay.
By post-operative day 9 he was transferred to the step down
floor. His epicardial wires were removed. Mr. [**Known lastname **] was
ready for discharge to a rehab by post-operative day 10.
Medications on Admission:
protonix 40
toprol XL 25
lisinopril 2.5
lasix 80 TID
digoxin 0.125
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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 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:*0*
6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
Disp:*qs qs* Refills:*0*
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs qs* Refills:*0*
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed.
Disp:*qs ML(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 12414**] Healthcare Center - [**Location (un) 12415**]
Discharge Diagnosis:
CAD, severe mitral regurgitation, severe tricuspid regurgitation
s/p redo sternotomy OPCABGx1, MVR, TV repair
congestive heart failure
hypercholesterol
hypertension
chronic renal failure
ITP
pancreatic cysts
renal artery stenosis
s/p CEA
s/p CABG1984
pulmonary hypertension
Discharge Condition:
good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, lotions, or powders on wounds.
Followup Instructions:
Please see your primary care physician and your cardiologist in
[**1-26**] weeks.
Please see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**3-28**] weeks. ([**Telephone/Fax (1) 11763**].
Call to make appointments.
Provider: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2151-12-22**] 3:00
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2152-3-7**]
10:20
Completed by:[**2151-12-2**]
ICD9 Codes: 4240, 5849, 4254, 5185, 9971, 4280, 5859, 2720, 2449, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8317
} | Medical Text: Admission Date: [**2180-10-20**] Discharge Date: [**2180-12-19**]
Date of Birth: [**2162-10-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Lumbar puncture
Stereotactic brain biopsy
Intubation and mechanical ventilation
LIJ central line placement
History of Present Illness:
[**Known firstname **] is a 17 yo right handed girl with childhood onset
relapsing MS referred here for urgent LP per IR from Dr. [**Name (NI) 58349**] clinic for positional but persistent HA without visual
disturbance concerning for increased ICP from infectious process
or pseudotumor cerebri.
.
Per records, given that patient refused to give hx, patient
reported persistent, positional HA to Dr. [**Last Name (STitle) 8760**] on [**10-10**] that
interfered with sleep. She denied any nausea/vomiting or visual
disturbance and was still on prednisone taper 10mg daily. The
steroids were stopped per Dr. [**Last Name (STitle) 8760**] on [**10-10**] then patient appears
to have presented to [**Hospital1 **] on [**10-12**] with 2 seizures (R arm
extension then head thrown back with followed by generalized
convulsion for ~ 1 minute) with EEG showing mainly L sided
discharges. Because she refused to be admitted, patient was
started on Dilantin then discharged with prescription which was
promptly thrown away per Mom. Open MRI at outside facility was
arranged per Dr. [**Last Name (STitle) 10208**] but patient aborted the study in 5
minutes due to anxiety. With some police and legal assistance,
patient was admitted to [**Hospital1 **] and had MRI under sedation on
[**10-17**] which showed a new T2/FLAIR lesion in the R superior-lateral
pons near trigeminal root entry and also question of enhancement
of left meninges. Although ID was consulted, patient was
clinically stable, hence further work-up was deferred and
patient was discharged with Keppra to be increased from 500 to
1000mg at bedtime in 1 week.
.
Given the hx of questions meningeal enhancement and persistent
positional headache in a patient with recent high dose steroids,
infectious process was suspected hence Dr. [**Last Name (STitle) 8760**] recommended
urgent LP under IR to rule out increased ICP and CNS infection.
.
As for her prior demyelinating disorder, patient developed
bilateral leg weakness followed by R eye vision loss after 2
weeks of URI symptoms and high fever back in [**5-13**]. Upon
admission to [**Hospital1 **], she was diagnosed with ADEM and treated
with IVMP for 5 days. She improved significantly but was
readmitted on [**6-12**] after recurrence of vision loss in R eye and
repeat imaging showed new lesions hence had another 5 day course
of IVMP. Then in [**7-13**], she presented with vague visual
complaints and found to have LUQ field cut and MRI showing
lesions in bilateral occipital lobes with brainstem lesions
hence received another 5 days of IVMP. In [**9-12**], she was
readmitted for vision loss and APD that recovered with another
course of IVMP. Then in [**7-18**], patient again had decreased
vision with pain in R eye hence received 3 days of IVMP with
oral steroid taper. She was also treated with Avonex from [**9-12**]
through [**2-16**] as weekly injections but discontinued due to
depression.
.
She had earlier been evaluated at [**Hospital3 14659**] as well where Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 58350**] believed that she has an NMO spectrum disorder
although Ab negative with absent myelopathy and good visual
recovery. He also advised considering prolonged steroid
treatment of 9 months co-administered with either CellCept or
Imuran.
.
Patient on admission was very upset that she had been told to
lay flat for 1 hr after LP hence would like to be discharged.
However, upon reassuring that she will be moved to a more
comfortable bed soon and that she needs treatment until
infections has been rule out, she was willing to stay, although
she was only semi-cooperative with the exam.
Past Medical History:
1. Childhood onset relapsing remitting MS [**First Name (Titles) **] [**Last Name (Titles) 41770**]-negative
neuromyelitis optica (NMO)
2. HTN
3. hx of myringostomy
4. s/p tonsillectomy
Social History:
Family from [**Country 15800**] but patient born and raised in the United
States. Lives at home with family. She was newly a freshman at
[**University/College 5130**] before becoming ill.
Family History:
No FH of MS or other neurological disease.
Physical Exam:
Exam:
Gen: Lying in bed supine, NAD
HEENT: NC/AT, moist oral mucosa
Neck: Normal lateral ROM
CV: RRR, no murmurs/gallops/rubs
Lung: Clear anteriorly
Abd: +BS, soft, nontender
Ext: No edema
Neurologic examination:
Mental status: Awake and alert, mostly cooperative with exam,
normal
affect. Oriented to person, place, and date. Speech is fluent
with normal comprehension. No dysarthria. No right left
confusion.
Cranial Nerves:
II: Pupils equally round and reactive but afferent pupillary
defect on R. Blinks to visual threat bilaterally.
III, IV & VI: Extraocular movements intact bilaterally, no
nystagmus.
V: Sensation intact to LT.
VII: Facial movement symmetric.
VIII: Hearing intact to finger rub bilaterally.
X: Palate elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline, movements intact
Motor:
Normal bulk and tone bilaterally. No observed myoclonus or
tremor. No asterixis or pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch and cold throughout.
Reflexes:
+2 and symmetric throughout.
Toes downgoing bilaterally
Coordination: FTN, FTF and RAMs normal.
Gait: Deferred since post LP and was told to be supine for > 1
hr.
Pertinent Results:
>>Labs on Admission<<
[**2180-10-20**] WBC-9.9 RBC-4.38 Hgb-12.7 Hct-39.9 MCV-91 MCH-29.0
MCHC-31.8
RDW-14.7 Plt Ct-339
[**2180-10-20**] Neuts-69.5 Lymphs-22.9 Monos-5.8 Eos-0.8 Baso-1.0
[**2180-10-20**] Glucose-142* UreaN-7 Creat-0.9 Na-139 K-3.9 Cl-103
HCO3-24
[**2180-10-23**] Calcium-9.5 Phos-4.0 Mg-2.6*
.
>>General Chemistries<<
VitB12-982 Folate-14.3
Ammonia-32
TSH-0.96
HIV-negative
CK- 3 Trop- 0.01
.
>>Immunology/Rheumatology<<
[**Doctor First Name **]-negative
Anti-TPO- <10
IgA-96
ACA IgG-3.1 ACA IgM-5.4
ESR-30 CRP-43.9 [**2180-11-18**]
ESR-90 CRP-260 [**2180-11-27**]
.
Anti-Ma 1&2
[**Location (un) **] 3
Anti-NMDA
.
>>Miscellaneous Chemistries <<
BETA-2-GLYCOPROTEIN 1 ANTIBODIES-NEGATIVE
Bartonella hensalae/[**Last Name (un) 7570**]-NEGATIVE
HERPES 6-NEGATIVE
ARYLSULFATASE A-NEGATIVE
ANAPLASMA PHAGOCYTOPHILUM-NEGATIVE
West Nile Virus-NEGATIVE
EASTERN EQUINE ENCEPHALITIS-NEGATIVE
RIBOSOMAL P [**Last Name (un) **]-NEGATIVE
PURKINJE CELL (YO) ANTIBODIES-NEGATIVE
NEURONAL NUCLEAR ([**Doctor Last Name **]) ANTIBODIES-NEGATIVE
GLUTAMIC ACID DECARBOXYLASE-NEGATIVE
VGKC [**Doctor Last Name **]-NEGATIVE
PARANEOPLASTIC PANEL-pending
RABIES-pending
.
>>CSF Studies<<
WBC RBC Polys Lymphs Monos Mesothe
TotProt GLU
[**2180-11-10**] 12:10PM 71 3* 0 98 2
18
[**2180-11-10**] 12:10PM 14 148 0 90 10
[**2180-10-31**] 11:30AM [**Telephone/Fax (1) 58351**] 2 96 1 1
61 62
[**2180-10-31**] 11:30AM [**Numeric Identifier 58352**]5 30 0
[**2180-10-20**] 06:30PM 486 740 24 66 10
31 60
[**2180-10-20**] 06:30PM [**Telephone/Fax (1) 58353**]3 5
.
EBV-NEGATIVE
HERPES 6-NEGATIVE HERPES SIMPLEX
VIRUS-NEGATIVE
[**Male First Name (un) 2326**] VIRUS-NEGATIVE LACTATE- 8
LYME-NEGATIVE TB-NEGATIVE
VARICELLA-NEGATIVE WEST NILE VIRUS-Negative
Bartonella-NEGATIVE 143-3 (prion disease)-
NEGATIVE
EEE- NEGATIVE
.
>>Other<<
HISTOPLASMA ANTIGEN-NEGATIVE
CSF CYTOLOGY-NEGATIVE FOR MALIGNANT CELLS ([**2180-11-10**])
.
>>Microbiology<<
BLOOD SMEAR-NEGATIVE FOR INTRACELLULAR/EXTRACELLULAR PARASITES
Blood Culture, Routine (Final [**2180-11-14**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
Blood Culture, Routine (Final [**2180-11-13**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
.
MRSA SCREEN (Final [**2180-11-16**]):No MRSA isolated.
.
URINE CULTURES(x8)-NO GROWTH
.
TOXOPLASMA IgG [**Month/Day/Year **] (Final [**2180-11-3**]):
NEGATIVE FOR TOXOPLASMA IgG [**Month/Day/Year **] BY EIA.
TOXOPLASMA IgM [**Month/Day/Year **] (Final [**2180-11-3**]):
NEGATIVE FOR TOXOPLASMA IgM [**Month/Day/Year **] BY EIA.
CMV IgG [**Month/Day/Year **] (Final [**2180-11-7**]):
NEGATIVE FOR CMV IgG [**Month/Day/Year **] BY EIA.
CMV IgM [**Month/Day/Year **] (Final [**2180-11-7**]):
NEGATIVE FOR CMV IgM [**Month/Day/Year **] BY EIA.
CRYPTOCOCCAL ANTIGEN(Final [**2180-11-10**]):
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
LYME SEROLOGY (Final [**2180-11-6**]):
NO [**Month/Day/Year **] TO B. BURGDORFERI DETECTED BY EIA.
.
CSF;SPINAL FLUID
GRAM STAIN (Final [**2180-10-20**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2180-10-23**]): NO GROWTH.
VIRAL CULTURE (Final [**2180-11-20**]): NO VIRUS ISOLATED.
.
[**2180-11-10**] 12:10 pm CSF;SPINAL FLUID Source: LP.
QUANTITY NOT SUFFICIENT FOR ACID FAST SMEAR (MAW). PENDING
.
>>IMAGING<<
MRI/MRV Head [**2180-10-24**]:
1. Motion-limited study with particularly limited postcontrast
images.
2. Confluent symmetric high T2 signal in the posterior body and
splenium of the corpus callosum, without mass effect or obvious
contrast enhancement. Smaller T2 hyperintensities in the
supratentorial white matter and in the pons. While nonspecific,
these findings are compatible with demyelination, which could be
due to multiple sclerosis, Lyme disease, sarcoidosis, or other
etiologies. Vasculitis could also be considered.
3. Nonvisualization of flow in the right transverse sinus could
be related to its nondominant status and motion artifact. If
there is a persistent clinical concern for thrombosis of the
right transverse sinus, then further evaluation could be
performed by a CT venogram.
.
EEG [**2180-10-22**]: This is an abnormal extended routine EEG due to
persistent left focal theta/delta slowing and sharp transients
phase reversing in the right parasagittal central regions. These
findings suggest a deep abnormality affecting projections to the
left hemisphere and a possible focus of cortical irritability in
the right central parasagittal region. There were no
electrographic seizures in the record.
.
EEG [**2180-10-26**]: This EEG monitoring captured 13 pushbutton
activations for clinical events that did not have any EEG
correlate of epileptiform activity. There was no ictal or
interictal epileptiform activity. The background activity was
slow some of the time suggestive of a mild encephalopathy with
slower activity seen sometimes more over the left than the right
hemisphere suggestive of a deep subcortical dysfunction more in
the left than the right hemisphere.
.
EEG [**2180-10-27**]: This telemetry captured 26 pushbutton activations
for several seconds of repetitively bending forward and
backwards when sitting in a chair or laying down in bed with no
epileptiform activity seen during these events. There was no
ictal or interictal epileptiform activity seen during this
recording. The background activity was diffusely slow, more so
over the left than the right hemisphere. In addition, the
background activity was not well-sustained bilaterally.
.
EEG [**2180-10-28**]: This telemetry captured 42 pushbutton activations
for different events of shaking, unresponsiveness, and blinking.
Most of them were not correlated with any change in the
background behavior; however, a few of them were correlated with
some more rhythmic delta activity seen predominantly over the
left fronto-temporal area. Similar rhythmic activity was also
sometimes captured by the automatic seizure detection programs,
not always with a clear clinical correlate. The background
activity was slow with slower activity seen over the left than
the right hemisphere.
.
EEG [**2180-10-29**]: This telemetry captured 20 pushbutton activations
for different events of agitation and shaking with no clear EEG
correlate. The background activity was slow with slower activity
seen over the left than the right hemisphere. In addition, there
were runs of more rhythmic 2.5 Hz activity seen predominantly
over the left fronto-temporal area and sometimes with no
clinical correlate. This rhythmic activity could represent
ongoing electrographic seizures.
.
EEG [**2180-10-30**]: This telemetry captured 10 pushbutton activations
for different episodes of posturing, agitation, shaking, and
blinking with no clear EEG correlate; however, with the EEG,
there were several runs of rhythmic delta activity seen
predominantly in the left fronto-temporal area lasting for up to
20 seconds and suggestive of electrographic seizure activity.
The background activity was slow with slower frequencies seen
over the left than right hemisphere.
.
EEF [**2180-11-9**]: This telemetry captured six pushbuttons as
described above. During portions of the routine, seizure and
pushbutton files, there are periods of rhythmic delta activity,
left frontal greater than right, that appear to evolve and are
suggestive of possible epileptiform activity. On at least one
occasion, this occurred following an episode of facial
twitching. Although there are no clear spike wave discharges on
this recording, the periods of rhythmic left frontal predominant
delta activity are suspicious for epileptiform discharges.
Overall, the background is very disorganized, consisting of a
[**3-14**] Hz delta activity with slowing more prominent on the left
hemisphere.
.
EEG [**2180-11-29**]:
IMPRESSION: This is an abnormal routine EEG due to slowing and
disorganization of the background rhythm with delta slowing in
the left temporal region and asymmetry of spindle activity which
is more pronounced in the left parasagittal to central regions.
These findings are consistent with a severe encephalopathy with
possible subcortical dysfunction in the left temporal region.
The asymmetry of the spindle activity may reflect a breach
artifact in the left parasagittal to central regions. There were
no electrographic seizures noted during this recording.
.
EEG [**2180-12-18**]:
FINDINGS:
ABNORMALITY #1: There was excessive focal slowing in the [**5-15**] Hz
range in the left fronto-central region. The background in this
area was also very irregular and mildly sharp.
ABNORMALITY #2: There were a few bursts of bifrontal paroxysmal
theta with sharp features.
BACKGROUND: Appeared to represent drowsiness in early sleep.
There was no normal waking background activity.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Produced no activation of the
record.
SLEEP: The patient appeared to remain drowsy or in early sleep
throughout most of the recording.
CARDIAC MONITOR: Showed a generally regular tachycardia with a
rate of approximately 110.
IMPRESSION: Abnormal EEG, largely in drowsiness, due to the left
frontal theta slowing and due to the infrequent bursts of
bifrontal theta with some sharp features. The first abnormality
suggests a focal dysfunction in the left anterior quadrant, but
it cannot specify the etiology. The irregular sharp background
in the same area suggests the presence of a skull defect at some
point. The bursts of focal slowing were paroxysmal and had some
sharp features raising concern for epileptogenesis, but there
were no definitely epileptiform abnormalities in this recording.
There were no electrographic seizures. A tachycardia was noted.
.
CTA CHEST W&W/O C&RECON [**2180-11-3**]: Widespread bilateral pulmonary
emboli. Mild dilatation of the main pulmonary artery is
compatible with elevated pulmonary arterial pressure.
.
MRI Spine [**2180-11-14**]:
1. No definite evidence for intramedullary abnormal enhancement
or abnormal T2 hyperintensity to suggest multiple sclerosis
plaques.
2. Left psoas muscles and right posterior paraspinal muscle
fluid-fluid levels, likely represent intramuscular hematomas
with surrounding inflammation of the muscles. In presence of
signs of infection, hemorrhagic abcesses cannot be excluded.
3. New large cystic lesion within the perisplenic region,
incompletely characterized on this examination. This can
represent the stomach, however, cystic lesion other than this
cannot be excluded. CT scan of the abdomen is recommended.
4. New right upper lobe opacification. Differential diagnostic
considerations would include right upper lobe atelectasis or
pneumonia. Given the acuity of this lesion, mass lesion is
unlikely. Right basilar lower lobe segmental dependent
atelectasis versus aspiration pneumonia.CT
.
CT Abdomen/Pelvis ([**2180-11-16**]): Cystic structure as seen on MR
examination from [**2180-3-17**] can be correlated to the fundus of the
stomach. Left psoas hematoma with small focus of active
extravasation. Hemorrhage tracking down left paracolic gutter
with small amount of pelvic hematoma. No discrete fluid
collections that would be concerning for abscess
formation.
.
CT Head ([**2180-11-17**]): No acute hemorrhage. Diffuse hypoattenuation
of the subcortical white matter, in particular posterior to the
lateral ventricles, consistent with overlying disease seen on
the prior MRI study. Slightly prominent ventricles for patient
age, unchanged from MRI exam
.
CT HEAD ([**2180-11-23**]) s/p biopsy:
FINDINGS: Left-sided craniotomy defect subcutaneous and small
amount of pneumocephalus is new since prior exam. No large
intracranial hemorrhage is seen. There is no mass effect or
[**Doctor Last Name 352**]-white matter differentiation, abnormality. Left inferior
basal ganglia sub-cm hypodensity likely represents a dilated
Virchow -[**Doctor First Name **] space. The visualized ventricles and extra-axial
spaces are within normal limits. Pneumocephalus in the left
frontoparietal region is seen, this likely represents the site
of biopsy. There is no fracture.
IMPRESSION: Pneumocephalus and post-surgical changes related to
recent biopsy. No large intracranial hemorrhage.
.
UNILAT UP EXT VEINS US LEFT ([**2180-11-28**]):
HISTORY: Left upper extremity swelling with PICC line in place.
FINDINGS: There is non-compressibility as well as echogenic
thrombus filling the left axillary vein and both brachial veins.
Thrombus surrounds the PICC line in one of the brachial veins.
There is normal flow and waveforms in the bilateral subclavian
veins. The left internal jugular, basilic, and cephalic veins
are patent.
IMPRESSION: Thrombosis of the left axillary and both left
brachial veins.
.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 58354**] is an 18 year old female with MS/NMO spectrum who
initially presented with headache, who then had a prolonged
hospitalization with evidence of severe encephalitis, as
described in detail below.
LEUKOENCEPHALITIS: When initially being evaluated for the
headache, the patient underwent a lumbar puncture (see results
section). She was started on a course of acyclovir which was
discontinued when CSF HSV was negative. She underwent MRI/MRV
of the head which showed demyelination but did not demonstrate
venous sinus thrombosis. There was also concern that her
presentation could have been consistent with seizures. On
admission she was continued on Keppra and was also started on
Zonegran. Keppra was eventually weaned due to concerns that it
could be exacerbating the behavioral problems. She had several
EEGs which showed non specific delta slowing that was not
clearly epileptic. MRI showed evidence of demyelination, as
above.
.
Patient became inceasingly non-verbal, disinhibited, and
disoriented over the course of her hospitalization. A host of
serum and CSF labs were obtained evaluating for various
infectious, immunologic, paraneoplastic,and rheumatologic
sources of her condition, however, work up was pan-negative(see
results section).
.
LPs showed a lymphocytic predominance but no organisms were ever
isolated. Dilantin ([**2180-10-31**]) was added to the zonisamide for
question of seizure and worsening encephalopathy. ID was
consulted [**11-1**] and recommended WNV, EEE, Cryptococcal, Toxo,
Lyme Ehrlichiosis, Bartenella,histoplasma, HH6 and CSF culture
which were negative (see results). HIV serum [**Month/Year (2) 41770**] test was
negative. Patient began to have stereotyped facial twiches and
UE stiffening that was concerning for seizure although this was
never clear. She was empirically started on solumedrol but her
metal status continued to decline. She became non verbal and not
responsive to noxious stimulus. But, she continued to
intermittently developed facial twiching and UE tremors
concerning for seizure. [**11-10**] Clonazepam started for rhythmic
delta slowing on EEG. It became unclear whether her worsening
mental status was related to her history of demyelinating
disorder or a new process. A brain biopsy was obtained on [**11-22**]
which showed leukoencephalitis but was otherwise negative.
Additional samples from the brain biopsy were sent to the [**Hospital1 **] for additional research. Serum was sent to the [**Last Name (un) 58355**] lab
at [**State 43840**] for examination for anti-NMDA
receptor antibodies, a paraneoplastic syndrome.
.
On [**12-1**] she showed dramatic improvement, and was much more
alert and interactive, talking in sentences. After having pulled
out her NG tube (below), she underwent a swallow evaluation and
was started on soft diet. She had waxing and [**Doctor Last Name 688**] levels of
alertness and interaction, but gradually advanced her diet and
became on average somewhat more interactive in the last week of
[**Month (only) 359**] and first week of [**Month (only) **]. Of note, by [**Month (only) **] she was
eating very vigorously and quickly, grabbing at food in front of
her.
.
In terms of her behavior, it was difficult to tell the various
contributions to the patient's behavior of encephalopathy, a
possible underlying psychiatric condition, or medications.
Overall, encephalopathy was likely the biggest contributor;
taken as a whole, her behaviors could be globally described as
consistent with frontal lobe dysfunction, with poor ability to
initiate positive behaviors other than grabbing at food, and
poor ability to process information, but a clear ability to
comprehend and respond to language as well as to react to
stimuli and defend herself against perceived threats. On mental
status exam she appeared confused and disoriented. Psychiatry
was consulted and followed her during the admission. Initially
the patient was placed on ativan/Zyprexa PRN. Standing Zyprexa
was then added. However, the patient developed progressively
worsening encephalopathy but with continued behavioral
outbursts.
.
At that point, ativan was discontinued and Zyprexa was given
PO/IM for behavioral outbursts. Keppra was also tapered off, as
above. She was put on dilantin for seizure control. In the
longer run, psychiatry suggested that Depakote or Trileptal
might be better choices for seizure medicines in the setting of
her behavioral issues, but a transition was deferred for
outpatient follow-up or rehab monitoring, with an imminent
transfer to rehab in mind. Psychiatry also suggested
anti-psychotics, but the patient's mother was quite concerned
about an earlier phase of the patient's admission in which she
felt that a decline in the patient's function was associated
with Zyprexa, and asked that the team not administer these
medications. Active discussion with the mother on this topic
continued, although the team did not insist on this given the
appearance of slow gradual albeit not dramatic improvement in
the patient's mental status. Pre-medication with small doses of
IM ativan was tried for physical therapy activities; it was
difficult to tell how helpful this was, and was undertaken with
the understanding of a risk of further disinhibition. Further
work on behavioral strategies will surely be an important part
of her rehabilitation stay.
.
MICU STAY s/p BRAIN BIOPSY:
She was transferred to the MICU s/p brain biopsy on [**11-23**] [**3-13**]
difficulty with extubation. Ms [**Known lastname 58354**] remained intubated
overnight, in the morning her sedation was weaned and ventilator
decreased to PSV intermittnatly. In the evening, she was
successfully extubated. She was monitored overnight and was
tachypnic and tachycardic, but breathing comfortably and
maintained O2 sats in the high 90s on RA. She was ultimately
transferred back to the floor where she remained thereafter.
.
TACHYCARDIA AND HYPERTENSION: Patient was admitted with a low
grade tachycardia 90s-100s and elevated BPs. She was eventually
found to have bilateral pulmonary emboli. An EKG, ECHO, and
cardiac enzymes were obtained, which were within normal limits.
Patient subsequently developed hypertensive episodes to 150-180
and captopril was started on [**11-7**] for BPS <130. She was started
on metoprolol later in [**Month (only) 359**]; then discontinued and replaced
with lisinopril to see if this would improve hypertension;
unfortunately, she then had systolic blood pressures to the 180s
and became tachycardic to the 120s-130s; metoprolol 25 [**Hospital1 **] was
restarted on [**12-13**] and blood pressures became mildly hypertensive
and heart rates came down to 100s-110s. Toradol was tried as a
trial to see if pain was driving these vital signs but seemed to
have little effect. A lovenox level was checked and was within
therapeutic range.
.
PULMONARY EMBOLISM: On [**11-2**], a PE-protocol CT scan was obtained
to evaluate for persistent tachycardia and tachypnea. She was
found to widespread bilateral PEs and heparin gtt was started.
She was eventually transitioned to lovenox. She had good
oxygenation though her tachycardia persisted. She had some
difficulty with extubation after her brain biopsy but was
extubated after an overnight stay in the MICU and soon after was
having room air oxygen saturations in the high 90s. Later in her
stay, a Factor Xa level was ordered to evaluate her lovenox
level and showed this was therapeutic as of [**12-14**].
.
BLOOD LOSS ANEMIA: Patient was found to have PEs as above. She
was initially started on heparin gtt (PTT goal 60-80). However
she was then found to have a psoas hematoma on [**11-16**] after noting
a precipitous decline in her hematocrit. She was tranfused and
hematocrit stabilized. She underwent an IR guided embolization
but imaging showed no active extravasation. Given tenous
coagulation status, an IVC filter was considered. At that time,
bilateral LENIs were negative so it was felt she was not benefit
from the procedure. Her heparin PTT goal was decreased 50-60.
Ultimately she was transitioned to therapeutic lovenox and her
hematocrit remained stable without further evidence of bleeding.
.
FEVER AND LEUKOCYTOSIS: On hospital day 12, patient begain
spiking temperatures to 101. ID was consulted as above (see
neuro section). She was also treated empirically for a UTI with
ceftriaxone [**11-6**] x3days. [**11-7**] she developed fever to 100.7 and a
luekocytosis WBC 17.0. She was started on vanco and zosyn
emperically. She was subsequently found to have a coag negative
staph bacteremia. She was treated for 2 weeks with vanco. Her
lines were pulled and replaced. She had a temperature of 100.6
on [**12-14**] and blood cultures were drawn, labs were drawn, and an
abdominal ultrasound was performed; this revealed...
.
IV ACCESS: Her initial PICC line was pulled in the setting of
her apparent line infection, and a central right IJ line was
placed. This was discontinued and ultimately replaced with a new
PICC on the left. This PICC was later found to have a left upper
extremity DVT associated with it and was pulled, and a RUE PICC
was placed. The patient then ultimately pulled this PICC line
out and it was not replaced, and in the last week of her
admission, medical care was given without IV access and labs
were drawn selectively and with the safety of phlebotomy and
nursing staff in mind.
.
CONSTIPATION: The patient developed constipation during the
hospitalization. This was treated with standing Senna/Colace,
as well as lactulose PRN. On [**11-2**] tube feeds were started
because of worsening encephalopathy and decreased PO intake. She
did not tolerate tube feeds and pulled out her NG tube. She had
some constipation in early [**Month (only) **] which was treated with
.
HYPERGLYCEMIA: Developed episodes of hyperglycemia while on tube
feed and Solumedrol, for which she received sliding scale
insulin. This was not necessary when she was not on steroids and
she had no evidence of diabetes.
.
Medications on Admission:
Keppra 500mg [**Hospital1 **]
Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for PRN constipation.
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain: do not give
for fever or fever symptoms until discussing with MD.
8. Phenytoin 125 mg/5 mL Suspension Sig: Four Hundred (400) mg
PO Q12H (every 12 hours): Please mix with breakfast and dinner
and time so that this is given with meals. Please follow-up
dilantin levels 1 day after admission, and notify MD for further
orders for following levels.
9. Enoxaparin 100 mg/mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours).
10. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
11. Ativan 2 mg/mL Solution Sig: One (1) mg Injection once
daily; avoid unless absolutely necessary as needed for
agitation.
12. Haldol 5 mg/mL Solution Sig: One (1) mg Injection once a day
as needed for agitation, psychosis: give for emergent issues,
consult w MD for further PRN orders as encephalopathy
resolves/changes.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Multiple sclerosis/NMO spectrum, with acute leukoencephalitis of
unclear origin
Pulmonary emboli
[**Name (NI) **] staph bacteremia
Discharge Condition:
Fair
Discharge Instructions:
Ms. [**Known lastname 58354**] had a lengthy hospital stay for a neurologic syndrome
shown by biopsy to be leukoencephalitis, but of unknown type.
Most studies are negative; a few further outside studies are
pending. Her mental status appears to be slowly improving but
further rehabilitation will be necessary. If she fails
rehabilitation, she should likely be readmitted to a neurology
service either at the [**Hospital1 18**] or another area academic tertiary
care hospital.
Followup Instructions:
NEUROLOGY FOLLOW-UP
.
She should have a follow-up appointment scheduled with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8760**] at [**Hospital1 18**] [([**Telephone/Fax (1) 11088**]] within two weeks of
being placed in rehab, to be scheduled for appropriate and safe
transport to and from rehabilitation; and then within 1-2 weeks
after discharge.
.
Lab results being followed up by [**Hospital1 18**] staff include NMDA
receptor antibodies ([**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]) and brain biopsy ([**Hospital3 14659**])
which are being evaluated by research laboratories. It is
possible if NMDA receptor is negative that an LP will need to be
performed. In her current state, this would need to be a planned
procedure likely under anesthesia, so it has been deferred given
that anesthesia has possibly contributed to over sedation and
encephalopathy post-procedure earlier in her course.
.
PRIMARY CARE
.
She should have a primary care appointment made for her to be
attended within one week of discharge from the rehabilitation
facility. She should make a transition from pediatric to adult
care.
.
To facilitate this transition, she should have an appointment
with Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**] in our [**Hospital 1944**] clinic as her
first post-discharge appointment. Dr. [**Last Name (STitle) 1520**] saw Ms. [**Known lastname 58354**] as
an inpatient. She is not a primary care physician but will be
able to organize and facilitate Ms. [**Known lastname 58356**] outpatient care
immediately post-discharge. If for some reason Dr. [**Last Name (STitle) 1520**] is
not available, please ask for another [**Hospital 1944**] clinic
appointment at [**Hospital3 **].
.
She should then have two follow-up appointments for primary
care. She should have a final pediatric appointment with Dr.
[**First Name (STitle) **] [**Name (STitle) **], [**Street Address(2) **], [**Hospital1 **],[**Numeric Identifier 58357**]; [**Telephone/Fax (1) 58358**]. She
should then have an adult internal medicine appointment shortly
thereafter with a physician at [**Hospital1 **]
Center's [**Hospital3 **]. Please bring Ms. [**Known lastname 58356**]
pediatric records from Dr.[**Name (NI) 58359**] office to this first
appointment. Physicians in this practice who currently have
availability include Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], who we recommend as an
excellent and caring physician. [**Name10 (NameIs) 2772**], if Dr. [**Last Name (STitle) **] does not
have an appointment available, she should have another primary
care physician assigned to her. Dr. [**Last Name (STitle) 1520**] can help with this
if it is not resolved to your satisfaction by the time of your
post-discharge appointment.
.
If there are problems with outpatient follow-up, please call Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4427**] at [**Telephone/Fax (1) 250**]. Because he may not be working at
[**Hospital3 **] after [**Month (only) **], he may not be the best primary
care physician for Ms. [**Known lastname 58354**] at this point, but because he knows
her from her inpatient stay, he can ensure that there is good
follow-up.
ICD9 Codes: 7907, 5990, 2851, 5119, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8318
} | Medical Text: Admission Date: [**2193-12-11**] Discharge Date: [**2193-12-14**]
Date of Birth: [**2113-3-25**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Upper GI Bleed
Major Surgical or Invasive Procedure:
EGD [**2193-12-12**] - Several ulcers and erosions in the duodenal bulb
History of Present Illness:
Mr [**Known lastname 110987**] is an 80 year old man who per the VA pharmacy is
on warfarin, digoxin and insulin as well as anti-hypertensives,
and who himself is a somewhat unclear medical historian, who
presents with a two day history of dark stools.
He says that on Tuesday he had a "major black bowel movement"
and was alarmed by this but did not know what to do so he drank
water and went to bed. He says that he then had a black stool
with additional red blood in the bowl today, and he called 911.
He requested to go to the VA which is where he gets all his care
but was brought to the [**Hospital1 18**] because it was closer.
On review of systems he said that he had gotten light-headed on
trying to get up from bed and was very weak and sometimes had to
call 911 for this; he appears to have had several falls. Denied
chest pain, palpitations, or shortness of breath; he said that
he sometimes has nausea which gets better when he drinks ice
water.
In the Emergency Department his initial vitals were 97.5,
114/70, 88, RR 14, 100% on room air. He was NG lavaged and by
the ED resident's report did have some blood on the return which
appeared to clear. He received 10 mg vitamin K and 2 units of
FFP. He got 2 L NS. He had some intermittent systolic blood
pressure in the 80s and 90s which responded well to IV fluid
boluses and his hemodynamics were otherwise stable in the ED by
report. He was also nauseous in the ED and received 2 doses of 4
mg IV zofran for this. He was transferred to the MICU for
further management.
In the MICU, he received no blood products. He underwent EGD,
which was remarkable for superficial ulcers in the duodenal
bulb. He did not require pressors or intubation. He was
transferred to the floor in stable condition.
Past Medical History:
Atrial Fibrillation
Hypertension
Diabetes
Hypercholesterolemia
Sleep Apnea, on CPAP
Congestive Heart Failure, unspecified
Social History:
Occupation: retired mechanical engineer; WWII veteran of Air
Force, was translator of Japanese
Drugs: denies
Tobacco: 30 py hx, quit 3 years ago
Alcohol: likes a bottle of wine a day, "But I keep running out
of wine"; denies any hx of withdrawals
Other: Lives alone, wife left him 3 years ago, not in [**Hospital 4382**]
Family History:
NC
Physical Exam:
Temp 35.5 ??????C HR: 83 BP: 108/44(58) RR: 16 SpO2: 100% in 2L
GENERAL: NAD
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, poor dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: irregularly irregular, S1/S2, 2/6 SEM at base
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
IMAGING:
=======
RADIOLOGY
CXR PA/LAT [**12-12**]: FINDINGS: The patient's condition required AP
positioning. There is a slight increase in density in the
lateral portion of the right lower lobe which may be partly due
to patient's gynecomastia and a small right pleural effusion.
Cardiomegaly is unchanged. Right-sided ICD leads in appropriate
position remain unchanged. IMPRESSION: No significant change in
the right lower lobe opacification. Part of this density may be
due to overlying gynecomastia.
.
EGD [**12-12**]: Several superficial non-bleeding ulcers and erosions
were found in the duodenal bulb. There was also duodenitis.
Ulcers appeared to be low risk for rebleeding, thus procedures
were not performed for hemostasis.
LABS:
====
[**2193-12-11**] 10:30AM BLOOD WBC-8.2 RBC-3.17* Hgb-9.4* Hct-27.5*
MCV-87 MCH-29.7 MCHC-34.3 RDW-15.2 Plt Ct-329
[**2193-12-12**] 02:37AM BLOOD WBC-7.9 RBC-2.84* Hgb-8.6* Hct-24.3*
MCV-85 MCH-30.3 MCHC-35.5* RDW-16.9* Plt Ct-269
[**2193-12-12**] 02:40PM BLOOD Hct-26.2*
[**2193-12-13**] 06:30AM BLOOD WBC-8.7 RBC-2.93* Hgb-8.8* Hct-25.4*
MCV-87 MCH-30.0 MCHC-34.5 RDW-16.7* Plt Ct-277
[**2193-12-13**] 05:45PM BLOOD Hct-25.5*
[**2193-12-14**] 11:51AM BLOOD Hct-27.9*
[**2193-12-11**] 10:30AM BLOOD PT-19.2* PTT-27.6 INR(PT)-1.8*
[**2193-12-11**] 04:39PM BLOOD PT-17.4* PTT-26.2 INR(PT)-1.6*
[**2193-12-12**] 02:37AM BLOOD PT-15.8* PTT-23.1 INR(PT)-1.4*
[**2193-12-13**] 06:30AM BLOOD PT-14.8* PTT-23.8 INR(PT)-1.3*
[**2193-12-14**] 07:45AM BLOOD PT-15.9* PTT-26.3 INR(PT)-1.4*
[**2193-12-11**] 10:30AM BLOOD Glucose-188* UreaN-65* Creat-1.5* Na-135
K-4.2 Cl-98 HCO3-23 AnGap-18
[**2193-12-11**] 04:39PM BLOOD Glucose-221* UreaN-59* Creat-1.3* Na-139
K-4.4 Cl-103 HCO3-26 AnGap-14
[**2193-12-12**] 02:37AM BLOOD Glucose-204* UreaN-50* Creat-1.2 Na-140
K-4.3 Cl-106 HCO3-26 AnGap-12
[**2193-12-13**] 06:30AM BLOOD Glucose-147* UreaN-31* Creat-1.1 Na-141
K-3.9 Cl-108 HCO3-26 AnGap-11
[**2193-12-14**] 07:45AM BLOOD Glucose-131* UreaN-28* Creat-1.2 Na-140
K-3.7 Cl-104 HCO3-27 AnGap-13
[**2193-12-11**] 04:39PM BLOOD ALT-14 AST-19 LD(LDH)-228 AlkPhos-46
Amylase-88 TotBili-0.6
[**2193-12-13**] 06:30AM BLOOD ALT-8 AST-17 AlkPhos-48 TotBili-0.8
[**2193-12-12**] 02:37AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.2
[**2193-12-13**] 06:30AM BLOOD Calcium-8.4 Phos-2.5* Mg-2.1
[**2193-12-14**] 07:45AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.8
[**2193-12-12**] 02:37AM BLOOD TSH-0.79
[**2193-12-11**] 04:39PM BLOOD Digoxin-0.7*
[**2193-12-11**] 04:39PM BLOOD Ethanol-NEG
MICRO:
=====
Blood Cultures: NGTD
RPR: negative
H. pylori: pending
Brief Hospital Course:
80 yo male with history of CHF, CAD, a-fib on Coumadin,
pacer/ICD placement with melena s/p EGD without obvious source.
Duodenitis and Gastritis: He was initially started on IV PPI
and received 2U pRBCs. He remained hemodynamically stable while
in-house with a stable Hct, and his EGD revealed evidence of
duodenal ulcerations. He remained on IV PPI for ~72 hours and
then transitioned to PO PPI [**Hospital1 **], that of which he will require
for 6 weeks. Also, given that this may be due to H. pylori,
serologies were sent and he was started empirically on triple
therapy may need to contact[**Name (NI) **] if the serologies are negative, as
he will not require treatment.
RLL CONSOLIDATION: Pt was initially started on levofloxacin in
unit for concern of pneumonia, although the lack of fevers,
cough or white count suggested the absence of infection and this
was held. He remained hemodynamically stable with this change.
CAD Native Vessle, Benign Hypertension, Atrial Fibrillation:
- CAD - His ASA and Coumadin were held initially but restarted
without complications prior to discharge. He was kept on his
statin throughout the hospitalization.
- Pump - Given the ongoing bleeding on admission his
anti-hypertensives were held and then restarted 24 hours after
the EGD. He tolerated this well.
- Rhythm - Pt has a-fib, on coumadin as an outpt. INR on
admission was 1.4. His Coumadin was restarted at 5mg, which is
change in his basline of 5 mg alternating daily with 7.5 mg, and
this will need to be followed in [**Hospital3 **]. The
INR also may be affected due to the initiation of antibiotics.
It is suggested that the patient go to the VA [**Hospital 3052**] on the Monday following discharge. He was maintained on
his home digoxin dosing throughout the hospitalization.
Obstructive SLEEP APNEA: Continued on CPAP
Diabetes type II Uncontrolled: Continue NPH 9 units [**Hospital1 **] +
humalog sliding scale
AlcoholDependence: The patient reports that he drinks a bottle
of wine a day and serum tox was negative on admission. He was
maintained on a Valium CIWA Scale although did not require
treatment for withdrawal. He was given MVI, Thiamine and Folate
and educated about the risks of continued alcohol use.
FALLS: Patient reports a history of falls that appear may be a
result of medications. He reports them as happening when he
stands quickly from a seated position, and denies any associated
chest pain, diaphoresis or SOB. He was seen by Physical Therapy
who suggested home physical therapy.
Medications on Admission:
PER VA PHARMACY
absorbase topical ointment
cyanacobalamin 1000 mcg/ml inj 1x/month
digoxin 0.125 mg daily
enalapril maleate 2.5 mg [**Hospital1 **]
furosemide 40 mg [**Hospital1 **]
insulin NPH 18 units breakfast and HS; insulin regular 5 units
at breakfast and dinner
metoprolol succinate 100 mg daily
simvastatin 40 mg daily
warfarin 5 mg Sat/Sun/Tues/Thurs, 7.5 mg daily MWF
miconazole powder
nystatin cream
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Enalapril Maleate 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. 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:*3*
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
11. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 14 days.
Disp:*64 Tablet(s)* Refills:*0*
12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis: UGIB secondary to duodenal ulcerations.
.
Secondary Diagnoses:
Atrial Fibrillation
Hypertension
Diabetes
Hypercholesterolemia
Sleep Apnea, on CPAP
Congestive Heart Failure, unspecified
Discharge Condition:
Afebrile, stable vital signs, tolerating POs, ambulating without
assistance.
Discharge Instructions:
You were admitted with an upper GI bleed that may be due to
ulcerations that were seen in your small bowel. This may be due
to a bacterial infection and we have started you on acid
blockers that you'll need to take twice a day, and you've also
been empirically started on a 2-week course of antibiotics and
you will be contact[**Name (NI) **] if you can stop these earlier.
.
1. Please take all medication as prescribed.
2. Please make all medical appointments.
3. Please return to the Emergency Room if you have any
concerning symptoms.
Followup Instructions:
Please follow-up with your PCP as previously scheduled.
Completed by:[**2193-12-16**]
ICD9 Codes: 2851, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8319
} | Medical Text: Admission Date: [**2180-8-4**] Discharge Date: [**2180-8-14**]
Date of Birth: [**2138-10-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
Transfer for outside hospital with SBP secondary to HCV
cirrhosis
Major Surgical or Invasive Procedure:
Paracentesis
Central venous line placement
History of Present Illness:
41yo female with a h/o end-stage liver disease from hepatitis C,
normally followed by Dr. [**Last Name (STitle) 10285**]. She has refractory ascites &
has weekly paracenteses with ~10L fluid removal with
administration of albumin. Pt admitted to [**Hospital3 3583**] on
[**8-2**] due to increasing ascites & SOB following dietary
non-compliance. In [**Hospital1 **] [**Last Name (NamePattern1) **] she became increasingly O2
dependent & was admitted to their ICU. She had paracentesis
with 11L removed & subsequently became hypotensive. Ascitic
fluid demonstrated SBP which eventually grew out alpha strep
(not enterococcus). Several hours later, pt aspirated & became
hypotensive/bradycardic with increasing SOB -> subsequently
intubated. CXR demonstrated a LLL infiltrate. Pt required
multiple pressors to maintain her BP. She was started on Zosyn
for her SBP & aspiration pneumonia. She also developed acute
renal failure with rising creatinine levels at [**Hospital1 46**].
Past Medical History:
End-stage liver disease - HCV
s/p transplant eval -> not candidate due to excessive BMI
Refractory ascites
Hyponatremia
Esophagitis & portal gastropathy
Neuropathy
Breast mass
h/o RLE cellulitis
Obesity
Social History:
Widowed. [**Name (NI) 1094**] mother, [**Name (NI) 622**], is health care proxy & her
partner, [**Name (NI) **] [**Name (NI) 780**], is alternate health care proxy.
h/o prior IVDU & ETOH abuse - currently in methadone program.
Family History:
Non-contributory
Physical Exam:
VS - 98.7, 91, 123/64, 17, 95% on AC 550x14/100%/8
Gen - ill appearing female, intubated/sedated
HEENT - NC/AT, PERRL, +icteric sclerae, ETT/OGT in place
CV - RRR, s1s2, no m/r/g
Lungs - course BS bilat, L base rhonchi/crackles
Abd - markedly distended, obsese, +BS
Ext - 2+ pitting edema BUE/BLE
Skin - jaundiced
Neuro - intubated/sedated, non-responsive
Pertinent Results:
[**2180-8-4**] 10:56PM GLUCOSE-76 UREA N-46* CREAT-2.1*# SODIUM-132*
POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-24 ANION GAP-16
[**2180-8-4**] 10:56PM ALT(SGPT)-1591* AST(SGOT)-2288* CK(CPK)-1292*
ALK PHOS-102 TOT BILI-9.6*
[**2180-8-4**] 10:56PM CK-MB-17* MB INDX-1.3 cTropnT-<0.01
[**2180-8-4**] 10:56PM ALBUMIN-3.2* CALCIUM-8.4 PHOSPHATE-6.3*
MAGNESIUM-2.2
[**2180-8-4**] 10:56PM CORTISOL-13.7
[**2180-8-4**] 10:56PM WBC-14.9*# RBC-4.16* HGB-13.2 HCT-39.7 MCV-96
MCH-31.8 MCHC-33.3 RDW-16.3*
[**2180-8-4**] 10:56PM NEUTS-67 BANDS-17* LYMPHS-7* MONOS-2 EOS-7*
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2180-8-4**] 10:56PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+ BURR-1+ TEARDROP-1+
[**2180-8-4**] 10:56PM PLT SMR-LOW PLT COUNT-125*
[**2180-8-4**] 10:56PM PT-22.5* PTT-44.0* INR(PT)-3.4
[**2180-8-4**] 10:56PM FIBRINOGE-179
[**2180-8-4**] 11:52PM TYPE-ART TEMP-36.7 RATES-14/ TIDAL VOL-550
PEEP-10 O2-100 PO2-87 PCO2-54* PH-7.26* TOTAL CO2-25 BASE XS--3
AADO2-577 REQ O2-94 INTUBATED-INTUBATED VENT-CONTROLLED
[**2180-8-4**] 11:52PM LACTATE-3.5*
[**2180-8-4**] 10:57PM URINE HOURS-RANDOM CREAT-146 SODIUM-<10
[**2180-8-4**] 10:57PM URINE OSMOLAL-311
[**2180-8-4**] 10:57PM URINE COLOR-Amber APPEAR-SlCldy SP [**Last Name (un) 155**]-1.020
[**2180-8-4**] 10:57PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-SM
[**2180-8-4**] 10:57PM URINE RBC-60* WBC-13* BACTERIA-RARE YEAST-MANY
EPI-2
Brief Hospital Course:
41yo female transferred from OSH to [**Hospital1 18**] MICU on [**2180-8-4**] with
hypoxic/hypercapneic respiratory failure, aspiration pneumonia,
septic shock, end-stage liver disease, SBP, refractory ascites,
acute renal failure, coagulopathy, and mixed
metabolic/respiratory acidosis. Pt continued on pressors &
antibiotics. Hepatology & renal consulted and assisted in
management of patient. Pt underwent multiple
diagnostic/therapeutic paracenteses with albumin replacement.
Pt also required multiple transfusions of FFP & PRBC's to
correct coagulopathy & anemia. Pt noted to have adrenal
insufficiency by [**Last Name (un) 104**]-stim test, placed on steroids. Pt was
able to be weaned off pressors on [**8-9**] although had to be
restarted on [**8-13**].
Following discussion of care with family by the MICU team, it
was determined that patient would be extubated & maintained with
comfort measures only. Following asystolic arrest, pt was
pronounced dead at 1445 on [**2180-8-14**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 28438**].
Medications on Admission:
Outpatient Meds: lasix, spironolactone, propranolol, MDI
Transfer Meds: dopamine drip, neosynephrine drip, zosyn,
propranolol, spironolactone, lasix, methadone, protonix, vitamin
K
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Spontaneous bacterial peritonitis
Aspiration pneumonia
Hepatitis C with cirrhosis
Refractory ascites
Septic shock requiring pressors
Adrenal insufficiency
Hyponatremia
Coagulopathy requiring transfusions
Anemia requiring transfusions
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 0389, 2761, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8320
} | Medical Text: Admission Date: [**2123-7-8**] Discharge Date: [**2123-7-9**]
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a [**Age over 90 **] year-old right-handed woman with a-fib on
coumadin
and history of stroke with residual minimal L-sided weakness who
presents with acute worsening of left-sided weakness and new
left
facial droop. Per the patient and her family, she was feeling
well yesterday. This morning she woke up and was unable to get
out of bed due to being unable to move her left side. Her
daughter [**Name (NI) **] was staying at her home and brought her to [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]. Her family notes that the left side of her face is droopy
and
she is having much more difficulty getting words out than usual,
both in the sense that they are slurred and poor verbal output.
On neuro ROS, the pt reports posterior pressure headache
(typical
of chronic HAs). She denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. No bowel or bladder incontinence or
retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
-atrial fib on coumadin - discovered 1 yr ago
-stroke - [**9-/2122**] - at time of a-fib discovery. Left-sided
hemibody (excluding face) weakness, recovered almost fully; 2nd
stroke with worsening of left-sided sx in [**4-/2123**] when she was
taken off coumadin briefly for skin cancer removal.
- HTN
- HL
- osteoarthritis
- "leaky" heart valve
- chronic headaches - posterior, pressure x years, responds to
acetaminophen
Social History:
Her family reports that her baseline is very sharp mentally,
doing crosswords and soduku daily. She typically has full
functional use of both hands. She uses a walker to walk. She
lives alone but children live close-by and she has additional
help daily. She takes her own medications using a timer and a
schedule. Never smoked tobacco, drank significant alcohol, or
used drugs. Has 3 grown children in the area. Retired nurse.
Family History:
non contributory
Physical Exam:
Physical Exam on Admission:
Vitals: T: 98.4 P: 87 R: 22 BP: 112/63 SaO2: 95% on 3L
General: Lying in bed, cooperative, NAD.
HEENT: NC/AT, no scleral icterus, MMM, no lesions in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: irreg irreg, 2/6 systolic murmur
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, 1+DP pulses
bilaterally.
Skin: no rashes or lesions
Neurologic:
-Mental Status: Alert, oriented x 3 (self, hospital, month and
year). Somewhat attentive, able to count forwards and backwards.
Paucity of speech, does not achieve fluency. Intact repetition
and comprehension. + paraphasic errors ("hand" for "glove" Names
[**2-16**] (key, glove, chair - all high frequency) on stroke card
correctly but does not attempt to name other objects. Does not
attempt [**Location (un) 1131**] when given stimulus. Abulic. Speech dysarthric.
Able to follow both midline and appendicular commands. Left
sided
neglect with R gaze deviation.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1.5mm and brisk. VF difficult to assess given
inattention and R gaze preference, appears to have full visual
fields with extinction on left. Funduscopic exam unable to be
completed well due to small pupils and patient inattention.
III, IV, VI: Eyes do not cross midline to left. Conjugate.
V: Facial sensation intact to light touch.
VII: Left lower facial droop.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii.
XII: Tongue clumsy with movements, appears to have more
difficulty with moving to left.
-Motor: Normal bulk. Left hemibody has dense flaccid hemiplegia.
R hemibody appears to have full strength, patient unable to
cooperate fully with formal strength testing. No adventitious
movements. No asterixis.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense throughout. Unable to cooperate with
proprioception. Extinction to DSS on left.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was extensor bilaterally.
-Coordination: No dysmetria on FNF in RUE. RAMs intact in RUE
-Gait: deferred
Physical Exam on Discharge:
expired
Pertinent Results:
Relevant Labs:
[**2123-7-8**] 09:00PM GLUCOSE-298* UREA N-18 CREAT-0.8 SODIUM-136
POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-23 ANION GAP-18
[**2123-7-8**] 09:00PM CALCIUM-8.9 PHOSPHATE-4.6* MAGNESIUM-1.4*
[**2123-7-8**] 09:00PM OSMOLAL-285
[**2123-7-8**] 09:00PM PT-16.2* PTT-79.0* INR(PT)-1.5*
[**2123-7-8**] 06:43PM URINE HOURS-RANDOM
[**2123-7-8**] 06:43PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2123-7-8**] 06:43PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.037*
[**2123-7-8**] 06:43PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
[**2123-7-8**] 06:43PM URINE RBC-5* WBC-6* BACTERIA-NONE YEAST-NONE
EPI-3
[**2123-7-8**] 06:43PM URINE MUCOUS-RARE
[**2123-7-8**] 03:59PM ALT(SGPT)-26 AST(SGOT)-77* CK(CPK)-224* ALK
PHOS-86 TOT BILI-1.0
[**2123-7-8**] 03:59PM CK-MB-3 cTropnT-<0.01
[**2123-7-8**] 03:59PM ALBUMIN-3.9
[**2123-7-8**] 03:59PM OSMOLAL-284
[**2123-7-8**] 01:43PM LACTATE-1.7
IMAGING:
CT SCAN (POST-HEMORRHAGIC EVENT)
- IMPRESSION: Interval development of massive hemorrhagic
conversion of a large right frontoparietal ischemic stroke,
resulting in subfalcine and downward transtentorial herniation,
associated with significant edema and 2.7 cm of midline shift to
the left, effacing the right lateral ventricle and entrapping
the left occipital [**Doctor Last Name 534**].
Brief Hospital Course:
Ms. [**Known lastname 31394**] was known to have suffered a large right sided
anterior frontal MCA stroke, possibly with an additional left
ACA component as well, in the setting of a history of atrial
fibrillation on warfarin with a subtherapeutic INR. She was
placed on a heparin infusion initially in the setting of likely
cardioembolic stroke. As part of her expected management plan,
she was transferred to the Neurology Step Down Unit with q2 hour
neurochecks - no change in neurologic examination or clinical
status was seen overnight except that she was more sleepy and
didn't answer questions at 0130 - of note, she remained
arousable and followed commands. Around 0425, Ms. [**Known lastname 31394**] was
noted to have fixed pupils with right at 6mm and left at 3mm,
with extensor posturing with her left arm to noxious stimulus
and continued flexion withdrawal in the other arm. Both the ICU
attending and chief resident were updated at this time, and the
family was contact[**Name (NI) **]. The patient's daughter (health care proxy)
reaffirmed keeping her DNR/DNI as previously
established as per the patient's wishes.
Intervention was initiated with Mannitol administration,
stopping the Heparin infusion, support her respiratory status
without intubation, and transfer
her to the Neurology ICU. The patient was stabilized, but
repeat non-contrast head CT revealed hemorrhagic conversion of
her MCA and ACA ischemic stroke with extension into the lateral
ventricles, as well as up to 27mm of right to left midline
shift. In the setting of this change and in discussion with her
daughter/HCP, she was made comfort measures only and expired at
0910 on [**2123-7-9**].
Medications on Admission:
coumadin 5mg daily 6 times a week, 2.5mg on the 7th day
synthroid 37.5mcg daily
atenolol 25mg po daily
amlodipine 5mg po daily
lasix 20mg po daily
occuvite
acidophilius
pravastatin 40mg po daily
quinipril 40mg po daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2123-7-9**]
ICD9 Codes: 431, 4019, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8321
} | Medical Text: Admission Date: [**2112-5-17**] Discharge Date: [**2112-5-24**]
Date of Birth: [**2112-5-17**] Sex: M
Service: NB
DIAGNOSES AT DISCHARGE: Prematurity.
Presumed sepsis, resolved.
Hyperbilirubinemia, resolved.
Feeding immaturity, resolved.
HISTORY: Patient is an 1835 gram male born at 34 1/7 weeks
admitted to the Neonatal Intensive Care Unit for prematurity.
He was born to a 25 year-old gravida III, para I to II mother
with an estimated date of confinement of [**2112-6-27**].
Prenatal laboratories included blood type B positive,
antibody negative, hepatitis B surface antigen negative, RPR
nonreactive, rubella immune and GBS unknown. Pregnancy was
reported to be unremarkable until night of delivery when
mother presented in spontaneous labor. Intrapartum course was
notable for spontaneous rupture of membranes 20 minutes prior
to delivery with one dose of intrapartum antibiotic
prophylaxis 10 minutes prior to delivery and rapid
progression of labor. He was born via spontaneous vaginal
delivery emerging vigorous with Apgar scores of 8 and 9. He
was brought to the Neonatal Intensive Care Unit in room air
without evidence of respiratory distress.
PHYSICAL EXAMINATION ON ADMISSION: Weight 1835 grams, 25th
percentile, length 43 cm, 25th percentile, length 43 cm, 25th
percentile, head circumference 29.5 cm, 10th to 25th
percentile. Vital signs on admission: Temperature 98, heart
rate 150, respiratory rate 40, blood pressure 61/31 and mean
of 48, O2 saturation 97% on room air. The baby was active and
vigorous with no distress, somewhat small appearing for
gestational age. Skin was warm, pink, well perfused, no rash.
Head, eyes, ears, nose and throat: Normocephalic, fontanelle
soft and flat, palate intact, nondysmorphic. Neck supple, no
lesions. Chest clear to auscultation, no grunting, flaring or
retracting. Cardiac: Regular rate and rhythm, no murmurs,
rubs or gallops. Femoral pulses 2+. Abdomen soft, no masses.
Three vessel cord, quiet bowel sounds. No hepatosplenomegaly.
Genitourinary: Normal male testes palpable. Anus patent.
Extremities no lesions. Hips and back: Normal. Neurologic:
Grossly normal tone and activity. Intact grasp and Moro.
HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Patient remained
comfortable on room air throughout hospitalization with no
episodes of apnea.
CARDIOVASCULAR: Patient remained hemodynamically stable
through hospitalization. At the end after starting on an
initial amount of fluid at 50 cc per kilo per day with 10%
dextrose infusion [**Known lastname **] was quickly able to take all of his
feeds by mouth reaching 150 cc per kilo per day at the time
of discharge with breast milk or Enfamil 24 calorie per ounce
formula. His D sticks remained stable throughout
hospitalization.
HEMATOLOGY: Initial hematocrit was 49 with a repeat of 45 on
day of life 6. Platelets were 190.
INFECTIOUS DISEASE: Initial white count was 7.2 with a left
shift. Differential of 22 polys and 12 bands. Given the left
shift a lumbar puncture was performed at day of life 2.
Results were reassuring for no infection. Antibiotics were
discontinued after 48 hours as cultures, blood and
cerebrospinal fluid cultures remained negative. On day of
life 5 [**Known lastname **] transiently dropped his temperature and
required temperature control with an Isolette for 24 hours.
At that time he had a CBC and blood culture drawn with a
reassuring differential of 35 polys and no bands. No
antibiotics were started.
GASTROINTESTINAL: [**Known lastname **] was started on phototherapy on day
of life 3 for a bilirubin of 9.9 and a direct component of
.4. Phototherapy was discontinued on day of life 5 with a
rebound of 5.4/0.3.
RENAL: Given the history of hydronephrosis seen on prenatal
ultrasounds [**Known lastname **] received a renal ultrasound on day of life
3 with normal results.
ROUTINE HEALTH CARE MANAGEMENT: He received his hepatitis B
vaccine. He passed his car seat test and he passed his bears.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) 61635**]
MEDQUIST36
D: [**2112-5-23**] 16:40:44
T: [**2112-5-23**] 17:42:50
Job#: [**Job Number **]
ICD9 Codes: 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8322
} | Medical Text: Admission Date: [**2126-11-16**] Discharge Date: [**2126-11-22**]
Date of Birth: [**2047-2-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3266**]
Chief Complaint:
Hepatic failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 56774**] is a 79 year-old woman with a history of essential
thrombocytosis, chronic anemia, and recently diagnosed ([**9-21**])
cirrhosis, ascites, and splenomegaly who presents with a several
day history of black tarry stools and one episode of brown
emesis.
Mrs. [**Known lastname 56774**] first began feeling fatigued 2 weeks prior to
admission, and missed a full week of work ([**2044-11-2**]) secondary
to this fatigue. On [**11-10**] she continued to feel tired and
lightheaded, but went to work anyway. On [**11-14**] she returned home
from bingo in the evening and threw-up watery brown emesis with
food. Though she cannot specify which day it began, at some
point over this week her stools began to appear black and tarry,
as they had when she was on iron therapy for anemia. On [**11-15**]
she came home from work so tired that she was unable to climb
the stairs in her home, and her family brought her to an outside
hospital later that evening.
Of note, per her medical record, in [**9-21**] Mrs. [**Known lastname 56774**] presented to
her PCP with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19341**] history of bilateral lower extremity
swelling and increased abdominal girth. Abdominal CT ([**9-21**]) at
an outside institution was read as massive ascites with a small
nodular liver and splenomegal. Endoscopy ([**2-20**]) report includes
hiatal hernia but no varices. Colonoscopy at this time was
reportedly negative. Therapeutic paracentesis revealed a
transudate suggestive of portal hypertension, with negative
cytology. Serology for Hep B and C were negative, the patient
does not drink alcohol or use tylenol regularly. Work-up for
autoimmune hepatitis was started. She was started on lasix and
aldactone, but could not tolerate the aldactone since she felt
??????dry??????.
At the outside hospital on [**11-15**] Mrs. [**Known lastname 56774**] was found to have an
elevated INR and HCT of 28.6 on admission that dropped to 21.5.
She could not be immediately transfused secondary to difficulty
matching packed red blood cells. She was given four units of
fresh frozen plasma, 2 units of packed red blood cells, and
started on prednisone 80 mg for supposed autoimmune hemolysis,
as well as folic acid.
On [**11-16**] she was admitted to the [**Hospital1 18**] MICU, where her intial
HCT post-transfusion was 28.5. The MICU course included banding
of esophageal varices and medical treatment with octreotide,
pantoprazole, and sucralfate. Prophylactic antibiotics were
started (metronidazole and levofloxacin, then changed to
ciprofloxacin at 500 mg PO q12 hours) to try to avoid
spontaneous bacterial peritonitis. EKGs were followed secondary
to a slight increase in troponin at outside hospital thought to
be due to demand ischemia secondary to blood loss, and an echo
was done secondary to a newly perceived heart murmur. The labs
sent from the MICU course are listed below.
Past Medical History:
1. Essential thrombocytosis
2. Anemia
3. Hepatosplenomegaly with ascites
4. Cystocele
Social History:
1. Cook at local school
2. No tobacco, EtOH, IVDA
Family History:
1. Mother - metastatic abdominal cancer
2. Father - bone cancer
3. Sister - breast cancer
4. Brother - stroke
5. Sister - liver transplant
Physical Exam:
T 97.1 HR 54 BP 110/60 RR 18 Sat 91% RA
GEN: Alert, awake, oriented, chatty, sitting in chair talking
with daughter. Thin [**Name2 (NI) 56775**] face not in proportion with swollen
appearance of extremities and abdomen.
HEENT: Head NC/AT. Sclerae anicteric, conjunctiva pale. PERRLA,
EOMs intact, VFs full. Nasal mucosa pink, without polyps. No
sinus tenderness. Oropharynx clear and nonerythematous. Mucous
membranes moist. Trachea midline. Neck supple. Thyroid not
enlarged and without nodules. No LAD.
CARDIO: JVP 4 cm above the sternal angle at 30?????? elevation.
Carotid pulses 2+ bilat.; upstrokes brisk; without bruits. PMI
appreciated at 4th-5th IC space on midaxillary line.
Holosystolic murmur obscuring S1 best heard at right upper
sternal border and lower left sternal border. Otherwise, S1 & S2
normal. No rubs, gallops, heaves or thrills.
PULM: Soft crackles at bases bilaterally. No wheezes or rhonchi.
[**Last Name (un) **]: Distended/obese, nontender. BS present in all 4 quadrants.
No bruits. Shifting dullness. Liver edge not felt, but abdomen
firm throughout right upper quadrant. Spleen tip felt at
umbilicus with splenic body extending to pelvic brim. Bandages
covering site of peritoneal tap. No CVA tenderness.
EXTR: Warm and well perfused bilaterally. Radial pulses 2+.
Post tib. and DP pulses 1+ bilat. Good capillary refill bilat.
1+ pitting lower extremity edema to mid-calf bilaterally.
Thickened DIP joints consistent with osteoarthritis bilaterally.
NEURO: AOx3. Rest of MMSE not performed. CNs II-XII intact to
direct testing. Light touch intract UEs and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. No
asterixis. No clonus.
SKIN: Skin fragile, warm, and moist. Facial skin appears tanned,
but difficult to assess presence of jaundice in overhead
lighting. Nails without clubbing or cyanosis. Hair of average
texture. No spider angiomata. No suspicious nevi. No rashes or
petechiae. Several large ecchymoses on arms, burn on right inner
wrist. No palmar erythema.
Pertinent Results:
[**2126-11-16**] 11:11PM BLOOD WBC-6.4 RBC-2.92* Hgb-9.6* Hct-28.5*
MCV-98 MCH-32.9* MCHC-33.6 RDW-20.3* Plt Ct-553*
[**2126-11-18**] 04:44AM BLOOD WBC-8.4 RBC-3.26* Hgb-10.7* Hct-32.8*
MCV-101* MCH-33.0* MCHC-32.7 RDW-19.8* Plt Ct-538*
[**2126-11-16**] 11:11PM BLOOD Neuts-92.0* Bands-0 Lymphs-6.5*
Monos-1.0* Eos-0.3 Baso-0.2
[**2126-11-16**] 11:11PM BLOOD PT-15.1* PTT-33.1 INR(PT)-1.4
[**2126-11-18**] 04:44AM BLOOD PT-15.5* PTT-31.2 INR(PT)-1.5
[**2126-11-18**] 04:44AM BLOOD Glucose-121* UreaN-41* Creat-0.8 Na-141
K-4.0 Cl-102 HCO3-33* AnGap-10
[**2126-11-16**] 11:11PM BLOOD Glucose-119* UreaN-41* Creat-0.8 Na-140
K-3.5 Cl-101 HCO3-32* AnGap-11
[**2126-11-18**] 04:44AM BLOOD ALT-27 AST-33 LD(LDH)-238 AlkPhos-65
TotBili-1.5 DirBili-0.6* IndBili-0.9
[**2126-11-16**] 11:11PM BLOOD ALT-30 AST-41* LD(LDH)-256* CK(CPK)-62
AlkPhos-69 TotBili-2.8* DirBili-1.0* IndBili-1.8
[**2126-11-18**] 04:44AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.1
[**2126-11-16**] 11:11PM BLOOD Albumin-3.1* Calcium-8.9 Phos-3.0 Mg-1.9
UricAcd-7.9* Iron-87
Brief Hospital Course:
Mrs. [**Known lastname 56774**] is a 79 year-old woman with history of essential
thrombocytosis, chronic anemia, and recently diagnosed ([**9-21**])
cirrhosis, ascites, and splenomegaly who presents with a several
day history of black tarry stools and one episode of brown
emesis.
1. GI bleed, source unknown, but thought to be secondary to
esophageal varices. After receiving packed red blood cells and
fresh frozen plasma, her hematocrit has stabilized. EGD
revealed varices, subsequently banded, but no active bleeding.
Negative colonsopy reported from [**2-20**]. HCT over past 24 hours
have been stable > 29. She was treated with sucralfate, nadolol,
octreotide and antibiotic prophylaxis. She remained stable in
that respect throughout her stay.
3. Decompensated chronic liver failure, unknown etiology: The
patient has cirrhosis diagnosed by CT, ascites, esophageal
varices, decreased synthetic function (increased INR, low
albumin). THe patient underwent a diagnostic/therapeutic
paracentesis on [**11-17**], [**2082**] cc of fluid consistent with ascites
(no malignant cells, serum-ascites albumin gradient = 2.0).
Various diagnoses were excluded both during this stay and prior
to arrival. These included infectious, alcoholic, NASH,
autoimmune, metabolic. A liver biopsy was performed on [**2126-11-20**]
which revealed cirrhosis but no evident causes. She underwent a
second therapeutic paracentesis prior to her discharge which
produced large amounts of fluid and relieved her mild shortness
of breath and hypoxia (sats. 91-92).
4. Anemia: There are multiple possible origins to Mrs. [**Known lastname 56774**]??????
anemia. Her anemia diagnosed in [**2-20**] was treated with iron and
transfusion, and is now exacerbated by her GI bleed. In
contradiction to her original treatment with iron and labs at
the outside hospital that indicate iron deficiency anemia, her
current anemia is macrocytic, the differential diagnosis of
which primarily includes deficiencies of folate or B12 secondary
to malnutrition or absorption disorders; however, Mrs. [**Known lastname 56774**]??????
lab values for both folate and B12 are elevated, most likely due
to supplementation. It is also possible that the macrocytosis
and elevated RDW were secondary to liver failure. Her
reticulocyte level is not high enough (2.9%) to cause such a
high MCV. Another possible cause of her anemia could be her
ten-year treatment with hydroxyurea. Data from the OSH included
a positive Coombs antibody test combined with the elevated
indirect bilirubin could indicate hemolysis, but in the setting
of cirrhosis with a normal haptoglobin level and normal LDH
significant hemolysis is unlikely. Thus, for treatment we
deferred from continuing the prednisone and folate started at
the OSH. As her iron levels are low, we restarted iron
supplementation.
5. Essential thrombocytosis: Has been taking hydroxyurea for at
least ten years. Platelets 538 on admission. The hematologist
advised to hold her hydroxyurea until her platelet count reached
800.
6. New murmurs: New murmurs of mitral and tricuspid
regurgitation and aortic stenosis auscultated and validated by
echocardiography.
Mrs. [**Known lastname 56774**] was discharged after an uncomplicated [**Hospital 56776**]
hospital stay with a diagnosis of decompensated liver failure
and gastrointestinal bleed. She was sent home in stable
condition and with close follow up with the GI service.
Medications on Admission:
1. Hydroxyurea 10 mg once daily
2. Aspirin 81 mg once daily
3. Lasix
4. Multivitamins
Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day): Please stop sunday night [**11-24**].
Disp:*20 Tablet(s)* Refills:*0*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
4. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily) as needed for PRN bowel mov't: Please ttitrate to [**2-19**]
bowel mov't per day if patient is showing signs of confusion.
Disp:*qs bottle* Refills:*1*
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Decompensation of liver failure with GI bleed
Discharge Condition:
good
Discharge Instructions:
Please take all medications as directed. Sucralfate should be
taken through Sunday [**11-24**], and Pantoprazole until your
procedure with Dr. [**Last Name (STitle) **]. Otherwise, the prescriptions are
on-going. Continue with incentive spirometry and ambulation at
home. Please call Dr. [**Last Name (STitle) **] and return to the ED immediately if
there you have vomit with dark material or blood, dark tarry
stools or blood per rectum, confusion that is not relieved by
lactulose, shortness of breath, dizziness, or any other
concerning symptoms. Please maintain a low-salt diet and
restrict fluids to 1.5L max per day. Your medications will need
to be adjusted in the near future by Dr. [**Last Name (STitle) **] according to how
much fluid you are retaining and future procedures.
Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2126-11-24**] for
EGD/banding procedure. Her office will call you with the time of
the appointment. Please follow-up with PCP within [**Name9 (PRE) 56777**] of
discharge.
Completed by:[**2126-12-11**]
ICD9 Codes: 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8323
} | Medical Text: Admission Date: [**2176-1-1**] Discharge Date: [**2176-1-7**]
Date of Birth: [**2134-11-23**] Sex: M
Service:
ADMISSION DIAGNOSIS:
1. Marfan's syndrome.
2. Aortic dilatation.
3. Possible aortic regurgitation.
DISCHARGE DIAGNOSES:
1. Marfan's syndrome.
2. Status post ascending aortic root repair.
HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old
male with a strong family medical history of Marfan's
disease. He has a [**7-14**] year history of heart palpitations
and is placed on Lopressor by his cardiologist, whom he has
been following for the last 10 years. The patient
experienced new chest and back pain in [**2175-11-5**] and
underwent echocardiogram and CTA, which revealed a dilated
aortic root for which the patient is referred for operative
management.
PAST MEDICAL HISTORY:
1. Marfan's syndrome.
2. Gastroesophageal reflux disease.
3. Borderline hypertension.
4. Right elbow surgery in [**2154**].
MEDICATIONS:
1. Lopressor 25 mg [**Hospital1 **].
2. Prilosec 20 mg q day.
3. Lotrisone cream [**Hospital1 **].
ALLERGIES: Penicillin and Demerol.
PHYSICAL EXAMINATION: The patient is a middle-age man who
appears well nourished and well developed in no acute
distress. Vital signs: Heart rate 60 normal sinus, blood
pressure 136/104, respirations 16. Height is 6 foot 3
inches, weight 220 pounds. HEENT: Atraumatic,
normocephalic. Extraocular movements are intact. Pupils are
equal, round, and reactive to light. Anicteric. Throat is
clear. Neck is supple, midline. No masses or
lymphadenopathy. Chest was clear to auscultation
bilaterally. Cardiovascular is regular, rate, and rhythm
with 2-3/6 systolic ejection murmur. No rubs. Abdomen is
soft, nontender, nondistended. No guarding or rebound. No
masses or organomegaly. Extremities: Warm, not cyanotic,
nonedematous x4. Neurologic is alert and oriented times
three. No focal motor or sensory deficits are noted.
LABORATORIES: Patient had preoperative laboratories done on
[**2175-12-27**] as follows: Complete blood count:
6.7/14.7/42.7/192. PT 12.5, INR 1.0, PTT of 34.9.
Chemistries: 141/4.1/102/27/18/0.7/81. ALT 27, AST 19,
alkaline phosphatase 87, bilirubin 0.6. Type and screen was
performed at that time.
Preoperative chest x-ray was unremarkable.
HOSPITAL COURSE: The patient was admitted for semi-elective
repair of his aortic root aneurysm. Patient underwent
procedure which was valve sparing without complication. In
the postoperative period, the patient was taken to the
Intensive Care Unit for closer monitoring. He was initially
maintained on the ventilator overnight while he was weaned.
Patient was also begun on a nitroglycerin drip to maintain
the systolic blood pressure of less than 120. The patient
was eventually started on Nipride and the nitroglycerin was
weaned off. The patient did receive three units of packed
red blood cells for a hematocrit of 20, and his
post-transfusion hematocrit was 27.
Cardiac index was 2.9 to 3.1 with the normal infusing at 0.5
mcg/kg/minute.
Patient was subsequently extubated on postoperative day #1
without incidence. His sats did well postextubation
maintaining sats about 95% on 3 liters nasal cannula.
Patient remained in sinus rhythm and with blood pressure
stable 120/60s. Insulin drip was weaned off and the patient
was begun on sliding scale insulin.
The patient was transferred to the floor on postoperative day
#2. Physical Therapy was begun, and the patient did have
significant complaints of incisional pain. Patient's floor
course was fairly unremarkable. Patient's chest tubes and
pacing wires were discontinued on postoperative day #3. His
Foley was also removed without complication. The patient had
some mild issues with weaning lower levels of supplemental
oxygen. He is still having oxygen requirement on
postoperative day #5 sating 93% on 2 liters.
Chest x-ray was obtained which showed a small left sided
pleural effusion and right basilar atelectasis. Pulmonary
toilet was encouraged. The patient was discharged on
postoperative day #6 with no oxygen requirement. He was
switched to Dilaudid for pain control secondary to his belief
that Percocet was not working as well anymore.
Patient was discharged to home, tolerating regular diet, and
adequate pain control with po pain medications, and without
any cardiac events or further episodes of palpitations or
chest pain.
PHYSICAL EXAMINATION ON DISCHARGE: General: In no acute
distress. Chest was clear to auscultation bilaterally.
Sternal incision is clean and dry without drainage. His
cardiovascular is regular, rate, and rhythm without murmurs,
rubs, or gallops. There are some slightly decreased breath
sounds at the left base. Abdomen is soft, nontender,
nondistended. Extremities are warm and well perfused without
edema or cyanosis x4. Neurologic is intact.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg [**Hospital1 **].
2. Colace 100 mg [**Hospital1 **].
3. Aspirin 325 mg q day.
4. Percocet 5/325 mg [**12-7**] q4h prn.
5. Dilaudid 4 mg 1-2 tablets q4h prn.
6. Ibuprofen 400 mg q6h.
7. Lasix 20 mg [**Hospital1 **] x7 days.
8. Potassium chloride 20 mEq [**Hospital1 **] x7 days.
FO[**Last Name (STitle) **]: The patient is to followup in [**12-7**] weeks with
Cardiology and address the diuresis and adjustment of cardiac
medications at that time. The patient should follow up with
Dr. [**Last Name (Prefixes) **] in one month.
DISCHARGE CONDITION: Good.
DISPOSITION: Home.
DIET: Ad lib.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2176-1-7**] 16:28
T: [**2176-1-9**] 06:21
JOB#: [**Job Number 46907**]
ICD9 Codes: 5180, 5119, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8324
} | Medical Text: Admission Date: [**2124-10-1**] Discharge Date: [**2124-10-6**]
Date of Birth: [**2059-8-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest and jaw pain
Major Surgical or Invasive Procedure:
Ascending aorta replacement (26MM Gelweave graft)
Resuspension of aortic valve
History of Present Illness:
this 62 year old caucasian female presented to the emergency
room with the sudden onset o fchest pain readiating to her jaw
at 1100 hours the day of admission. The pain resolved, however,
she developed epigastric discomfort and general malaise.
A CTA demonstrated mural thrombus with some contrast within the
clot. This involved the ascending and descending aorta tothe
renal arteries. She was seen by cardiac surgery and taken
emergently to the operating room.
Past Medical History:
raynaud's disease
ADHD
s/p laminectomy for spinal stenosis
s/p TAH
brachial plexus injury-left
Social History:
1.5 oz Vodka/D
lactose intolerance
nonsmoker
retired psychiatrist
Family History:
Mother had [**Name (NI) 2481**]
Father had [**Name2 (NI) 499**] cancer
Physical Exam:
Admission
VS T HR70 BP93/42 RR16 02sat 99%RA
Gen comfortable
HEENT NCAT/EOMI, OP-wnl
Pulm CTA
CV RRR, nl S1-S2
Abdm soft, NT/ND
Ext no C/C/E
Neuro speach fluent
sternum stable
Pertinent Results:
[**2124-10-1**] 09:47PM WBC-10.9 RBC-2.69*# HGB-8.2* HCT-23.8* MCV-88
MCH-30.6 MCHC-34.6 RDW-13.6
[**2124-10-1**] 09:47PM PLT COUNT-261
[**2124-10-1**] 09:47PM PT-15.3* PTT-49.4* INR(PT)-1.3*
[**2124-10-1**] 12:30PM ALT(SGPT)-17 AST(SGOT)-25 CK(CPK)-123 ALK
PHOS-62 TOT BILI-0.5
[**2124-10-1**] 12:30PM GLUCOSE-121* UREA N-28* CREAT-1.1 SODIUM-135
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-24 ANION GAP-14
[**2124-10-1**] 12:30PM cTropnT-<0.01
[**Known lastname 107018**],[**Known firstname 107019**] [**Medical Record Number 107020**] F 65 [**2059-8-11**]
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2124-10-1**] 1:39 PM
[**Last Name (LF) 4758**],[**First Name3 (LF) 2353**] EU [**2124-10-1**] SCHED
CTA CHEST W&W/O C&RECONS, NON-; CTA ABD W&W/O C & RECONS; CTA
PELVIS W&W/O C & RECONS Clip # [**Clip Number (Radiology) 107021**]
Reason: Please evaluate for aortic dissection
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
65 year old woman with no sig PMH, present with acute onset
of severe chest
pain, radiating to the back, started with valsalva.
REASON FOR THIS EXAMINATION:
Please evaluate for aortic dissection
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: JXKc SUN [**2124-10-1**] 2:42 PM
Acute intramural hematoma that begins at the aortic origin,
involving the
ascending and descending aortas. Emergent surgical eval
recommended. d/w Dr.
[**Last Name (STitle) **].
Final Report
HISTORY: 65-year-old female with no significant past medical
history who
presents with acute onset of severe chest pain radiating to the
back, started
with Valsalva. Evaluate for aortic dissection.
No prior studies available for comparison.
TECHNIQUE: MDCT axial images were obtained from the thoracic
inlet to the
symphysis pubis with administration of IV contrast. Coronal and
sagittal
reformations were obtained.
CTA AORTA: There is an acute intramural hematoma, originating
from the aortic
root, and extending to involve the thoracic ascending aorta as
well as the
descending aorta to the level of the aortic bifurcation in the
abdomen. There
is a focal puddling of contrast within an intramural location
(3:15) in the
descending thoracic aorta, as well as at the level of the renal
arteries
(3:54) on the right. The celiac artery, SMA, and renal arteries
originate
from the true lumen.
CT OF THE CHEST WITH IV CONTRAST: The heart and pericardium
reveal no
evidence of a hemopericardium or pericardial effusion. There are
no
pathologically enlarged mediastinal, hilar, or axillary lymph
nodes. Within
the lungs, there is a focus of ill-defined airspace opacity
anteriorly within
the right upper lobe (3:19), likely infectious or inflammatory
in nature. In
addition, there is a 4-mm nodule within the right upper lobe
(3:27), as well
as a tiny pleural-based nodule within the right middle lobe
(3:38). Otherwise,
the lungs are clear.
CT OF THE ABDOMEN WITH IV CONTRAST: The liver, gallbladder,
spleen, pancreas,
adrenal glands, and left kidney are normal. Peripheral wedge
shaped
hypodensities in the right kidney are concerning for renal
infarcts.
The stomach, small bowel, and large bowel are within normal
limits. There is
no free air, free fluid or pathologic adenopathy.
CT OF THE PELVIS WITH IV CONTRAST: Urinary bladder, rectum, and
uterus are
unremarkable. There is no pelvic free fluid or adenopathy.
OSSEOUS STRUCTURES: There are severe multilevel degenerative
changes of the
lumbar spine, with scoliosis and a Grade 2 anterolisthesis of L4
on L5.
IMPRESSION:
1. Acute intramural hematoma involving the ascending and
descending aorta,
originating from the aortic root. A focus of contrast is seen in
an
intramural location within the descending thoracic aorta as well
as at the
level of the renal arteries. Emergent surgical evaluation
recommended.
2. Segmental right renal infarct.
Findings were discussed immediately with Dr. [**Last Name (STitle) **] and
immediately posted to
the ED dashboard.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 3934**] [**Name (STitle) 3935**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 107018**], [**Known firstname 107019**] [**Hospital1 18**] [**Numeric Identifier 107022**] (Complete)
Done [**2124-10-1**] at 6:33:39 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2059-8-11**]
Age (years): 65 F Hgt (in): 69
BP (mm Hg): / Wgt (lb): 123
HR (bpm): BSA (m2): 1.68 m2
Indication: Aortic dissection. Chest pain.
ICD-9 Codes: 441.00, 786.51
Test Information
Date/Time: [**2124-10-1**] at 18:33 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Last Name (NamePattern5) 9958**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW5-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 40% to 50% >= 55%
Aorta - Sinus Level: 3.6 cm <= 3.6 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aorta - Arch: 2.0 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *9.2 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 7 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 4 mm Hg
Aortic Valve - Valve Area: *2.0 cm2 >= 3.0 cm2
Findings
The is an ascending aortic intramural hematoma beginning at the
origin of the coronary arteries and extending at least to the
level of the takeoff of the subclavian arteries. Flow in the RCA
and LMCA was verified by using color doppler. There was no
dissection flap seen.
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal regional LV systolic function.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Normal
descending aorta diameter. Simple atheroma in descending aorta.
Ascending aortic intimal flap/dissection.. Thickened aortic wall
c/w intramural hematoma.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Moderate
(2+) AR.
MITRAL VALVE: Normal mitral valve leaflets. No MS. [**Name13 (STitle) **] MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE BYPASS
1. The left atrium is normal in size.
2. Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). 3. Right
ventricular chamber size and free wall motion are normal.
4. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. There is no aortic valve stenosis.
Moderate (2+) aortic regurgitation is seen.
5. The mitral valve leaflets are structurally normal. No mitral
regurgitation is seen.
6. There is no pericardial effusion.
POST BYPASS
1. There is mild to moderate aortic regurgitation.
2. The synthetic graft is seen with its origin at the
sinotubular junction. There is no apparent leak.
3. Left ventricular function is unchanged.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2124-10-2**] 15:27
Brief Hospital Course:
After evaluation and review of studies, the patient was taken
emergently to the OR where circumferential clot was found in
the ascending aorta, with out an obvious intimal tear. The
ascending aorta was replaced with a 26mm Gelweave graft and the
aortic valve was resuspended. Circulatory arrest was utilized
for a 20 minute period. See operative note for details. She
weaned from CPB easily and Propofol alone. She was
coagulopathic and was corrected with slowing of bleeding.
She remained hemodynamically stable after surgery. On the
morning after surgey she self-extubated. Her chest tubes and
epicardial wires were removed. She was transferred to the
surgical step-down floor. Her beta-blockade was titrated up as
tolerated. She was ready for discharge to home on
post-operative day 5.
Medications on Admission:
Estratest, Adderall, ibuprofen
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Amphetamine-Dextroamphetamine 5 mg Tablet Sig: Four (4)
Tablet PO daily ().
7. Estratest 1.25-2.5 mg Tablet Sig: One (1) Tablet PO once a
day.
8. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain.
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Type A Thoracic aortic dissection s/p Asc Ao replacement
Raynaud's disease
brachial plexus injury
attention deficit hyperactivity disorder
s/p hysterectomy
s/p spinal stensosis surgery
Discharge Condition:
good
Discharge Instructions:
no lifting more than 10 pounds for 10 weeks
no driving for 4 weeks and off all narcotics
shower daily, no baths or swimming
no lotions, creams or powders to incisions
report any temperature greater than 100.5.
report anyredness or drainage from incisions
take all medications as directed
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr [**First Name (STitle) **] [**Name (STitle) 107023**] (PCP) ([**Telephone/Fax (1) 107024**] in [**2-6**] weeks
Dr. [**Last Name (STitle) 914**] in 3 months with a CT scan with MMS protocol and en
echocardiogram ([**Telephone/Fax (1) 170**])
Completed by:[**2124-10-6**]
ICD9 Codes: 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8325
} | Medical Text: Admission Date: [**2172-3-14**] Discharge Date: [**2172-4-20**]
Date of Birth: [**2172-3-14**] Sex: F
Service: NEONATAL
DISCHARGE DIAGNOSIS:
1. Premature female infant, 33 5/7 weeks gestation.
2. Rh incompatibility.
3. Hyperbilirubinemia.
4. Apnea and bradycardia of prematurity.
5. Feeding immaturity.
6. S/P PPS murmur and flow.
[**Known lastname **] is the former 2.630 kilogram female infant born at 33
5/7 weeks gestation to a 31 year-old gravida III, para I, now
II, SAB I, A negative, Rh sensitized female whose remaining
prenatal screens were noncontributory. Group B strep status
was unknown. Pregnancy was complicated by preterm labor
treated with bed rest and terbutaline at 32 weeks gestation.
She had known Rh isoimmunization from a previous loss at 20
weeks gestation that was not recognized until a time frame in
which RhoGAM could no longer be given. In this pregnancy the
fetus did not require an in utero transfusion. There was no
hydrops on ultrasound but the delta OD on a [**3-11**] amnio was near
zone 3 and therefore the mother was admitted for induction.
She was beta complete and intrapartum antibiotic prophylaxis
was administered.
Because of failed induction mother was delivered by cesarean
section.
As indicated above, her previous history was notable for a 20
weeks loss in [**2167**] and a term infant in [**2168**]. That baby
required phototherapy and an exchange transfusion times one.
The infant was delivered with Apgars of 8 and 8 and admitted
to the Newborn Intensive Care Unit at [**Hospital1 190**].
On admission the baby weighed 2.630 kilograms at the 90th
percentile, head circumference 31.5 cm at the 50th percentile
and height 46 cm at the 75th percentile.
An initial D stick was 37 and the infant received a bolus of
D10W and repeat sugar was 42. The infant was maintained on
intravenous for several days and by [**3-17**] was off intravenous
and remained euglycemic at that time.
1. Respiratory: The infant remained in room air throughout
her hospital course. She had episodes of apnea and
bradycardia that were insufficient to start her on caffeine.
Because of ongoing episodes which were all self resolved, with
parents consent, we sent her home on an apnea monitor.
2. Cardiovascular: Infant had a soft intermittent murmur,
that is heard at LSB, out to apex, over both scapula, without
bounding pulses and appears to be consistant with PPS. At
one point during her stay when she had a drop in hematocrit to
24 a murmur was quite audible at that time and with
transfusion it became softer and at times difficult to
appreciate. It reappeared as Hct was in mid 20 range.
3. Feeding and nutrition: The infant was being breast fed
twice a day or bottle fed with mother's expressed milk at 20
calories per ounce.As she improved in the volume amount she
was taking she began to have some episodes of choking and
desats. The nipple was changed to [**First Name8 (NamePattern2) **] [**Last Name (un) **] medium feeder after
the slow flow was tried and she had difficulty with the very
slow flow. Mother was most comfortable with the [**Name (NI) **] low flow
nipple and that was she went home on. On [**4-7**] she was seen by
the feeding team who recommended a fluroscopic swallow study
at CHMC, which was done on [**4-8**] and showed no anatomic
abnormalities and no aspiration using the medium flow [**Last Name (un) **]
nipple.These episodes are being attributed to immature
suck/swallow and breathing coordination. Her weight prior to
discharge was 3.570kg.
4. Hematologic: Mother A negative, baby O positive, [**Name (NI) 36243**]
was positive. The initial bilirubin was 4.0/0.2 and she was
placed under phototherapy. Her peak bilirubin on day of life
4 was 16. Her peak bilirubin was on [**3-18**] at 16.9. The
infant was placed under four phototherapy lights and
bilirubin slowly decreased thereafter. The direct bilirubin
never rose above 0.3. She was slowly weaned off of
phototherapy and by [**3-25**] was down to single phototherapy with
the bilirubin of 7.3/0.2. On [**3-26**] phototherapy was
discontinued and a 24 hour rebound bilirubin was 6.2 with a
48 hour rebound bilirubin at 6.8. On [**4-14**] her bili was
2.2.
On [**3-18**] and [**3-19**] the infant was given 1 gram per kilogram of
IVIG in the hopes of binding some of the antibody and that
the coated cells would not hemolyze as rapidly.
Hematocrit at first was 42 and by [**3-21**] it had come down to
24.3. At that time she received 20 cc per kilogram of packed
red blood cells, O negative, with negative C. She responded
well to that and her follow up hematocrit on [**3-23**] was 34.9.
She had several hematocrits thereafter and on [**4-14**]
her hematocrit was 24.7 and her reticulocyte count 4.4,
however because of tiring with feeds and ongoing choking
episodes she had her second PRB transfusion on [**4-16**] with her
last Hcton [**4-20**] of 39.
Her peak reticulocyte count was 11.4 but her earlier
reticulocyte counts were ranging between 2 and 11.8.
Hearing screen performed on [**4-1**] was normal.
Immunizations: Hepatitis B vaccine was administered on [**3-29**].
DISCHARGE MEDICATIONS; FerInSol 0.3 cc PO QD
PolyViSol 1cc PO QD
Infant is to be followed up at [**Hospital1 **] [**First Name4 (NamePattern1) 392**] [**Last Name (NamePattern1) **]
by Dr. [**First Name4 (NamePattern1) 2048**] [**Last Name (NamePattern1) **] within five days of discharge.
VNA to go to home day post discharge.
Weekly hematocrits to be followed until the infant is
approximately 6 weeks of age and at that time most maternal
antibody should no longer be present in a significant amount.
Infant to remain on home monitor for 1 month or at discretion
of pediatrician.
Because of transfusions, infant will need a repeat state
screen in [**1-7**] months.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 50-393
Dictated By:[**Last Name (NamePattern1) 38304**]
MEDQUIST36
D: [**2172-4-20**] 08:40
T: [**2172-4-20**] 08:42
JOB#: [**Job Number 54699**]
ICD9 Codes: 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8326
} | Medical Text: Admission Date: [**2117-6-8**] Discharge Date: [**2117-6-28**]
Date of Birth: [**2030-12-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
Weakness and falls
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
The patient is an 86 year old male with multiple medical issues
including previously treated follicular lymphoma, diastolic CHF,
paroxysmal atrial fibrillation, COPD no longer on home O2, and
CKD who was admitted to OSH on [**2117-6-6**] with weakness and falls
at home.
.
On that admission, he was found to be in atrial fibrillation
with labs notable for CK 500-600s, Calcium 12.5, PTH not
elevated, Creatinine 1.4, and HCT 27 (baseline in mid 30s). His
head CT head showed no acute process. He was given 1500 ml IV
fluids with improvement in his calcium to 10.7. He converted to
sinus rhythm at 70 bpm with vital signs stable. He was recently
being evaluated here for possible Nissen fundoplication, and was
transferred to [**Hospital1 18**] for further management of his anemia and
hypercalcemia.
.
On reaching the floor, he reported some recent dyspnea on
exertion and dizziness when standing. He denied any other acute
complaints. He notes that his activiy level has been declining,
and he no longer likes to walk around his home due to fatigue
and dyspnea. he uses a walker when he does ambulate. He was
previously on home oxygen for COPD, but no longer uses it. He
lives alone with support from his neighbors for shopping.
.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea, or
congestion. Denies cough. Denies chest pain, pressure,
tightness, or palpitations. Denies nausea, vomiting, diarrhea,
constipation, or abdominal pain. No recent change in bowel or
bladder habits. No dysuria or hematuria. No rashes or concerning
skin lesions. Denies arthralgias or myalgias. Review of systems
was otherwise negative.
Past Medical History:
# Follicular Lymphoma
-- advanced disease with pulmonary, pleural, kidney involvement
-- s/p 1.5 cycles of Bendamustine/Rituxan, last [**2116-1-2**]
-- complicated by acute CHF and rapid AFib during treatment
-- treatment held since then, but clinically stable
# Chronic diastolic CHF -- prior systolic CHF as well
-- most recent LVEF 55% ([**2116-4-13**]), prior TTE with LVEF 15%
([**2115**])
# Paroxysmal Atrial Fibrillation -- during chemotherapy
# Hypertension
# Chronic pleural effusions
# COPD -- previously on home oxygen
# Chronic Kidney Disease
# Renal Mass -- related to lymphoma
# BPH
# Hypothyroidism
# Paraesophageal hernia -- present for 10 years
# UGIB History
# Chronic Anemia -- requiring transfusions
# GERD
# Spinal compression fractures
# Right Inguinal Hernia Repair
# Macular degeneration
# Posterior vitrious detachment
# Cataracts s/p surgery
# compression fracutre T11, L1-L2 (s/p fall in [**Month (only) **])
Social History:
# Home: Lives alone, does not ambulate much in home. Uses walker
when he does. Neighbors help with shopping. Eats mostly premade
meals, does not cook much. VNA 1x per week on tues. puts meds
in boxes. 2 sons- [**Known firstname **], lawyer in [**Name2 (NI) **], hcp, full code.
other son in NJ is Urologist.
# Work: Retired
# Tobacco: Smoked 3 PPD for 25 years, quit in [**2075**]
# Alcohol: None
# Drugs: None
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
# Mother: Died from cancer, unsure of type.
# Father: Tuberculosis
# Sister: Unsure how she is doing.
Physical Exam:
ADMISSION
VS: T 98.4, BP 150/76, HR 74, RR 22, SpO2 95% on RA
Gen: Elderly male in NAD. Oriented x3. Mood, affect appropriate.
Hard of hearing.
HEENT: Sclera anicteric. Left pupil slightly smaller than right
but both reactive to light. Slight left lid ptosis. EOMI. MMM,
OP benign.
Neck: JVP not elevated. No cervical lymphadenopathy. No carotid
bruits noted.
CV: RRR with normal S1, S2. No M/R/G.
Chest: Respiration unlabored. Coarse breath sounds and few
scattered crackles without focal findings.
Abd: Bowel sounds present. Soft, NT, ND. No organomegaly or
masses.
Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses
intact radial 2+, DP 2+, PT 2+.
Skin: No rashes, ulcers, or other lesions noted.
Neuro: CN II-XII grossly intact. Strength 4/5 in left arm, [**5-22**]
in other limbs. No pronator drift. Normal rapid alternating
movements on right, slower on left. Performance of
finger-to-nose worse on left than right. Normal speech.
DISCHARGE:
VS: RR 16
Gen: Elderly male in NAD. Oriented x3.Hard of hearing. appears
comfortable
HEENT: Sclera anicteric. Left sided Horner's syndrome. OP -
moist w/ brownish plaque on tongue
Neck: JVP not elevated.
CV: RRR with normal S1, S2. soft systolic murmur across
precordium. ?diastolic murmur + S3 gallop
Abd: Bowel sounds present. Soft, NT, ND. No organomegaly or
masses.
Ext: WWP. No C/C/E. 2+ DP
Pertinent Results:
ADMISSION
[**2117-6-9**] 01:58AM BLOOD WBC-6.2 RBC-3.44* Hgb-10.0* Hct-31.7*
MCV-92# MCH-28.9 MCHC-31.4 RDW-13.1 Plt Ct-231
[**2117-6-9**] 01:58AM BLOOD Neuts-72.8* Lymphs-12.5* Monos-8.5
Eos-5.4* Baso-0.7
[**2117-6-9**] 01:58AM BLOOD Glucose-97 UreaN-17 Creat-1.3* Na-139
K-4.0 Cl-106 HCO3-20* AnGap-17
[**2117-6-9**] 01:58AM BLOOD ALT-19 AST-33 LD(LDH)-263* CK(CPK)-115
AlkPhos-67 TotBili-0.5
[**2117-6-9**] 01:58AM BLOOD Albumin-3.5 Calcium-10.7* Phos-3.2
Mg-1.4*
.
PERTINENT
[**2117-6-9**] 01:58AM BLOOD ALT-19 AST-33 LD(LDH)-263* CK(CPK)-115
AlkPhos-67 TotBili-0.5
[**2117-6-10**] 07:50AM BLOOD LD(LDH)-222
[**2117-6-9**] 11:00AM BLOOD CK-MB-4 cTropnT-<0.01
[**2117-6-9**] 01:58AM BLOOD CK-MB-5 cTropnT-<0.01
[**2117-6-9**] 01:58AM BLOOD TSH-3.1
[**2117-6-9**] 04:10AM BLOOD PTH-<6*
.
CHEST (PA & LAT) Study Date of [**2117-6-9**] 9:14 PM
As compared to the previous radiograph from [**2117-6-6**], there
is no relevant
change. The known left apical mass is obliterated by the soft
tissues of the
neck. Unchanged evidence of moderate cardiomegaly with moderate
pulmonary
edema and signs of interstitial fluid overload. Presence of a
small left
pleural effusion cannot be excluded. No newly appeared
parenchymal opacities.
.
CT CHEST W/O CONTRAST Study Date of [**2117-6-10**]
1. Left apical mass, substantially progressed since [**2117-3-21**] and chest radiograph from [**2117-1-17**], progressing into
the neck with multiple pulmonary metastases and liver
hypodensities, highly concerning for metastatic disease.
Findings are most likely representing Pancoast tumor, primary
lung malignancy. Lymphoma will be substantially less likely.
2. Unusual appearance of the left kidney, partially imaged with
this
technique which is not tailored for evaluation of renal disease.
If
clinically warranted, correlation with ultrasound or dedicated
CT or MR might be considered. Correlation with urine cytology
might also be beneficial.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
====================================
Mr. [**Known lastname 88299**] is an 86 year old male with multiple medical issues
including previously treated follicular lymphoma, paraesophageal
hernia, diastolic CHF, afib, COPD who was admitted to OSH on
[**2117-6-6**] with weakness and falls, during workup at [**Hospital1 18**] found to
have new diagnosis of metastatic cancer likely from the lung.
ACTIVE ISSUES:
==================
# L upper lung malignancy (Pancoast tumor):
Discovered on work-up of hypercalcemia with CT scan on [**6-13**].
Oncology consult thought likely primary lung cancer that has
metastasized to liver and R lung, less likely lymphoma. Oncology
gave a 6-month prognosis and recommended that pt would not be a
good candidate for treatment as he is too weak, did not tolerate
chemotherapy in the past, and biopsy would not be helpful as
treatment would not change despite the type of cancer.
Palliative care was consulted and contributed to his care.
# Goals of care:
Patient was made DNR/DNI during his stay. Multiple family
meetings were held throughout the admission with patient's son
[**Name (NI) **] (also healthcare proxy), Dr. [**Last Name (STitle) **] (palliative care),
Dr. [**First Name (STitle) 3459**] (oncologist), and medical team. Given the patient's
prognosis and after extensive discussion with the patient and
his son, his code status was change to "comfort measures only."
# Coffee ground emesis in setting of GERD with paraesophageal
hernia:
Pt began to experience symptoms during [**Date range (1) 88300**]. Differential
included gastritis, GERD causing upper GI bleed, hiatal hernia
(ulceration/gastritis/erosions), cancer metastasis invading into
upper GI mucosa, gastric outlet obstruction, or tumor impinging
on the emesis nerve tract (i.e. C3-5). NG tube was inserted, but
pt pulled it out in the MICU and refused to have it replaced.
Sucralfate and PPI were given to treat upper GI bleed. Aspirin
was discontinued. Pt was recently undergoing evaluation by
Thoracic Surgery for repair of a large paraesophageal hernia -
Dr. [**First Name (STitle) **] was peripherally involved in goals of care discussions
and decided not to operate in light of patient's current
clinical status and risk of possibly reducing the patient's
quality of life post-operatively and inability to wean off the
ventilator.
- Continue PPI and sucralfate for comfort
- Standing tylenol and fentanyl patch for pain control.
Hydromorphone PRN for breakthrough pain.
- Anti-emetics as needed for comfort (promethazine and zofran)
# Dyspnea in setting of aspiration pneumonitis:
Complicated by untreated COPD, hiatal hernia, and pulmonary mass
causing pulmonary compression from mass effect. He desaturated
on [**6-13**] and required MICU transfer and non-rebreather. However
his respiratory status improved rapidly suggesting aspiration.
In the MICU there was concern for HCAP, for which he was treated
with IV vancomycin and cefepime for 8 days. When vital signs
were last checked he was saturating in the low-mid 90s on 3L
nasal cannula.
- Continue Oxygen as needed for comfort
# Weakness and Falls:
His recent weakness and falls are most likely multifactorial.
His recent fall may have been related to atrial fibrillation,
weakness from hypercalcemia or anemia, and mechanical fall from
tripping. Orthostatics were negative.
# Hypercalcemia:
He was hypercalcemic at outside hospital with reportedly low
PTH. His hypercalcemia is likely related to new malignancy given
his known history of follicular lymphoma, ongoing anemia, and
elevated LDH. Fluids were given for hypercalcemia, which
improved during admission. Last checked Ca was 8.8 on [**6-16**]. No
further interventions were done since hypercalcemia did not
appear to be symptomatic.
# Hiccups:
Pt had recurrent hiccups making him extremely uncomfortable. He
is currently asymptomatic. Most likely from hiatal hernia
affecting diaphragm or mass pushing on vagus nerve. We treated
him with chlorpromazine 5 mg PO TID, which improved his hiccups.
- Continue chlorpromazine to reduce hiccups for comfort. Can
stop if patient is over-sedated or hiccups resolve.
# Anemia:
His hematocrit was roughly stable 25-30 without receiving any
transfusions during this admission. Transfusion was decided to
not be in lines with goals of care and labs were not drawn as of
[**2117-6-16**].
# Left Hand/Arm Pain: Most likely from brachial plexus
compression from pancoast tumor.
- Standing tylenol and fentanyl patch for pain control.
Hydromorphone PRN for breakthrough pain.
CHRONIC ISSUES:
==================
# Chronic Diastolic CHF: Throughout his stay he appeared
euvolemic with minimal LE edema or crackles. [**3-/2117**] EF of 50%.
Sodium restriction was eased as consistent with goals of care.
# Paroxysmal Atrial Fibrillation:
He was initially in AFib at OSH, which may have precipitated his
recent weakness and falls. He converted spontaneously at OSH and
was in sinus rhythm on arrival. He had negative troponins. He is
not currently on anticoagulation, and is likely not a good
candidate given his recent falls, poor functional capacity, and
goals of care. Aspirin was discontinued in setting of GI bleed.
Telemetry was discontinued as consistent with goals of care but
patient was in sinus rhythm prior to that.
- His metoprolol was stopped since not contributing to comfort.
If patient is having symptomatic palpitations, could consider
restarting metoprolol in the future.
# Hypertension: He was somewhat hypertensive on arrival, most
likely due to his pain. His metoprolol was stopped since not
contributing to hs comfort.
# Hypothyroidism: We continued his home Levothyroxine 50 mcg PO
DAILY. Can consider discontinuing this later if not contributing
to comfort.
TRANSITIONAL ISSUES:
=====================
# Dispo: being discharged to inpatient hospice.
# Contacts: hcp/son [**Known firstname **] [**Telephone/Fax (3) 88301**];
# Code Status: DNR/DNI, Comfort Measures Only.
Medications on Admission:
Aspirin 81 mg PO DAILY - on hold x months
Metoprolol Tartrate 50 mg PO TID
Hydralazine 20 mg PO TID
Furosemide 40 mg PO DAILY - on hold x months
Isosorbide Mononitrate ER 30 mg PO DAILY
Levothyroxine (LEVOXYL) 50 mcg PO DAILY
Omeprazole 20 mg PO BID -- unsure why two PPIs
Sucralfate 1 gram PO Q6H
Colace 100 mg PO BID PRN constipation
Multivitamin 1 tab PO DAILY
Discharge Medications:
1. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
2. fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. chlorpromazine 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
6. promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for nausea.
7. ondansetron HCl 4 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for nausea.
8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
9. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
10. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] House - [**Location (un) 13588**]
Discharge Diagnosis:
Primary diagnosis: lung malignancy, hypercalcemia, fall
Secondary diagnosis: diastolic heart failure,
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 88299**],
You were admitted to the hospital for evaluation of falls,
weakness, and high calcium levels. Unfortunately, we found that
the underlying cause of this was a lung tumor. After much
discussion, it was decided to focus on comfort and discharge you
to hospice.
Take care.
Followup Instructions:
N/A
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]
ICD9 Codes: 5070, 2851, 4254, 2930, 5119, 4280, 496, 5859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8327
} | Medical Text: Admission Date: [**2140-1-18**] Discharge Date: [**2166-2-26**]
Date of Birth: [**2102-12-24**] Sex: M
Service: Cardiac [**Doctor First Name **]
HISTORY OF PRESENT ILLNESS: This is a 63 year-old gentleman
with a known history of aortic valve disease, atrial
fibrillation and nonsustained ventricular tachycardia with
recent worsening of congestive heart failure. The patient
underwent cardiac catheterization on [**2166-1-17**] which showed
severe aortic regurgitation, mild aortic stenosis, left
ventricular ejection fraction of 20% with an elevated left
ventricular and diastolic pressure and no significant
coronary artery disease.
The patient was admitted on [**2166-2-14**] for elective aortic
valve replacement with Dr. [**Last Name (STitle) 1537**].
PAST MEDICAL HISTORY:
1. Aortic valve disease.
2. Rheumatic heart disease.
3. History of nonsustained ventricular tachycardia.
4. History of congestive heart failure with decreased
ejection fraction.
5. Asthma.
6. Obesity.
7. Sleep apnea.
8. Osteoarthritis.
9. History of syncope thought to be due to arrhythmias.
10. Questionable Amiodarone toxicity.
PREOPERATIVE MEDICATIONS:
1. Aspirin 325 milligrams po q day.
2. Nasacort two puffs q day.
3. Dulcolax q day.
4. Colace q day.
5. Flomax 0.8 milligrams po q HS.
6. Flovent two puffs [**Hospital1 **].
7. Lasix 40 milligrams po q day.
8. Lisinopril 5 milligrams po q day.
9. Naprosyn prn.
10. Potassium Chloride 20 milliequivalents po q day.
11. Serevent q day.
ALLERGIES: NKDA.
PREOPERATIVE PHYSICAL EXAMINATION: Pulse 80 regular rate and
rhythm. Blood pressure 120/60. The patient is awake, alert
and oriented times three. Neck - full range of motion. Chest
is clear. Cardiac - regular rate and rhythm. Neurologically
the patient is within normal limits.
LABORATORY DATA: EKG is sinus rhythm with elevated PR
interval.
Hematocrit 42.1, sodium 141, potassium 4.9, chloride 99,
bicarb 30, BUN 14, creatinine 0.9.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2166-2-14**] for an aortic valve replacement with a #[**Street Address(2) 15189**]. [**Male First Name (un) 923**] with Dr. [**Last Name (STitle) 1537**]. Transesophageal
echocardiogram intraoperatively after the valve was replaced
showed an ejection fraction of 50%. Please see operative
note for further details. The patient was transferred to the
Intensive Care Unit on Dobutamine, lidocaine which was
started intraoperatively for ventricular ectopy,
Neo-Synephrine and Propofol infusion in stable condition.
The patient was weaned and extubated on first postoperative
night. The patient continued on Dobutamine and lidocaine
infusion. Lidocaine was discontinued on his first
postoperative day. Dobutamine infusion was weaned off. The
patient remained in the Intensive Care Unit on postoperative
day one for hemodynamic monitoring.
On postoperative day two the patient was off all of his
infusions. The patient was started on Coumadin for
anticoagulation. The patient's chest tubes were removed. The
patient was transferred out of the Intensive Care Unit to
[**2-22**].
On postoperative day three electrophysiology service was
consulted due to the patient's history of nonsustained
ventricular tachycardia as well as atrial fibrillation. IT
was decided at that time since the patient had a history of
questionable Amiodarone toxicity with decreased pulmonary
function, Amiodarone would not be started. The patient will
be started on Digoxin for rate control of atrial
fibrillation. The patient had episode of rapid atrial
fibrillation which was treated with Amiodarone. The patient
also had multiple episodes of nonsustained ventricular
tachycardia for which the patient was asymptomatic.
Electrophysiology service was consulted. It was decided to
continue the patient on beta-blocker and Digoxin.
On postoperative day three Neurology was consulted as the
patient had noticed right eyelid drooping. The patient also
reported having sensation of tingling in his right hand that
had resolved since surgery. When the patient was examined by
Neurology he was found to have no visual changes. It was
thought that the right ptosis could be due to a hematoma on
the right side of his neck where his central line was placed.
He was also noted to have right finger extension abductor
weakness and right ulnar sensory loss which subsequently
improved. It was felt thought to be a mild peripheral
neuropathy. Neurology continued to follow him over several
subsequent days and felt that the patient continued to
improve. The patient continued to have rhythm disturbances
with nonsustained ventricular tachycardia and paroxysmal
atrial fibrillation. The patient remained hemodynamically
stable throughout.
The patient was presented with the options of medications for
rate control versus electrophysiology study and potential
defibrillator. The patient was in favor of rate control with
medications and to be monitored with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts
monitor. To be followed up by the electrophysiology team and
his cardiologist at a later date.
The patient was started on Heparin infusion on postoperative
day four as the patient was subtherapeutic with his
anticoagulation. The patient converted into sinus rhythm on
postoperative day seven. Although the patient continued to
have episodes of paroxysmal atrial fibrillation as well as
nonsustained ventricular tachycardia which the patient was
asymptomatic. The patient remained in the hospital on a
Heparin infusion as he continued to be subtherapeutic on his
anticoagulation from Coumadin. The patient was ambulating on
his own, working with Physical Therapy.
On postoperative day 12 the patient's INR was 2.2. The
patient was cleared for discharge to home.
DISCHARGE PHYSICAL EXAMINATION: Tmax 96.9F, pulse 60 sinus
rhythm, blood pressure 138/78, respiratory rate 18. Oxygen
saturation on room air 96%. The patient is awake, alert and
oriented times three. The patient has mild ptosis of the
right eye. The patient reports improved weakness and
numbness in his right hand. Otherwise the patient is
grossly, neurologically intact. Breath sounds are clear
bilaterally without wheezes or rhonchi. Heart is regular rate
and rhythm with sharp click, no murmur. Abdomen is obese,
soft, nontender. The patient is tolerating a regular diet.
Sterile incision has Steri strips intact. The wound is clean
and dry, no erythema or drainage.
LABORATORY DATA FROM [**2166-2-18**]: White blood cell count 6.6,
hematocrit 24, sodium 138, potassium 4.5, chloride 102,
bicarb 28, BUN 19, creatinine 0.8, glucose 93.
On [**2166-2-26**] the patient's PT is 17.6, INR 2.2.
DISCHARGE MEDICATIONS:
1. Lopressor 75 milligrams po bid.
2. Lasix 40 milligrams po q day.
3. KCL 20 milliequivalents po q day.
4. Colace 100 milligrams po bid.
5. Enteric coated aspirin 325 milligrams po q day.
6. Serevent two puffs [**Hospital1 **].
7. Flovent two puffs [**Hospital1 **].
8. Multi vitamin q day.
9. Flomax 0.8 milligrams po q day.
10. Digoxin 0.375 milligrams po q day.
11. Percocet 5/325 one to two tablets po q four hours prn.
12. Coumadin. The patient is to receive 15 milligrams on the
evening of [**2166-2-26**] and the evening of [**2166-2-27**]. The patient
is to have a PT INR drawn on [**2166-2-28**] and Coumadin dosing is
to be done by his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
DISCHARGE INSTRUCTIONS: The patient is to be discharged with
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor per the recommendations of the
electrophysiology service. Results will be called to his
cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 120**].
The patient is to follow up with his primary care physician
in two weeks. The patient is to follow up with Dr. [**Last Name (STitle) 1537**] in
three to four weeks.
The patient is to follow up with his cardiologist, Dr.
[**Last Name (STitle) 120**] in three to four weeks.
The patient is to continue to use his BiPAP machine for his
obstructive sleep apnea as he did preoperatively.
DISCHARGE DIAGNOSIS:
1. Status post aortic valve replacement.
2. History of atrial fibrillation.
3. Nonsustained ventricular tachycardia.
4. Decreased left ventricular ejection fraction.
5. Asthma.
6. Obstructive sleep apnea requiring BIPAP.
7. Obesity.
8. Osteoarthritis.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 3870**]
MEDQUIST36
D: [**2166-2-26**] 10:33
T: [**2166-2-26**] 11:08
JOB#: [**Job Number 15190**]
ICD9 Codes: 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8328
} | Medical Text: Admission Date: [**2197-6-14**] Discharge Date: [**2197-6-20**]
Date of Birth: [**2125-5-6**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
1. Abdominal pain
2. Shortness of breath
Major Surgical or Invasive Procedure:
[**2197-6-14**]: Cecectomy
History of Present Illness:
72yo F presents with a 2-day history of abdominal pain. Pain
initially developed on [**6-12**] in a periumbilical distribution.
Since that time, the pain has localized to the LUQ; though she
complains of generalized severe pain throughout her abdomen, the
pain is interrupted by especially painful knife-like sensations
in the LUQ. She has noted worsening nausea in the past few
hours, but has not yet vomited. Her last meal was at onset of
pain 2 days ago. She does not recall her last passing of flatus
or stool, but believes she did not have a bowel movement in the
last 24 hours. Her last colonoscopy was two years ago, and
negative. Denies fevers or chills.
Past Medical History:
COPD (emphysema and chronic bronchitis, not on home O2),
hypercholesterolemia, breast cancer (T2N0, ER positive), brain
aneurysm
PSH: R breast lumpectomy '[**81**]
Social History:
+ Tob, 2.5ppd x55y. social EtOH. patient is retired, works
as volunteer.
Family History:
Mother with lung cancer and MI, maternal uncle with [**Name2 (NI) 499**]
cancer, and maternal aunt with MI. maternal GM with breast
cancer
Physical Exam:
On Admission:
98.4 / 98.4 92 132/52 18 97% on 2L NC
Patient oriented x3, NAD but uncomfortable
Lungs have bilateral diminished breath sounds, slight wheezing
on
expiration.
RRR, mild tachycardia
Abdominal exam showed soft, non-distended abdomen, with
voluntary
guarding. Pain elicited most notably on moderate palpation in
LUQ
and periumbilical region. no rebound nor guarding.
DRE found no palpable abnormalities, nl tone, trace stool in
vault, guaiac negative.
WWP sans C/C/E
On Discharge:
VS: 96.6, 80, 126/64, 16, 96 4L n/c
Gen: NAD
CV: RRR with occasional Sinus tachycardia
Lungs: B/l diminished throughout
Abd: Midline incision with surgical staples, c/d/i
Ext: Warm, no c/c/e
Neuro: AO x 3
Pertinent Results:
[**2197-6-14**] 07:35AM GLUCOSE-133* UREA N-6 CREAT-0.4 SODIUM-139
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-29 ANION GAP-9
[**2197-6-14**] 07:35AM CALCIUM-7.6* PHOSPHATE-3.5 MAGNESIUM-1.5*
[**2197-6-14**] 07:35AM HCT-41.5
[**2197-6-14**] 04:36AM PT-11.9 INR(PT)-1.0
[**2197-6-14**] 03:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2197-6-14**] 03:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2197-6-14**] 12:00AM GLUCOSE-141* UREA N-11 CREAT-0.5 SODIUM-134
POTASSIUM-4.7 CHLORIDE-95* TOTAL CO2-28 ANION GAP-16
[**2197-6-14**] 12:00AM estGFR-Using this
[**2197-6-14**] 12:00AM LIPASE-14
[**2197-6-14**] 12:00AM ALBUMIN-4.2
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 9320**],[**Known firstname 420**] [**2125-5-6**] 72 Female [**-1/2209**]
[**Numeric Identifier 9321**]
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **]. ALMASHAT/dif
SPECIMEN SUBMITTED: [**Last Name (STitle) **].
Procedure date Tissue received Report Date Diagnosed
by
[**2197-6-14**] [**2197-6-14**] [**2197-6-16**] DR. [**Last Name (STitle) **]. SEPEHR/ttl
Previous biopsies: [**Numeric Identifier 9322**] SIGMOID [**Numeric Identifier **] POLYP/ok.
[**Numeric Identifier 9323**] SIGMOID POLYP.
[**Numeric Identifier 9324**] (Not on file)
DIAGNOSIS:
[**Numeric Identifier **], cecum, cecectomy:
- Unremarkable [**Numeric Identifier 499**].
- Unremarkable small intestine.
- One unremarkable lymph node.
[**2197-6-13**] EKG:
Normal sinus rhythm. RSR' pattern in leads V1-V2 with QRS
duration
of 78 milliseconds. Compared to the previous tracing of [**2197-3-7**]
no
diagnostic interval change.
[**2197-6-14**] CT ABD:
IMPRESSION:
1. Cecum appears to be flipped and is in the left upper
abdominal quadrant
concerning for cecal volvulus in appropriate clinical setting.
Surgical
consult recommended.
2. Diverticulosis with no evidence of diverticulitis.
3. Left adrenal nodule, incompletely characterized. MRI
recommended in a
nonurgent setting.
4. Gallbladder fundal thickening, likely adenomyomatosis.
5. Calcified fibroid uterus.
[**2197-6-15**] Chest CTA:
IMPRESSION:
1. New bilateral small- to moderate-sized pleural effusions with
interlobular thickening suggest a degree of volume overload. In
addition, area of bronchial plugging involving the right lower
lobe with nonspecific
consolidation that could relate to atelectasis and aspiration,
though early pneumonia is not excluded.
2. Severe emphysema.
3. No evidence of pulmonary embolism to the subsegmental levels.
[**2197-6-15**] EKG:
Atrial fibrillation with rapid ventricular response at
approximately 150.
Borderline low voltage. Delayed precordial R wave progression,
possibly normal variant. Non-specific repolarization
abnormalities. Compared to the previous tracing of [**2197-6-15**] sinus
tachycardia at a rate of 115 has given way to atrial
fibrillation at a rate of 150.
[**2197-6-17**]: CHEST XRAY:
Cardiomediastinal contours are normal. Small bilateral pleural
effusions
larger on the left side are unchanged. The component of the
pulmonary edema has resolved. Persistent, unchanged opacities in
the left lower lobe and lingula are consistent with infectious
process. It is unchanged though from prior study.
Test Name Value Reference Range Units
[**2197-6-20**] 06:35
COMPLETE BLOOD COUNT
White Blood Cells 8.2 4.0 - 11.0 K/uL
PERFORMED AT WEST STAT LAB
Red Blood Cells 3.95* 4.2 - 5.4 m/uL
PERFORMED AT WEST STAT LAB
Hemoglobin 12.1 12.0 - 16.0 g/dL
PERFORMED AT WEST STAT LAB
Hematocrit 38.0 36 - 48 %
PERFORMED AT WEST STAT LAB
MCV 96 82 - 98 fL
PERFORMED AT WEST STAT LAB
MCH 30.7 27 - 32 pg
PERFORMED AT WEST STAT LAB
MCHC 31.9 31 - 35 %
PERFORMED AT WEST STAT LAB
RDW 13.0 10.5 - 15.5 %
PERFORMED AT WEST STAT LAB
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 300 150 - 440 K/uL
PERFORMED AT WEST STAT LAB
[**2197-6-20**] 06:35
RENAL & GLUCOSE
Glucose 101* 70 - 100 mg/dL
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
PERFORMED AT WEST STAT LAB
Urea Nitrogen 6 6 - 20 mg/dL
PERFORMED AT WEST STAT LAB
Creatinine 0.3* 0.4 - 1.1 mg/dL
PERFORMED AT WEST STAT LAB
Sodium 139 133 - 145 mEq/L
PERFORMED AT WEST STAT LAB
Potassium 4.2 3.3 - 5.1 mEq/L
PERFORMED AT WEST STAT LAB
Chloride 99 96 - 108 mEq/L
PERFORMED AT WEST STAT LAB
Bicarbonate 34* 22 - 32 mEq/L
PERFORMED AT WEST STAT LAB
Anion Gap 10 8 - 20 mEq/L
CHEMISTRY
Calcium, Total 8.3* 8.4 - 10.3 mg/dL
PERFORMED AT WEST STAT LAB
Phosphate 3.7 2.7 - 4.5 mg/dL
PERFORMED AT WEST STAT LAB
Magnesium 1.8 1.6 - 2.6
Brief Hospital Course:
General Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment. On [**2197-6-14**], the patient underwent
cecectomy, which went well without complication (reader referred
to the Operative Note for details). After a brief, uneventful
stay in the PACU, the patient arrived on the floor NPO, on IV
fluids and antibiotics, with a foley catheter, and epidural
analgesia for pain control. The patient was hemodynamically
stable.
Neuro: The patient received Dilaudid PCA with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications. Patient continue to
take 2-6 mg Dilaudid PO.
CV: Patient was stable from cardiac standpoint after surgery,
with RRR and occasional sinus tachycardia. On [**6-18**] patient
developed an onset of rapid a-fib with HR up to 150s. Patient
was started on IV Metoprolol, and she was reversed to regular
rhythm. After been transitioned to PO Lopressor on [**6-19**], patient
had several episodes of sinus tachycardia, which was resolved
with IV Lopressor. Since [**2197-6-19**] the patient remained stable
from a cardiovascular standpoint. She continued on Metoprolol 25
mg TID.
Pulmonary: Patient had a long history of COPD and smoking. She
denies use of supplemental O2 at home, but reported feeling SOB
with minimal activities. Post surgery patient was on 3-4L O2 and
on POD# 1 desaturated to 80s. Patient was transferred in ICU to
r/o PE. Chest CT was negative for emboli, but revealed b/l
pulmonary edema. Patient was started on nebulizers and chest PT.
Her pulmonary function improved and she was transferred back to
the floor. Currently patient continue to use 3-4L via nasal
cannula with stable O2 Sats 95-97%. Patient advised to follow up
with her PCP regarding home O2 use.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Wound has staples,
which need to be removed on [**6-24**] and replaced with steri
strips.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Lipitor
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) INH
Inhalation Q6H (every 6 hours) as needed for wheezing/sob.
2. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) INH Inhalation q6h () as needed for wheezing.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
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) as needed for constipation.
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation.
8. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Lipitor 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] House Rehabilitation & Nursing Center - [**Location (un) 5087**]
Discharge Diagnosis:
1. Cecal volvulus
2. COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-22**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed in Rehab on [**2197-6-24**]
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
Follow up with your primary care doctor regarding a nodule on
the upper part of your right lung that was seen on chest x-ray
in [**2-15**] weeks after discharge.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 3201**]
Date/Time:[**2197-7-7**] 2:00. [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**]
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2038**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2197-8-7**] 11:00
Completed by:[**2197-6-20**]
ICD9 Codes: 9971, 2720, 3051, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8329
} | Medical Text: Admission Date: [**2145-8-28**] Discharge Date: [**2145-9-12**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7223**]
Chief Complaint:
Pre-syncope
Major Surgical or Invasive Procedure:
1.Pacemaker placement
2. Surgical evacuation of Hematoma at pacemaker site
History of Present Illness:
The patient is a [**Age over 90 **]-year-old male with a past medical history of
atrial fibrillation, Hypertension and has a mechanical aortic
valve which was placed approximately 30 years ago for a "leaky"
aortic valve per patient. The patient is on home Coumadin
therapy for his atrial fibrillation and valve. He presented to
the emergency room complaining of multiple presyncopal episodes.
The patient describes these episodes as sudden occurences of
lightheadedness while sitting at the table. He would then set
his head down on the table and within seconds the symptoms would
resolve. These episodes occur at rest and never happen when the
patient is walking or up and about and more active. He denies
palpitations, chest pain, shortness of breath, and he has no
associated nausea or vomiting. These episodes have occurred [**12-27**]
x in the past week. No related orthopnea, PND, or edema.
.
Pt was recently admitted to the cardiology service for similar
episodes. It was felt that his episodes were due to bradycardia
secondary to severe HTN up to SBP 220s. The patient was started
on lisinopril, amlodipine and HCTZ. Upon discharge, HR ranged in
70s, SBP in 130s. Of note, the patient has been inadvertently
taking [**11-25**] his prescribed dose of amlodipine prescribed over the
past week.
.
In the ED, initial vital signs were: Temp 97.1 F, Pulse Rate 48,
BP 180/72 and RR 18, oxygen saturation 100% RA. His HR ranged
from 40-60 in slow atrial fibrillation. On telemetry, he
reportedly had occasional pauses of up to 3-5 seconds, but he
remained asymptomatic during these pauses.
.
On the floor the patient promptly triggered for marked nursing
concern and persistent HR < 40. Patient had multiple [**2-27**] second
pasuses on telemetry with narrow junctional escape beats.
Cardiology was consulted who recommended deferring temporary
pacing wire given elevated INR and history of mechanical valve.
Patient was transferred to CCU for closer observation and
monitoring overnight. On arrival to CCU patient denied chest
pain, SOB, PND, orthopnea, LE Swelling, syncope or other
complaints.
Past Medical History:
1. CARDIAC RISK FACTORS:: Hypertension
2. CARDIAC HISTORY: No interventions in past.
3. OTHER PAST MEDICAL HISTORY:
- Atrial fibrillation, on coumadin, no beta-blocker
- HTN
- Aortic valve replacement 30 years ago on coumadin
- Chronic Kidney Disease, Baseline Cr 1.5-1.8
- Emphysema by CXR - no O2 requirement, no medical therapy.
Social History:
Patient lives in [**Location 47**] with his wife in his own home. 45
pack year smoking history. Quit 30 years ago.
Family History:
non contributory
Physical Exam:
Vitals: T 97.8, BP 147/78, HR 59, RR 18, O2 sat: 98% on RA
Gen: Well appearing, NAD.
HEENT: NCAT.Sclera anicteric. No pallor or cyanosis.
Neck: Supple. No [**Doctor First Name **], no JVD.
Cardiac: no rubs/gallops, systolic murmur with audible
mechanical click
Lungs: Breathing comfortably at rest, No crackles or wheezes.
Abdomen: Soft, NT, ND. No masses. No rebound or guarding.
Extremities: Warm, well perfused. No edema. Good distal pulses.
Neuro: A+Ox3. CN 2-12 intact and symmetric. Grossly non focal.
Able to move all extremities.
Pulses: dopplerable LE pulses, femoral 1+ b/l, radial 2+ b/l
Carotids: Audible mechanical murmur, no bruits.
.
At time of discharge:
Pt's Exam is unchanged except for extensive erythema and edema
of left arm secondary to tracking of blood associated with pace
maker insertion. He has a palpable, but small hematoma
surrounding his pacer site which is bandaged.
Pertinent Results:
[**2145-8-28**] : EKG: Atrial fibrillation with bradycardia HR 40-50bpm,
left axis, no hypertrophy, mildly peaked T-waves, no acute ST-T
changes
.
TELEMETRY [**2145-8-28**]: Bradycardia with junctional escape, frequent
pauses of [**2-27**] seconds duration
.
[**2145-8-30**] TTE / ECHO : (no priors for comparison) The left atrium
is elongated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. A mechanical aortic valve
prosthesis is present. The discs appear to move, but the
transaortic gradient is higher than expected for this type of
prosthesis (unless very small prosthesis - details unknown). .
Mild (1+) aortic regurgitation is seen. [The amount of
regurgitation present is normal for this prosthetic aortic
valve.] The mitral valve leaflets and supporting structures are
thickened. No mitral stenosis. Moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is borderline pulmonary artery systolic pressure. There is
no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Well seated aortic valve prosthesis with slightly increased
gradient. Increased PCWP. Moderate mitral regurgitation.
Borderline pulmonary artery systolic hypertension.
[**2145-8-31**] CXR post-pacemaker placement: Single-chamber pacemaker
lead ending in the right ventricle. The rest of the study is
grossly unchanged compared to the previous scan.
[**2145-8-28**] 05:40PM BLOOD WBC-4.9 RBC-3.22* Hgb-10.8* Hct-32.3*
MCV-100* MCH-33.5* MCHC-33.5 RDW-13.9 Plt Ct-140*
[**2145-8-29**] 05:55AM BLOOD WBC-4.9 RBC-2.79* Hgb-9.9* Hct-27.5*
MCV-99* MCH-35.6* MCHC-36.0* RDW-13.8 Plt Ct-117*
[**2145-9-10**] 01:25PM BLOOD WBC-4.7 RBC-2.64* Hgb-8.8* Hct-25.7*
MCV-98 MCH-33.2* MCHC-34.1 RDW-17.6* Plt Ct-253
[**2145-9-11**] 05:50AM BLOOD WBC-5.7 RBC-2.74* Hgb-9.1* Hct-26.8*
MCV-98 MCH-33.0* MCHC-33.7 RDW-17.2* Plt Ct-240
[**2145-8-29**] 12:46AM BLOOD PT-23.1* PTT-35.7* INR(PT)-2.2*
[**2145-9-8**] 07:00AM BLOOD PT-15.2* PTT-29.7 INR(PT)-1.3*
[**2145-9-11**] 05:50AM BLOOD PT-23.6* INR(PT)-2.3*
[**2145-8-28**] 05:40PM BLOOD Glucose-87 UreaN-40* Creat-1.8* Na-138
K-4.9 Cl-103 HCO3-28 AnGap-12
[**2145-9-11**] 05:50AM BLOOD Glucose-86 UreaN-39* Creat-1.6* Na-142
K-4.5 Cl-109* HCO3-26 AnGap-12
[**2145-8-29**] 05:55AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2145-8-28**] 05:40PM BLOOD VitB12-791 Folate-GREATER TH
[**2145-9-9**] 05:10PM BLOOD Triglyc-54 HDL-50 CHOL/HD-2.7 LDLcalc-73
[**2145-8-29**] 05:55AM BLOOD TSH-2.5
[**2145-8-28**] 05:40PM BLOOD Digoxin-<0.2*
Brief Hospital Course:
In summary, Mr. [**Known lastname 11679**] is a [**Age over 90 **]-year-old male with PMH atrial
fibrillation, HTN, and s/p AVR on coumadin who presented with
pre-syncope, bradycardia and prolonged pauses on telemetry/EKG
and was referred to the EP team at [**Hospital1 18**]. Ultimately, after
evaluation it was felt that Mr. [**Known lastname 11679**] would benefit from a
pacemaker. He underwent surgery on [**2145-8-31**] and had a local
complication of a left anterior subclavian and anterior shoulder
region small hematoma after his procedure with some additional
ecchymotic tracking down his left arm. He was given a pressure
dressing and warm compresses for comfort after the procedure.
Throughout this time he had a slight dip in his Hct levels from
29-30 range to 25-26 range but was hemodynamically stable and
did not require transfusion. Discharge delayed by hematoma and
by subtherapeutic INR. Pt has a INR goal of 2.5 to 3.0 given his
atrial fibrillation, advanced age, hypertension, and mechanical
valve.
.
# Rhythm: pt persistently in Atrial fibrillation. Ventricular
rate maintained in the 60-70 range by pacer. Pt not orthostatic
or lightheaded. Will need to maintain INR of 2.5 to 3.0 given
Atrial-fib and valve. INR will be followed by PCP who followed
INR prior to this admission.
- Pt will f/u with Dr. [**First Name (STitle) 1075**] at [**Hospital1 **].
.
# CAD: No known CAD, no e/o active ischemia by EKG and no prior
infarcts on ECG.
- Ruled out MI, 2 sets cardiac enzymes negative
.
#Presyncope: Likely [**12-26**] to bradycardia. No syncope or falls.
- Negative w/u for other causes with U/A, UCx, CXR, ECHO, B12,
TSH level
.
# HTN: adequately controlled at the time of discharge in the SBP
range of 110 to 135
.
# s/p Aortic Valve Replacement: INR goal 2.5-3 as above
.
# Chronic renal failure: Cr at baseline of 1.5-1.8 during
hospitalization
.
# Follow-up: Pt has appt's with Cardiology and PCP. [**Name10 (NameIs) **] family
is actively involved in his healthcare and is aware of these
appts and the need for close follow-up of INR.
Medications on Admission:
HCTZ 25 mg
Amlodipine 10 mg dialy
Lisinopril 40 mg daily
Warfarin 2.5 mg daily
Lanoxin 0.125 mg daily
Discharge Medications:
1. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic Q6H (every 6 hours): continue until you see
your opthamologist.
Disp:*1 tube* Refills:*2*
5. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q12H (every
12 hours) as needed for pain.
7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours): Stop taking after [**2145-9-15**].
Disp:*8 Capsule(s)* Refills:*0*
8. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QHS
(once a day (at bedtime)).
9. Outpatient Lab Work
Please check INR, Hct on [**2145-9-13**] and call results to Dr. [**Name (NI) 79783**] office.([**Telephone/Fax (1) 79784**]
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Atrial Fibrillation and Bradycardia requiring pacemaker
placement
Mechanical AVR
Hypertension
Infected left tear duct
Discharge Condition:
The patient was stable at time of discharge with no complaints
of left pacemaker site pain, no chest pains, dizziness or
palpitations. Hematoma site improved.
INR 2.5
Hct 26.5
BUN 33 and Cr 1.5
Discharge Instructions:
You had a very low heart rate and required a pacemaker. Please
don't move your left arm over your head or tuck in your shirt
for the next 6 weeks. No lifting more than 5 pounds for 6 weeks.
Keep the bandage dry, no showers until after you see the [**Hospital **]
Clinic physicians at [**Hospital1 18**] for a follow-up pacemaker appointment
on [**2145-9-14**]. You can also follow-up with Dr. [**First Name (STitle) 1075**] for ongoing
pacemaker management. You may take a bath as long as the pacer
dressing stays dry. You had some bleeding around the pacer site
and into your left arm and needed some fluid and blood to keep
your blood pressure up.
.
New medicines: You can
.
Please stop these medicines: You can stop taking your previous
Lanoxin medication.
Followup Instructions:
Cardiology:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**], MD Phone: [**Telephone/Fax (1) 6256**] Date/Time: 3:30pm on [**9-17**], please call the office if this time is not possible, but
you must see Dr. [**First Name (STitle) 1075**] at some point next week.
[**Hospital1 18**] EP Follow-up appointment : Please return to the [**Location (un) 436**]
of the [**Hospital 23**] Clinic Building at [**Hospital1 18**] on [**2145-9-14**] at 10am for
a follow-up appointment to check your pacemaker and hematoma.
.
Primary Care:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17234**], MD Phone: ([**Telephone/Fax (1) 79784**] Date/time: pt's family
will call for an appt. Please continue to follow your INR level
with your Coumadin therapy with a goal INR of 2.5-3.5.
.
Opthamology:
Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2145-9-13**]
2:30pm at the [**Hospital 18**] [**Hospital **] Clinic
Completed by:[**2145-9-20**]
ICD9 Codes: 5849, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8330
} | Medical Text: Unit No: [**Numeric Identifier 70342**]
Admission Date: [**2181-11-10**]
Discharge Date: [**2181-12-7**]
Date of Birth: [**2181-11-10**]
Sex: F
Service: Neonatology
IDENTIFICATION: [**Known lastname 45731**] [**Known lastname **]-[**Known lastname **] is a 27 day old former 32
[**12-30**] wk infant who is being discharged from the [**Hospital1 18**] NICU.
HISTORY: The patient is a 32 and [**12-30**] week baby who was
delivered at 1350 grams who was admitted to the neonatal ICU
for prematurity. She was delivered to a 31 year old G3, P1,
now 2 mother with the following prenatal screens: Maternal
[**Month/Day (4) 41770**] positive with anti-[**Doctor Last Name **] B. Maternal blood type was
AB+, hep B surface antigen negative, RPR nonreactive, rubella
immune, GBS status unknown. Pregnancy was complicated by
pregnancy induced hypertension and fetal IUGR first noted at
28 weeks of pregnancy. She was betamethasone complete on
[**2181-10-14**]. Mom has a history of HSV with the last
recorded outbreak in [**2180-11-23**]. Maternal obstetric
history is also notable for a prior fetal loss at 25 weeks
gestation in [**2177**]. She has a history of a 34 week male
infant delivered 10 years ago in [**Country 6171**].
This infant was delivered via C-section for concerning fetal
decelerations and breech fetal positioning.
In the delivery room, the patient's Apgars were 6 and 8. She
received PPV in the OR. In the NICU, her weight was noted to
be 1350 grams, 10-25th percentile, length 39.5 cm, 10-25%
percentile, head circumference 28 cm, 10-25% percentile.
There were no other dysmorphologies noted.
HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: The infant received blow-by oxygen in the delivery
room and then transitioned quickly to RA. Since that time, she
has been stable in RA without significant work of breathing. She
did experience apnea of preamturity, not requiring caffeine
therapy, and by the time of discharge, she had been without
spells for greater than 5 days (last [**11-30**]).
CARDIOVASCULAR: She never received any pressors. A soft
intermittent murmur was heard over the course of hospitalization.
Evaluation on [**12-3**] with EKG, CXR, 4-extremity blood pressures,
and pre/post-ductal saturations was unremarkable. If the murmur
persists, outpatient evaluation with cardiology can be
considered.
FEN/GI: The patient was initially maintained on IVF and
parenteral nutrition. An umbilical venous catheter was placed
after birth and removed day of life 7. She was begun on enteral
feedings on day of life [**12-25**], advanced to full enteral feeding
by day of life 9 without difficulty, and was subsequently
advanced to breast milk supplemented to 28 calories per oz. On
day of life 16, [**11-26**], she developed significant abdominal
distension with increased aspirates, but otherwise remained
well-appearing. CBC and cx were done, which were unremarkable.
KUB was notable for mildly distended loops. She was made NPO for
approximately 24 hours, with improvement in exam following large
stool. Feedings were restarted and advanced to breast milk 26
calories/oz supplemented with HMF and MCT oil. Infant was
gradually transitioned from PG feeds to PO feeds, achieving all
PO feeds by [**Date range (1) 70343**]. In anticipation of discharge, feedigns
were changed to breast milk 26 calories/oz supplemented with
neosure powder. On [**11-9**], however, infant developed guiac
+ stools; no visible blood was seen, although some stools were
noted to have mucous. Infant remained well-appearing with no
other signs of feeding intolerance, and feedings were changed to
breast-milk 26 supplemented with nutramigen powder for presumed
protein intolerance. Mother's diet has very limited dairy. By
the time of discharge, infant continues to appear well with
adequate intake, although stools remain guiac positive. Further
monitoring in hospital for [**12-25**] additional days to insure feeding
tolerance was discussed with mother, but family preferred
discharge on [**12-7**] with outpatient follow-up. Discharge weight
was 1835 grams.
HEME: Last hematocrit was drawn on [**11-26**] and was 32.6.
Infant did not receive any transfusions, and was maintained on
supplemental iron. Her max bilirubin was 6.3 noted on day of
life 3. She received phototherapy for 4 days. As mentioned
previously, maternal blood type is AB+ with anti-[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 41770**]. Baby's blood type was A-/Coombs-.
ID: Infant underwent sepsis evaluation after birth and again on
day of life 16, with cultures negative on both occasions.
NEURO: Day of life 9 head ultrasound was performed which was
normal on [**11-19**].
SENSORY: She passed her hearing screen on [**2181-12-4**].
OPHTHALMOLOGY: Eyes were examined most recently on
[**11-26**] revealing immaturity of the retinal vessels in zone
III, but no ROP. A follow up exam has been scheduled for [**12-25**].
DISCHARGE DISPOSITION: Home.
Primary pediatrician will be Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Hospital2 70344**] [**Hospital3 37830**]. The phone number there is [**Telephone/Fax (1) 70345**]. Fax number is [**Telephone/Fax (1) 37833**].
CARE RECOMMENDATIONS:
DIET: Feeds at discharge will be mother's milk 20 supplemented to
26 kcal with Nutramigen powder.
MEDICATIONS:
1. Iron O.3 mL (25 mg/mL) po qd.
2. Goldmine multivitamins 1 mL po qd.
RHCM: Car seat safety screening passed [**12-5**]. Hepatitis B
vaccine #1 given [**12-6**]. Synagis given [**12-7**]. Newborn screens
were sent per protocol, last on [**11-25**]; no abnormal results have
been reported to date.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 3 criteria:
1. Born at less than 32 weeks.
2. Born between 32 and 35 weeks with 2 of the following:
Daycare during RSV season, smoker in the household,
neuromuscular disease, airway abnormalities, or school
age siblings.
3. Chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers.
FOLLOW UP APPOINTMENTS RECOMMENDED:
1. VNA in [**12-25**] days.
2. Primary pediatrician in 3 days.
3. Dr. [**Last Name (STitle) **], ophthalmology, [**12-25**].
DISCHARGE DIAGNOSES:
1. Prematurity at 32 weeks.
2. Intrauterine growth retardation, small for gestation age
infant.
3. Sepsis evaluation.
4. Apnea of prematurity.
5. Presumed protein intolerance.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Last Name (NamePattern1) 66322**]
MEDQUIST36
D: [**2181-12-6**] 17:16:24
T: [**2181-12-6**] 18:34:00
Job#: [**Job Number 70346**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8331
} | Medical Text: Admission Date: [**2126-4-12**] Discharge Date: [**2126-4-14**]
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
EKG changes
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2126-4-12**]
History of Present Illness:
86 yo female with COPD, pulm HTN, TR who presented to OSH after
a stranger knocked into her at her [**Hospital3 **] facility
causing her to fall and fracture her left hip. She did not have
any LOC. In addition, she sustained a laceration to her right
lower leg and received 6 stiches at OSH. At OSH, pt had CT scan
of Left hip which showed a cervical neck fracture of the left
proximal femur. She had a routine pre-op evaluation; however
her pre-op EKG showed ST elevations in V2-V4. The patient was
completely asymptomatic. She denied chest pain or pressure.
Her SOB was at baseline. She did have some nausea, vomiting and
diaphoresis at the OSH. She was transferred to [**Hospital1 18**] for
cardiac cath. Her cardiac cath earlier today showed clean
coronaries. The patient tolerated the procedure without
complication. The orthopedic team was consulted for management
of her hip fracture.
.
The patient denies any chest pain or pressure currently. She
reports that she does not want to undergo hip repair despite
being informed of the risks. She refuses to go to get x-rays
for further evaluation.
.
ROS: She denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, or hemoptysis. She denies recent
fevers, chills or rigors. She denies exertional buttock or calf
pain. Has occasional abdominal pain, alternating diarrhea and
constipation but has not had a colonoscopy, occasional blood in
stool with straining.
.
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:
Pulmonary HTN
Tricuspid regurgitation
CPD
Osteoporosis c/b thoracic spine fracture resulting in chronic
mid back pain
Hypertension
h/o pyelonephritis
h/o left hydronephrosis of uncertain eitology
h/o pneumonia - required stay in rehab prior to transfer to
[**Hospital3 **]
s/p appendectomy
s/p oophrectomy
Social History:
She lives in an [**Hospital3 **] facility at [**Location (un) 582**]. Had been
living independently until 3 months ago when she had a pneumonia
and required inpatient rehab prior to her transfer to [**Hospital 4382**]. Son is an administrator and internist at [**Hospital1 3325**]. Has 2 daughters who live locally.
-Tobacco history: She started smoking as a teenager and quit
smoking 3 months ago.
-ETOH: denies
-Illicit drugs: denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T=98.1 BP=102/49 HR=63 RR=15 O2 sat=96% 4L
GENERAL: thin elderly female 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 no JVD.
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: LLE shortened and externally rotated. 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:
[**2126-4-12**] 09:28PM BLOOD WBC-10.4 RBC-3.87* Hgb-12.0 Hct-36.9
MCV-95 MCH-31.0 MCHC-32.5 RDW-13.5 Plt Ct-259
[**2126-4-13**] 03:58AM BLOOD WBC-10.5 RBC-3.75* Hgb-11.7* Hct-35.4*
MCV-94 MCH-31.2 MCHC-33.1 RDW-13.4 Plt Ct-235
[**2126-4-12**] 09:28PM BLOOD Glucose-123* UreaN-27* Creat-1.2* Na-132*
K-5.5* Cl-101 HCO3-26 AnGap-11
[**2126-4-13**] 03:58AM BLOOD Glucose-105 UreaN-28* Creat-1.2* Na-133
K-5.5* Cl-101 HCO3-28 AnGap-10
[**2126-4-13**] 01:24PM BLOOD Glucose-158* UreaN-27* Creat-1.1 Na-135
K-4.2 Cl-103 HCO3-25 AnGap-11
[**2126-4-12**] 09:28PM BLOOD CK(CPK)-52
[**2126-4-13**] 03:58AM BLOOD CK(CPK)-41
[**2126-4-13**] 01:24PM BLOOD proBNP-[**Numeric Identifier 82170**]*
[**2126-4-12**] 09:28PM BLOOD Mg-1.9
[**2126-4-13**] 03:58AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.0
[**2126-4-13**] 01:24PM BLOOD Mg-1.8
[**2126-4-12**] 02:26PM BLOOD Type-ART O2 Flow-100 pO2-319* pCO2-58*
pH-7.26* calTCO2-27 Base XS--1
[**2126-4-12**] 02:46PM BLOOD Type-ART pO2-74* pCO2-54* pH-7.27*
calTCO2-26 Base XS--2 Intubat-NOT INTUBA
.
Cardiac Catheterization [**2126-4-12**]
1. Coronary angiography in this right-dominant system revealed:
--the LMCA had no angiographically apparent disease
--the LAD had no angiographically apparent disease
--the LCX had no angiographically apparent disease
--the RCA had a calcified proximal 50% stenosis.
2. Limited resting hemodynamics revealed elevated systemic
arterial
systolic pressures, with SBP 156 mmHg.
FINAL DIAGNOSIS:
1. No obstructive CAD
2. Moderate systemic arterial systolic hypertension.
.
[**2126-4-12**] TTE
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: 4.7 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.3 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.1 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 1.8 cm
Left Ventricle - Fractional Shortening: 0.42 >= 0.29
Left Ventricle - Ejection Fraction: 70% >= 55%
Left Ventricle - Lateral Peak E': 0.10 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 9 < 15
Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 1.3 m/sec
Mitral Valve - E/A ratio: 0.62
Mitral Valve - E Wave deceleration time: 235 ms 140-250 ms
TR Gradient (+ RA = PASP): *59 to 66 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Increased IVC
diameter (>2.1cm) with <35% decrease during respiration
(estimated RA pressure (10-20mmHg).
LEFT VENTRICLE: Normal LV wall thickness. Small LV cavity.
Overall normal LVEF (>55%). No resting LVOT gradient.
RIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. Borderline
normal RV systolic function. Abnormal systolic septal
motion/position consistent with RV pressure overload.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root.
AORTIC VALVE: Moderately thickened aortic valve leaflets.
Minimal AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate mitral annular calcification. Mild thickening of mitral
valve chordae. Calcified tips of papillary muscles. No MS. LV
inflow pattern c/w impaired relaxation.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Normal tricuspid valve supporting structures. No TS. Moderate to
severe [3+] TR. Severe PA systolic hypertension.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is normal in size. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity is small. Overall left
ventricular systolic function is normal (LVEF 70%). The right
ventricular free wall is hypertrophied. The right ventricular
cavity is dilated with borderline normal free wall function.
There is abnormal systolic septal motion/position consistent
with right ventricular pressure overload. The aortic valve
leaflets are moderately thickened. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. The left ventricular inflow pattern suggests impaired
relaxation. The tricuspid valve leaflets are mildly thickened.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is severe pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
[**2126-4-13**] CXR
The lung volumes are near normal, the hemidiaphragms are
relatively low, but not flattened. Moderate scoliosis leads to
asymmetry of the rib cage. In both lungs, right more than left,
a reticular pattern of opacities is seen in both perihilar
regions and in the right upper region. Without comparison, the
nature of these lesions is difficult to determine, they could be
the result of fibrotic or a chronic inflammatory process, but
could also result from chronic overhydration.
Moderately enlarged cardiac silhouette, slightly enlarged right
and left
hilus, potentially suggesting pulmonary hypertension. No
evidence of pleural effusions, no acute overhydration. Bilateral
apical thickening.
.
[**2126-4-13**] Lower extremity doppler U/S
Preliminary Report !! WET READ !!
no dvt seen in either lower extremity
.
[**2126-4-13**] CTA CHEST
Preliminary Report !! PFI !!
Pulmonary embolus within the right middle lobe segmental artery.
Bilateral pleural effusions. Extensive COPD, cardiomegaly,
vascular calcifications. Areas of increased opacity in the right
upper lobe may represent infection. Additional areas of opacity
in the right middle lobe may represent infarct or atelectasis.
Brief Hospital Course:
1) EKG changes - Perioperative EKG prior to transfer to [**Hospital1 18**]
showed ST elevations in V3-V4 and to a lesser extent in
II,III,F,V5-V6. TnI was 1.9 with normal CK. She was given
aspirin, plavix, lovenox, and lopressor. A similar EKG was
obtained upon transfer to [**Hospital1 18**]. Cardiac cath [**4-12**] revealed a
right-dominant system with a calcified 50% proximal stenosis in
the RCA but no angiographically apparent disease in the LMCA,
LAD, and LCX. TTE [**2126-4-12**] revealed normal left atrial size with
an estimated right atrial pressure 10-20mmHg, normal left
ventricular wall thickness and a small left ventricular cavity,
normal left ventricular systolic function (LVEF 70%),
hypertrophied right ventricular free wall, dilated right
ventricular cavity with borderline normal free wall function,
abnormal systolic septal motion/position consistent with right
ventricular pressure overload, moderately thickened aortic valve
leaflets with a minimally increased gradient consistent with
minimal aortic valve stenosis, mildly thickened mitral valve
leaflets, left ventricular inflow pattern suggesting impaired
relaxation, mildly thickened tricuspid valve leaflets with
moderate to severe [3+] tricuspid regurgitation, and severe
pulmonary artery systolic hypertension. Cardiac enzymes were
trended with no elevation in her CK's threfore this was felt not
to be cardiac ischemia.
.
2) Pulmonary Embolus - On hospital day 2, the patient had
low-grade fever, tachycardia, worsening hypoxemia with resting
oxygen saturation in the mid 90's on 6 L NC, new T-wave
inversions in V3 and deeper T-wave inversions in V4. CTA of the
chest revealed right middle lobe segmental pulmonary emboli,
right middle lobe pulmonary infarct vs. atelectasis, moderate
bilateral pleural effusions, and volume overload. Heparin and
lasix infusions were started. Lower extremity doppler ultrasound
was negative for DVT.
.
3) Left femoral neck fracture - Seen in consultation by
orthopaedic surgery who recommended proceeding with ORIF.
However, based on the preference of the patient and her family,
she was transferred to [**Hospital3 3583**] for further management.
Medications on Admission:
Celexa 10mg PO daily
Omeprazole 20mg PO daily
Senna 2 tabs daily at 4pm
Lisinopril 5 mg PO daily
Lidoderm 5% patch, one patch to lower back 12 hrs each day
Calcium with Vit D 600mg PO BID
Tylenol 650mg Q4hrs PRN for pain
Compazine 10mg PO BID PRN nausea/vomiting
Ibuprofen prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours): do not exceed 4 grams in 24 hours.
2. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): place
on between 8 AM and 8 PM then remove.
5. Heparin (Porcine) in NS 10 unit/mL Kit Sig: ASDIR units
Intravenous every six (6) hours: Diagnosis: Pulmonary Embolism
Patient Weight: 40.824 kg
Initial Bolus: 1000 units IVP
Initial Infusion Rate: 750 units/hr
Target PTT: 60 - 100 seconds
PTT <40: 1600 units Bolus then Increase infusion rate by 150
units/hr
PTT 40 - 59: 800 units Bolus then Increase infusion rate by 100
units/hr
PTT 60 - 100*:
PTT 101 - 120: Reduce infusion rate by 100 units/hr
PTT >120: Hold 60 mins then Reduce infusion rate by 150
units/hr.
6. Furosemide 10 mg/mL Solution Sig: 2.5 mg Injection INFUSION
(continuous infusion).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
8. Calcium Carbonate 500 mg (1,250 mg) Capsule Sig: One (1)
Capsule PO once a day.
9. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO once a day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1) Left femoral neck fracture
2) Pulmonary embolus
3) Pleural effusions
4) Pulmonary hypertension
5) Tricuspid regurgitation
6) Emphysema
Discharge Condition:
Transfer to [**Hospital3 3583**].
Discharge Instructions:
You were admitted to the hospital following a fall and left hip
fracture. You declined surgery at [**Hospital1 18**] and were transferred to
[**Hospital3 3583**] at your request.
You were diagnosed with blood clots in the lung, also known as
pulmonary emboli, and were started on blood thinning medication.
Followup Instructions:
Please follow the recommendations of your medical and
orthopaedic doctors [**First Name (Titles) **] [**Hospital3 3583**].
Completed by:[**2126-4-14**]
ICD9 Codes: 5119, 4168, 4019, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8332
} | Medical Text: Admission Date: [**2168-7-18**] Discharge Date: [**2168-7-22**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Bradyarrhythmia, transfer for evaluation of PPM
Major Surgical or Invasive Procedure:
Pacemaker placement on [**2168-7-19**]: [**Company 1543**] Sensia
History of Present Illness:
Mr. [**Known lastname **] is a 89 year old male with PMH significant for chronic
lymphocytic leukemia, IDDM, CAD s/p CABG ([**2141**]) who is
transferred from [**Hospital **] hospital for bradycardia.
.
Patient experienced fatigue and weakness for the past few days.
On [**7-16**] he fell out of a chair onto the floor when adjusting
himself. He states that his head got stuck in the legs of the
desk. He denies losing consciousness but he states that he
"fell asleep." His He denies CP, nausea, diaphoresis, shortness
of breath. His daughter found him on the groud ~4hours later.
In the ED at [**Location (un) **], his VS T 98.3, HR 73, RR 20, BP 141/60, O2
96% RA. Labs were notable for trop 8.58, CK 618, CK-MB 28.3,
hct 24.8, plt 80, Cr 1.6. The patient was given aspirin, but
not started on heparin gtt.
.
ECG showed Wenckebach block with bradycardia. Per OSH records,
he had multiple runs of NSVT, the longest 10-15sec and was given
lidocaine iv. Per nursing report, however, patient was stated
to have 15-20 sec pause. He had persistent bradycardia with HR
of 30s and a temporary pace wire was placed. He was also
transfused 2 pRBC while there (hct improved to 29). An
echocardiogram was done that showed mild MR/TR, biatrial
enlargement, EF 50%, dyssynergic septum with RV temp pacing.
His Trop per nursing report peaked to 10.3.
.
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.
S/he denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, -Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-CABG: s/p CABG [**2141**]
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Chronic lymphocytic leukemia, on procrit
- DMII, insulin dependent
- CAD, s/p CABG [**2141**]
- BPH
- Bl cataract surgery
- SCC of the scalp
- H/o bradycardia, PPM not recommended
Social History:
Lives independently. Retired broadcast engineer. Has eight
children.
-Tobacco history: None
-ETOH: None
-Illicit drugs: None
Family History:
Mother w/ [**Name2 (NI) 499**] cancer.
Physical Exam:
GENERAL: Elderly male, thin, in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Dry MMM. No
xanthalesma.
NECK: Supple with flat JVP. Guaze covering area of excised SCC
c/d/i.
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:
Pt with thyroid nodule this admission which needs f/u
[**2168-7-18**] 09:42PM PT-12.0 PTT-25.2 INR(PT)-1.0
[**2168-7-18**] 09:42PM PLT SMR-LOW PLT COUNT-96*
[**2168-7-18**] 09:42PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-1+ MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL
OVALOCYT-1+
[**2168-7-18**] 09:42PM NEUTS-25* BANDS-2 LYMPHS-73* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2168-7-18**] 09:42PM WBC-8.6 RBC-3.28* HGB-11.1* HCT-33.2*
MCV-101* MCH-33.7* MCHC-33.3 RDW-17.3*
[**2168-7-18**] 09:42PM TSH-1.4
[**2168-7-18**] 09:42PM CALCIUM-8.1* PHOSPHATE-2.9 MAGNESIUM-2.1
[**2168-7-18**] 09:42PM CK-MB-4 cTropnT-0.34*
[**2168-7-18**] 09:42PM ALT(SGPT)-19 AST(SGOT)-30 LD(LDH)-241
CK(CPK)-288 ALK PHOS-83 TOT BILI-0.6 DIR BILI-0.2 INDIR BIL-0.4
[**2168-7-18**] 09:42PM estGFR-Using this
[**2168-7-18**] 09:42PM GLUCOSE-311* UREA N-29* CREAT-1.3* SODIUM-138
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-24 ANION GAP-10
Brief Hospital Course:
89 year old male with PMH significant for chronic lymphocytic
leukemia, IDDM, CAD s/p CABG ([**2141**]) who is transferred from
[**Hospital **] hospital for PPM for symptomatic bradycardia.
# Symptomatic Bradycardia: Patient's fall was suspected to be
secondary to symptomatic bradyarrhythmia. His ECG from the OSH
showed Wenckebach and CHB. Per report, as an outpatient patient
had sinus pauses on Holter monitor. Patient underwent placement
of PPM and tolerated this procedure well. He was treated with
antibiotics for 48hours. His pacemaker was interrogated and
working well. Patient will follow up in device clinic next
week. Please see page 1 for pacer site care and activity
restrictions.
.
# Non ST Elevation Myocardial Infarction: Patient has a history
of CABG (anatomy unknown). His cardiac markers were elevated at
OSH and at [**Hospital1 18**]. While here he denied any chest pain. Patient
was limited to receiving anti-aggregation therapy (see below).
He was started on lisinopril, metoprolol after PPM was placed,
ASA 325. Lipitor was started at discharge. His lipid panel is
pending at this time. There was a discussion at discharge about
persuing stress testing but given his CLL, it was thought that
medical management was most appropriate at this time.
.
# Acute on Chronic Kidney Disease: Patient's Cr was 1.6 at OSH.
His urine was notable for large blood and there was a concern
for rhabdo. On arrival to [**Hospital1 18**] patient's Cr was 1.4, which
remained stable. He also had protein in his urine which
suggested likely underlying renal insufficiency likely secondary
to diabetes. His metformin and glipizide were held, but
restarted on discharge.
.
# CLL: With likely bone marrow involvement: thrombocytopenia and
anemia. ANC 2150. His counts were monitored and procrit was
held. Platelets decreased to 64 on day of discharge, Hct stable
at 30. No signs of overt bleeding. Given the patient will not be
able to f/u with his home Hematologist (Dr. [**First Name (STitle) 12795**] in [**Location (un) **]
VT) an appt was made wth Dr. [**Last Name (STitle) **] at [**Hospital1 **] [**Location (un) 620**] for further
monitoring. Dr. [**Last Name (STitle) **] will decide when to restart Procrit and
arrange for monitoring of labs. FeSo4 was continued. Please
check labs on Monday [**7-25**].
.
# IDDM: Held metformin and glipizide, but restarted on
discharge. Patient continued on home lantus.
.
# BPH: Continued terazosin
.
# Thyroid nodule: An incidental thyroid nodule was seen on CT
scan, which needs to be followed as an outpatient.
.
# S/P Mohs Surgery for Squamous Cell CA on scalp on [**7-14**]. His
daughter has been changing the dressing daily. Sutures can be
removed on [**7-26**], then a non-occlusive dressing to the site until
there is only pink skin visible.
Medications on Admission:
MEDICATIONS:
Folic acid 1mg daily
metformin 500mg [**Hospital1 **]; 250mg at noon
ecotrin 81mg daily
glipizide 10mg [**Hospital1 **]
terazosin 10mg daily
MVI
iron tab daily
lantus 10U daily
procrit
.
MEDICATIONS ON TRANSFER:
aspirin 325 daily
lipitor 80mg daily
metoprolol 25mg [**Hospital1 **]
MVI
terazosin 10mg qhs
tylenol 650mg Q4prn
SLN prn
ISS
HSC
Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): Hold
SBP < 100.
4. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
at bedtime.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Metformin 500 mg Tablet Sig: 0.5 Tablet PO NOON (At Noon).
8. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 1 days.
10. Terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
11. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Hold for diarrhea.
15. Outpatient Lab Work
Please check CBC and chem-7 on Monday [**2074-7-23**]. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
17. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **]
Discharge Diagnosis:
Primary Diagnosis:
Acute systolic Dysfunction: EF 30%
Non ST Elevation Myocardial Infarction
Complete Heart Block
Acute on chronic Kidney Disease
.
Secondary Diagnosis:
Chronic lymphocytic leukemia
Diabetes Mellitus on Insulin
Coronary Artery Disease s/p CABG [**2141**]
Benign Prostatic Hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You had a fall at home and was brought to [**Hospital **] Hospital with
a heart attack. You were then transferred here to [**Hospital1 18**] for
treatment. You were also very anemic and had some dangerous
heart rhythms. We placed a pacemaker to fix your heart rhythms
and gave you some blood. You blood count and platelet counts are
still quite low, you should consider seeing a
hematologist/oncologist for this within the next month. You can
return to your doctor [**First Name (Titles) **] [**Last Name (Titles) 3914**] or you can go to a doctor close
to Newbridge:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
[**Hospital1 **] Hospital - [**Location (un) 620**]
[**Street Address(2) 3001**]
[**Location (un) 620**], [**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 38619**]
Fax: [**Telephone/Fax (1) 85425**]
Date/time: Wednesday [**7-27**] at 1:30pm
.
Medication changes:
1. Increase aspirin to 325 mg to prevent another heart attack
2. Start Lisinopril to help your heart pump better
3. Start Tylenol for pain at the pacer site as needed
4. Start Clindamycin to prevent an infection at the pacer site,
you have one more day left
5. Start Atorvastatin to lower your cholesterol
6. Start Colace and senna to prevent constipation.
.
Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes
up more than 3 lbs.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2168-7-26**]
4:00pm
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**]. [**Location (un) **], [**Hospital Ward Name 5074**] [**Hospital1 18**].
.
Primary Care:
Provider: [**Name10 (NameIs) 14218**], [**Name11 (NameIs) **] Phone:([**Telephone/Fax (1) 85426**] Date/Time:
[**2168-7-29**] 8:30am This appt needs to be cancelled if pt is still
in MA
.
Cardiology:
[**8-8**] at 11:20am with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**Hospital Ward Name 23**] Clinical
Center, [**Location (un) 436**]. [**Location (un) **], [**Hospital Ward Name 516**] [**Hospital1 18**]
.
Hematology/Oncology:
[**Last Name (LF) **], [**First Name3 (LF) **] H., MD
[**Hospital1 **] Hospital - [**Location (un) 620**]
[**Street Address(2) 3001**]
[**Location (un) **], across from Medical Day care. Please stop at
registration first.
[**Location (un) 620**], [**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 38619**]
Fax: [**Telephone/Fax (1) 85425**]
Date/time: Wednesday [**7-27**] at 1:30pm
ICD9 Codes: 5849, 5859, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8333
} | Medical Text: Admission Date: [**2105-3-20**] Discharge Date: [**2105-3-25**]
Date of Birth: [**2026-6-26**] Sex: F
Service: MEDICINE
Allergies:
A.C.E Inhibitors
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
NG tube placement
History of Present Illness:
78 yo female with h/o DM,HTN, PVD, who presented with two days
of feeling unwell. She was unable to urinate x2 days and has not
had a BM in the last day. Today she stood up and syncopized
after attempting to have BM and was unresponsive. EMS was called
and SBP was in the 90s with HR initially in the 60s and trending
down to the 50s. She was also c/o epigastric pain.
On arrival to the [**Hospital1 18**] ER, the pt immediately syncopized.
Her HR decreased to the 30s-40s and SBPs decreased to the
50s-70s. EKG demonstrated a junctional rhythm. She received 0.5
mg of atropine x 2, glucagon 5 mg x1 and IVFs wide open, for a
total of 6L NS. This resulted in improvement of HR and BPs.
Labs demonstrated an elevated lactate as high as 5.2 and
potssium of 8.2. She was treated with sodium bicarb, calcium
gluconate, insulin and D50 x2. She also received 30 mg PO
kayexalate. Repeat K was 6. Renal was called and UA appeared
c/w pre-renal etiology. Of note, when foley was placed
initially, only 100 cc of urine was drained. She later had a
total of 200-300 cc of UOP after 6L of NS.
Additionally, she was on a NRB during her time in the ER and
then her sats dropped to the 70s-80s. She was thought to be
volume overloaded,so started on bipap with improvement in sats.
She was also started on cefepime, flagyl and levofloxacin to
cover PNA and possible abdominal infection. Of note, she had a
non-contrast CT of the abdomen, which demonstrated possible
thrombosis of the SMA and heterogenous attenuation of the liver.
CT of the chest demonstrated possible b/l PNA. She was
evaluated by surgery who did not think there was any surgical
intervention indicated at the time. She was stable on bipap and
trasnferred to the MICU.
.
Upon speaking with pt in the MICU (grandson translating), she
has been feeling crampy abd pain for several days. Her biggest
complaint is that she tried to have a BM but was unable. Upon
questioning she stated she had worse lower back pain and some
substernal CP over the lsat week. CP is a substernal, pressure
that improved with exertion and was intermittent. She denied
diaphoresis, SOB, f/c.
.
Upon further discussion with the patient and family, it was
discovered the patient had been taking high dose NSAIDS for
several days prior to admission.
Past Medical History:
1. Non-insulin-dependent diabetes mellitus.
2. Hyperlipidemia.
3. Hypertension.
4. Gastroesophageal reflux disease.
5. Backpain-lumbar radiculopathy
6. Osteoporosis
7. PVD: s/p right leg angiogram
6. Admit in [**2099**], s/p syncopal event and fall, after which she
had backpain, constipation, abdominal distention and urinary
incontinence. Had spinal MRI with T1/T2 lesions c/w hemangioma
and T12 compression fx. Several disc bulges were noted but no
cord compression. Also had narcotic ileus.
Social History:
The patient denies alcohol or tobacco use. She lives in
[**Location 686**] with her family. She is [**Location 11543**]
and speaks Creole dialect.
Family History:
N/C
Physical Exam:
VS: T: 98.9 BP: 141/65 HR: 59 RR: 21 O2 sat: 94% on 6L NC
Gen: well appearing, pointing to her abdomen
HEENT: anicteric, dry MM
Neck: supple, obese
Pulmonary: exp wheezes b/l, moving air well
Cardio: bradycardic with regular rate
Abd: soft, very distended, NT, +BS
Ext: 1+ edema b/l
Neuro: pt mentating and moving all extremities
Pertinent Results:
Echo [**7-2**]: The left atrium is normal in size. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%) Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
CT abd/chest w/out contrast (PRELIM READ): Limited study for
evaluation of bowel ischemia in the absence of IV contrast.
Heterogenous attenuation of the liver, with large geographic
areas of low attenuation, may reflect fatty change but in the
appropriate clinical setting, ischemia or inflammation are
alternative possibilities.
Focal hyperdense segment of SMA, occasionally associated with
acute thrombus. [**Month (only) 116**] be further evaluated with mesenteric vessel
doppler, considering patient's clinical status does not permit
contrast administration.
Bibasilar pulmonary consolidation, aspiration versus bilateral
pneumonia.
.
C. cath [**12-1**]:
1. Central aortic hypertension
2. Moderarate celiac artery lesion
3. Severe LTPT and PA lesion with one vessel run off to the L
foot via PA
4. successful atherectomy and PTA of the L TPT lesion
5. Successful PTA of the L PA lesion
.
EKG: narrow junctional rhythm with rate of 59, RBBB
Brief Hospital Course:
78 yo female with DM II, HTN, PVD, admitted to MICU ([**Date range (1) 17717**])
with ARF and resulting syncope in setting of high dose
ibuprofen.
.
# Acute Renal Failure: Admitted with a creatnine of 2.4 and
severe hyperkalemia. FENa 0.23% c/w pre-renal etiology. Also in
setting of high dose NSAID use, with likely resultant decrease
of renal blood flow. Resolved with IVF. She will have a renal
function check in 1 week. If her renal function is stable at
that time, she will resume her [**Last Name (un) **]. She received clear
instructions to avoid NSAIDs in the future.
.
# Syncope: Likely secondary to high junctional rhythm and
multiple metabolic derranagements on admission. With high
junctional rhythm at the time of syncope in ED, with
hyperkalemia to 8, treated with atropine, gluccagon, insulin,
bicarb and calcium. No further events on telemetry in the MICU.
BB and CCB initially held in the MICU, BB reintroduced and
tolerated well. CCB being held in the setting of bradycardia.
.
# Hypoxia: In the ED with desaturation to 70-80%, requiring
facemask. Treated initially with levofloxacin and flagyl until
[**3-22**]. Also diuresed with concern for volume overload. On room
air throughout the remainder of her hospitalizaiton. Suspect
that acute desaturation in ED is secondary to aspiration
pneumonitis (bilateral infiltrates seen on CT scan) in setting
of syncope and altered mental status. ECHO for w/u of syncope
revealed e/o RV hypokinesis. Subsequent CTA was negative for
PE.
.
# Hypertension: In MICU with SBP 170s. Reintroduced home regimen
of BB without complications. However, she was noted to have
junctional rhythm on admission (see below) and thus her
diltiazem was discontinued. Her [**Last Name (un) **] was held in the setting of
renal failure. Norvasc was started for BP control.
.
# Pulmonary Hypertension: Unclear etiology. No smoking history,
no evidence of PE on CTA. Clinical history not suggestive of
sleep apnea. She would benefit from a pulmonary follow up as
outpt for further w/u of her pulmonary hypertension.
.
# Abdominal Distension: With self-reported constipation, and
abdominal distension in the MICU. NGT placed and discontinued in
MICU. Abdominal exam remained benign. Treated initially with
levofloxacin and flagyl empirically ([**Date range (1) 17717**]); all antibiotics
discontinued since then. Her distension likely reflects ileus
versus constipation. She tolerated a regular diet on discharge.
.
# Transaminitis: AST/ALT 400s on admission, continued to trend
down. Suspect component of ischemic hepatopathy with junctional
rhythm and hypotension. But also with question of fatty liver on
CT scan. If her LFTs continue to be elevated, further w/u with
[**Name (NI) 5283**] son[**Name (NI) **] as an outpt is recommended.
.
# Question of SMA thrombosis: Question of SMA thrombosis on CTA
scan on admission. Clinical picture did not seem c/w acute
mesenteric artery thrombosis. She remained abdominal pain free
and without changes in her bowel habits. She was continued on
her outpt regimen of ASA, plavix, statin for her history of PVD.
Medications on Admission:
Amitriptyline 20 mg qhs
Atenolol 25 m daily
Atorvastatin 10 mg daily
Plavix 75 mg daily
Diltizaem 120 mg q12 hour
Gabapentin 300 mg [**Hospital1 **]
Glucophage 1000 mg [**Hospital1 **]
Vicodin 5-500 mg tab q 6-8 hrs prn
Ibuprofen 600 mg q6 hours prn
Insulin SS
Lantus 68 units sc daily
Lyrica 50 mg TID
Protonix 40 mg qod
Valsartan 160 mg daily
ASA 325 mg daily
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Insulin Glargine Subcutaneous
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Pregabalin 25 mg Capsule Sig: Two (2) Capsule PO tid ().
8. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO bid prn as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
13. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 17718**] Health Care
Discharge Diagnosis:
Primary
Acute renal failure
Hyperkalemia
Ileus
Transaminitis
Bradycardia, junctional rhythm
Secondary
Anemia
Hypertension
Type II Diabetes mellitus
Peripheral vascular disease
Hyperlipidemia
Vertigo
Discharge Condition:
good, tolerating POs, saturating on room air
Discharge Instructions:
You were admitted with kidney failure. You were found to have
elevated levels of potassium. You were treated with hydration
and your kidney function normalized. You also had a low heart
rate from an elevated potassium. All of these issues normalized
once your kidney function improved.
It is very important that you discontinue your pain medications
including ibuprofen, tylenol and other pain medications such as
vicodin with opioid properties (such as oxycodone, percocet,
etc). Your amitriptyline was also discontinued. Your lorsartan
was discontinued because of your recent contrast administration
with CT scan. This should be restarted by Dr. [**Last Name (STitle) **] as an
outpt. Your diltiazem was also discontinued. You were started
on a medication called norvasc. Please take all of your other
medications as directed.
Please return to the emergency room or see your PCP if you have
any of the following symptoms:
Chest pain, difficulty breathing, palpitations, loss of
consciousness or any other serious concerns.
Followup Instructions:
We have scheduled the following appointment for you with Dr.
[**Last Name (STitle) **]:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2105-4-3**] 12:45
It is important that you have the following labs drawn at your
appointment with Dr. [**Last Name (STitle) **]:
Chem 7 and LFTs. You are being given a requisition to have
these labs drawn.
You should also schedule an appointment with pulmonary clinic in
the next 1-2 months. They can be reached at ([**Telephone/Fax (1) 513**].
Completed by:[**2105-4-9**]
ICD9 Codes: 5849, 5070, 2762, 2760, 2767, 4019, 2724, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8334
} | Medical Text: Admission Date: [**2195-3-5**] Discharge Date: [**2195-3-13**]
Date of Birth: [**2124-2-1**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline Analogues / Zinc / Optiray 350
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
70F w/ esophageal dysmotility, parkinson's, chronic aspiration
PNA w/ J-tube in place, p/w respiratory distress. Per caretaker,
her respiratory distress began this morning when she found the
patient to be lethargic and with a 02sat of 56%. The [**Last Name (un) 105578**]
notes that, for the last 2 days, the patient was complaning of a
sore throat, productive cough and denied any fever or
chills,hemoptosis, no diarrhea or vomitting. The caretaker notes
that the patient admitted to swallowing a mint this morning.
[**Last Name (un) 4273**] any recent sick contact or change in weight. Caretaker
[**Last Name (un) **] patient had any chest pain and was oriented to self
during the episode. She reports the patient last apiration
pneumonia in [**2193**].
The patient was brought to the emergency departement with EMS.
.
In the ED VS were: T:99.2 HR:103 BP:151/62 RR:22 O2 sat26%. Labs
were notable for: Blood gas:7.32/52/430/28 BaseXS=0, Lacate 2.1,
and troponinT: <0.01. CXR showed a LLL opacity, which may
represent atelectasis, though superimposed infection cannot be
excluded. Pulmonary vasculature is mildly prominent. She
received cefepime and levofloxacin. She was found to be in
respiratory distress with thick secretions and was intubated and
transfered to the MICU.
Past Medical History:
1. Castleman's disease: unicentric. Found incidentally on
splenectomy done for "splenic pain" around [**2176**]. Has had lymph
nodes sampled in past to r/o lymphoma but all have shown
reactive lymph tissue only. Followed by Dr. [**Last Name (STitle) 410**]. (Heme/Onc)
2. anaplastic thyroid cancer s/p radical neck dissection, at
age 15
3. Esophageal webs and esophageal dysmotility. Has had numerous
esophageal dilatations.
4. Recurrent aspiration pneumonias sputum Cx growing
Pseudomonas, MRSA
5. Chronic pulmonary disease
6. MRSA osteomyelitis of olecranan s/p multiple debridements
7. Hx Bipolar d/o
8. GERD
9. Osteoporosis: has broken both hips, left in [**11-7**], right with
failed ORIF and redo at [**Hospital1 2025**]
10. Hx zoster
11. Hx depression, chronic pain
12. HTN
13. Parkinson's disease
Social History:
Retired social worker. [**Name (NI) 6934**] with walker and assistance at
baseline. No Etoh, [**Name (NI) **], drugs. Lives at home w/ 24 hour health
aid. POA = [**Name (NI) **] [**Name (NI) 105568**] (a lawyer).
Family History:
1. Father: HTN, DM, depression, died MI, age 59.
2. Mother: HTN, hypercholesterolemia, died MI, age 82.
3. Sister: HTN
Physical Exam:
ADMISSION EXAM:
VS: T: HR:63 BP:95/41 O2 sat92%
GEN: intubated, sedated. responsive to voice
HEENT: Neck supple, no LAD, JVD below clavicle.
CV:RRR distant heart sound. No murmur rubs or gallops
LUNGS: coarse breath sounds troughout.
ABD:soft, tender to palpation. no rebound, no [**Last Name (un) **]. Jtube
site surrounded by erythematous base,not warm to touch,without
exudates or ulcers of fistula.
EXT: warm and Well perfused,no edema or cyanosis
.
DISCHARGE EXAM:
General: Awake and alert
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: erythma and excoriations surrounding j-tube dressing.
patient with new j-tube
Pertinent Results:
ADMISSION LABS:
[**2195-3-5**] 11:00AM BLOOD WBC-19.7*# RBC-3.59* Hgb-10.8* Hct-33.0*
MCV-92 MCH-30.1 MCHC-32.7 RDW-15.0 Plt Ct-432
[**2195-3-5**] 11:00AM BLOOD Neuts-68 Bands-1 Lymphs-27 Monos-1* Eos-2
Baso-0 Atyps-1* Metas-0 Myelos-0
[**2195-3-5**] 11:00AM BLOOD Glucose-148* UreaN-24* Creat-1.3* Na-137
K-5.2* Cl-100 HCO3-29 AnGap-13
[**2195-3-5**] 11:00AM BLOOD ALT-4 AST-17 AlkPhos-83 TotBili-0.3
[**2195-3-5**] 11:00AM BLOOD Lipase-21
[**2195-3-5**] 11:00AM BLOOD PT-12.9 PTT-21.4* INR(PT)-1.1
[**2195-3-5**] 11:00AM BLOOD Albumin-3.2*
[**2195-3-5**] 11:05AM BLOOD Lactate-1.5
.
DISCHARGE LABS:
[**2195-3-13**] 05:45AM BLOOD WBC-11.4* RBC-3.56* Hgb-10.5* Hct-31.3*
MCV-88 MCH-29.6 MCHC-33.6 RDW-16.1* Plt Ct-380
[**2195-3-8**] 04:28AM BLOOD Neuts-65 Bands-2 Lymphs-16* Monos-9
Eos-7* Baso-1 Atyps-0 Metas-0 Myelos-0
[**2195-3-12**] 06:42AM BLOOD Glucose-84 UreaN-13 Creat-0.7 Na-140
K-4.5 Cl-102 HCO3-32 AnGap-11
.
MICROBIOLOGY:
[**2195-3-5**] Blood Cx: pending
[**2195-3-5**] Sputum Cx:
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
.
Blood Culture, Routine (Final [**2195-3-11**]): NO GROWTH
.
IMAGING: Several CXR please refer to OMR for full list.
Admission [**2195-3-5**] CXR:
1. New left lower lobe opacity, concerning for pneumonia.
2. Small left pleural effusion.
.
Following extubation CXR [**2195-3-10**]:
In comparison with the study of [**3-9**], the endotracheal tube and
nasogastric tube have been removed. Little overall change in the
diffuse
bilateral pulmonary opacifications, consistent with elevation of
pulmonary
venous pressure with bilateral pleural effusions and compressive
atelectasis. The possibility of supervening pneumonia at the
bases cannot be excluded on this image in the appropriate
clinical setting.
Brief Hospital Course:
71 F w/ esophageal dysmotility, parkinson's, chronic aspiration
PNA w/ J-tube in place, p/w respiratory distress c/w aspiration
PNA.
.
While in the MICU, the patient was treated for:
# RESPIRATORY DISTRESS: likely [**2-4**] aspiration event. Patient has
a history of aspiration PNA, her CXR shows new LLL opacity,
elevated WBC 19. The patient most likely diagnosis is an
aspiration pneumonitis which could progress to an aspiration
pneumonia. Patient had a history of PNA with pseudomonas, MRSA
and ESBL and was covered with Vancomycin([**3-5**]-) and Cefepime.
Patient also had an history of UTI with ESBL and cefepime
replaced by Meropenem ([**3-7**]-). The patient remained afebrile
while on drug regimen and WBC trended down from 21.4 to 9.47.
Patent passed SBT and RSBI and was extubated on [**3-9**] and is
stable on nasal canula. During her stay, she developed bilateral
pleural effusion which do not require diuresis at this point.
.
#J-be leak. Patient with a fistula lateral to her Jtube and has
declined surgical intervention. Currently on tube feeds.
.
# Anemia: Hct is 33.0 from a baseline of 38 in [**2194**].
Hemodynamically stable. There was no sign of active bleed
.
# Renal failure: Creatinine increased to 1.3 from a baseline of
1.0 after first dose of vancomycin and stabelize down to 0.9.
.
Course on the medical floor:
# Aspiration pneumonia: Sputum culture grew MRSA. Patient was
treated with Vancomycin and Meropenum for total 8 day course.
She was afebrile throughout her stay. Patient is a very high
aspiration risk. She was instructed not to take anything by
mouth. This was also explained to her health aide. She was
instructed that taking anything by mouth she would aspirate
which could result in death. She was discharged on home O2 NC
for O2 sat > 90% (she already has O2 at home).
.
# J-tube: There was a leak in her j-tube consequently this was
changed by IR. Patient has a fistula lateral to her J-tube and
has declined surgical intervention. Wound care saw her during
her stay and recommendations where made on discharge.
Medications on Admission:
ALBUTEROL SULFATE -
Entered by MA/[**Name2 (NI) **] Staff - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - 1 ampule(s) via nebulizer three to four times a
day as needed for shortness of breath or wheezing
ATROPINE - 1 % Drops - 2 drops(s) under tongue every 4 hours as
needed for prn for sucretions being administered by VNA
CARBIDOPA-LEVODOPA [SINEMET] - 25 mg-100 mg Tablet - 1 Tablet(s)
by mouth q4hours while awake Please give at 8 am, noon, 4 pm,
and
8 pm daily
ESCITALOPRAM [LEXAPRO] - (Prescribed by Other Provider) - 20 mg
Tablet - 1 Tablet(s) by mouth once a day
ESOMEPRAZOLE MAGNESIUM [NEXIUM PACKET] - 40 mg Susp,Delayed
Release for Recon - 1 packet by mouth once a day use as directed
FENTANYL [DURAGESIC] - 100 mcg/hour Patch 72 hr - apply one
patch
every 72 hours
FENTANYL [DURAGESIC] - 25 mcg/hour Patch 72 hr - 1 q 72 horly
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth at bedtime
HYDROMORPHONE [DILAUDID] - 2 mg Tablet - 1 Tablet(s) by mouth
four times a day as needed for for pain
IRON POLYSACCH COMPLEX-B12-FA [FERREX 150 FORTE] - 150 mg-25
mcg-1 mg Capsule - 1 Capsule(s) by mouth once a day
LAMOTRIGINE [LAMICTAL] - (Prescribed by Other Provider) - 200
mg
Tablet - 1 Tablet(s) by mouth daily
LEVOTHYROXINE - 75 mcg Tablet - 1 Tablet(s) by mouth daily
LORAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth 1 tablet in a.m. and 2 tablets at H.S
ONDANSETRON HCL - 4 mg Tablet - 1 Tablet(s) by mouth three times
a day as needed for FOR NAUSEA
PRIMIDONE - 50 mg Tablet - 0.5 (One half) Tablet(s) by mouth
daily
PROMETHAZINE - (Prescribed by Other Provider) - 25 mg
Suppository - 1 (One) Suppository(s) rectally three times a day
QUETIAPINE [SEROQUEL] - 200 mg Tablet - 1 Tablet(s) by mouth at
bedtime
SODIUM POLYSTYRENE SULFONATE - Powder - 15 grams by mouth
every
other day
CALCIUM CARBONATE - 200 mg (500 mg) Tablet, Chewable - 1 (One)
Tablet(s) by mouth twice a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (OTC) - 400 unit
Capsule - 1 Capsule(s) by mouth twice a day
FERROUS SULFATE [IRON (FERROUS SULFATE)] - (OTC) - 325 mg (65
mg) Tablet - 1 Tablet(s) by mouth once a day
NUTRITIONAL SUPPLEMENT - FIBER [FIBERSOURCE] - (Prescribed by
Other Provider) - Liquid - 1200 calories via tube daily
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Name2 (NI) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
2. carbidopa-levodopa 25-100 mg Tablet [**Name2 (NI) **]: One (1) Tablet PO
QID (4 times a day).
3. escitalopram 10 mg Tablet [**Name2 (NI) **]: Two (2) Tablet PO DAILY
(Daily).
4. fentanyl 100 mcg/hr Patch 72 hr [**Name2 (NI) **]: One [**Age over 90 **]y Five
(125) mcg Transdermal Q72H (every 72 hours).
5. gabapentin 250 mg/5 mL Solution [**Age over 90 **]: Three Hundred (300) mg
PO HS (at bedtime).
6. lamotrigine 100 mg Tablet [**Age over 90 **]: Two (2) Tablet PO DAILY
(Daily).
7. primidone 50 mg Tablet [**Age over 90 **]: 0.5 Tablet PO DAILY (Daily).
8. Seroquel 200 mg Tablet [**Age over 90 **]: One (1) Tablet PO at bedtime.
9. hydromorphone 2 mg Tablet [**Age over 90 **]: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
10. levothyroxine 75 mcg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY
(Daily).
11. lorazepam 1 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily).
12. lorazepam 1 mg Tablet [**Age over 90 **]: Two (2) Tablet PO HS (at
bedtime).
13. ondansetron 4 mg Tablet, Rapid Dissolve [**Age over 90 **]: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
14. promethazine 25 mg Suppository [**Age over 90 **]: One (1) Suppository
Rectal Q8H (every 8 hours).
15. cholecalciferol (vitamin D3) 400 unit Tablet [**Age over 90 **]: One (1)
Tablet PO BID (2 times a day).
16. ferrous sulfate 300 mg (60 mg Iron) Tablet [**Age over 90 **]: One (1)
Tablet PO DAILY (Daily).
17. iron-vitamin B complex Oral
18. sodium polystyrene sulfonate 15 g/60 mL Suspension [**Age over 90 **]: One
(1) PO every other day.
19. calcium carbonate Oral
20. esomeprazole magnesium 40 mg Susp,Delayed Release for Recon
[**Age over 90 **]: One (1) PO once a day.
21. atropine 1 % Drops [**Age over 90 **]: Two (2) drops Ophthalmic every four
(4) hours as needed for secretions.
22. nystatin 100,000 unit/g Cream [**Age over 90 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
23. Fibersource Tube Feeds
Advance tube feeds to cycle @ 80/hr x 18hrs overnight. If she
tolerates increase to 120/hr x 12 hrs.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Aspiration pneumonia
Aspiration
Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You developed a pneumonia after aspirating a mint. Due to severe
difficulty breathing you required a breathing tube (called
intubation) and was in the ICU for several days. Once your
pneumonia improved your breathing tube was removed. You were
treated with strong antibiotics for 8 days total.
.
DO NOT TAKE ANYTHING BY MOUTH. YOU WILL ASPIRATE AGAIN WHICH
COULD RESULT IN DEATH.
.
When you were here your feeding tube was changed by [**Hospital **].
.
Follow your medication list as printed.
Followup Instructions:
Department: [**State **]When: THURSDAY [**2195-3-19**] at 12:00 PM
With: [**First Name8 (NamePattern2) 8741**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
.
Department: NEUROLOGY
When: WEDNESDAY [**2195-5-6**] at 3:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], M.D. [**Telephone/Fax (1) 541**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2195-3-16**]
ICD9 Codes: 5070, 5119, 5849, 4019, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8335
} | Medical Text: Admission Date: [**2163-1-3**] Discharge Date: [**2163-2-2**]
Date of Birth: [**2089-6-9**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Rocephin
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2163-1-24**]: Percutaneous (bronchoscopic guided) tracheostomy tube
placement.
[**2163-1-12**]: Pleural fluid tap bilaterally
[**2163-1-3**]: Exploratory laparotomy, Resection of sigmoid colon.
End colostomy, mobilization of splenic flexure, gastrostomy
tube.
History of Present Illness:
Ms. [**Known lastname **] is a 73-year-old woman, who 10 days ago underwent a
resection of a sigmoid polyp at an outside institution. She
subsequently developed an abdominal wall dehiscence
necessitating return to the OR with repair of the
fascia and placement of retention sutures. Today she presented
with feculent drainage from her wound, leukocytosis, and gross
peritonitis. Surgical intervention was required.
Past Medical History:
H/o pneumonia, Polymyalgia rheumatica, HTN
Surgical Hx: TAH (benign disease)
Social History:
Lives with husband, former school teacher. Has 2 grown children
and 2 granddaughters. Denies tobacco, EtOH.
Family History:
NC
Physical Exam:
HR 110, RR 34
Alert female in moderate discomfort
Non-icteric sclera, flushed face
Coarse breath sounds bilaterally
Sinus tachycardia
Abdomen diffusely tender, +rebound and guarding, feculant
material arising from lower aspect of wound
Pertinent Results:
[**2163-1-3**] 06:00PM BLOOD WBC-23.7* RBC-4.13* Hgb-11.4* Hct-33.9*
MCV-82 MCH-27.7 MCHC-33.7 RDW-15.4 Plt Ct-362
[**2163-1-8**] 03:29AM BLOOD Neuts-88* Bands-6* Lymphs-2* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-1*
[**2163-1-3**] 06:00PM BLOOD PT-14.5* PTT-31.3 INR(PT)-1.3*
[**2163-1-3**] 06:00PM BLOOD Glucose-57* UreaN-41* Creat-0.9 Na-135
K-5.1 Cl-100 HCO3-26 AnGap-14
Radiology
[**1-28**]: CXR/KUB-improving edema, minimal atelectasis, small
effusions, NJ in position
[**1-24**]: CT [**Last Name (un) 103**]: [**Month (only) **]. perihepatic, LLQ collections. Mod. bilat.
effusions
[**1-24**]: CXR mildly improved opacities
[**1-21**] : CXR worsening multifocal opacities
[**1-20**]: CXR with no significant change
[**1-20**]: KUB no bowel dilation or evidence of obstruction
[**1-19**]: Echo: EF 75%, no Wall motion abnormalities, hyperdynamic,
tricuspid regurgitation 1+
[**1-18**]: CT abdomen: Drainage of 5cc of serous fluid from LLQ.
Dilated loops of bowel,
[**1-18**]: CXR bilateral multifocal alveolar opacities c/w ARDS &
Denser bibaslar consilidation, potentially pneuomia or
aspiration.
[**1-12**]: CT head: no acute process
PATHOLOGY
[**2163-1-3**] Colon, segmental resection:
Acute perforation with acute serositis and reaction to fecal
material.
Organizing peritonitis with fibrous peritoneal adhesions and
submucosal suture reaction.
There is no intrinsic colitis or neoplasm.
Brief Hospital Course:
Ms [**Known lastname **] was taken directly to the OR on [**2163-1-3**] for fecal
peritonitis. She underwent sigmoid colectomy with end colostomy
and g tube placement, see op report for details. She tolerated
the procedure well. She recovered in the PACU, was extubated and
transferred to TSICU for further recovery. She remained on
Ampicillin/Cipro/Flagyl, steroid taper with foley catheter, NPO,
wound care and TPN. ID was consulted for assistance with
anitbiotic regimen. In TSICU she was afebrile, with leukocytosis
but continued to improve clinically with PT/OT. She had bowel
sounds and was weaned to nasal cannula oxygen.
.
POD#4 she was transferred to a telemetry post-surgical unit. She
was noted to have some mental status changes and narcotic
regimen was adjusted.
.
Cardiovascular: POD#5 she developed hypertension and was
aggressively beta blocked. CXR and CT imaging was obtained every
few days for follow up. POD#6 imaging revealed bilateral pleural
effusions.
Respiratory: She was noted to have worsening breath sounds
POD#[**2-25**], and inability to wean from NC oxygen. POD#9 she
underwent right thoracentesis in IR with good result. Post
procedure she developed decreased level of consciousness and
decreased respiratory rate. She was transferred to TSICU for
closer monitoring. She received PRBCs, cardiac enzymes were
cycled and IV lasix. CE's remained negative. POD#10 LLQ
thoracentesis done with good result.
Gastrointestinal: Trophic TFs were initiated on POD#8 and were
advanced daily to goal on POD#11. POD#12 she failed her swallow
exam, she remained NPO.
GU: Urine culture positive for MRSA on POD#9.
.
Leukocytosis/Peritonitis:
Leukocytosis persisted and was monitored closely. She was
changed to Vanc/Cipro/Flagyl IV. Blood cultures, & urine
cultures were followed which remained negative. Her Central line
was removed and replaced, culture tip was negative. Foley
catheter was changed. POD#7, white count was 46. Fluconazole was
added for yeast in her urine. POD# 10 Meropenem was added.
Leukocytosis improved POD#[**8-4**].
.
She remained in the TSICU until POD#13, when she was transferred
again to [**Hospital Ward Name 121**] 9 after being weaned to room air.
POD#14 she developed a low grade fever, with worsening abdominal
pain. POD#15 she developed worsening breath sounds and required
frequent yankaur suctioning. Chest x ray revealed recurrent
pleural effusions. She was taken to CT for follow up of
abdominal fluid collections with oral contrast placed in the G
tube. She had an aspiration event of tubefeeding and oral
contrast upon returning to the floor. A chest xray was obtained
immediately which appeared similar to the one earlier in the
day. Her respiratory status deteriorated throughout the
afternoon, requiring O2 on 4L for spo2 94%. She was transported
to IR for evacuation of an abdominal fluid collection. A pigtail
drain was left in place. Upon return from the procedure she
developed respiratory distress. She was transferred to the TSICU
and was intubated. Subsequent CXR revealed infiltrates diffusely
throughout lung fields, consistent with ARDS.
CV: Required pressors for support POD#16. Weaned POD#17. Remains
on high dose beta blockers for tachycardia.
Respiratory: Remains ventilator dependent. Was unable to wean
off Assist control. Due to inability to wean, tracheostomy was
placed POD#22. She has tolerated trials of CPAP. CXRs improved.
Currently no opacities. Vent settings: CPAP + PS Fi02:40 Vt
380, Rate 23, Peep 5, PS 8.
GI: Her TFs were adjusted several times due to high residuals.
POD#22-23 she developed vomiting. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1372**]-Jejunal tube was placed
for feeding. She has tolerated NJ feedings with no nausea or
vomiting. G tube has been to gravity since NJ placed.
Ostomy has produced soft brown stool and measurable loose green
stools throughout admission. C diff remains negative.
Abdomen: Her abdomen has remained intact, soft and nontender.
She was closed with retention sutures and has required [**Hospital1 **]
abdominal wet to dry dressing changes. No positive cultures in
abdominal wound.
GU: Foley catheter remains intact. She remains on precautions
for MRSA and VRE in her urine.
Nutrition: She was supplemented with TPN for her entire
admission, she was weaned from TPN on POD# 24. Remains on TFs
per NJ tube, tolerating well.
Peritionitis: remains on broad spectrum antibiotics for
peritonitis and pulmonary coverage. Leukocytosis improved, now
15. Infectious disease consultation recommended a course of
antibiotics (vanco, meropenem, fluconazole) to continue for 2
weeks post-drain removal ([**2162-1-25**]). She was discharged to rehab
with a 6day course remaining.
Medications on Admission:
prednisone 2, Evista 60, lisinopril 10, omeprazole 20, advair
250/50, folate, ASA 81
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
3. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation Q6H (every 6 hours) as needed for wheezing.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
11. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
12. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime).
13. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day) as needed.
14. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
15. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous Q6H (every 6 hours) for 6 days.
16. Fluconazole in Saline(Iso-osm) 400 mg/200 mL Piggyback Sig:
One (1) dose Intravenous Q24H (every 24 hours) for 6 days.
17. Erythromycin Lactobionate 500 mg Recon Soln Sig: Two Hundred
Fifty (250) Recon Soln Intravenous [**Hospital1 **] (2 times a day).
18. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous once a day for 6 days.
19. Insulin
Per sliding scale. Administer as directed.
20. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
21. Evista 60 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. Large bowel perforation/prior polypectomy wound breakdown s/p
repair with colectomy
2. resolving peritonitis/sepsis
3. ARDS and subsequent respiratory failure
4. Pleural effusions
Discharge Condition:
stable.
Discharge Instructions:
Please call your surgeon or return to the emergency department
if you develop chest pain, shortness of breath, fever greater
than 101.5, foul smelling or colorful drainage from your
incisions, redness or swelling, severe abdominal pain or
distention, persistent nausea or vomiting, inability to eat or
drink, or any other symptoms which are concerning to you.
No tub baths or swimming. You may shower. A mild amount of
clear/reddish drainage from your incisions is normal. You
should report any dark, thick, or purulent drainage. The wound
will continue to need damp dressings changed twice daily.
Activity: No heavy lifting of items [**9-5**] pounds until the
follow up
appointment with your doctor.
Medications: Continue medications on your discharge
instructions.
Followup Instructions:
You have an appointment to see Dr. [**Last Name (STitle) **] in the [**Hospital Ward Name 23**]
Clinical Center [**Location (un) 470**] surgical services on [**2-18**] 1:15.
Please make arrangements for her to be transported by ambulance
if necessary for this appointment.
Completed by:[**2163-2-2**]
ICD9 Codes: 5990, 5119, 5070, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8336
} | Medical Text: Admission Date: [**2176-7-1**] Discharge Date: [**2176-7-7**]
Date of Birth: [**2115-8-12**] Sex: M
Service: [**Last Name (un) **]
PREOPERATIVE DIAGNOSIS: End-stage liver disease secondary to
alcoholic cirrhosis.
PAST MEDICAL HISTORY:
1. History of encephalopathy.
2. Grade I varices.
3. History of gout.
4. History of depression.
5. Status post exploratory laparotomy and left-sided
colectomy for perforated diverticulitis in [**Month (only) 956**] of
[**2175**].
PRINCIPAL PROCEDURE: Orthotopic liver transplant on [**2176-7-1**].
HOSPITAL COURSE: Mr. [**Known lastname **] is a 60-year-old gentleman
with a history of end-stage liver disease secondary to
alcoholic cirrhosis. He was admitted to the transplant
surgery service on [**2176-7-1**] for a workup for an
orthotopic liver transplant. On [**2176-7-1**] he received
an orthotopic liver transplant, and postoperatively was
admitted to the surgical intensive care unit. He did quite
well in the surgical intensive care unit. LFTs were trending
downward. He received a liver transplant ultrasound which
showed good flow within his hepatic veins, portal vein, as
well as his hepatic artery. On postoperative days #1 and #2,
he was weaned off the ventilator towards extubation. He was
extubated without complication.
On postoperative day #2, Mr. [**Known lastname **] was doing well in the
ICU and was transferred to floor status. He continued to do
well. His diet was advanced to a regular diet, which he
tolerated without difficulty. He was seen and evaluated by
physical and occupational therapy and worked well with them.
Additionally, he was seen and evaluated by ostomy care nurses
for assistance with management of his colostomy status post
transplant surgery.
On postoperative day #6 - on [**2176-7-7**] - Mr. [**Known lastname **]
was ambulating well on his own, he was tolerating a regular
diet, had appropriate output from his ostomy, and was ready
for discharge home; per the transplant surgery service and
per physical and occupational therapy.
DISCHARGE STATUS: Mr. [**Known lastname **] was discharged home from [**Hospital1 **] Hospital on [**2176-7-7**].
DISCHARGE INSTRUCTIONS:
1. He was instructed to follow up with the Transplant
Surgery Clinic on this coming Thursday; or to call or
follow up sooner if he has any concerns or questions.
2. He was instructed on appropriate care for his ostomy, and
will be seen and evaluated by our visiting nurse
assistance for management of this. He has taken care of
this before, but will need some assistance status post
transplant.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d..
2. Famotidine 20 mg p.o. b.i.d..
3. Clozaril 400 mg p.o. daily.
4. Mycophenolate 1 gram p.o. b.i.d..
5. Oxycodone 1 to 2 tablets p.o. q.4-6h. p.r.n. pain.
6. Prednisone 20 mg p.o. daily.
7. Senna 1 tablet p.o. p.r.n..
8. Tacrolimus ______ mg p.o. b.i.d.; he is to follow up for
level checks - this was arranged with the transplant
coordinator.
9. Valcyte 900 mg p.o. daily.
10. Bactrim 1 tablet p.o. daily.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**]
Dictated By:[**Name8 (MD) 57264**]
MEDQUIST36
D: [**2176-7-7**] 16:23:48
T: [**2176-7-7**] 17:21:25
Job#: [**Job Number 63239**]
ICD9 Codes: 2749, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8337
} | Medical Text: Admission Date: [**2117-12-6**] Discharge Date: [**2117-12-24**]
Date of Birth: [**2067-4-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p Pedestrian Struck by Auto
Major Surgical or Invasive Procedure:
s/p ORIF-IM nail Left Tib/Fib Fracture [**12-6**]
s/p Closed Reduction and ORIF Bilateral Mandible Fracture
History of Present Illness:
50 yo male pedestrian struck by auto at high speed; +ETOH.
Patient found down by EMS and was transferred to [**Hospital1 18**] for
trauma care.
Past Medical History:
PTSD
Social History:
Married; employed in construction field
Family History:
Noncontributory
Physical Exam:
Admission VS: BP135/palp HR 104 T 98 po
Gen: Combative
HEENT: Hematoma forehead; unstable mandible; blood in airway
Neck; c-collar
Chest: Equal BS
Cor: RRR
Abd: soft NT/ND
Extr: MAE except LLE; abrasions LUE/LLE; deformity LLE
Pertinent Results:
[**2117-12-6**] 11:37PM TYPE-ART PO2-376* PCO2-38 PH-7.39 TOTAL
CO2-24 BASE XS--1
[**2117-12-6**] 11:37PM LACTATE-3.4*
[**2117-12-6**] 11:21PM GLUCOSE-102 UREA N-9 CREAT-0.9 SODIUM-144
POTASSIUM-3.2* CHLORIDE-112* TOTAL CO2-22 ANION GAP-13
[**2117-12-6**] 11:21PM CALCIUM-6.8* PHOSPHATE-2.8 MAGNESIUM-1.2*
[**2117-12-6**] 09:16PM HGB-11.3* calcHCT-34
[**2117-12-6**] 08:08PM LACTATE-2.0
[**2117-12-6**] 07:53PM CK(CPK)-937*
[**2117-12-6**] 07:53PM PLT COUNT-163
[**2117-12-6**] 07:53PM PT-12.0 PTT-28.2 INR(PT)-1.0
[**2117-12-6**] 05:55PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2117-12-6**] 04:45PM ASA-NEG ETHANOL-309* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
TIB/FIB (AP & LAT) LEFT [**2117-12-6**] 5:28 PM
TIB/FIB (AP & LAT) LEFT; KNEE (AP, LAT & OBLIQUE) LEFT
Reason: eval for fracture
[**Hospital 93**] MEDICAL CONDITION:
50 year old man with open tib fib
REASON FOR THIS EXAMINATION:
eval for fracture
INDICATION: 50-year-old in motor vehicle accident with open
tibial-fibular fracture.
Two views of the left knee, one view of the left tibia and
fibula, and two views of the left ankle.
FINDINGS:
There is a transverse fracture through the mid tibial diaphysis
with medial displacement of the distal fracture fragment. A
curvilinear lucency is also seen in the more proximal tibial
diaphysis, also likely representing a fracture line. Two oblique
fractures are seen fibular diaphysis. The first is within the
proximal third, and the second in the mid fibula. The free
fragment between these two fracture lines is medially displaced
relative to the proximal fibular diaphysis, and the distal
fibular fracture fragment is slightly medially angulated.
Views of the right knee demonstrate no fracture or dislocation
within the knee joint. No knee effusion is present. Views of the
ankle demonstrate a normal- appearing mortise with no ankle
fracture or dislocation.
Gauze is seen overlying the soft tissues around the tibial
fracture.
IMPRESSION:
Multiple fractures of the tibia and fibula as described above.
TIB/FIB (AP & LAT) IN O.R. LEFT IN O.R. [**2117-12-6**] 10:08 PM
TIB/FIB (AP & LAT) IN O.R. LEF; -77 BY DIFFERENT PHYSICIAN
Reason: ORIF LT TIBIA FX
HISTORY: 50-year-old male with ORIF of left tibia fracture.
FINDINGS: 13 intraoperative fluoroscopic spot images were
obtained without a radiologist present and compared with
[**2117-12-6**]. There has been interval placement of an
intramedullary rod within the tibia with proximal and distal
cortical screws fixating the transverse fracture of the
mid-diaphysis. There has been reduction of the medial
displacement of the distal fracture fragment and there is now
near anatomic alignment. Also noted is the oblique fracture line
of the more proximal tibial diaphysis. Two oblique fractures are
again seen through the fibular diaphysis. The ankle mortise is
congruent.
IMPRESSION: Status post ORIF of tibia fracture as described.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2117-12-6**] 4:59 PM
CT SINUS/MANDIBLE/MAXILLOFACIA; CT RECONSTRUCTION
Reason: eval for fx
[**Hospital 93**] MEDICAL CONDITION:
50 year old man with ped struck, combative. unstable mandible
REASON FOR THIS EXAMINATION:
eval for fx
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Status post struck by car.
TECHNIQUE: Axial non-contrast images through the facial bones
were obtained. Coronal and sagittal reformatted images were
obtained.
CT FACIAL BONES: Slightly to the left of midline is a minimally
displaced fracture through the anterior mandible. Slightly to
the right of midline is a mildly comminuted fracture through the
right anterior mandible. Small foci of air are seen about the
fracture fragments. Associated malocclusion of the teeth is
identified. No other fractures are identified. The surrounding
soft tissue structures are unremarkable.
IMPRESSION: Mandibular fractures as described above.
CT HEAD W/O CONTRAST [**2117-12-6**] 4:58 PM
CT HEAD W/O CONTRAST
Reason: eval for ich
[**Hospital 93**] MEDICAL CONDITION:
50 year old man with ped struck, combative
REASON FOR THIS EXAMINATION:
eval for ich
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Pedestrian struck by car.
TECHNIQUE: Routine non-contrast CT.
FINDINGS: There is an, approximately, 5- x 4-mm hyperdense focus
within the right frontal lobe. There is no mass effect, shift of
normally midline structures, or hydrocephalus. Other than this
hyperdense focus the density values of the brain parenchyma are
within normal limits. The [**Doctor Last Name 352**]-white matter differentiation is
preserved. The ventricles and sulci are normal in size. The
surrounding osseous and soft tissue structures are unremarkable.
There is no evidence for fracture. The visualized paranasal
sinuses are well aerated.
IMPRESSION: Small hematoma within the right frontal lobe. No
fractures identified.
CT HEAD W/O CONTRAST [**2117-12-7**] 8:57 AM
CT HEAD W/O CONTRAST
Reason: please eval interval change in head bleed
[**Hospital 93**] MEDICAL CONDITION:
50 year old man with SAH
REASON FOR THIS EXAMINATION:
please eval interval change in head bleed
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Subarachnoid hemorrhage vs. intraparenchymal
hemorrhage, evaluate for change.
COMPARISON: Non-contrast head CT from [**2117-12-6**].
TECHNIQUE: Non-contrast head CT.
FINDINGS: Again seen is a small focus of high density in the
right frontal lobe, measuring approximately 4 mm in diameter and
unchanged in appearance since the prior study. Additionally,
there is a newly apparent focus of high density seen only on
series 2, image 24 in the right parietal lobe. Given that this
is only seen on a single image, it may represent artifact, but
could also represent a separate area of small intraparenchymal
hemorrhage. No other intra or extra-axial hemorrhages are
identified. There is no shift of normally midline structures, no
hydrocephalus, no intracranial mass lesion, and no evidence of
vascular territorial infarction. The [**Doctor Last Name 352**] white matter
differentiation is well preserved and the density values of the
brain parenchyma are within normal limits. No fractures are
identified. The visualized paranasal sinuses and mastoid air
cells are well pneumatized. Soft tissue structures appear
unremarkable.
IMPRESSION: Stable appearance to the intraparenchymal hemorrhage
in the right frontal lobe, possible new focus of
intraparenchymal hemorrhage in the right parietal lobe.
These findings were discussed with the surgical intern taking
care of the patient at the time of interpretation.
MANDIBLE (PANOREX ONLY) PORT [**2117-12-9**] 9:12 PM
MANDIBLE (PANOREX ONLY) PORT
Reason: AP only, postop eval
[**Hospital 93**] MEDICAL CONDITION:
50 year old man s/p ORIF b/l mandible
REASON FOR THIS EXAMINATION:
AP only, postop eval
INDICATION: 50-year-old status post ORIF bilateral mandibular
fracture.
Single frontal view of the mandible demonstrates two plates with
screws transfixing the mandibular fracture. There are also
numerous wires seen along the mandible and the maxilla fixing
the fracture.
Brief Hospital Course:
Patient admitted to Trauma Service. Orthopedic, Neurosurgery and
OMFS were consulted. He was taken to the operating room on [**12-6**]
for ORIF-IM nail left tib/fib fracture. Neurosurgery recommended
non-surgical approach for his IPH; repeat head CT stable.
Patient taken to the operating room on [**2117-12-9**] by OMFS where he
underwent closed reduction; ORIF bilateral mandible fractures;
he was also trached with a PEG being placed during that time.
His jaw is wired shut; the plan is for removal of these wires by
OMFS in 2 weeks.
He was placed on CIWA protocol for ETOH withdrawal; he did
require sitters; restraints and antipsychotics for increased
agitation during his initial hospitalization. These have all
been discontinued as of [**12-15**]. Patient has been cooperative with
his care; working with PT. He is ambulating with rollling walker
and has begun crutch training. Speech therapy has evaluated
patient for Passy Muir valve; his trach was down sized on [**12-15**]
to a #7 and again on [**12-23**] to a #4. He is currently tolerating
the Passy Muir valve with good oxygen saturations. He is taking
in a full liquid diet and started on calorie counts.
Patient was originally screened for rehab and was deemed at a
too high of a level of functioning by his insurance reviewers.
Patient and caregiver [**First Name (Titles) 66458**] [**Last Name (Titles) **] for discharge to home.
He will require home skilled nursing, PT, OT, Speech &
Respiratory therapy at home.
On [**12-24**] PT gave clearance for the patient to go home w/
crutches, supervision by his wife, and home physical therapy.
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*350 ML* Refills:*0*
2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*500 ML* Refills:*0*
3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day): [**Month (only) 116**] be crushed.
Hold fror HR <60 and SBP < 110.
Disp:*90 Tablet(s)* Refills:*2*
4. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane TID (3 times a day).
Disp:*350 ML* Refills:*2*
5. Milk of Magnesia 800 mg/5 mL Suspension Sig: One (1) PO
twice a day as needed for constipation.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
s/p Pedestrian Struck by Auto
Small Right Frontal Intraparenchymal Hematoma
Mandible Fracture
Grade I Open Left Tibia/Fibula Fracture
Discharge Condition:
Stable
Discharge Instructions:
Follow up in Trauma Clinic in [**3-26**] weeks.
Follow up in [**Hospital **] Clinic in 1 month
Follow up with Oral Facial Maxillo Surgery in 2 weeks for
removal of jaw wires.
Followup Instructions:
Call [**Telephone/Fax (1) 1228**] for an appointment in [**Hospital **] Clinic
Call [**Telephone/Fax (1) 6439**] for an appointment in Trauma Clinic
Call [**Telephone/Fax (1) 66459**] for an appointment with OMFS for removal
of jaw wires
Completed by:[**2117-12-24**]
ICD9 Codes: 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8338
} | Medical Text: Admission Date: [**2122-2-21**] Discharge Date: [**2122-2-25**]
Date of Birth: [**2052-4-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12**]
Chief Complaint:
Right Lower Quadrant Pain, Hypotension
Major Surgical or Invasive Procedure:
Embolization of the left hepatic artery.
History of Present Illness:
Mr. [**Known lastname 1968**] is a 69 year old male with a history of HIV (CD4 238),
hepatitis C and multifocal hepatocellular carcinoma with
admission in [**9-/2121**] for hemoperitoneum from bleeding cancer
focus who presents from home with right lower quadrant abdominal
pain which began approximately thirty minutes after he bent down
to pick up a crate at the supermarket. The pain continued to
worsen and became more diffuse with enlargement of his abdomen.
The pain is now severe and [**8-29**]. It was associated with nausea,
vomiting. It was not associated with diarrhea, constipation,
dysuria or hematuria. It was not associated with lightheadedness
or dizziness. He presented to the emergency room.
.
In the emergency room his initial vitals were T: 99.2 HR: 94 BP:
66/36 RR: 16 O2: 100% on RA. He received a total of 4L normal
saline and 2 unit PRBCs with stabilization of his blood pressure
to the 120s systolic. He transiently required levophed but this
was quickly turned off. He received vancomycin 1 gram IV and
zosyn 4.5 mg IV as well as fentanyl 50 mcg x 1 and dilaudid 1 mg
x 1. He underwent a diagnostic paracentesis which showed a
calculated hematocrit of 18.5 with 2278 WBCs. He underwent a CT
scan with IV contrast which showed a large amount of new
perihepatic hemorrhage with evidence for active extravasation at
site of previous liver capsular rupture. Moderate amount of
abdominal pelvic hemorrhage. New segment VIII low attenuation
concerning for metastasis. Increased metstatic disease burden in
left lobe. No distant metastasis. He was seen by the surgical
consult service who recommended that he undergo emergent IR
embolization of bleeding region.
.
On arrival to the floor his blood pressure is in the 130s
sytolic and his heart rate was in the 110s. He continued to note
pain in his abdomen. He endorses pain with deep inspiration and
mild dyspnea. He denies nausea, vomiting, dysuria, hematuria,
lightheadedness, dizziness, melena, hematochezia, leg pain or
swelling. All other review of systems negative in detail.
.
Pateint's HCT was stable for 24 hours in the unit in 30s. It
bumped appropiately after 2 RBC units. Antibiotics were stopped.
Patient has been afebrile. Now he is transfered to the OMED
service to further management of his bleeding and to discuss
treatment options.
Past Medical History:
Past Medical History:
-HIV on HAART - last CD4 238, viral load 334 on [**2122-2-15**]
-Hepatitis C (genotype 1), last viral load 693,000 on [**2120-12-3**]
-Hepatocellular Carcinoma with multifocal disease, not a
ressection candidate complicated by hemoperitoneum in [**9-27**]
requiring IR embolization
Social History:
Patient is single and rents a room from an elderly woman and
acts as her caretaker. [**Name (NI) **] was born in Bermuda. Has 3 daughters
and 1 son. Smokes [**Name2 (NI) **] 1 pack every 3-4 days for the past 15
years. No ETOH in 8 years. Prior heavy use in past. No IVDU in
15 years. Prior to this used IV heroin and cocaine.
Family History:
Diabetes. No known history of malignancy.
Physical Exam:
Vitals: T: 100.3 HR: 103 BP: 148/95 RR: 18 O2: 98% on 2L
.
General: Awake, alert, speaking in full sentences, wheezes
HEENT: Sclera anicteric, MM moist, oropharynx clear, no
lymphadenopathy, parotid gland enlargement
Neck: JVP not elevated
Cardiac: Tachycardic, regular rhythm, s1 + s2, SEM RUSB [**2-23**],
rubs, gallops
Lungs: expiratory wheezes, no rales or ronchi. Pt has
ginecomastia.
GI: firm, distended, tender diffusely, present bowel sounds, no
rebound tenderness, + guarding
GU: foley draining red urine, small testes
Ext: Warm and well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neurologic: No asterixis, grossly intact, A&Ox3, cerebelar exam
intact, adequate strenght.
Pertinent Results:
On Admission:
[**2122-2-21**] 06:40PM WBC-13.5*# RBC-3.47* HGB-10.6* HCT-33.1*
MCV-96 MCH-30.7 MCHC-32.1 RDW-18.4*
[**2122-2-21**] 06:40PM NEUTS-79.9* LYMPHS-15.6* MONOS-3.9 EOS-0.3
BASOS-0.3
[**2122-2-21**] 06:40PM PLT COUNT-436
[**2122-2-21**] 06:40PM PT-13.2 PTT-26.9 INR(PT)-1.1
[**2122-2-21**] 06:40PM GLUCOSE-238* UREA N-13 CREAT-1.5* SODIUM-132*
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-20* ANION GAP-18
[**2122-2-21**] 06:40PM ALT(SGPT)-65* AST(SGOT)-55* ALK PHOS-108 TOT
BILI-0.5
[**2122-2-21**] 06:40PM ALBUMIN-3.0*
[**2122-2-21**] 06:55PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2122-2-21**] 06:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2122-2-21**] 06:55PM URINE RBC-0-2 WBC-[**4-29**]* BACTERIA-FEW
YEAST-NONE EPI-0-2 TRANS EPI-0-2
[**2122-2-21**] 11:57PM LACTATE-1.6
[**2122-2-21**] 11:57PM TYPE-ART TEMP-36.6 PO2-73* PCO2-39 PH-7.34*
TOTAL CO2-22 BASE XS--4 INTUBATED-NOT INTUBA
[**2122-2-21**] 11:44PM HCT-26.8*
[**2122-2-21**] 11:44PM PT-14.0* PTT-28.4 INR(PT)-1.2*
.
EKG: sinus tachycardia at 101, left axis deviation, left
anterior fascicular block, no acute ST segment changes.
.
Imaging:
CXR: Lung volumes are mildly diminished. No consolidation or
edema is noted. The mediastinum is unremarkable. The cardiac
silhouette is within normal limits for size. A small hiatal
hernia is incidentally noted. No effusion or pneumothorax or
free intraperitoneal air identified. The osseous structures are
grossly unremarkable.
.
CT Abdomen with contrast:
1. Increase in the extent of metastatic disease, likely
hepatocellular carcinoma, involving the left lobe of the liver
and evidence of capsular rupture and large volume of
hemoperitoneum. A new 8 mm hypoattenuating focus within the
right lobe of the liver is now seen. An area of increased
attenuation within the center of the hemoperitoneum adjacent to
the liver is concerning for active extravasation. Overall, the
amount of hemoperitoneum has increased in size when compared
back to the initial presentation of this condition on the CT of
[**2121-10-4**]. Surgical consultation advised.
2. Moderate hiatal hernia.
3. Left renal cyst.
.
Upon Discharge:
[**2122-2-25**] 05:35AM BLOOD WBC-11.8* RBC-3.56* Hgb-10.7* Hct-32.1*
MCV-90 MCH-30.1 MCHC-33.4 RDW-17.6* Plt Ct-266
[**2122-2-25**] 05:35AM BLOOD Plt Ct-266
[**2122-2-25**] 05:35AM BLOOD Glucose-79 UreaN-12 Creat-0.6 Na-133
K-3.1* Cl-101 HCO3-25 AnGap-10
[**2122-2-25**] 05:35AM BLOOD ALT-413* AST-141* LD(LDH)-836*
AlkPhos-280* TotBili-3.0* DirBili-1.8* IndBili-1.2
[**2122-2-25**] 05:35AM BLOOD Albumin-2.8*
Brief Hospital Course:
Impression: 69 year old male with history of HIV (CD4 238),
hepatitis C and multifocal hepatocellular carcinoma who presents
with abdominal pain found to have hemoperitoneum with associated
shock likely from bleeding liver malignancy.
.
Hemoperitoneum: Patient with evidence of active extravasation
of contrast on abdominal CT scan and calculated peritoneal fluid
hematocrit of 18. Hemodynamically stable s/p 4L normal saline
and two units PRBCs in ED. He underwent IR embolization of the
left hepatic artery. He was monitored 24 hours in the ICU with
frequent HCT that were stable. He did not require further
transfusions. His pain was controlled with IV dilaudid and then
switched to an oral regimen.
.
Hypotension/Hemorrhagic Shock: Related to acute blood loss in
the setting of hemoperitoneum.
.
Acute Renal Failure: Patient's creatinine upon presentation was
1.5 and improved up to 0.6 upon discharge after IVF and stopping
hemorrhage. It was thought to be pre-renal renal failure since
patient improved rapidly and there were no cast suggesting ATN.
He had good UOP.
.
Hyperglycemia: No documented history of hyperglycemia but blood
glucose on chemistry panel is 238. He was started on ISS. He had
minimal requirements during hospitalization.
.
HIV: CD4 count 238 with viral load of 334 on [**2122-2-11**]. HAART was
continued.
.
Hepatocellular Carcinoma: Patient is not good candidate for
resection and has already failed hepatic artery embolization in
the past. He now bleed into the abdomen and most likely has
metastatic disease (not proven). Extensive discussions took
place between Dr. [**Last Name (STitle) **] and him and decided to give a 2-week
break and then meet to evaluate for either continuing hospice
care or oral chemotherapy regimen with sorafenib.
.
FEN: Regular diet.
.
Access: 2 16 g peripheral IVs.
.
Prophylaxis: pneumoboots, home PPI.
.
Code: DNR/DNI.
.
Contact: Proxy name: [**Name (NI) 23548**] [**Name (NI) **] (sister) Phone: [**Telephone/Fax (1) 23549**].
.
Disposition: Home with hospice.
Medications on Admission:
Senna 8.6 mg [**Hospital1 **]:PRN
Combivir 150 mg-300 mg [**Hospital1 **]
Kaletra 200 mg-50 mg 2 Tablets [**Hospital1 **]
Methadone 5 mg TID:PRN
Tylenol 325 mg TID:PRN
Omeprazole 20 mg daily
Ibuprofen 400 mg TID:PRN
Lactulose 30 mls TID:PRN for constipation
Oxycodone 5 mg Tab Q4:PRN
Discharge Medications:
1. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
2. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet
PO BID (2 times a day).
3. Lopinavir-Ritonavir 200-50 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Methadone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain: Then continue your regular
oxycodone, once the pain improves. Do not drive or do high risk
activities. This medication has sedative effects.
Disp:*15 Tablet(s)* Refills:*0*
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO once a
day as needed for constipation.
9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
10. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
Abdominal Hemhorrage secondary to hepatocelular carcinoma.
.
Secondary Diagnosis:
Hepatocellular Carcinoma
Hepatitis C
Cirrhosis
HIV
Discharge Condition:
Stable, tolerating PO, pain controlled, ambulating.
Discharge Instructions:
You were seen at the [**Hospital1 18**] for abdominal pain. You had a CT scan
of your abdomen that showed signs of bleeding. Some fluid from
your abdomen was obtained and it showed blood corroborating the
prior clinical impression. You bleed from your liver massess,
therefore you underwent ebolization of one of the arteries of
your liver to stop the bleeding. You required multiple blood
transfusions to replete the loss. We followed closely your blood
level and it was stable and you did not further require any
transfusions. You had exacerbation of your abdominal pain that
was controlled with dilaudid. You will meet with Dr. [**Last Name (STitle) **] and
Dr. [**Last Name (STitle) 4613**] (see below) to discuss further oral chemotherapy and
other ways we can help you.
.
If you have chest pain, shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) 691**] changes in the
abdominal pain, [**Last Name (un) 23550**] stools, blood in your stools, or anything
else that concerns you please come back to our ER.
.
We started you on a nicotine patch. You can use if if you want
to stop smoking. Do not use the patch and smoke at the same
time.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2122-3-13**]
10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 23551**], MD Phone:[**Telephone/Fax (1) 447**]
Date/Time:[**2122-3-13**] 10:00
.
Please follow with oyour PCP within [**Name Initial (PRE) **] month of discharge.
ICD9 Codes: 5849, 5715, 2851, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8339
} | Medical Text: Admission Date: [**2105-12-26**] Discharge Date: [**2105-12-28**]
Date of Birth: [**2034-10-28**] Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending:[**First Name3 (LF) 9965**]
Chief Complaint:
angioedema
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
71-year-old female with history of HTN on lisinopril, NIDDM who
presents with angioedema and was intubated for airway
protection.
.
The patient had a URI the past 3 weeks but was otherwise well.
Last PM she was noted to have poor control of secretions and
nausea. She went to bed and awoke in the AM with increased
tongue swelling, unable to speak, and poor secretion control.
Her daughter brought her to [**Name (NI) 4199**] Hospital. At [**Last Name (un) 4199**] she was
treated with decadron, famotidine and benadryl. She was
transferred to [**Hospital1 18**] for further care.
.
In the ED, initial VS were: T 98.1, HR 74, BP 172/80, RR 18,
SvO2 100% 2L NC. In the EW, they attempted oropharyngotracheal
intubation three times without success. She underwent
nasotracheal intubation using fiberoptic scope. Per report there
was significant swelling of the larynx and vocal cords. She was
sedated with propofol.
.
Per report, within the past year she had lip swelling which was
attributed to lisinopril (however, this medication was
continued). The daughter denies any recent shellfish or peanuts.
No new foods or medications (other than ibuprofen and colace 2
weeks ago). Daughter denies fever, night sweats, headache,
shortness of breath, wheezing, palpitations, weakness, diarrhea,
constipation, dysuria, rashes. She did note nausea, chest
discomfort and tongue swelling.
Past Medical History:
- Myopia
- NIDDM c/b proliferative diabetic retinopathy
- HTN
- HLD
- h/o vitreous hemorrhage
- s/p cataract removal
Social History:
Lives with daughter. Independent ADLs. Born in [**Country 2045**]. To US in
[**2082**].
- Tobacco: Never
- Alcohol: None
- Illicits: None
Family History:
Sister and brother with DM, HLD. Otherwise no known history. No
allergy history.
Physical Exam:
Vitals: T: 99.8 BP: 150/64 P: 86 R: 14 O2: 100% intubated
Vent Settings: FiO2 0.5, PEEP 5, Vt 450, rate 14
General: Sedated, intubated, occassionally with gag, not
responsive, moving all extremities spontaneously
HEENT: Sclera anicteric, MMM, swollen tongue, secretions pouring
out side of mouth, pupils constricted
Neck: supple, JVP not elevated, no LAD
CV: RR, nl rate, nl S1, S2, no murmurs, rubs, gallops
Lungs: CTAB, anterior examination, no wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no edema
Neuro: Sedated, minimally responsive. Spontaneously moving
extremities, gag reflex intact.
Pertinent Results:
[**2105-12-27**] 08:07AM BLOOD WBC-12.0*# RBC-3.75* Hgb-11.2* Hct-33.8*
MCV-90 MCH-29.8 MCHC-33.1 RDW-13.6 Plt Ct-230
[**2105-12-26**] 06:43AM BLOOD WBC-4.4 RBC-4.11* Hgb-12.1 Hct-36.2
MCV-88 MCH-29.5 MCHC-33.4 RDW-13.8 Plt Ct-244
[**2105-12-26**] 06:43AM BLOOD Neuts-57.1 Lymphs-37.7 Monos-3.3 Eos-1.6
Baso-0.3
[**2105-12-26**] 06:43AM BLOOD PT-10.9 PTT-28.1 INR(PT)-1.0
[**2105-12-27**] 08:07AM BLOOD UreaN-24* Creat-1.2* Na-142 K-4.1 Cl-109*
HCO3-20* AnGap-17
[**2105-12-26**] 06:43AM BLOOD Glucose-126* UreaN-18 Creat-1.1 Na-142
K-4.3 Cl-106 HCO3-24 AnGap-16
[**2105-12-26**] 08:32AM BLOOD Rates-14/ Tidal V-450 pO2-484* pCO2-39
pH-7.38 calTCO2-24 Base XS--1 -ASSIST/CON
CXR [**12-26**]:
FINDINGS: The patient has received an endotracheal tube. The tip
of the tube projects 4 cm above the carina. The tube could be
advanced by 1 cm. No evidence of complications, notably no
pneumothorax.
Borderline size of the cardiac silhouette without pulmonary
edema. No pleural effusions. No focal parenchymal opacities
suggesting pneumonia.
Labs on discharge:
[**2105-12-28**] 07:45AM BLOOD WBC-7.6 RBC-4.02* Hgb-11.8* Hct-35.8*
MCV-89 MCH-29.3 MCHC-32.9 RDW-13.7 Plt Ct-215
[**2105-12-28**] 07:45AM BLOOD Glucose-90 UreaN-22* Creat-1.0 Na-143
K-3.5 Cl-111* HCO3-23 AnGap-13
[**2105-12-28**] 07:45AM BLOOD ALT-10 AST-18 AlkPhos-35 TotBili-0.7
[**2105-12-28**] 07:45AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.7
Brief Hospital Course:
Patient is a 71-year-old female with PMH of HTN on lisinopril
who presented with angioedema requiring brief intubation.
Patient had a traumatic intubation requiring nasopharyngeal
intubation in the emergency room. At time of intubation by
report there was significant tongue edema and laryngeal edema
consistent with angioedema. At the time of transfer to the
general medicine floor this tongue edema had entirely resolved.
# Angioedema: Likely secondary to lisinopril. Less likely NSAIDs
and aspirin which were restarted at time of discharge. She was
treated with famtotidine and methylprednisolone 40 mg IV Q8H x
24hours. Famotidine and steroids were discontinued after 24
hours and she was extubated. SLisinopril was added as an
allergy. She was restarted on her home H2-blocker.
# Hypertension: She was started on metoprolol as calcium channel
blockers are also associated with angioedema. No ACEi or [**Last Name (un) **]
should be given in the future given the risk of angioedema.
# pain: Likely MSK in nature given tenderness to palpation of
back, scapula, flank and epigastrum. Per patient and family, had
extensive work-up as an outpatient. We do not currently have
access to those reports. EKG was not significant for cardiac
pathology. She was given tylenol and restarted on home NSAIDs
and oxycodone at time of discharge.
# fever: Patient with mild temperature elevation to 100.5 in the
ICU which did not recur while on the general medicine floor.
This was thought most likely due to inflammation from angioedema
and airway trauma. Her leukocytosis was likely from steroids as
this was trending down at discharge. She had a negative
urinalysis and chest x-ray without infiltration. Throat pain was
likely secondary to intubation and not an infectious process as
it did not start until after extubation.
# cough: The patient and her family reported a cough of 1 month
duration. This was likely a post-viral syndrome as she had
previously had a URI vs a cough secondary to lisinopril.
Lisinopril had been discontinued and supportive care was
provided for the cough. Chest x-ray was without infiltrate.
# NIDDM: She is on metformin at home but was given insulin
sliding scale while inpatient.
#CODE: Full (confirmed)
#Contact: daughter [**Name (NI) 92271**] [**Telephone/Fax (1) 92272**]; [**Name2 (NI) **] [**Telephone/Fax (1) 92273**]
Medications on Admission:
- Metformin XR 1500mg PO daily
- Aspirin 81mg PO daily
- Atorvastatin 40mg PO daily
- Ranitidine 300mg PO daily
- Lisinopril 20mg PO daily
- Diclofenac Sodium 75mg PO daily
- Alendronate 70mg PO daily (not on med list)
- Colace 100mg PO BID
- Ibuprofen 600mg PO q8H prn pain
- Multivitamin
Discharge Medications:
1. metformin 1,000 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day: combine with 500mg to
equal 1500mg daily.
2. metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day: combine with 1000mg to
equal 1500mg daily.
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*QS1month ML(s)* Refills:*0*
10. Tessalon Perles 100 mg Capsule Sig: One (1) Capsule PO three
times a day as needed for cough.
Disp:*60 Capsule(s)* Refills:*0*
11. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for pain.
12. multivitamin Tablet Sig: One (1) Tablet PO once a day.
13. tramadol 50 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-angioedema secondary to lisinopril
Secondary:
- hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 69**]
because of swelling of your tongue and throat. You were
intubated with a breathing tube down your throat and your were
diagnosed with angioedema (swelling of the throat) likely caused
by lisinopril.
You should NEVER take lisiopril or other ace-inhibitors or
angiotensin receptor blockers in the future for blood pressure
due to the risk of throat swelling.
While you were here, some of your medications were changed.
STOP lisinopril
STOP Diclonfenac
STOP oxycodone
START guafenesin and tesselon pearls if needed for cough
START metoprolol for blood pressure
START tramadol (ultram) for pain
Followup Instructions:
You should call your primary care doctor's officer tomorrow for
a follow-up appointmnent this week. Please bring these papers to
your visit.
Completed by:[**2105-12-28**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8340
} | Medical Text: Unit No: [**Numeric Identifier 69098**]
Admission Date: [**2172-9-22**]
Discharge Date: [**2172-10-19**]
Date of Birth: [**2172-9-22**]
Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname 44129**] is a 31 and
[**1-14**]-week boy born to a 27-year-old G1/P0 (to 1) mother with
[**Name2 (NI) **] type O+, antibody negative, hepatitis B surface antigen
negative, rubella immune, RPR nonreactive, GBS unknown with
rupture of membranes at delivery. The baby was beta complete
on [**2172-9-17**]. Mother received magnesium prior to
delivery. Delivery was performed primarily due to severe
maternal pregnancy-induced hypertension (PIH). Apgar scores
were 8 and 8. The patient was also with a history of
intrauterine growth restriction. The patient was born by C-
section due to the maternal indications.
PHYSICAL EXAMINATION ON ADMISSION: Patient was premature,
small for gestational age male with good respiratory effort,
color, and tone. Initial birth weight was 838 grams, which is
less than 10 percentile, length 34 cm less than 10th
percentile, head circumference 26 cm approximately 10th
percentile. Patient had anterior fontanelle soft, flat, and
open, mildly low set and posterior rotated ears. Palate
intact. No distress. Three-vessel cord. No
hepatosplenomegaly. Normal male external genitalia. Both
testes descended in the scrotum. No hip click. Patent anus.
No sacral dimple. Normal tone. Moving all extremities.
Extremities: Warm and well perfused and active.
D-stick on admission was 46.
SUMMARY OF HOSPITAL COURSE BY SYSTEM:
1. RESPIRATORY: The patient was on room air from time of
birth with very little/brief respiratory support
necessary. Has had no significant desaturations or oxygen
requirement during his life. Is now day of life 26.
2. CARDIOVASCULAR: No history of pressor requirement. The
patient with heart rates consistently in the 130 to 150
or 160 range. No significant issues. No murmur noted for
this patient during stay.
3. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was
transitioned from central parenteral nutrition to enteral
feeds, reaching full feeds of breast milk at 20-
kilocalories per ounce and 150 mL/kg/day on [**2172-10-10**]. Since that time the patient's calories have been
increased to today, [**2172-10-19**]; at which time the
patient is at breast milk supplemented to 30 kilocalories
per ounce with Beneprotein at 150 mL/kg/day. No history
of electrolyte abnormalities.
4. GI: The patient with normal stool. No history of heme
positivity. Peak bilirubin for patient was on day of life
1, and was 6.5. Since that time the patient underwent
phototherapy, which was discontinued on day of life 6
with a rebound bilirubin of 3.1.
5. HEMATOLOGY: The patient's last CBC on [**2172-10-2**] was a white count of 13; hematocrit of 43; platelets
of 130k.
6. INFECTIOUS DISEASE: The patient is status post 1-week
course of vancomycin and gentamicin initiated on [**10-2**], [**2171**], on day of life 10, due to a significant
increase in spells as well as pustule noticed at waist.
No organism detected. The patient treated for 1 week with
vancomycin and gentamicin with resolution of symptoms and
has been off antibiotics since [**2172-10-10**].
7. NEUROLOGY: Normal head ultrasound on [**2172-9-29**].
8. SENSORY:
1. AUDIOLOGY: Screening not performed.
2. OPHTHALMOLOGY: Eye exam performed on [**2172-10-12**]
noted immature zone 3 with followup recommended in 3
weeks.
CONDITION ON TRANSFER: Stable.
DISCHARGE DISPOSITION: Transferred to [**Hospital3 417**]
Hospital NICU.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19419**].
CARE RECOMMENDATIONS:
1. Feeds at time of transfer: Breast milk 30 kilocalories
with Beneprotein at 150 mL/kg/day. At this point, the
majority of the feed is being given with nasogastric
tube, with minimal oral efforts from baby at this time.
2. Car seat position screening not performed.
3. Medications are iron and vitamin E. Caffeine discontinued
on [**2172-10-11**] without significant apnea of
prematurity at this point.
IMMUNIZATIONS RECOMMENDED: No immunizations noted on chart
at this time.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: (1) born at less than 32
weeks; (2) born between 32 and 35 weeks with 2 of the
following -- Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school-age siblings; or (3) with chronic lung disease.
In addition, influenza immunization is recommended annually
in the Fall for all infants once they reach 6 months of age.
Before this age, and for the first 24 months of the child's
life, immunization against influenza is recommended for
household contacts and out-of-home caregivers.
FOLLOW-UP APPOINTMENTS: Will be scheduled at the time of
discharge from transfer hospital.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Small for gestational age (SGA).
3. Rule out sepsis.
4. Feeding immaturity.
5. Hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**]
Dictated By:[**Name8 (MD) 69099**]
MEDQUIST36
D: [**2172-10-19**] 15:13:29
T: [**2172-10-19**] 15:56:47
Job#: [**Job Number 69100**]
ICD9 Codes: 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8341
} | Medical Text: Admission Date: [**2114-1-2**] Discharge Date: [**2114-1-27**]
Date of Birth: [**2039-2-18**] Sex: F
Service: General Surgery
ADMITTING DIAGNOSIS: Chest pain.
DISCHARGE DIAGNOSIS: Chest pain, status post cardiac stent
complicated by retroperitoneal bleed with repair and
postoperative small bowel obstruction.
PROCEDURES:
1. Cardiac catheterization with stent of LAD.
2. Exploration and repair of right external iliac artery
laceration.
3. Re-exploration and repair of retroperitoneal bleeder.
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
female transferred to [**Hospital1 69**] on
[**2114-1-2**] with new onset angina. The patient was taken to the
cardiac catheterization lab on [**2114-1-3**] and was noted to have
an 80% stenosis of the mid LAD that was stented. The
procedure was complicated by a large retroperitoneal bleed
and the patient was taken emergently to the operating room,
underwent a right external iliac repair. Postoperatively the
patient had ongoing hypotension and transfusion requirement
and was taken back to the operating room for re-exploration
and repair of a retroperitoneal bleeder. She stabilized
hemodynamically. The patient was extubated on postoperative
day #6 and was transferred to the floor and required
aggressive pulmonary toilet. She started on Levo and Flagyl
for presumptive aspiration pneumonia. She was also noted to
have increased total bilirubin to 3.1, direct bilirubin to 2
and alkaline phosphatase to 496. A right upper quadrant
ultrasound showed gallbladder sludge but no stones. There
was no intra or extrahepatic ductal dilatation. Subsequently
the patient was noted to develop abdominal distention and
emesis as well as a white blood cell count of 15,000. On
[**1-14**] the patient underwent a CAT scan that showed a small
bowel obstruction and an NG tube was placed with 1-2 liters
output in 24 hours.
PAST MEDICAL HISTORY: 1) MI status post left circumflex
stent [**11-4**] with an EF of 50-55%.
PAST SURGICAL HISTORY: 1) Right total hip replacement. 2)
Hernia repair. 3) Appendectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS: On admission, Aspirin 325 mg po q d, Lopressor
12.5 mg po bid, Plavix - patient had completed course.
PHYSICAL EXAMINATION: The patient is afebrile, vital signs
are stable. She is confused and oriented only to person.
Heart is regular rate and rhythm. There are decreased breath
sounds at her bases bilaterally. Her abdomen is soft,
distended, nontender, her incision is clean, dry and intact.
Extremities are soft and warm, well perfused.
HOSPITAL COURSE: As noted in the history of present illness,
the patient was admitted on [**1-2**] and was taken to the cath
lab. She underwent a mid LAD stent and post procedure noted
to have a large retroperitoneal bleed. She was taken
emergently to the OR. This was repaired. The right external
iliac artery was repaired. She had ongoing hypotension and
transfusion requirement postoperatively. She was taken back
to the operating room for re-exploration and repair of a
retroperitoneal bleeder. Hemodynamically she stabilized and
was extubated on postoperative day #6. She was then
transferred to the floor and was started on Levo and followed
for presumptive aspiration pneumonia. Her LFTs were noted to
be elevated and right upper quadrant ultrasound only revealed
gallbladder sludge, no stones, no intra or extra hepatic
ductal dilatation. She subsequently developed abdominal
distention, emesis and a white blood cell count to 15,000.
CT scan on [**1-14**] showed distal small bowel obstruction and NG
tube was placed with approximately 2 liters output. The
patient was then transferred to the general surgery service
for further management. The patient's NG tube continued to
have high output. As the patient's urine output was low, she
was aggressively hydrated, she was kept npo, she was started
on Somatostatin. She was also started on a Heparin drip in
place of her Plavix for her cardiac stents. Her TPN was
continued. From a vascular standpoint the patient had an
essentially uneventful postoperative course as well. The
patient remained npo until she was noted to have some return
of bowel function at which time her diet was advanced, her
Heparin drip was stopped, she was started on her outpatient
cardiac meds. As she was tolerating this well and her
abdominal exam remained benign, it was decided that she would
be discharged to rehab on [**2114-1-27**] in stable condition.
DISCHARGE MEDICATIONS: Lopressor 12.5 mg po bid, Serevent
MDI 2 puffs [**Hospital1 **], Albuterol nebs q 4 hours prn wheezing,
Aspirin 325 mg po q d, Plavix 75 mg po q d to be taken
through [**2-4**], Haldol 1 mg po q h.s., Tylenol 650 mg po q 4-6
hours prn, Colace 100 mg po bid. The patient was told to
call Dr.[**Name (NI) 5695**] office for follow-up as well as to call
Dr.[**Name (NI) 10946**] office for follow-up and to call her
primary care doctor as well as her cardiologist for
follow-up. She was told to call or return for any questions
or problems.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11126**]
Dictated By:[**Last Name (NamePattern1) 4985**]
MEDQUIST36
D: [**2114-1-26**] 17:07
T: [**2114-1-26**] 19:54
JOB#: [**Job Number 37241**]
ICD9 Codes: 5070, 5990, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8342
} | Medical Text: Admission Date: [**2168-12-21**] Discharge Date: [**2169-1-2**]
Date of Birth: [**2100-11-27**] Sex: F
Service:
ADDENDUM
DISCHARGE MEDICATIONS: Coumadin titrated to INR of 3.0-3.5,
Calcium Carbonate 500 mg p.o. t.i.d., Lasix 20 mg p.o. b.i.d.
X 10 days, Potassium 20 mEq p.o. b.i.d. x 10 days, then
change to just Lasix 20 mg p.o. q.d. with 20 mEq q.d. for her
stat prior dose, Glucophage 500 mg p.o. t.i.d., Avandia 4 mg
p.o. q.d., Digoxin 0.5 mg q.d., Amaril 2 mg p.o. q.d.,
................ p.r.n., .............. suppository p.r.n.,
Aspirin 325 mg p.o. q.d., regular Insulin sliding scale
150-200 3 U, 201-250 6 U, 251-300 9 U.
FOLLOW-UP: The patient is to follow-up with Dr.
................. after discharge from rehabilitation in
regards to coumadinization. He is to follow-up with Dr.
[**Last Name (STitle) **] for cardiothoracic issues. She is to follow-up
with Dr. [**Last Name (STitle) **] for cardiology issues.
DISPOSITION: She is being discharged to rehabilitation.
[**Last Name (STitle) **] DR. [**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] 02-351
Dictated By:[**Name8 (MD) 16758**]
MEDQUIST36
D: [**2169-1-2**] 10:39
T: [**2169-1-2**] 10:40
JOB#: [**Job Number 31546**]
ICD9 Codes: 4280, 9971, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8343
} | Medical Text: Admission Date: [**2146-10-30**] Discharge Date: [**2146-11-1**]
Date of Birth: [**2091-6-5**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Ambien / Metronidazole
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Agitation/ speech disturbance
Major Surgical or Invasive Procedure:
Intubation/ extubation
History of Present Illness:
Patient is a 55 y/o female with a PMHx of DM complicated by
neuropathy, HTN, hypercholesterolemia, hepatitis C and h/o
polysubstance use who presents with concerns for a stroke.
Patient was at her usual baseline yesterday evening and went to
bed at her usual time of ~11pm. At 05:30 her son also spoke to
her describing her as having normal speech. However at ~7am she
was then noted to be aphasic and moaning in bed found by her
son.
EMS was contact[**Name (NI) **] and she was brought to [**Hospital1 18**]. Of note, she
likely vomited en route. Here she was noted to follow simple
comands but was combative prompting sedation and intubation.
Past Medical History:
CAD and question of history of old inferior MI based upon EKG,
partially reversible defect on
MIBI [**6-16**]
Chronic dizziness and gait disorder
Hearing loss L ear x past year
Diabetes mellitus - on Lamictal for neuropathy
HTN
Cataract [**Doctor First Name **]
Hepatitis C
Hyperlipidemia
GERD
Atypical migraines - on Topamax
Social History:
-Tobacco: recently quit smoking; smoked since age 12, one ppd
-ETOH: hx of alcohol abuse
-IVDA: hx of heroin and cocaine abuse
Family History:
Alcoholism, diabetes
Physical Exam:
PE on admition
HEENT: NCAT, mucous membranes moist and pink, sclera
non-icteric, OP clear
- Neck: Supple, no thyromegaly, no lymphadenopathy, no bruits
- Lungs: Clear bilaterally, good aeration, no wheezing/crackles
- Cardiac: Normal S1 and S2, no murmur
- Abdomen: S/NT/obese, normoactive BS
- Extremities: warm, no C/C/E
Neurologic Examination:
- MS: Unintelligible / dysarthric speech, per report able to
say
"no" but did not witness
- Cranial Nerves:
I: not tested
II: Blinks to visual threat, pupils 3->1.5mm bilaterally
III, IV, VI: eyes midline, no nystagmus, doesn't follow
commands
for VFFTC testing, turns whole head in direction of sounds /
questions
V: unable to assess
VII: Facial movements grossly symmetric, unable to assess for
subtle facial droop
VIII: unable to assess
IX, X: gag intact
[**Doctor First Name 81**]: unable to assess
XII: unable to assess
- Motor: Normal bulk and tone, restrained, full grasp with both
hands, attempts to pull out ETT symmetrically, withdrawals legs
from restraints with good strenght
- Coordination: unable to assess
- Reflexes: No clonus, toes downgoing bilatrally
[**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach
C5-6 C7-8 C5-6 L3-4 S1-2
Right 2 2 2 1 1
Left 2 2 2 1 1
Pertinent Results:
[**2146-10-30**] 10:57PM ALT(SGPT)-64* AST(SGOT)-55* LD(LDH)-200 ALK
PHOS-100 AMYLASE-136* TOT BILI-0.2
[**2146-10-30**] 10:57PM CK-MB-5 cTropnT-<0.01
[**2146-10-30**] 10:57PM %HbA1c-5.7 eAG-117
[**2146-10-30**] 10:57PM TRIGLYCER-166* HDL CHOL-43 CHOL/HDL-2.9
LDL(CALC)-49
[**2146-10-30**] 08:59PM LACTATE-1.5 NA+-140 K+-3.7 CL--106
ct head:
IMPRESSION:
1. No evidence of hemorrhage or loss of [**Doctor Last Name 352**]-white matter
differentiation or
mass effect on CT head without contrast.
2. CT perfusion demonstrates no evidence of asymmetric perfusion
to indicate
acute ischemia or infarct.
3. CT angiography of the neck demonstrates 50% narrowing of the
right and 25
to 50% narrowing on the left near the carotid bifurcation.
4. CT angiography of the head demonstrates no vascular
occlusion, stenosis or
aneurysm greater than 3 mm in size. Vascular calcifications are
seen at
cavernous carotids bilaterally.
5. Retained secretions in the nasopharynx likely due to
intubation.
MRI head: Wet read. No acute process
Brief Hospital Course:
Mrs [**Known lastname 6330**] was admitted as a code stroke. She was seen in the ED
and was noted to be agitated and had a speech disturbance that
was not described in detail. A complete neurologic examination
was not completed in ED. The patient was intubated in the ED and
had a STAT CT head done. This was negative. She then proceeded
to get an MRI of the brain done. This was also negative. She was
extubated the next day without problems. She was awake
interactive, oriented and had not known what had occurred the
day before. She denies any fever/chills/headache. She states she
has never had a seizure and takes Lamictal for her peripheral
neuropathy secondary to DM II.
Medications on Admission:
-Humalog 75-25 17U q am and 20U q pm
-Lamictal 200mg [**Hospital1 **]
-Lisinopril 5mg daily
-Metformin 500mg [**Hospital1 **]
-Omepraxole 20mg daily
-Simvastatin 80mg daily
-Sumatriptan 50mg daily
-Tramadol 50mg q 8hrs prn headaches
-ASA 81mg daily
-IB 800mg prn
-Aleve
-Nicotine patch
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary
- Acute/transient altered Mental status (etiology unknown)
Secondary
-DM, insulin dependent - followed at [**Last Name (un) **] in the past but has
not been see recently
-HTN
-Hypercholesterolemia - last lipids checked in [**2141**]
-Hep C - per notes in remission
-Diabetic neuropathy
-Atypical Meniere's disease x 5 years - characterized by
imbalance and lightheadedness
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for workup of your speech disorder and altered
mental status. You were intubated in the ER for tests to rule
out stroke. You had a CT of your head and an MRI of your brain
which did not show any evidence of stroke. You were extubated
the next day. You had an EEG which did not show any seizure
activity. We are not sure what had caused this but it could have
been a seizure.
Followup Instructions:
Please follow up with your primary care physician in the next
2-3 weeks. Call [**Telephone/Fax (1) 250**] for an appointment.
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 275**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2146-12-21**] 3:50
Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2147-1-9**] 11:30
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
ICD9 Codes: 3572, 2724, 2720, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8344
} | Medical Text: Admission Date: [**2110-8-8**] Discharge Date: [**2110-8-8**]
Date of Birth: [**2067-6-17**] Sex: F
Service: MEDICINE
Allergies:
lisinopril / hydrochlorothiazide
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
hoarseness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 91708**] is a 43 yo female h/o discoid lupus and hypertension
who presented to the ED with hoarseness, sensation of throat
closing, and nausea and vomiting that started this evening.
Patient had been on lisinopril, although perhaps not taking this
consistantly. She was switched to lisinopril-HCTZ combination
pill at her NP[**MD Number(3) **] [**2110-8-6**]. She took 1 dose of the new
medication [**2110-8-7**]. She awoke at 2 am this morning with
sensation of shortness of breath and nausea, and had emesis x 7
times. She drove herself to the ED. She reports no chest pain,
rash, abdominal pain, or diarrhea. Physical exam in the ED shows
no stridor or adventitious sounds in the lung fields, but
presence of uvular hydrops and some respiratory distress,
although the pt remained on roomn air with good O2 sats. Patient
symptomatically improved after Epipen, solumedrol 125mg,
Benadryl 50mg IV, and famotidine 60mg IV. She is being admitted
to the MICU for observation x 24 hours
.
On the floor, pt is quite tired. She c/o sore throat. No emesis
since 3 or 4am. No nausea currently.
Past Medical History:
DEPRESSIVE DISORDER
TUBERCULOSIS ([**2086**]; tx meds x 2 yrs-neg cxray x 2
THROAT PAIN feels like something in throat-gags freq
URINARY, INCONTINENCE, STRESS FEMALE
ALOPECIA (dx by derm biopsy cutaneous lupus)
PYELONEPHRITIS, ACUTE ([**2083**])
DYSMENORRHEA, MENORRHAGIA
HTN
Social History:
Mother dies from stomach CA. Uncle died from tongue CA (smoker).
Family History:
- Tobacco: Current smoker, 1ppd x 15 years
- Alcohol: Drinks 2 drinks 3xs per week, no Hx of withdrawl Sx
Physical Exam:
On Admission:
General: Alert, oriented, appears fatigued but otherwise
comfortable
HEENT: Sclera anicteric, MMM, no lip swelling
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, no clubbing, cyanosis or edema
On discharge:
Angioedema of the uvula much improved.
Pertinent Results:
[**2110-8-8**] 05:47AM BLOOD WBC-6.6 RBC-4.77 Hgb-10.7* Hct-33.3*
MCV-70* MCH-22.5* MCHC-32.2 RDW-17.7* Plt Ct-240
[**2110-8-8**] 05:47AM BLOOD Neuts-49.5* Lymphs-44.4* Monos-3.8
Eos-2.0 Baso-0.3
[**2110-8-8**] 05:47AM BLOOD Glucose-100 UreaN-13 Creat-0.8 Na-137
K-3.5 Cl-102 HCO3-25 AnGap-14
Brief Hospital Course:
43yo F with HTN whose antihypertensive was swuitched from
lisinopril to lisinopril-HCTZ who presents with feeling as if
her throat was closing.
# Angioedema: Likely ACEi-related angioedma given the absence of
any other systemic symptoms and the fact that angioedema can
occur any time while on the drug. She was treated with IV
solumedrol in the ED, converted to PO prednisone on the floor,
benadryl, famotidine, and an epipen. Her edema was greatly
improved at time of discharge and she was tolerating a diet. She
was discharged on amlodipine 10mg, epipen and prednisone 40mg x
5 days. She was told to follow-up with her PCP [**Last Name (NamePattern4) **] [**2-15**] days and
to be referred to allergy. She was told to avoid both HCTZ and
ACEi. Both drugs were added to her allergy list.
# HTN: Discharged on amlodipine 10mg daily and told to follow-up
with her PCP.
Medications on Admission:
Lisinopril-Hydrochlorothiazide 20-25 mg Oral Tablet TAKE ONE
TABLET DAILY
Ibuprofen 800 mg Oral Tablet TAKE 1 TABLET THREE TIMES A DAY AS
NEEDED take WITH FOOD
Hydroquinone 4 % Topical Cream apply to face TWICE DAILY
Clobetasol 0.05 % Topical Solution Apply sparingly twice daily
Ammonium Lactate (LAC-HYDRIN) 12 % Topical Lotion APPLY TO BOTH
FEET QD
NUQUIN HP 4 % TOPICAL CREAM (DIOXYBENZONE/PDO/HYDROQUINONE)
apply TWICE DAILY to TO AFFECTED AREA
Discharge Medications:
1. prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for
5 days.
Disp:*10 Tablet(s)* Refills:*0*
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. hydroquinone 4 % Cream Sig: One (1) application Topical twice
a day: apply to the face twice a day.
4. clobetasol 0.05 % Cream Sig: One (1) apply Topical once a
day: apply to affected area. Do not apply to the face.
5. ammonium lactate 12 % Lotion Sig: One (1) application Topical
twice a day: apply to feet.
6. epinephrine 0.15 mg/0.15 mL Combo Pack Sig: One (1)
Intramuscular Once as needed for allergic reaction, trouble
breathing for 1 doses: Use in extreme case of difficulty
breathing/ throat closing.
Disp:*1 pen* Refills:*3*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Angioedema
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Last Name (Titles) 91709**],
It was a pleasure taking part in your care. You were admitted to
[**Hospital1 18**] for difficulty breathing and throat swelling. This was
likely a reaction to one of your blood pressure medications. You
were treated with medications including epinephrine, steroids,
and benadryl, and your breathing and swelling improved. You were
monitored in the ICU prior to discharge home.
The following changes to your medications were made:
- STOP lisinopril
- STOP hydrochlorothiazide
- START Prednisone 40mg daily for 5 days
- START amlodipine 10mg by mouth daily
- Please fill, and carry, an epinephrine pen with you at all
times so that you may use it in the event that you have this
reaction again
Please take all other medications as prescribed.
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **] [**2-15**] days.
Please have your primary care doctor refer you to an allergy
specialist.
Completed by:[**2110-8-8**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8345
} | Medical Text: Admission Date: [**2142-1-13**] Discharge Date: [**2142-1-15**]
Date of Birth: [**2067-3-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4760**]
Chief Complaint:
Bleeding from mouth/nose
Major Surgical or Invasive Procedure:
Nasal packing placement
NGT placement
Transfusion of blood products
History of Present Illness:
Mr. [**Known lastname 21006**] is a Spanish-speaking 74 yoM (son is translating in
the [**Name (NI) **]) with a h/o CAD (s/p stent [**12-18**]), CVA, GERD and asthma
who presented to the ED from home with 2+ hours of "spitting up"
blood. Per patient and family, this was not [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 104845**] or
hemoptysis, but rather blood in the OP. He denied emesis, cough,
ENT pain, abd/chest pain, melena/brbpr and SOB.
.
In the ED, VS were T 99.2, P 79, BP 176/76, RR 14, 99% RA. NG
tube was attempted to be placed twice w/o success; thus, NG
lavage was not performed. He was noted to have bleeding from his
NP and the right nares was packed (around 5 pm pm on [**2142-1-13**]). By
8 pm, the packing had been soaked through; the patient was then
given affrin and a balloon was put in place to tamponade the
bleed. Hct was 32.9 on admission with a baseline in low 40's as
of [**10-18**] (MCV unchanged). Given he was not tachycardic or
orthostatic, he did not receive an RBC transfusion in the ED.
.
Of note, the patient is on warfarin for stroke/TIA (?); ED notes
say had a DVT in RLE one month ago and has been on Coumadin
since that time, though has older rxn in OMR. His INR was noted
to be 14.1 on admission. He was given 10 mg IV Vit K; two units
of FFP have been ordered but not yet administered. The ED staff
also spoke with the cards fellow given the recent stent
placement (in right ? LE artery for PVD); they advised to keep
on ASA and plavix currently.
.
ENT saw him in the ED and did a flex scope and standard anterior
rhinoscopy. They noted several areas of oozing along the septum
bilaterally w/o a clear single, brisk source. Gauze soaked in
bacitracin was placed in the right nares. Left nares was packed
with gelfoam and surgicell packing. Oral cavity clear.
.
The ED staff spoke with the GI fellow, who is deferring EGD
tonight and is recommending IV PPI overnight. Low suspicion for
UGIB.
Past Medical History:
TIA, on Coumadin
Asthma
Hyperlipidemia
Hypertension
Diabetes
GERD
H/O prostate cancer
CAD, s/p MI with LV dysfunction, EF 45-50%
PVD
s/p CABG x2 in [**2132**] with SVG-PDA occluded
s/p RCA stent x 2 (in [**2137**] (?[**2138**]), [**2139**]); with Cypher [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]/p
bilateral renal artery stenting followed by redo left renal
artery stent for in-stent restenosis in [**2138-7-11**]
H/O right occipital infarct with residual lest sided visual
impairment
H/O cataract of left eye
Macular hole in left eye
S/P phacoemulsificatiion, posterior chamber intraocular lens
placement, pars plana vitrectomy, membrane peel of left eye
Social History:
-- He lives with his signficant other [**First Name8 (NamePattern2) 46975**] [**Last Name (NamePattern1) 3234**]
([**Telephone/Fax (1) 104846**]).
-- He does not smoke or drink.
-- He is retired from maintenance and previously worked as a
bricklayer in [**Male First Name (un) 1056**].
-- He emmigrated to the US 35 years ago.
Family History:
- not contributory
Physical Exam:
General: well appearing; somewhat restless in bed
HEENT: nose packed in ED (did not remove to examine); OP clear
w/o evidence of bleeding
Lungs: CTA b/l
Cardio: III/VI ?SEM, loudest at LUSB; no m.r.g.
Abd: soft, NTND, no suprapubic tenderness
EXTREMITIES: no edema
SKIN: no rashes, no cyanosis
NEURO: AA, OX3; CN II - XII in tact
Pertinent Results:
[**2142-1-13**] 05:15PM BLOOD WBC-14.8*# RBC-4.22* Hgb-11.3* Hct-32.9*
MCV-78* MCH-26.8* MCHC-34.4 RDW-14.7 Plt Ct-186
[**2142-1-13**] 05:15PM BLOOD Neuts-87.6* Lymphs-8.9* Monos-2.9 Eos-0.4
Baso-0.2
[**2142-1-13**] 05:15PM BLOOD PT-105.1* PTT-96.9* INR(PT)-14.1*
[**2142-1-13**] 05:15PM BLOOD Glucose-221* UreaN-34* Creat-1.5* Na-139
K-4.8 Cl-101 HCO3-32 AnGap-11
[**2142-1-13**] 05:15PM BLOOD ALT-27 AST-28 AlkPhos-141* TotBili-0.4
[**2142-1-14**] 05:02AM BLOOD CK-MB-3 cTropnT-<0.01
[**2142-1-14**] 12:45PM BLOOD CK-MB-3 cTropnT-<0.01
[**2142-1-14**] 05:02AM BLOOD Calcium-8.8 Phos-2.4* Mg-1.9
.
ECG: NSR 78, nml axis, first degree AVB, no new ST changes
Brief Hospital Course:
ASSESSMENT/PLAN: 74 y/o spanish speaking M with h/o PVD s/p
stenting of RLE in [**12-18**], CVA, GERD and asthma who presented to
the ED with gross epistaxis and hct drop in setting of elevated
INR.
.
#) Epistaxis/Bleed: Initially unknown source, however ENT scoped
the patient and visualized bleeding. There were several areas of
oozing along the septum bilaterally w/o a clear single, brisk
source. Gauze soaked in bacitracin was placed in the right
nares. Left nares was packed with gelfoam and surgicell packing.
Pt was reversed with Vitamin K and FFP, treated with Keflex and
monitored overnight in the ICU. Bleeding was felt to be
secondary to extremely supratherapeutic INR. Patient reported
taking his coumadin twice a day which likely led to increased
levels. Hct decreased from 38 to 29, however it remained stable
after packing. He was called out to the floor on the 2nd
hospital day and Hct remained stable. His coumadin was held and
on the day of discharge INR was 1.2. He will continue Keflex
while packing in place and this will remain in for 5 days. He
will follow up with Dr. [**Last Name (STitle) **] (ENT) for packing removal.
Given recent stent placement he was continued on ASA and plavix.
.
#) ARF: BUN 34, Cr 1.5 on admission; baseline Cr 1.0-1.1.
BUN:Cr ratio suggested pre-renal etiology. Cr returned to
baseline with IVF.
.
#) LEUKOCYTOSIS: WBC was 14 on admission. Patient was afebrile.
Felt to be stress response given no localized signs of
infection. He was treated with Keflex prophylactically and WBC
normalized on day of discharge.
.
#) CAD/recent stent: The ED staff spoke with the cardiology
service given the recent stent placement in RLE; they advised to
keep on ASA and plavix.
.
#) GERD: Initially on protonix [**Hospital1 **] given concern for possible GI
source of bleed. This was then stopped and patient was
discharged on his usual outpatient ranitidine.
.
#) DIABETES: Patient is on metformin and NPH as outpatient.
His metformin was held while in house. He was placed on a
insulin SS while inpatient. He will resume his outpatient
regimen on discharge.
.
#) HYPERLIPIDEMIA: Continued statin.
.
#) ASTHMA: Continued albuterol and advair.
.
#) HTN: On amlodipine and lisinopril at home. Antihypertensives
were initially held given bleeding. These were restarted at
discharge.
.
#) CODE: full (confirmed with son)
.
#) COMMUNICATION: son [**Name (NI) **] [**Name (NI) 1071**] [**Telephone/Fax (1) 104847**]; PCP [**Last Name (NamePattern4) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 608**]
Medications on Admission:
Nitroglycerin 0.3 SL prn
Aspirin 325mg daily
Albuterol IH 2 puff Q6H prn
ALbuterol 4mg tab PO Q12
Amlodipine 5mg po daily
Albuterol 100mg Daily
Atorvastatin 80mg Daily
Clonidine 0.1 mg PO BID
Advair 100-50 IH [**Hospital1 **]
Lisinopril 20mg PO daily
Singulair 10mg po Daily
Ranitidine 150mg PO daily
Iron 325 po Daily
Fexofenadine 60mg PO daily
Plavix 75 mg Daily
Warfarin 5mg PO Daily
Insulin NPH 35 units QAM
Loratadine 10mg PO daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
Five (35) units Subcutaneous once a day: please resume your home
dose of insulin.
14. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
15. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 4 days.
Disp:*12 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Epistaxis s/p nasal packing
Elevated INR
Secondary:
Coronary artery disease
CVA
GERD
Asthma
Hypertension
Diabetes
Discharge Condition:
Stable, no further bleeding, INR normalized
Discharge Instructions:
You were admitted to the hospital for bleeding from your nose.
This was felt to be due to your coumadin level being too high.
You should NOT take your coumadin until your nasal packing is
removed and you follow up with Dr. [**Last Name (STitle) **].
Please stop your coumadin. You will need to complete a course
of antibiotics to prevent infection at the packing site. You
can continue your other medications as prescribed. You should
keep your follow up appointments as below.
Please avoid straining and bending over to prevent recurrent
bleeding.
Please call your doctor if you have recurrent bleeding, chest
pain, difficulty breathing, high fevers or other concerning
symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2142-1-25**]
10:30
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2142-1-25**]
11:00
Provider: [**Last Name (NamePattern5) 7224**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2142-1-25**]
1:30
.
Please follow up with Dr. [**Last Name (STitle) **] on Thursday, [**1-18**] at
9am to have your packing removed. His office is located at [**Last Name (NamePattern1) 10357**]. ([**Hospital **] medical building) on the [**Location (un) **], suite E.
Call [**Telephone/Fax (1) 41**] if you have any questions.
.
Please follow up with Dr. [**Last Name (STitle) **] in one week.
ICD9 Codes: 5849, 2859, 4019, 412, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8346
} | Medical Text: Admission Date: [**2168-11-16**] Discharge Date: [**2168-11-23**]
Date of Birth: [**2097-9-4**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
CC: SOB, cough
.
HPI: 71 yo M with recent diagnosis of metastatic nonsmall cell
lung cancer (unresectable stage IV) s/p first treatment of
taxol, carboplatin, and zometa on [**2168-11-15**] presents with
worsening SOB, cough, and fever. Pt underwent his first round
of chemotherapy yesterday. Per report he had intermittent
desaturations to 89-92% during chemo. This am he awoke with
fever to 100.6 and worsening productive cough. He took tessalon
pearls and Robitussin with codeine without relief.
.
In the ED his temp was 102, HR 100-120's, BP 160-180's, RR
26-34, satting 95% on NRB. He was given
Levo/Flagyl/Vanco/Azithro. A Chest CT revealed a large left
pleural effusion and LLL/lingular/portions of LUL collapse
(worsened significantly compared to [**2168-10-22**]). He was
transferred to the [**Hospital Unit Name 153**] for further management.
.
Upon arrival to the [**Hospital Unit Name 153**] he was noted to have a RR of 40 with a
gas of 7.47/32/68. He was intubated. His BP's dropped to the
80's with sedation/intubation and he was started on levophed.
An A-line and central line were placed.
.
Past Medical History:
- metastatic nonsmall cell lung cancer (unresectable stage IV)
s/p Taxol, Carboplatin, and Zometa on [**2168-11-15**]
- gout
Social History:
quit smoking 53 years ago, smoked 20 pack years.
asbestos exposure while in military
lives with wife, is retired
employed previously as electrician
Daughter [**Name8 (MD) **] RN @ [**Hospital1 18**]
Family History:
father died 83years lung cancer
mother died of liver cancer, ? age
sister CAD, s/p CABG
Physical Exam:
Tm 102 Tc 101.4 BP 80/45 HR 95 RR 14 Sat 100%
AC Vt 550/RR 14/PEEP 12/FiO2 100%
Gen: intubated, sedated
HENNT: MMM, anicteric
Neck: no LAD, no JVD
CV: tachy, regular, nl S1S2, No M/R/G
Lungs: coarse breath sounds, bibasilar crackles, no wheezes
Abd: soft, NT/ND, +BS, No HSM
Ext: no edema, strong DP/PT pulses bilaterally
Neuro: moving all extremeties
Pertinent Results:
[**2168-11-16**] 10:51PM TYPE-[**Last Name (un) **] TEMP-38.4 RATES-16/ PO2-155* PCO2-42
PH-7.37 TOTAL CO2-25 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED
[**2168-11-16**] 09:47PM PLEURAL TOT PROT-4.3 GLUCOSE-185 LD(LDH)-273
[**2168-11-16**] 09:47PM PLEURAL HCT-2.5*
[**2168-11-16**] 09:47PM PLEURAL WBC-2922* RBC-[**Numeric Identifier 62249**]* POLYS-17*
LYMPHS-37* MONOS-18* EOS-2* ATYPS-7* MESOTHELI-2* MACROPHAG-2*
OTHER-15*
.
Studies:
- CT chest [**2168-11-16**]:
1. No evidence of pulmonary embolism.
2. large left pleural effusion and collapse of left lower lobe,
lingula and portions of the left upper lobe have worsened
significantly compared to [**2168-10-22**]. Occlusion of the left
lower lobe and lingular bronchi
3. Bulky mediastinal and bilateral hilar adenopathy.
4. New pathological fracture of the left seventh rib. Lytic foci
within the T1 vertebral body and right fifth rib are unchanged.
6. Patchy opacity within the right lower lobe, likely reflecting
an
infectious or inflammatory process.
.
- CXR [**2168-11-16**]: Interval increased left pleural effusion, and
increasing parenchymal opacities in left lower lobe and lingula.
Given the known lesions in the left hila, this is concerning for
postobstructive pneumonia/atelectasis. Mediastinal and hilar
lymphadenopathy. Left rib met.
.
- MRI head [**2168-11-5**]: Mild-to-moderate brain atrophy. No
enhancing lesions are seen. No evidence of mass effect or
hydrocephalus.
.
- PET CT scan:
1. Intense FDG avidity in the partially collapsed left lower
lobe extending to the hilum. The intensity of this uptake is
greater than expected for postobstructive inflammatory change
alone and is consistent with the given history of non-small cell
lung cancer.
2. FDG-avid bilateral hilar adenopathy and widespread bilateral
mediastinal adenopathy.
3. Multiple foci of FDG-avid lytic metastases involving the left
scapula, the left lamina of T1, the right 5th rib (with
pathologic fracture), the left 7th rib, the right sacrum and
right acetabulum. Asymmetric activity associated with the right
L5 pars defect may
be degenerative.
.
- Chest CT [**2168-10-22**]: bulky, bilateral mediastinal
lymphadenopathy as well as bilateral hilar adenopathy, the
largest lymph nodes include a subcarinal node or mass measuring
approximately 2.5 cm x 3.5 cm in diameter. There are also
bilateral calcified pleural plaques present. The lower lobe is
partially collapsed, and within the area of enhancing
atelectatic lung, there is a low-density rounded area measuring
2.0 cm x 1.8 cm in diameter. The lungs also demonstrate
emphysematous changes, also was found to have a
small-to-moderate pleural effusion and a small pericardial
effusion. Additional central peri-bronchovascular thickening in
the left lower lobe was found which could be related to
lymphatic obstruction or localized lymphangitic spread of tumor.
Brief Hospital Course:
A/P: 71 yo M with recently diagnosed metastatic non small cell
lung cancer (unresectable stage IV) s/p first treatment of
Taxol, Carboplatin, and Zometa on [**2168-11-15**] presents with
worsening cough and fever.
.
Patient's shortness of breath, cough and fever were likely
secondary to a post-obstructive pneumonia in setting of a known
malignancy. Patient was started on empiric broad spectrum
coverage with vancomycin/levofloxacin/metronidazole. CT chest
revealed a large left pleural effusion and collapse of left
lower lobe, lingula and portions of the left upper lobe. Shortly
after transfer to the ICU patient became hypoxic and required
intubation. Tap of left pleural effusion on [**11-16**] was positive
for non-small cell carcinoma. A left sided chest tube was
placed. Bronchial washings, subcarinal mass, and paratracheal
lymph node obtained on [**11-19**] were again consistent with
malignancy. Repeated blood, sputum, and urine cultures did not
identify etiology of infection; viral screen also negative.
Course was further complicated by developing neutropenia (s/p
chemotherapy). Aztreonam and AmBisome were both added for
broader coverage. The oncology service was following along
throughout his ICU course. Patient received Neupogen 300 mcg SC
daily for neutropenia. Despite the placement of a second chest
tube, patient continued to have hypoxic respiratory failure,
secondary to large malignant pleural effusion and left lung
collapse. Patient became hypotensive, likely secondary to
sepsis, and required pressors and fluid boluses to maintain his
CVP and urine output. The patient's primary oncologist Dr.
[**Last Name (STitle) 3274**] had a discussion with the patient's family regarding
goals of care and the patient's prognosis and a decision was
made to make him CMO. The patient passed away at 1:55 am on
[**2169-11-23**].
Medications on Admission:
1. Allopurinol 300 mg PO DAILY
2. Tessalon Perles 200 mg t.i.d.
3. Robitussin With Codeine cough syrup
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired on [**2169-11-23**].
Discharge Condition:
Discharge Instructions:
Followup Instructions:
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
ICD9 Codes: 486, 5180, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8347
} | Medical Text: Admission Date: [**2172-6-22**] Discharge Date: [**2172-7-1**]
Date of Birth: [**2099-7-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11217**]
Chief Complaint:
Left hip fracture, atrial fibrillation
Major Surgical or Invasive Procedure:
ORIF Left femur
History of Present Illness:
This is a 79 year old man who resides in a nursing home, with a
history of dementia, CAD, a-fib on coumadin, DM2, who had an
unwitnessed fall and fractured his hip. It is unclear, due to
the patient's mental status, if there was any lightheadedness,
or near syncope prior to the fall. Orthopaedics was consulted
and requested a medicine admission because of some changes on
the EKG demonstrating ST depression.
.
The patient was diagnosed with prostate cancer ([**Doctor Last Name **] [**2-28**]) in
[**2164**] and his guardian at that time decided on conservative
management. He has been followed by Dr. [**Last Name (STitle) 4229**], but has not had
any treatment. A bone scan in [**5-2**] showed increased uptake in
bilateral femurs and multiple ribs. His guardian has recently
changed, and due to recent general health deterioration, the
question of aggressive treatment is being revisited. A bone
scan in [**5-2**] demonstrated uptake in bilateral proximal femurs
and multiple ribs. Further history cannot be obtained secondary
to patient's mental status.
.
In the ED, vital signs on admission were T:99.6 BP159/88 HR101
RR 14 and O2sat 94%RA. Fingerstick blood glucose 133. The
patient had multiple imaging studies and was seen by
orthopaedics felt he was a surgical candidate.
Past Medical History:
dementia with delusions
CAD
atrial fibrillation on coumadin
hypertension
Anemia (baseline HCT 23)
cardiomyopathy
sick sinus syndrome with pacemaker
prostate cancer [**Doctor Last Name **](3+3)
depression
Social History:
Mr. [**Known lastname **] lives at nursing home. No known family members. [**Name (NI) **]
a guardian. [**Name (NI) **] other social history elicited.
Family History:
unknown
Physical Exam:
VS:T99.2, BP160/90, HR140 RR20 o2sat 94%on 4L
Gen: Lethargic, arousable by tapping only, incomprhensible
language
Neck: in C-collar. No JVD
CV: irregular rhythm, tachycardic, no murmurs
Lungs: clear anteriorly, unable to auscultate posterior seconday
to C-spine precautions
Abd: soft, non-tender, +bowel sounds
Ext: warm, intact dp and tp pulses bilaterally. L lower
extremity externally rotated
Neuro: opened eyes to verbal stimulation. Very confused,
answered questions with incomprehensible answers. Unable to
cooperate with exam for cranial nerves. Moving upper
extremities and lower Right extremity spontaneously.
Pertinent Results:
ADMITTING LABS
[**2172-6-22**] 10:05AM WBC-5.9 RBC-3.43* HGB-9.0* HCT-27.6* MCV-80*
MCH-26.4* MCHC-32.8 RDW-15.6*
[**2172-6-22**] 10:05AM PLT COUNT-276#
[**2172-6-22**] 10:05AM NEUTS-81.3* LYMPHS-15.5* MONOS-2.9 EOS-0.3
BASOS-0.1
[**2172-6-22**] 10:05AM PT-18.4* PTT-29.2 INR(PT)-1.7*
[**2172-6-22**] 10:05AM CK(CPK)-41
[**2172-6-22**] 10:05AM cTropnT-<0.01
[**2172-6-22**] 10:05AM GLUCOSE-141* UREA N-16 CREAT-0.7 SODIUM-143
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-29 ANION GAP-15
[**2172-6-22**] 10:19AM HGB-10.2* calcHCT-31
[**2172-6-22**] 06:56PM LACTATE-2.1*
OTHER PERTINENT LABS:
[**2172-6-22**] 09:35PM CK(CPK)-43
[**2172-6-22**] 09:35PM CK-MB-NotDone cTropnT-<0.01
[**2172-6-23**] 06:00AM BLOOD CK(CPK)-36*
[**2172-6-23**] 06:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2172-6-23**] 06:00AM BLOOD WBC-7.7 RBC-2.97* Hgb-7.8* Hct-23.5*
MCV-79* MCH-26.3* MCHC-33.1 RDW-15.7* Plt Ct-261
Radiology:
CT Head ([**2172-6-22**]): No bleed. Chronic sm vessel ischemic changes,
lacunar infarcts, and atrophy. Slight asymmetry of lateral
ventricles, left larger than right, prob related to atrophy and
of questionable clinical significance
.
CT C-Spine ([**2172-6-22**]):Multiple possible dystrophic nuchal
ligament
calcification/ossification versus post-traumatic sequelae. Other
abnormalities as noted above. In view of the extensive spinal
stenosis, the possibility for post-traumatic cord injury needs
to be considered.
.
HIP X-ray ([**2172-6-22**]):There is a intertrochanteric fracture
without significant displacement of the bony fragments.
Additionally, there is a large lytic lesion involving the
proximal femur extending into the intertrochanteric region.
There is a endosteal scalloping present. This makes the fracture
a pathologic fracture
.
CXR([**2172-6-22**]): Left lower lobe opacity, which may be due to
atelectasis, aspiration or contusion. Suspected right lateral
sixth rib fracture.
.
.
OLD STUDIES:
-bone scan ([**5-2**]) The described findings are consistent with
possible metastases to the ribs. Bilateral femoral and right
humeral metaphyseal uptake is of uncertain etiology and
significance. Left T12 activity could be metastatic or
degenerative in nature.
.
-echo ([**7-/2166**]) Overall left ventricular systolic function is
severely depressed with some sparing of the basal posterolateral
wall. Right ventricular systolic function appears depressed. The
aortic root is moderately dilated. The ascending aorta is mildly
dilated. The aortic leaflets (3) are mildly thickened. No
definite aortic regurgitation is seen except with ectopic beats.
The mitral valve leaflets are mildly thickened. Mild mitral
regurgitation is seen.
EKG: afib low 100s. [**Street Address(2) 1766**] depression in V4-V5 and TWI in
V4-V6. No olds for comparison.
Brief Hospital Course:
79 yo man s/p ORIF for pathologic L hip fracture likely
secondary to prostate CA, immediate post-op course complicated
by an episode of apnea in setting of fluid overload and Afib
with RVR.
.
Since his admission, the patient has had difficulty with control
of his Afib, which prompted a trigger on [**6-22**] PM for HR 130-150.
It was determined that he missed a dose of atenolol on the day
of transfer. He responded to 10mg of metoprolol, with HR
decreasing to 90-100 bpm. The pt was to go to OR for ORIF of
left femur on [**6-23**], but due to difficulty contacting his legal
guardian until late in the day, he went to the OR [**6-24**]. Because
his INR was elevated from the coumadin, he received 2u FFP
initially, then another 5u FFP in the OR. His hct had also come
down since admit, so he was given 2u PRBCs on [**6-23**] and an
additional 3u PRBCs in the OR. Also in the OR, he had about
600cc IV crystalloid in, 200cc EBL + 640cc urine out. He
received 8mg IV morphine, and 2u regular insulin for a FS 163.
.
Upon return to the medical floor, he was found to be somnolent
and in rapid Afib with VS of T 97.3, BP 140/80, HR 160 irreg, RR
22, 100% on 3LNC. He was noted to have a non-productive cough,
lungs with crackles. He received 5mg IV metoprolol twice with no
HR response, then another 10mg IV metoprolol still without
decrease in HR. He had a NGT to allow for PO meds, given his
poor mental status. During the placement, he had minimal gag but
was not fighting or appropriately agitated. Thereafter, the RN
noted that the pt was apneic 3 times for 30-60 seconds each
time. When he stopped breathing the fourth time, a code was
called.
.
In the code, he was found to have electrical HR 150-200 bpm,
though only perfusing at a pulse rate of around 60 bpm. His
pressure was maintained with SBP 130-140 mmHg. It was difficult
to obtain a pulse ox [**Location (un) 1131**], and by the time one was obtained
he was satting 100% on a NRB face mask. His lungs sounded wheezy
and with crackles, and once the OR record was reviewed, he was
ordered for a CXR and 40mg IV lasix (on 20mg PO at baseline). An
ABG was obtained on the NRB: 7.50/32/180. Initially, he was to
receive Narcan, but after the ABG, deep suctioning, and a venous
blood draw, he became more alert and no longer apneic. CXR
showed increased pulm edema on L side. He was transferred to the
MICU overnight for observation and transferred to the floor the
next day.
.
Mr. [**Known lastname **] developed an E. coli urinary tract infection which
was found to be pansensitve and a course of antibiotics were
completed on the floor. A repeat UA will need to be done by the
nursing home. At the time of transfer to the floor, he was
responsive to his name and stimulation. He was cleared of his C
spine officially from neurosurgery after flex/ex films.
According to the attending physician, [**Name10 (NameIs) **] was back to his
baseline mental status. His blood pressures remained stable and
Lisinopril was titrated up to 40mg. Metoprolol was titrated for
rate control of Afib, aspirin for coronary artery disease, and
an insulin sliding scale for DM. The surgical site is healing
well. Pain was treated with tylenol. Over the course of the
hospitalization pt had been fluid overloaded and then diuresed
aggressively. He required careful monitoring of fluid status
and urine output.
.
In terms of his prostate cancer, Mr. [**Known lastname **] is not currently
receiving treatment although he has a new guardian who is
considering more aggressive treatment options. It is not
documented as metastatic, though recent ([**5-2**]) bone scan has
concerning lesions. The results of the ortho biopsy are still
pending at discharge.
.
Code status: Full code. Confirmed with legal guardian [**Name (NI) **]
[**Name (NI) **] on [**6-25**] at 1430.
Medications on Admission:
coumadin 6mg QHS
MVI
poly iron 150mg QDay
lipitor 10mg QOD
nitro-dur patch 0.3mg on at 9am, off at 9pm
colace 100mg [**Hospital1 **]
metformin 500mg [**Hospital1 **]
doxazosin 4mg Qpm
remeron 15mg Qhs
asa 81mg daily
atenolol 100mg Qday
buproprion 75mg Qday
furosemide 20mg Qday
glipizide 2.5mg XR Qday
Lisinopril 20mg Qday
Discharge Medications:
1. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Bupropion 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
6. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 4 weeks.
7. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
9. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
10. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
11. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-30**]
Drops Ophthalmic PRN (as needed).
12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day) as needed for Afib.
13. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 16662**] - [**Street Address(1) **]
Discharge Diagnosis:
Atrial fibrillation with RVR
Dementia
Anemia
Prostate Cancer
-------------------
CAD s/p MI
HTN
Discharge Condition:
Stable.
Discharge Instructions:
Please take all medications as prescribed.
INR needs to be monitored while at the nursing home. Once you
are therapeutic (INR 2.0-3.0), the lovenox may be discontinued.
The result of the orthopedic biopsy is still pending. Please
follow up.
As you have just finished a course of antibiotics for a UTI, a
follow up UA is necessary to ensure that the UTI is resolved.
Followup Instructions:
Please obtain a repeat UA, as pt has just finished a course of
antibiotics for a urinary tract infection.
INR needs to be monitored while at the nursing home. Once you
are therapeutic (INR 2.0-3.0), the lovenox may be discontinued.
The result of the orthopedic biopsy is still pending. Please
follow up.
[**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 10941**] [**2172-7-2**] 11:00
DEVICE CLINIC Phone:[**Telephone/Fax (1) 59**] [**2172-11-4**] 9:00
ICD9 Codes: 5990, 4254, 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8348
} | Medical Text: Admission Date: [**2183-9-11**] Discharge Date: [**2183-9-22**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
-s/p hemoclip of duodenal vessel
-s/p embolization of gastroduodenal artery
-s/p hemoclip of jejunal vessel and epinephrine injection into
gastric mucosa
History of Present Illness:
The patient is an 81 year old female with a PMH of
hemorrhoidal and diverticular bleeding, HTN, CAD s/p 3 vessel
CABG, and recently diagnosed MDS. The patient lives in
[**Location **], and she was recently hospitalized there from mid [**Month (only) **]
until [**8-31**] for management of a GI bleed. During her
hospitalization, she was found to have AVMs. Given her low
platelets, the GI team was unable to cauterize her AVMs. She
was given IVIG, platelets, and Amicar; after a bump in her
platelets, her AVMs were cauterized. The patient notes that
during her hospitalization, she received blood transfusions
every 2-3 days. She was discharged from that hospital on [**9-10**].
This past weekend, she moved to [**Location (un) 86**] to live with her son and
daughter-in-law.
Since she has been in [**Location (un) 86**], she has continued to have
some rectal bleeding. She has seen Dr. [**Last Name (STitle) 1407**], her new PCP, [**Name10 (NameIs) **]
Dr. [**Last Name (STitle) **], her hematologist. Today, she was referred for
outpatient colonoscopy and EGD. Colonoscopy disclosed
diverticulosis of the colon, grade 3 internal hemorrhoids, and
melena in the cecum and ascending colon. EGD disclosed a site of
active bleeding in the fourth portion of the doudenum. The
actual source could not be localized and apeared to be behind a
fold laterally. A hemoclip was placed and the area was tattooed
with [**Country 11150**] ink. The patient was referred to Interventional
Radiology for emergent mesenteric angiogram. During the
procedure, no active bleeding was visualized. The
gastroduodenal artery was embolized distal and proximal to the
clip placed by GI.
The pateint tolerated the angiogram well. Following the
procedure, she had labs drawn and was found to have a HCT=22
(despite receiving 2 U PRBCs yesterday for a HCT of 22). She
will be transferred to the MICU for further observation.
Past Medical History:
1) CAD s/p 3 vessel CABG
2) CHF
3) Osteoarthritis
4) High cholesterol
5) Hypothyroidism
6) HTN
7) Heart murmurs since age 10, when she was diagnosed with
scarlet fever and diptheria. She reports some neck surgery
around the time of this diagnosis.
8) MDS, diagnosed in [**5-18**]. Bone marrow biopsy was consistent
with MDS and refractory anemia with excess blasts. The bone
marrow showed 11% blasts.
9) Hemorrhoidal and diverticular bleeding, diagnosed when the
patient was admitted to a hospital in [**Location (un) **] in [**3-19**].
Social History:
The patient has an 80-pack year smoking history. She quit in
[**2162**]. She currently does not drink alcohol, but she was a
social drinker in the past. Her husband died of [**Name (NI) 2481**]
disease. She is a retired social worker. She recently moved
from [**Location (un) 19061**] to [**Location (un) 86**] so that she may be with her family.
Family History:
No family history of cancer. Her mother died at age [**Age over 90 **] of a MI.
Physical Exam:
General: Pleasant elderly female lying in bed in NAD.
VS: 98.9 191/38 89 18 97% RA
HEENT: NC/AT. PERRL. EOMI. Sclerae anicteric. MMM. No
petechiae.
Neck: Supple. No cervical lymphadenopathy. No JVD. No carotid
bruits.
Lungs: CTAB. No rales, wheezes, or crackles.
CVS: RRR. S1, S2. III/VI systolic murmur at LUSB, radiating to
carotids.
Abd: Obese, NT, ND, +BS.
Extr: Trace LE edema. Warm. R groin site w/ small amt of
bleeding. L PICC line in place.
Skin: Scattered ecchymoses.
Neuro: AxOx3. CN II-XII grossly intact. Strength 5/5 in all
extremities. Motor function and sensation intact.
Pertinent Results:
[**2183-9-11**] 06:15PM BLOOD WBC-1.9* RBC-2.61* Hgb-7.5* Hct-22.3*
MCV-85 MCH-28.7 MCHC-33.7 RDW-18.7* Plt Ct-19*
[**2183-9-21**] 05:16AM BLOOD WBC-3.5* RBC-3.48* Hgb-10.4* Hct-30.9*
MCV-89 MCH-29.9 MCHC-33.7 RDW-19.0* Plt Ct-43*
[**2183-9-11**] 06:15PM BLOOD Neuts-43* Bands-3 Lymphs-50* Monos-3
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1*
[**2183-9-16**] 10:30AM BLOOD Neuts-50 Bands-1 Lymphs-38 Monos-4 Eos-0
Baso-0 Atyps-0 Metas-3* Myelos-4* NRBC-1*
[**2183-9-16**] 10:30AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-2+
Macrocy-2+ Microcy-NORMAL Polychr-1+ Ovalocy-2+
[**2183-9-11**] 06:15PM BLOOD Plt Smr-RARE Plt Ct-19*
[**2183-9-11**] 06:15PM BLOOD PT-13.3 PTT-22.9 INR(PT)-1.2
[**2183-9-19**] 06:28AM BLOOD PT-12.7 PTT-21.8* INR(PT)-1.1
[**2183-9-18**] 11:53AM BLOOD Plt Ct-67*#
[**2183-9-21**] 05:16AM BLOOD Plt Ct-43*
[**2183-9-11**] 06:15PM BLOOD Fibrino-390
[**2183-9-12**] 08:00AM BLOOD Gran Ct-820*
[**2183-9-12**] 08:00AM BLOOD Glucose-97 UreaN-47* Creat-1.1 Na-145
K-4.4 Cl-113* HCO3-26 AnGap-10
[**2183-9-21**] 05:16AM BLOOD Glucose-129* UreaN-44* Creat-1.4* Na-142
K-3.7 Cl-115* HCO3-18* AnGap-13
[**2183-9-11**] 06:15PM BLOOD ALT-9 AST-15 AlkPhos-40 TotBili-0.5
[**2183-9-14**] 06:45AM BLOOD LD(LDH)-180 TotBili-0.6
[**2183-9-11**] 06:15PM BLOOD Albumin-2.5* Calcium-6.5* Phos-3.2 Mg-1.7
UricAcd-8.7*
[**2183-9-21**] 05:16AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.8
[**2183-9-22**] 05:30AM BLOOD WBC-5.1 RBC-3.61* Hgb-11.0* Hct-31.1*
MCV-86 MCH-30.5 MCHC-35.4* RDW-19.0* Plt Ct-31*
[**2183-9-22**] 05:30AM BLOOD Plt Ct-31*
[**2183-9-22**] 05:30AM BLOOD Glucose-122* UreaN-43* Creat-1.5* Na-140
K-3.8 Cl-115* HCO3-18* AnGap-11
EGD ([**9-11**]):
-Schatzki's ring
-Thick gastric folds, biopsied.
-In the fourth portion of the doudenum, there was a site of
active bleeding. The actual source could not be localized and
appeared to be behind a fold laterally. A hemoclip was placed
and the area was tattooed with [**Country 11150**] ink. Otherwise normal EGD
to second part of the duodenum and jejunum.
Colonoscopy ([**9-11**]):
-Diverticulosis of the colon.
-Grade 3 internal hemorrhoids.
-Blood in the cecum and ascending colon.
-Otherwise normal Colonoscopy to cecum.
Angiography ([**9-11**]): (Prelim)
-Patient underwent embolization to gastroduodenal artery
proximal and distal to hemoclip.
EGD ([**9-18**]):
-Hemorrhagic AVM in proximal jejunum identified and clipped with
endoclip.
-Epinephrine injected into region of severe gastritis.
Brief Hospital Course:
81 yo F patient was admitted on [**2183-9-11**] and a summary of her
hospital course will be done by system:
1.) GI bleeding - On day of admission, pt underwent EGD with
hemoclip placement on bledding AVM in 4th portion of duodenum
and embolization of gastroduodenal artery. Subsequently, pt had
an appropriate HCT response to 2 units PRBCs from 23 to 29.
Thereafter, pt had episodes of 100-200cc melena on [**8-9**],
[**9-15**] and [**9-17**]. After each, HCT decreased by [**3-20**] points and was
treated with transfusion as indicated below under "treatment of
anemia." In addition to these episodes of melena, pt was likely
experiencing continuous GI bleeding as BUN was elevated from
baseline of 0.8 to 1.3-1.8 during most of hospital course.
Following 2 episodes of melena on [**9-15**], patient underwent a
Bleeding Study which revealed a faint area of increased tracer
accumulation in LUQ that was possibly related to a slow bleed at
3rd-4th portion of duodenum. Following melena on [**9-17**], pt
underwent repeat EGD, during which a hemorrhagic AVM in the
proximal jejunum was identified and an endoclip was placed;
additionally, severe gastritis was observed and 7cc of
epinephrine was injected into the most severe region. Following
this procedure, the patient recevied 2 units of pRBCs and has
had no further melena; HCT has been stable at > 29.8.
2.) MDS - Mr. [**Known lastname 58415**] has a lifelong Hx of anemia w/ superimposed
MDS and refractory anemia and thrombocytopenia with excess blast
type II (11% blasts and trisomy 8). She has required pRBC
transfusions since [**5-18**] about once weekly despit Procrit. At
admission, in addition to her GI bleeding, she was having
intermittent, persistent bleeding from her nasal mucosa. In
hospital, PLT goal was > 20 due to ongoing bleeding and HCT goal
was > 25 given CAD. Transfusions were given as needed as
indicated below. Patient was followed closely by hematology,
with followup by Dr. [**Last Name (STitle) **] as an outpatient.
#Treatment of thrombocytopenia: on [**9-15**], prednisone was initiated
at 80mg po qd, amicar was increased to 2g q6h and danazol was
begun at 200mg q12h and titrated up to 400mg q12h at d/c;
additionally, 30g IVIG was given for 5 days from [**9-15**] to [**9-19**].
Danazol can cause fluid retention, sun-sensitivity and
fluctations in glucose levels; therefore, Given Hx of cardiac
disease, she needs close following for fluid overload. Plan is
to decrease prednisone dose at 1st outpatient visit with
hematology, scheduled for [**9-30**]. In total, patient received 42
units of platelets. All platelets must be HLA matched. PLT
67-57-41-43 4 days prior to discharge and 31 at discharge. Given
this trend downwards, will need close follow up of PLT count s/p
d/c. Range while inpatient = 17 (on [**9-14**] & [**9-15**]) to 67.
#Treatment of anemia: patient recieved a total of 9 units of
pRBCs while an inpatient to maintain HCT > 25. Transfusions were
given followed by 20mg IV LASIX. Most recent transfusion of 2 U
pRBC given 4 days prior to discharge. HCT stable for 3 days
prior to discharge at >29.8, and = 31.1 at d/c. Range during
inpatient = 22.3 ([**9-11**]) to 31.1.
3.) Cardiac: EKG at admission: Sinus bradycardia with
nonspecific lateral ST-T changes w/ no previous tracing for
comparison. Patient remained hemodynamically stable throughout
course with pulse range 42-72 and BP range 100-160/50-77.
#HTN: Tends to be refractory. Large pulse pressure differential.
Pt. continued on outpatient regimen of metoprolol, losartan,
amlodipine, terazosin and clonidine. Lopressor maintained at
50mg po bid, may be titrated back to 100mg [**Hospital1 **] as outpatient.
#Pump: Echo (TTE) on [**9-12**]: moderate [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**], LV EF = 60-65%.
4.)Access: Pt has PICC line in place from [**Location (un) 19061**], approx 2wk
PTA. Heme consulted who recommended PICC can remain in place
for up to 3 months. PICC kept in place and will be removed as an
outpatient by hematology. If long term access needed for regular
transfusions, consider Hickman placement.
5.)Renal: on [**9-14**], cr bumped from 1.1 to 1.7, despite good urine
production. This may have been due to increased amnt
intra-luminal bleeding. Additionally, a prerenal state may have
contributed from the setting of GIB. Patient was given 2U pRBC
and
Cre trended downward to 1.2 on [**9-19**]. Range during course 1.1-1.7.
6.)PUML: CXR at admission: well placed L PICC with L lung base
atelectasis. Patient maintained good oxygen saturation
throughout course with range=94-99% RA.
7.)ID: WBC count low throughout course with range 1.1 ([**9-16**]) to
4.1. Pt maintained on neutropenic precautions beginning [**9-16**].
Patient remained afebrile throughout course with Tmax=99.6 and
no antibiotics were given. Neupogen not indicated as PMN
remained >500. Severe gastritis was observed on EGD and H.
pylori serology was +. Therefore, initiating therapy on day of
d/c: amoxicillin + clarithromycin + PPI.
8.)FEN: patient was maintained on liquid to soft-solid diet for
much of course given ongoing GI bleeding. Patient tolerated 3
days of regular diet prior to d/c. Lytes were repleted as
needed.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12738**] HMS4 for [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD.
Medications on Admission:
Protonix 40 mg PO qd
Amicar 2 g PO q6h
Synthroid 25 mcg PO qd
Zocor 80 mg PO qd
Danazol 200 mg PO bid
Clonidine .1 mg PO bid
Terazosin 2 mg PO qd
Cozaar 100 mg PO qd
Lopressor 100 mg PO bid
Norvasc 10 mg PO qAM, 5 mg PO qPM
Caltrate 600 mg PO qd
MVI 1 tab PO qd
Lasix 40 mg PO bid
Colace 100 mg PO bid
Discharge Medications:
1. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
3. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QAM
(once a day (in the morning)).
4. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Losartan Potassium 50 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
6. Terazosin HCl 2 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
8. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Aminocaproic Acid 500 mg Tablet Sig: Four (4) Tablet PO Q6H
(every 6 hours).
Disp:*480 Tablet(s)* Refills:*2*
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12
hours).
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Caltrate 600 Oral
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Don't take if having diarrhea.
14. Prednisone 20 mg Tablet Sig: Four (4) Tablet PO QD (once a
day).
Disp:*40 Tablet(s)* Refills:*2*
15. Danazol 200 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
Disp:*112 Capsule(s)* Refills:*2*
16. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
17. Amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day
for 14 days.
Disp:*56 Tablet(s)* Refills:*0*
18. Heparin Flush (Porcine) in NS 100 unit/mL Kit Sig: Two (2)
ml Intravenous once a day: PICC care: 10ml NS followed by 2ml
of 100Units/ml heparin (200units heparin) each lumen QD and PRN.
Inspect Site every shift.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
-Gastrointestinal bleeding
-Duodenal and jejunal arterio-venous malformations.
-CAD, s/p 3 v. CABG
-osteoarthritis
-Mylodysplastic syndrome (MDS): associated with anemia and
thrombocytopenia
-hypercholesterolemia
Discharge Condition:
stable
Discharge Instructions:
Please call your doctor if you have any further bleeding from
your rectum, chest pain, lightheadedness, abdominal pain,
nausea, vomiting, fevers or chills.
You will need to have your hematocrit and platelet count checked
on Tuesday, [**2183-9-23**] at your visit with your primary care
physician. [**Name10 (NameIs) **] will need to take an ambulance to your doctor's
office before your scheduled appointment.
Followup Instructions:
Please follow-up with your PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) 20**] [**Name Initial (NameIs) **]. ([**Telephone/Fax (1) 1408**])
on Tuesday, [**9-23**] at 2:00PM. Please be sure to have your
blood drawn for a complete blood count (CBC) at that time.
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and his fellow Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] in the department of hematology on Tuesday, [**9-30**]
at 10AM. Call [**Telephone/Fax (1) 15328**] with any questions.
Please make an appointment to see Dr. [**First Name (STitle) **] [**Name (STitle) 11326**] in the
department of gastroenterology in [**3-19**] weeks.
Provider: [**Name10 (NameIs) 17515**] CHAIR 1A Date/Time:[**2183-9-18**] 10:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2183-9-18**] 10:00
Provider: [**Name10 (NameIs) **] Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2183-10-8**] 10:00
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 5849, 4280, 2720, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8349
} | Medical Text: Admission Date: [**2185-9-14**] Discharge Date: [**2185-9-23**]
Service: MEDICINE
Allergies:
Codeine / Penicillins / Aspirin / Fentanyl
Attending:[**First Name3 (LF) 2605**]
Chief Complaint:
Foreign body aspiration
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
81yo F w/ MMP including lung cancer s/p RML and LUL lobectomies,
with new L hilar mass and R base mass, who was eating lunch at
her [**Hospital3 **] facility today when she aspirated what she
thought was a piece of lamb. She was seen in the nursing station
at her [**Hospital3 **] facility and was felt to be doing OK, so
was sent to her room. However 15 mins later, the pt's aide noted
that she had a lot of frothy white sputum, was abdominal
breathing, and was not talking much. Her color also looked off.
Her O2 sats were only 70% at the time and she was unable to talk
(her speech was very garbled). She was taken to the [**Hospital1 18**] ER for
evaluation by EMS. EMS had her on 15L by NRB. On arrival to the
hospital, her sats were only in the 60s on a NRB. She was given
another combivent nebulizer w/o improvement. CXR revealed no
radioopaque objects in her trachea. Her sats began to drop into
the 50s and she was tachypneic to the 30s, usuing accessory
muscles of respiration. She was noted to be AAOx3 and agreed to
be intubated. She was given ativan, etomidate, and
succinylcholine. After intubation, her sats improved to the 90s
and she was stabilized on the vent. She was transferred to the
MICU for bronchoscopy and retrieval of the foreign body.
Bronchoscopy revealed an object lodged in the R main bronchus.
Multiple attempts were made at obtaining the food particles, but
2 mushrooms were eventually dislodged. She continued to do well
post-bronchscopy but the decision was made to keep her intubated
in case repeat bronchoscopy was needed in the AM to insure that
all food particles had been retrieved.
Past Medical History:
# Lung cancer
- s/p RUL lobectomy in [**2169**] for bronchoalveolar carcinoma
- s/p segemental resection of posterior segment of LUL in [**2173**]
- path = adenoca NOS, moderately differentiated features, neg LN
- repeat mass found in LUL in [**2183**] -> bronchoscopy -> developed
resp failure post bronch requiring ventilation (? [**1-20**] muscle
rigidity from fentanyl)
- path of [**2184-1-22**] mass = infiltrating adenoca w/ papillary
features
- then found L hilar mass -> 6 cycles chemo w/ navelbine + XRT
- L hilar mass enlarged, plus new mass at R lung base (20 x
13mm)
- opted for no further treatment
# COPD
- last PFTs in [**2173**] - FEV1 1.80, FVC 2.05, FEV1/FVC 88 (125%)
# hypothyroidism
# h/o TIA/CVA
- MRA in [**2172**] showed 80%+ stenosis of [**Doctor First Name 3098**], 90%+ of [**Country **]
- s/p L CEA in [**2172**] (h/o R CEA in past)
- [**2182**]: R ICA w/ 70-79% stenosis L ICA w/ 60-69% stenosis
- MRA in [**2182**] showed subacute vs. acute infarct L internal
capsule
- per neuro notes, strokes have been bilateral and had residual
L sided hemiparesis (though not noted on neuro exams)
# Parkinson's
# PVD and claudication
# Cervical stenosis
- s/p anterior cervical disk excision and fusion of screws
# HTN
# Osteoarthritis and osteoporosis
# s/p R THR in [**2171**] for OA
- then had R hip dislocation in [**2181**], s/p closed reduction
# OSA - not on CPAP
# h/o PUD
# Depression
# CRI - baseline Cr is 1.7 - 3.2 in last 2 yrs
Social History:
Lives at [**Location 5583**] House x 2 yrs. 90 pack-yr smoker. h/o EtOH
abuse. Widowed, husband died in [**2171**].
Family History:
NC
Physical Exam:
VS - T 97.2, BP 173/73, HR 86, RR 26, sats 100% on AC 450x12,
PEEP 10, FiO2 60%
Gen: Thin, cachetic elderly female, sedated and intubated.
HEENT: Sclera anicteric. L pupil 5mm, reactive, R pupil 3mm,
reactive. Neck supple, no JVD.
CV: RR, normal S1, S2. No m/r/g.
Lungs: CTA anteriorly, no wheezes/rhonchi/crackles. Unable to
sit pt up to listen posteriorly.
Abd: Soft, NTND. + BS. No masses.
Ext: 2+ DP, radial pulses bilaterally.
Neuro: Sedated. Withdraws all 4 extremities to painful stimuli.
Upgoing toes bilaterally.
Pertinent Results:
LABS on admission:
WBC 9.7, Hct 36.8, Plt 351, MCV 93
(diff: 83.9N, 12.6L, 2.8M, 0.6E, 0.1B)
PT 11.9, PTT 29.1, INR(PT) 1.0
Na 142, K 4.3, Cl 102, HCO3 26, BUN 30, Cr 1.9, Glu 145
CK(CPK) 12*, CK-MB NotDone, trop <0.01
ABG pO2-32* pCO2-46* pH-7.39 calTCO2-29 Base XS-1
EKG: sinus, rate 90, normal intervals, normal axis, LAE
(biphasic P waves in V1-V2), no Q waves, no ST or TW changes
.
CXR [**2185-9-14**]: Compared with [**2184-12-8**], the patchy infiltrates in
the right lung have cleared, but the region of clustered linear
opacities in the left upper lung field are still present, either
more confluent or smaller in size. No acute infiltrates or
obvious CHF or effusions.
The patient is status post lower anterior cervical spine fusion,
with her chin somewhat low in position at this time. Whether
this is a fixed posture or not is uncertain.
.
CXR [**2185-9-14**]: (my read) R line clear, L hilar mass, ETT 2 mm
above carina, normal heart size
.
[**2185-9-14**] 02:35PM BLOOD WBC-9.7 RBC-3.94* Hgb-12.4 Hct-36.8
MCV-93 MCH-31.4 MCHC-33.7 RDW-14.7 Plt Ct-351
[**2185-9-15**] 06:03AM BLOOD WBC-9.3# RBC-3.48* Hgb-11.1* Hct-33.2*#
MCV-95 MCH-32.0 MCHC-33.6 RDW-14.6 Plt Ct-282
[**2185-9-16**] 04:31AM BLOOD WBC-9.7 RBC-3.34* Hgb-10.9* Hct-31.3*
MCV-94 MCH-32.5* MCHC-34.7 RDW-14.7 Plt Ct-256
[**2185-9-18**] 04:34AM BLOOD WBC-9.7 RBC-3.71* Hgb-12.2 Hct-35.3*
MCV-95 MCH-32.9* MCHC-34.6 RDW-14.9 Plt Ct-292
[**2185-9-19**] 07:05AM BLOOD WBC-7.2 RBC-3.57* Hgb-11.5* Hct-33.8*
MCV-95 MCH-32.2* MCHC-34.0 RDW-14.9 Plt Ct-341
[**2185-9-20**] 05:35AM BLOOD WBC-7.4 RBC-3.38* Hgb-10.9* Hct-31.7*
MCV-94 MCH-32.3* MCHC-34.5 RDW-15.3 Plt Ct-326
[**2185-9-21**] 09:44AM BLOOD WBC-7.4 RBC-3.36* Hgb-11.2* Hct-31.5*
MCV-94 MCH-33.2* MCHC-35.4* RDW-15.1 Plt Ct-319
[**2185-9-14**] 02:35PM BLOOD PT-11.9 PTT-29.1 INR(PT)-1.0
[**2185-9-14**] 02:35PM BLOOD Glucose-145* UreaN-30* Creat-1.9* Na-142
K-4.3 Cl-102 HCO3-26 AnGap-18
[**2185-9-15**] 03:47AM BLOOD Glucose-77 UreaN-25* Creat-1.2* Na-143
K-3.0* Cl-115* HCO3-19* AnGap-12
[**2185-9-15**] 06:03AM BLOOD Glucose-93 UreaN-29* Creat-1.8* Na-142
K-3.9 Cl-108 HCO3-25 AnGap-13
[**2185-9-16**] 04:31AM BLOOD Glucose-87 UreaN-19 Creat-1.5* Na-145
K-3.5 Cl-112* HCO3-23 AnGap-14
[**2185-9-17**] 04:55AM BLOOD Glucose-96 UreaN-19 Creat-1.5* Na-145
K-3.5 Cl-109* HCO3-21* AnGap-19
[**2185-9-18**] 04:34AM BLOOD Glucose-97 UreaN-21* Creat-1.5* Na-145
K-3.9 Cl-109* HCO3-22 AnGap-18
[**2185-9-19**] 07:05AM BLOOD Glucose-110* UreaN-17 Creat-1.2* Na-144
K-3.3 Cl-107 HCO3-25 AnGap-15
[**2185-9-20**] 05:35AM BLOOD Glucose-96 UreaN-17 Creat-1.3* Na-139
K-3.6 Cl-105 HCO3-26 AnGap-12
[**2185-9-21**] 09:44AM BLOOD Glucose-134* UreaN-20 Creat-1.6* Na-148*
K-3.9 Cl-105 HCO3-26 AnGap-21*
[**2185-9-21**] 05:00PM BLOOD Glucose-95 UreaN-23* Creat-1.5* Na-138
K-4.1 Cl-105 HCO3-21* AnGap-16
[**2185-9-14**] 02:35PM BLOOD CK(CPK)-12*
[**2185-9-14**] 02:35PM BLOOD cTropnT-<0.01
[**2185-9-14**] 02:35PM BLOOD CK-MB-NotDone
[**2185-9-15**] 03:47AM BLOOD Calcium-6.1* Phos-2.7 Mg-1.6
[**2185-9-16**] 04:31AM BLOOD Calcium-8.2* Phos-4.2 Mg-1.7
[**2185-9-18**] 04:34AM BLOOD Calcium-9.6 Phos-3.0 Mg-1.9
[**2185-9-19**] 07:05AM BLOOD Calcium-9.3 Phos-2.9 Mg-1.5*
[**2185-9-14**] 02:47PM BLOOD pO2-30* pCO2-58* pH-7.31* calTCO2-31*
Base XS-0
[**2185-9-14**] 02:49PM BLOOD pO2-32* pCO2-46* pH-7.39 calTCO2-29 Base
XS-1
Brief Hospital Course:
81 yo F w/ h/o lung cancer not amenable to treatment, dementia
and prior CVAs s/p mult. aspirations, htn, CRI presented w/
hypoxic respiratory failure [**1-20**] aspiration now moving towards
palliative care management.
In the MICU, she continued to do well post-bronchoscopy and was
extubated on [**2185-9-15**]. She has had excellent O2 saturations
averaging 96% on room air during the day. However, she has
required 2L NC overnight while in the MICU. Her MICU course has
been significant for hypertension. She has been NPO with h/o
recurrent aspirations in the past and has had an NG tube in
which she has removed several times, not because she is delerius
but because she doesn't like it. When she is given her po blood
pressure medications, her BP runs in the 130s. However, when NG
is not in, she has required IV hydralazine and SL isordil with
BPs in the 150s-180s. She has not yet had a speech and swallow
evaluation as her mental status would not tolerate until
recently.
HTN: Patient's MICU stay was complicated by hypertension as she
was NPO for aspiration risk and would not maintain an NG tube.
On IV hydralazine, SL isosorbide, BPs were in the 160s-180s. IV
lopressor was added and BPs decreased slightly but persisted in
180s at times. Patient failed video swallow again and a family
meeting was held with the geriatrics team. [**Hospital **] healthcare
proxy along with patient and family input decided that patient
should be made DNR/DNI and should be allowed to be fed for
improved quality of life. Patient's diet was advanced and
patient did well without evidence of respiratory compromise.
Her affect greatly improved after starting to eat again. All
of her IV blood pressure medications were stopped and she was
started back on her home dose norvasc and isosorbide dinitrate.
She had improved BP control back on her oral medication regimen.
.
# ASPIRATIONS: She failed repeat swallow evaluation but family
determined that patient's code status should be changed and
patient should be allowed to eat and take medications as
described above given her poor prognosis to improve the quality
of her life. Staff were instructed to take comfort measures
only if patient were to aspirate including O2, suctioning,
nebulizers, and morphine. All medications given were crushed.
As well, all unnecessary medications including fexofenadine,
donepazil, flonase, simvastatin, and pletal were discontinued.
Palliative care was consulted and were actively involved in the
goals of her care.
.
# INCREASED SECRETIONS- patient has had increased secretions
post extubation in MICU which persisted on the floor. These were
managed with bedside suctioning, frequent suctioning by nurses,
and hyoscyamine which was changed from prn to QID standing
doses.
.
# HYPOXIC RESPIRATORY FAILURE: Likely due to foreign body
aspiration.(2 mushrooms were found in the R main bronchus).
Extubated on [**9-15**] and then saturated well on room air with only
occasional dips into the low 90s overnight when not on her CPAP
machine.
.
# OSA: She normally uses CPAP outside of hospital and was
started on CPAP [**9-18**] with improved overnight O2 saturations.
.
# h/o TIA/STROKE: No change in neurologic exam. No active
issues. Pletal was d/c'ed as above
.
# CRI- baseline Creatinine in last year seemed to be between
1.5-2.0. Patient persisted at former baseline with infrequent
gentle IV hydration to supplement po intake.
.
# DEMENTIA: No acute issues. Aricept d/c'ed as above.
.
# HYPOTHYROIDISM: No active issues. She was restarted on her
home dose levothyroxine once po medications restarted.
.
# DEPRESSION: She initially had a flattened affect which
improved once patient's diet was advanced. She was continued on
her lexapro throughout admission.
.
# PUD- No acute issues. She was initially managed on protonix
which was changed to her home med prevacid once diet was
advanced as patient was receiving crushed meds and protonix
could not be crushed
Medications on Admission:
MVI 1 tab PO QD
Flonase 1 spray INH QD
Levsin elixir .125mg PO Q4-6 prn
Norvasc 10mg PO QHS
Aricept 10mg PO QHS
Prevacid 30mg PO BID
Albuterol inhalers 1-2 puffs INH Q4 prn
Tessalon perles 100mg PO TID
Lexapro 20mg PO QD
Levoxyl 50mcg PO QD
Cilostazol (pletal) 100mg PO QD
simvastatin 40mg PO QHS
Isosorbide 10mg PO TID
Loratidine 10mg PO QD
.
** only med NOT on list is Ritalin 10mg PO TID - ordered [**8-23**],
reordered [**7-24**] **
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
3. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
6. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for constipation: hold for loose stools.
Disp:*60 Tablet(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Disp:*120 Tablet(s)* Refills:*2*
8. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO twice a day.
10. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID (4 times a day).
Disp:*120 Tablet, Sublingual(s)* Refills:*2*
11. CPAP
at night per previous settings
12. Morphine Concentrate 20 mg/mL Solution Sig: 1-20 mg PO Q1hr
SL as needed for pain or respiratory distress.
Disp:*qs * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hospice of the good [**Doctor Last Name 9995**]
Discharge Diagnosis:
Primary:
1. hypoxic respiratory failure
2. aspiration
3. dysphagia
.
Secondary
1. lung cancer
2. hypertension
3. hypothyroidism
4. COPD
5. hyperlipidemia
6. obstructive sleep apnea
7. depression
8. chronic renal failure
Discharge Condition:
stable
Discharge Instructions:
Please take all medications as prescribed.
.
Please follow up with Dr. [**First Name8 (NamePattern2) 712**] [**Name (STitle) 713**] as listed below.
.
Please call your doctor or return to the hospital if you
experience chest pain, shortness of breath, difficulty
swallowing, fevers, chills, abdominal pain, or any other
concerns.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 713**] as below:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2185-10-4**]
8:30
.
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2185-11-22**]
2:00
.
.
Please follow up with orthopedics as below:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Date/Time:[**2186-7-7**] 11:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2608**] MD, [**MD Number(3) 2609**]
ICD9 Codes: 496, 5859, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8350
} | Medical Text: Admission Date: [**2124-9-14**] Discharge Date: [**2124-10-14**]
Date of Birth: [**2063-12-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Seizure, brain mass
Major Surgical or Invasive Procedure:
Intubation, central line placement and removal, arterial line
placement and removal, tracheostomy placement and removal, PEG
placement, lumbar puncture x 2, PICC placement, Bronchoscopy x
2, Laryngoscopy
History of Present Illness:
Patient is a 60 year old female with auto-immune hepatitis who
was found to be unresponsive by her family, and seizing after a
fall.
.
She was first seen for evaluation of her liver disease in
[**State 4565**] and [**State 8780**] in [**2124-5-21**]. At that time she had
recently returned from a trip to [**Country 651**] from [**Month (only) 547**] to [**2124-5-21**].
During that travel she developed severe itching associated with
extremity swelling and edema. These subsequently subsided but
when she returned she sought medical attention. On laboratories
she was noted to have elevated liver function tests and
subsequently progressed to "near fulminant liver failure." In
mid [**Month (only) **] her INR was 1.6 (peaked at 2.0), bilirubin was 23 and
her transaminases were 300-400. Her WBC count was 6.8, hct 31.2,
platelets 125, total bilirubin 23, AST 441, ALT 306 Alkaline
phosphatase 297, albumin 2.5, INR 1.6. Her electrolytes were
within normal limits. Her lipase was 367. Her [**Doctor First Name **] was positive
at 1:80. Her hepatitis B surface angigen, hepatitis C antibody,
hepatitis A IgG and IgM were negative. She underwent a liver
biopsy on [**2124-6-13**] which showed reactive hepatocytes,
cholestasis, and inflammatory infiltrate. The biopsy was felt to
be consistent with autoimmune hepatitis, drug reaction or
extra-hepatic obstruction. She was started on immuran and
prednisone on [**2124-6-21**] for presumed autoimmune hepatitis with
plans to also undertake an MRCP to assess for sclerosing
cholangitis. Per OSH notes she did have an MRCP but report not
available to us at [**Hospital1 18**]. Between [**2124-6-21**] and [**2124-7-14**] her total
bilirubin decreased from 21 to 17 (direct 9.8) with a decrease
in her transaminases to AST 176 and ALT 223 with alkaline
phosphatase of 213. Lipase at that time was 595 and INR was 1.7.
She was scheduled to complete a prednisone taper starting at 30
mg and tapering over one month to 10 mg daily. She was also
started on ursodiol in late [**Month (only) 205**]. There are no additional
laboratory values between then and her admission here on [**2124-9-14**]
although per the patient's family she was under the care of a
naturopath while in [**Location (un) 86**] in [**Month (only) 216**] who was administering a
number of naturopathic supplements (including iron) to help with
her liver disease, and laboratory work was taken. The patient
reported that despite improvement in her laboratory values she
continued to feel fatigued and had swelling of her legs.
.
The patient lives in [**State 8780**] but immediately prior to this
admission was visiting family in [**Location (un) 3844**]. Per family
report, over the last several days the patient was lethargic,
had difficulty with movement, swelling, foot numbness, and
fatigue. On the day prior to admission, she complained of fever
and chills and had a recorded temperature of 102. On the
morning of admission on [**2124-9-14**], her family found the patient
on the floor with reported seizure activity. EMS responded and
administered valium, which did not break the seizure fully. In
the field, she had a HR of 120s and was breathing spontaneously.
She was taken to an outside hospital, where her seizure was
broken with fosphenytoin and ativan. Due to concerns over airway
protection and unresponsiveness, she was intubated at that time.
A CT of head, by report, demonstrated a left frontal mass and
left frontal subarachnoid hemorrhage. She was transferred to
[**Hospital1 18**] for further management. In the [**Hospital1 18**] emergency room, she
was given Vitamin K, 2 units of FFPs, and decadron 10 mg IV.
Upon arrival to [**Hospital1 18**], she was found to be hypothermic and
hypotensive, and was placed on pressors. A repeat head CT
confirmed the above findings. She was initially admitted to the
neurosurgial ICU, when decision was made not to operate she was
transfered to the medical service for continued work up and
treatment.
Past Medical History:
1. Autoimmune hepatitis - Diagnosed [**2124-5-21**].
2. Bronchitis
3. per report, evaluated at [**Doctor Last Name 21721**] for arthritis in [**2124-4-20**]
Social History:
Patient lives in [**State 8780**] and was visiting family members in [**Name2 (NI) **]
[**Name (NI) **]. Per report, there is no history of tobacco or alcohol
use. She lives alone, works as an education consultant for a
chartered school. She has a law degree. She visited [**Country 12602**] 8
months ago. She has also visited [**Country 3399**], [**Country 15800**], and other
Subsaharan countries for work and as a tourist.
She visited [**Country 651**] in [**Month (only) 547**] and spent 21 days there. This trip
was part of an educational exchange program, for which she
serves on the board of directors. As noted elsewhere, she toured
various parts of [**Country 651**] and stayed mainly in hotels; she did
visit rural areas, however.
Family History:
Non-contributory. No history of liver disease, infections or
auto-immune diseases.
Physical Exam:
(At time of admission to MICU)
General: Intubated, opens eyes spontaneous at times. NAD.
HEENT: NC/AT. No scleral icterus. Pupils reactive bilaterally.
No scleral icterus or conjunctival pallor. No facial asymmetry
noted.
Neck: C-collar in place. IJ in place.
Lungs: Rhoncerous sounding bilaterally. No wheezes. Bilateral
breath sounds.
Cardiac: Borderline tachycardic, regular, no m/g/r
Abdomen: Soft, NT, ND, +BS
Extr: Warm, 2+ pitting edema to just above ankle bilaterally.
A-line in place over right radial.
Neuro: Opens eyes occasionally, no purposeful movements noted.
Withdraws feet R>L to noxious stimuli. Reflexes 3+ right
patella, 2+ left, 3+ bilaterally at bicesp. PERRL.
Skin: 1 cm erythemaous lesion over left 3rd finger. No other
lesions noted. Lines appear c/d/i.
Pertinent Results:
[**2124-9-16**] 08:36AM CEREBROSPINAL FLUID (CSF) WBC-79 RBC-1280*
Polys-58 Lymphs-24 Monos-0 Atyps-4 Macroph-14
[**2124-9-16**] 08:36AM CEREBROSPINAL FLUID (CSF) WBC-101 RBC-732*
Polys-57 Lymphs-26 Monos-0 Atyps-4 Macroph-13
[**2124-9-16**] 08:36AM CEREBROSPINAL FLUID (CSF) TotProt-257*
Glucose-8
[**2124-9-28**] 12:39PM CEREBROSPINAL FLUID (CSF) WBC-14 RBC-634*
Polys-2 Lymphs-89 Monos-0 Atyps-3 Macroph-6
[**2124-9-28**] 12:39PM CEREBROSPINAL FLUID (CSF) WBC-33 RBC-656*
Polys-1 Lymphs-96 Monos-0 Macroph-3
[**2124-9-28**] 12:39PM CEREBROSPINAL FLUID (CSF) TotProt-89*
Glucose-58 LD(LDH)-48
Blood Culture, Routine (Final [**2124-9-21**]):
REPORTED BY PHONE TO [**Doctor First Name 80500**] [**Doctor Last Name **] -CC6C- @ 14:45
[**2124-9-17**].
LISTERIA MONOCYTOGENES. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
LISTERIA MONOCYTOGENES
|
AMPICILLIN------------<=0.12 S
PENICILLIN G---------- 0.12 S
TRIMETHOPRIM/SULFA---- 0.5 S
Anaerobic Bottle Gram Stain (Final [**2124-9-16**]):
REPORTED BY PHONE TO [**Doctor First Name 26**] [**Doctor Last Name **] @ 1700 ON [**9-16**] - CC6C.
GRAM POSITIVE ROD(S).
[**2124-9-15**] 8:23 pm URINE Source: Catheter.
**FINAL REPORT [**2124-9-18**]**
URINE CULTURE (Final [**2124-9-18**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
[**2124-9-16**] 8:36 am CSF;SPINAL FLUID Source: LP TUBE 3.
**FINAL REPORT [**2124-10-6**]**
GRAM STAIN (Final [**2124-9-16**]):
THIS IS A CORRECTED REPORT 2105, [**2124-9-16**].
REPORTED BY PHONE TO [**Name6 (MD) 3688**] [**Name8 (MD) **] MD (#[**Numeric Identifier 80501**]) AT 2100 ON
[**2124-9-16**].
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
PREVIOUSLY REPORTED AS AT 1215 ON [**2124-9-16**].
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2124-9-19**]):
LISTERIA MONOCYTOGENES. SPARSE GROWTH.
SULFA X TRIMETH <=0.5/9.5 UG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
LISTERIA MONOCYTOGENES
|
AMPICILLIN------------<=0.12 S
PENICILLIN G----------<=0.06 S
TRIMETHOPRIM/SULFA---- S
FUNGAL CULTURE (Final [**2124-10-6**]): NO FUNGUS ISOLATED.
[**2124-9-22**] 3:51 pm BRONCHIAL WASHINGS
GRAM STAIN (Final [**2124-9-22**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2124-9-25**]):
OROPHARYNGEAL FLORA ABSENT.
ACINETOBACTER SP.. >100,000 ORGANISMS/ML..
sensitivity testing performed by Microscan.
SENSITIVE TO Levofloxacin <= 2 UG/ML.
SENSITIVE TO Cefepime <= 2 UG/ML.
SENSITIVE TO MEROPENEM <= 1 UG/ML.
YEAST. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER SP.
|
CEFTAZIDIME----------- <=2 S
CIPROFLOXACIN--------- <=0.5 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
PIPERACILLIN---------- 16 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=2 S
POTASSIUM HYDROXIDE PREPARATION (Final [**2124-9-25**]):
TEST CANCELLED, PATIENT CREDITED.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
FUNGAL CULTURE (Final [**2124-10-6**]):
YEAST.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2124-9-25**]):
SPECIMEN NOT PROCESSED DUE TO: DUPLICATE REQUEST.
REFER TO VIRAL CULTURE FOR RESULTS.
PATIENT CREDITED.
[**2124-10-11**] 9:47 am URINE Source: CVS.
**FINAL REPORT [**2124-10-12**]**
URINE CULTURE (Final [**2124-10-12**]): NO GROWTH.
[**2124-10-12**] 07:16AM BLOOD WBC-3.1* RBC-2.38* Hgb-8.5* Hct-24.8*
MCV-105* MCH-35.8* MCHC-34.2 RDW-23.3* Plt Ct-120*
[**2124-10-11**] 06:01AM BLOOD WBC-3.1* RBC-2.40* Hgb-8.3* Hct-25.0*
MCV-104* MCH-34.7* MCHC-33.3 RDW-23.9* Plt Ct-107*
[**2124-10-10**] 06:10AM BLOOD WBC-3.8* RBC-2.40* Hgb-8.6* Hct-24.9*
MCV-103* MCH-35.6* MCHC-34.4 RDW-24.6* Plt Ct-133*
[**2124-10-12**] 07:16AM BLOOD Plt Ct-120*
[**2124-10-12**] 07:16AM BLOOD PT-15.9* PTT-39.2* INR(PT)-1.4*
[**2124-10-11**] 06:01AM BLOOD Plt Ct-107*
[**2124-10-11**] 06:01AM BLOOD PT-15.4* PTT-36.7* INR(PT)-1.4*
[**2124-10-10**] 06:10AM BLOOD Plt Ct-133*
[**2124-10-10**] 06:10AM BLOOD PT-15.1* PTT-38.7* INR(PT)-1.3*
[**2124-9-29**] 04:03AM BLOOD Ret Aut-5.4*
[**2124-9-15**] 04:47PM BLOOD ACA IgG-22.0* ACA IgM-11.8
[**2124-9-15**] 04:47PM BLOOD Lupus-NEG
[**2124-10-12**] 07:16AM BLOOD Glucose-98 UreaN-9 Creat-0.4 Na-139
K-3.1* Cl-111* HCO3-26 AnGap-5*
[**2124-10-11**] 10:08PM BLOOD K-3.4
[**2124-10-11**] 03:20PM BLOOD K-3.1*
[**2124-10-11**] 06:01AM BLOOD Glucose-105 UreaN-10 Creat-0.5 Na-141
K-2.5* Cl-110* HCO3-27 AnGap-7*
[**2124-10-10**] 06:10AM BLOOD Glucose-111* UreaN-12 Creat-0.5 Na-141
K-2.7* Cl-109* HCO3-26 AnGap-9
[**2124-10-9**] 05:56AM BLOOD Glucose-117* UreaN-12 Creat-0.4 Na-138
K-2.9* Cl-108 HCO3-27 AnGap-6*
[**2124-10-8**] 06:18AM BLOOD Glucose-100 UreaN-11 Creat-0.4 Na-141
K-3.6 Cl-112* HCO3-27 AnGap-6*
[**2124-10-7**] 05:48PM BLOOD K-2.8*
[**2124-10-12**] 07:16AM BLOOD ALT-32 AST-33 LD(LDH)-288* AlkPhos-414*
TotBili-0.9
[**2124-10-11**] 06:01AM BLOOD ALT-35 AST-37 LD(LDH)-284* AlkPhos-453*
TotBili-1.1
[**2124-10-10**] 06:10AM BLOOD ALT-39 AST-40 LD(LDH)-281* AlkPhos-528*
TotBili-1.1
[**2124-10-9**] 05:56AM BLOOD ALT-46* AST-47* LD(LDH)-289* AlkPhos-604*
Amylase-187* TotBili-1.2
[**2124-10-8**] 06:18AM BLOOD ALT-55* AST-54* LD(LDH)-262* AlkPhos-657*
Amylase-199* TotBili-1.0
[**2124-10-12**] 07:16AM BLOOD Albumin-2.0* Calcium-7.6* Phos-2.5*
Mg-1.9
[**2124-10-11**] 06:01AM BLOOD Calcium-7.6* Phos-2.9 Mg-2.0
[**2124-10-10**] 06:10AM BLOOD Calcium-7.8* Phos-3.3 Mg-2.0
[**2124-10-9**] 05:56AM BLOOD Calcium-7.5* Phos-2.4* Mg-2.0
[**2124-10-8**] 06:18AM BLOOD Albumin-1.7* Calcium-7.4* Phos-2.6*
Mg-2.2 Iron-61
[**2124-10-8**] 06:18AM BLOOD calTIBC-146* Ferritn-371* TRF-112*
[**2124-9-24**] 04:08AM BLOOD Hapto-<20*
[**2124-9-19**] 04:06AM BLOOD calTIBC-139* Ferritn-760* TRF-107*
[**2124-9-19**] 10:05AM BLOOD AMA-NEGATIVE
[**2124-9-15**] 04:47PM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:160
[**2124-9-15**] 04:47PM BLOOD CRP-34.3*
[**2124-9-29**] 03:42PM BLOOD PEP-POLYCLONAL IgG-2451* IgA-441* IgM-212
IFE-NO MONOCLO
[**2124-9-19**] 10:05AM BLOOD IgG-1783*
RT APPROVED DATE: [**2124-9-19**]
SPECIMEN RECEIVED: [**2124-9-18**] [**-7/3756**] SPINAL FLUID
SPECIMEN DESCRIPTION: Received 2ml pale yellow fluid.
Prepared 1 ThinPrep slide.
CLINICAL DATA: 60 y/o female with fevers, brain lesion.
REPORT TO: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DIAGNOSIS: Cerebrospinal fluid:
NEGATIVE FOR MALIGNANT CELLS.
DIAGNOSED BY:
[**First Name8 (NamePattern2) 5335**] [**Last Name (NamePattern1) 5336**], CT(ASCP)
[**First Name11 (Name Pattern1) 636**] [**Last Name (NamePattern4) 5337**], M.D.
Cardiology Report ECG Study Date of [**2124-9-14**] 7:47:22 AM
Sinus bradycardia. Non-specific ST-T wave changes. No previous
tracing
available for comparison.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
56 100 110 462/455 13 -55 -1
CXR [**9-14**]:
INDICATION: 60-year-old woman intubated for subarachnoid
hemorrhage and
seizure. [**Month/Year (2) **] ET tube, NG tube and for pneumonia or CHF.
COMPARISON: None available.
The ET tube tip is 2.7 cm from the carina, would recommend
pulling back
approximately 1-2cms. The NG tube tip is in the stomach. The
lungs are clear,
without evidence of pneumonia or CHF. There is bibasilar
atelectasis amd a
probable small left basal effusion. There is mild degenerative
change in the
thoracic spine.
IMPRESSION: No acute intrathoracic process. Suggest pulling back
ET tube [**12-22**]
cms as discussed with Dr [**Last Name (STitle) **].
[**9-14**] CT HEAD WITHOUT CONTRAST
INDICATION: Subarachnoid hemorrhage, with new mass, seizure,
[**Month/Year (2) 4656**] for
interval change and please compare with outside hospital CT.
TECHNIQUE: MDCT-acquired contiguous axial images of the head
were obtained
without intravenous contrast.
COMPARISON: Outside hospital CT from 5:30 a.m. from the same
date.
FINDINGS: There is a 4.3 x 2 cm area of low attenuation in the
left frontal
lobe with minimal surrounding edema and mild mass effect. There
is bilateral
fronto-parietal subarachnoid hemorrhage. There is loss of the
adjacent [**Doctor Last Name 352**]-
white matter differentiation without midline shift. There is no
intraventricular hemorrhage. There are no fractures. The
paranasal sinuses
and mastoid air cells are clear.
IMPRESSION: Large area of left frontal low attenuation lesion,
which may
represent acute infarct or tumor. In addition there is bilateral
fronto-
parietal subarachnoid hemorrhage without significant midline
shift This is not
significantly changed since the study at 5:30 a.m. from the same
date.
An MRI would be more sensitive for assesment of the left frontal
lesion.
[**9-14**] MRI OF THE HEAD WITHOUT AND WITH CONTRAST, [**2124-9-14**]; MRA OF THE
HEAD, [**2124-9-14**]
INDICATION: 60-year-old woman with new intracranial mass,
hemorrhage, and
seizures. [**Year (4 digits) **] for mass or aneurysm.
TECHNIQUE: MRI of the brain was performed with axial gradient
echo, T2-
weighted, FLAIR, diffusion-weighted sequences. Additionally,
multiplanar pre-
and post-gadolinium T1-weighted sequences were obtained. MRA was
performed
with 3D time-of-flight imaging through the head. Multiple MIP
reconstructions
were created on a separate workstation.
COMPARISON: Head CT of [**2124-9-14**].
FINDINGS: Within the left frontal lobe, there is a heterogeneous
region
containing focal regions of peripheral enhancement. Centrally,
there are
regions of blood products. There is surrounding edema. Portions
of this
focus demonstrate restricted diffusion. The focus of abnormal
signal
encompasses approximately 4.2 x 2.7 cm. In addition to this
dominant focus,
there are several punctate foci of high signal on
diffusion-weighted
sequences, including the right frontal lobe, lateral to the
right caudate,
left temporal, and right parietal lobes. While no definite low
signal can be
demonstrated on the ADC reconstructions, these foci may also
represent small
infarcts. Septic emboli are a differential consideration.
As demonstrated on the recent CT, there is subarachnoid blood
layering within
the sulci bilaterally. There are bifrontal subdural collections,
most
prominent in the frontal regions, where they measure up to 6 mm
in thickness.
There is heterogeneous FLAIR signal intensity, which could
suggest the
presence of blood products.
There is a prominent vessel coursing along the surface of the
right frontal
lobe, with a prominent parenchymal focus of linear enhancement.
This likely
represents a developmental venous anomaly.
MRA:
The ICAs are of normal caliber, course, and contour bilaterally.
The right
vertebral artery is dominant. There is no significant
intracranial stenosis.
There is no aneurysm. The major vessels of the anterior and
posterior
circulation demonstrate normal caliber, contour, and course.
There is no midline shift. Ventricles and cisterns are patent.
Globes and
orbits and extracranial soft tissues are unremarkable.
IMPRESSION:
1. Large abnormality within the left frontal lobe characterized
by peripheral
enhancement, surrounding edema, blood products, and restricted
diffusion.
Differential considerations for this lesion would include an
abscess with
associated hemorrhage versus an infarct with hemorrhage. There
are numerous
punctate foci of abnormal signal bilaterally which may also
represent either
small infarcts or septic emboli.
2. Subarachnoid hemorrhage, as see on the recent CT.
3. Bilateral subdural fluid collections, most prominent in the
frontal
regions, where they measure up to 6 mm in thickness. There is
heterogeneous
signal within it, which could suggest the presence of acute
blood product.
4. Right frontal developmental venous anomaly.
5. Normal MRA.
[**2124-9-19**] EEG:
FINDINGS:
ABNORMALITY #1: Focal and lateralized slowing was noted toward
the end
of the record with 1-2 Hz slower theta and faster delta from the
left
mid-temporal, central, posterior temporal, and parietal regions.
No
associated sharp or spike activity was seen. The runs of slowing
tended
to last several seconds.
ABNORMALITY #2: A slowed and disorganized background was seen
both
posteriorly and anteriorly. The posterior rhythm was relatively
low to
moderate voltage and of a pseudoperiodic nature verging on a
burst-voltage reduction pattern not as extreme as a burst
suppression
pattern. The faster rhythms were in the faster delta and slower
theta
range. The anterior-posterior voltage gradient was not
preserved.
BACKGROUND: No normal background rhythms for age were seen.
HYPERVENTILATION: Not performed.
INTERMITTENT PHOTIC STIMULATION: Not performed.
SLEEP: Not obtained.
CARDIAC MONITOR: No arrhythmias noted.
IMPRESSION: Abnormal EEG due to a burst-reduction and
pseudoperiodic
record overall with marked slowing in the theta and delta range
with
additional focal and lateralized slowing in the left mid to
posterior
head regions without associated spike or sharp discharges. This
would
suggest a diffuse encephalopathy of a moderate to moderately
severe
degree with accentuated slowing over the left hemisphere from
the mid to
posterior regions suggestive of a possible structural or
destructive
process in that area. No epileptiform abnormalities were noted,
however.
[**2124-9-19**] Echocardiogram:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. There is focal thickening of the right
coronary cusp of the aortic valve which measures 0.5 x 0.5 cm;
cannot exclude valvular vegetation. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve. No
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Focal thickening of the right coronary cusp of the
aortic valve without aortic regurgitation. Cannot exclude aortic
valve vegetation. If clinically indicated, a TEE would better
assess for endocarditis. Preserved regional and global
biventricular systolic function.
[**2124-9-29**] MRI
IMPRESSION:
1. Increased enhancement and mild increase in surrounding edema
in the left
frontal lesion, which now demonstrates intrinsic slow diffusion,
consistent
with an abscess.
2. Additional areas of new enhancement are seen in the right
frontal lobe and
in the region of right caudate head.
3. New small bilateral frontal hypointense effusions.
4. Diffuse in meningeal enhancement which could be due to
meningeal
inflammation.
5. Bilateral extensive mastoid middle ear and sphenoid sinus
soft tissue
changes.
[**2124-10-3**] Echocardiogram
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. The interatrial septum is aneurysmal. No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. Overall left
ventricular systolic function is normal (LVEF>55%). The aortic
valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. There are filamentous
strands on the aortic leaflets consistent with Lambl's
excresences (normal variant). No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. No vegetation/mass is seen on the pulmonic valve. There
is a trivial/physiologic pericardial effusion.
IMPRESSION: No vegetations or clinically-significant regurgitant
valvular disease. No PFO, ASD, or cardiac source of embolism
seen.
Compared with the prior study (images reviewed) of [**2124-9-20**],
the localized lucency in near the crux of the heart is likely a
coronary artery.
MRCP, [**2124-10-7**]
INDICATION: 60-year-old woman with history of autoimmune
hepatitis.
TECHNIQUE: Multiplanar T1- and T2-weighted breath-hold
independent imaging
was performed on a 1.5 Tesla magnet, including dynamic
sequential images
obtained prior to, during, and after the uneventful
administration of 0.1
mmol/kg of gadolinium-DTPA.
COMPARISON: Correlation is made with abdominal ultrasound dated
[**2124-10-3**] and abdominal CT dated [**2124-9-18**].
FINDINGS: There is a right pleural effusion. Atelectasis is
noted at both
bases.
The liver is nodular in contour. There is multifocal abnormal,
patchy,
linearly-oriented T2 signal abnormality throughout the liver, in
a pattern
suggestive of bridging fibrosis. There are no focal lesions. The
regions of
fibrosis are associated with capsular retraction.
There is no intra- or extra-hepatic biliary dilatation. The
gallbladder is
thick-walled, likely relating to the patient's underlying liver
disease. No
definite gallstones are identified.
Spleen, pancreas, kidneys, and adrenals are grossly normal,
allowing for
limitations of non-breath-hold technique. There is ascites.
Bowel is normal in
caliber.
Bone marrow signal is grossly normal. Subcutaneous edema is
noted. Note is
made of Tarlov cysts associated with several sacral nerve roots.
IMPRESSION:
Morphologic changes and diffuse abnormal signal throughout the
liver, in
keeping with hepatitic fibrosis. No biliary dilatation.
[**2124-10-9**]: VIDEO OROPHARYNGEAL SWALLOW STUDY
The study was performed in conjunction with the speech pathology
department.
Continuous fluoroscopic observation was provided during
administration of
multiple consistencies of barium. The patient displayed moderate
to severe
oral phase swallow dysfunction with decreased tongue propulsion,
and delayed
swallow initiation. Once swallow initiation was started,
however, the
pharyngeal phase appeared unremarkable. A single episode of
frank aspiration,
which was silent was demonstrated during straw sip
administration of thin
liquid barium consistency which appeared to improve with chin
tuck maneuvers.
Mild residue was also noted within the valleculae bilaterally
with nectar and
puree consistencies. Focused examination of the vocal cords was
not possible
as no phonation was able to be elicited from the patient.
[**2124-10-10**]: MRI Head
IMPRESSION:
1. Mild decrease in the size of the small enhancing lesion, in
the head of
the caudate nucleus on the right side and a few smaller lesions
noted in the
right centrum semiovale and in the left centrum semiovale
adjacent to the
largest lesion in the left frontal lobe, which itself has not
signficantly
changed. No new lesions.
2. Bilateral moderate subdural fluid collections are unchanged.
3. Unchanged diffuse fluid/mucosal thickening in the mastoid air
cells on
both sides.
[**2124-10-11**] CXR (AP)
FINDINGS: In comparison with the study of [**10-5**], the patient has
taken a much better inspiration. There is still mild
indistinctness of pulmonary vessels, though the vascular status
is certainly improved from the previous
examination. PICC line remains in place. Probable mild
atelectatic change in the retrocardiac region at the left base.
ADMISSION LABS
[**2124-9-14**] 04:34PM CK(CPK)-57
[**2124-9-14**] 04:34PM CK-MB-NotDone cTropnT-<0.01
[**2124-9-14**] 04:34PM PHENYTOIN-10.8
[**2124-9-14**] 04:34PM PT-16.4* PTT-33.9 INR(PT)-1.5*
[**2124-9-14**] 04:11PM TYPE-ART PO2-223* PCO2-33* PH-7.47* TOTAL
CO2-25 BASE XS-1
[**2124-9-14**] 12:49PM VoidSpec-CLOTTED SP
[**2124-9-14**] 08:09AM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP
[**2124-9-14**] 08:09AM LACTATE-1.6
[**2124-9-14**] 08:00AM GLUCOSE-129* UREA N-12 CREAT-0.6 SODIUM-131*
POTASSIUM-3.2* CHLORIDE-105 TOTAL CO2-22 ANION GAP-7*
[**2124-9-14**] 08:00AM estGFR-Using this
[**2124-9-14**] 08:00AM ALT(SGPT)-35 AST(SGOT)-45* LD(LDH)-342*
CK(CPK)-53 ALK PHOS-86 TOT BILI-2.5*
[**2124-9-14**] 08:00AM LIPASE-112*
[**2124-9-14**] 08:00AM CK-MB-NotDone cTropnT-<0.01
[**2124-9-14**] 08:00AM ALBUMIN-2.2* CALCIUM-6.6* PHOSPHATE-2.1*
[**2124-9-14**] 08:00AM WBC-3.1* RBC-2.30* HGB-9.8* HCT-28.1*
MCV-122* MCH-42.5* MCHC-34.8 RDW-17.7*
[**2124-9-14**] 08:00AM PLT COUNT-82*
[**2124-9-14**] 08:00AM PT-20.0* PTT-39.6* INR(PT)-1.9*
[**2124-9-14**] 08:00AM FIBRINOGE-221
DISCHARGE LABS:
[**2124-10-13**] 05:12AM BLOOD WBC-3.4* RBC-2.45* Hgb-8.6* Hct-25.9*
MCV-106* MCH-35.3* MCHC-33.4 RDW-23.4* Plt Ct-98*
[**2124-10-13**] 05:12AM BLOOD PT-15.3* PTT-37.4* INR(PT)-1.4*
[**2124-10-13**] 05:12AM BLOOD Glucose-95 UreaN-8 Creat-0.3* Na-138
K-2.6* Cl-114* HCO3-19* AnGap-8
[**2124-10-13**] 02:01PM BLOOD K-3.2*
[**2124-10-13**] 05:12AM BLOOD ALT-23 AST-30 LD(LDH)-263* AlkPhos-312*
TotBili-0.7
[**2124-10-13**] 12:41AM BLOOD Genta-1.0*
Brief Hospital Course:
Patient is a 60 year old female with past medical history of
autoimmune disease, who presented on [**9-14**] with seizure, found to
have Listeria bacteremia, meningitis, and likely Listeria brain
abscess, s/p prolonged intubation, now s/p tracheostomy and
removal, now awake and alert and breathing comfortably on room
air.
.
#) Listeria bacteremia and meningitis/encephalitis/abscess and
resultant altered mental status:
.
Listeria noted in blood and CSF cultures from [**9-15**] and [**9-16**]
respectively. Her recently immuno-suppressed state secondary to
steroid and azathioprine treatment for auto-immune hepatitis may
have pre-disposed her to infection. Initial imaging revealed
small SAH and large mass, likely abscess with several satellite
lesions. Serial head CT??????s and MRIs have been stable showing
large left hemisphere lesion and and interval resoluton of
bleed and multiple septic emboli. TTE and TEE completed as noted
(abnormal, but no definite abscess or vegetation). EEG was not
suggestive of convulsive status. Repeat LP and blood cultures
all show no growth.
- ID service consulted. Ampicillin and gentamicin were started
on [**9-17**]. ID recommends 6 week course then repeat head MRI to
reassess. Tentative date of completion of abx is [**2124-10-28**].
- Neurology service consulted for initial seizure presentation,
recommend Levetiracetam 1500 [**Hospital1 **] indefinitely for seizure
prevention.
.
#) Respiratory failure: Patient intubated for airway protection
in setting of altered mental status, and underwent tracheostomy
on [**2124-9-22**] due to persistent altered mental status. Over her
hospital course her mental status improved and she was able to
be weaned off trach mask and supplemental oxygen. Her trach was
decannulated by the interventional pulmonology service on [**10-9**].
.
#) Hemoptysis: Patient had episodes of significant hemoptysis
and blood around her trach site. Bronchoscopy demonstrated an
erosion that was felt to likely be the source of her bleeding.
CTA was negative for fistula. No further bleeding noted. Repeat
bronchoscopy after latest episode of hemoptysis on [**10-5**] found a
bleeding lesion in the trachea, which was coagulated with good
hemostasis. Since then, there have been no repeat episodes and
her hematocrit and respiratory status have remained largely
stable.
.
#) Pancytopenia: Pt was pancytopenic on admission and remained
so throughout hospital stay. All cell counts stable at time of
discharge. Pt admitted on prednisone and imuran for autoimmunie
hepatitis, initially immunosuppressants thought to be culprits,
but were held throughout admission without resolution of
pancytopenia; other possibilities included stress of acute
infection, viral process. Hematology service consulted.
Hemolytic work up negative. Flow cytometry negative for
malignancy, bone marrow bx deferred this admission. TPMT
returned positive, consistent with heterozyogous state, which
suggests increased risk of myelosuppression with Imuran
treatment. Throughout her stay, the patient's hematocrit was
closely monitored, and she did require several blood
transfusions.
.
#) Elevated Coagulation Studies: Stable. Her elevated INR had
been felt to be secondary to nutritional deficiencies and liver
disease. Per hematology and laboratory values, DIC appears to be
less likely, but still will continue to monitor for this
possibility. The patient was continued on pneumoboots for DVT
prophylaxsis given her increased coagulation studies, as well as
the uncertainty regarding continued bleeding around her brain
heparin SC was deferred.
.
#) Elevated LFTs: On admission her LFTs were essentially normal.
During her stay had an elevation most notable in alk phos as
well as a mild elevation in transaminases which are again
trending down. The hepatology team was consulted. RUQ ultrasound
consistent with liver disease, no other concerning pathology (no
ductal dilation or gall bladder abnormalities noted). There was
concern that her autoimmune hepatitis could be returning, but
the team was hesitant to start her on any immunosupressive
therapies given the severe comorbid infection in this patient.
Hepatology recommended a MRCP, which showed findings c/w
cirrhosis, as well as some ascites. Hepatology also recommended
starting ursodiol, but no Imuran or prednisone given her acute
infection. She should follow up with her liver team upon
completion of antibiotics for consideration of restarting
treatment for her autoimmune hepatitis.
.
#) Pt had acinetobacter growing in her sputum sample during ICU
stay. Decision made not to treat due to abscence of clinical
disease. As above pt tolerated vent and 02 weaning without
addition of antibiotics.
.
#) During initial decompensated illness, there was concern for
systemic fungal infection. A B-glucan test was positive and pt
was transiently treated with amphotericin. Fungal cultures of
blood and CSF were persistently negative and this was
discontinued. Currently it is thought that this may have been a
false positive in setting of listeria infection or possibly her
ampicillin. Our ID consultants recommend that this be repeated
after completion of antibiotic treatment for confirmation of
this.
.
#) Hypokalemia: On the medical floor, the patient was noted to
be persistently hypokalemic, with a low of 2.5 on [**2124-10-14**].
Various causes were considered including medication effects from
Gentamycin or Keppra. Of note, her creatinine has consistently
been 0.4-0.6. Potassium was repleted daily. A TTKG calculated
[**10-12**] was 10.33, which was inconsistent with the measured
hypokalemia and suggestive of renal losses. The patient's
potassium will need close monitoring and repletion. She is at
risk to develop renal failure due to cumulative gent dosing, her
renal function should be monitored closely for this reason and
to prevent developmement of hyperkalemia in face of aggressive
repletion. On discharge she was ordered for 60 mEq of potassium
[**Hospital1 **] but this dose will likely need to be adjusted and would
recommend [**Hospital1 **]-TID potassium monitoring.
.
#) ENT - ENT service was consulted when pt developed partial
vocal cord paralysis after extubation and trach decannulation
seen by laryngoscope. It is hoped that this may resolve as pt
recovers. The ENT team recommends [**Hospital1 **] PPI to prevent any GERD
associated laryngeal edema complicating her recovery and follow
up with their service in [**12-22**] months.
.
#) FEN: When the patient was unresponsive, a PEG tube was
placed, and she was receiving tube feeds on transfer to the
floor. These feeds were continued. When the patient had a
swallow study on [**2124-10-6**], there was concern for aspiration, so
a video swallow study was scheduled for [**2124-10-9**]. These results
are listed above. At this time, she was cleared to take ground
solids, and thin liquids with a chin tuck. Her tube feeds were
continued, as she was taking in only a relatively small amount
PO. At time of discharge nutrition services were obtaining
calorie counts to assess possibility of PEG removal. Pt is
profoundly malnourished perhaps in part due to her personal
dietary choices of an organic diet which has limited her
voluntary PO in-hospital intake.
.
On day of discharge [**Known firstname 12705**] vital signs are stable, she has
no oxygen requirement. Her dense right sided hemiplegia has
improved markedly since presentation and she is now able to move
and grip with her right hand and wiggle her toes. She is alert
and oriented x 3. She does have some persistent attention
deficits and difficulty with complex tasks (see neurology
consult note for full details of current functional neurologic
status).
Medications on Admission:
Potassium, Imuran 50 mg daily, Ursodiol, Prednisone 10 mg (being
tapered). Dosages unavailable.
"Naturopath" supplements started in [**2124-7-21**]:
(from the D'Adamo Institute)
Formula O, B6-B2, B12-B2, Folic Acid, C, Iron, Selenium, Liver,
cod liver oil, NAC, Bonerneal/Support, Pancreas, Chromium, Zinc,
Magnesium & Zinc, Adrenal, Potassium, Whey Protein Powder,
Psyllium Seed Blend, Stractan, Flax seed oil, Kidney herbal tea,
Liver disease/cc/stomac 601, licorice solid extract, Bronchial
drops, boswellia.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Year (4 digits) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Acetaminophen 160 mg/5 mL Solution [**Year (4 digits) **]: [**10-9**] mL PO Q6H
(every 6 hours) as needed: Do not exceed 4 g Acetaminophen
daily.
3. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Docusate Sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: Ten (10) mL PO BID (2
times a day).
5. Levetiracetam 100 mg/mL Solution [**Month/Year (2) **]: 1500 (1500) mg PO BID
(2 times a day).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Year (2) **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
7. Folic Acid 1 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY (Daily).
8. Ursodiol 250 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO BID (2 times a
day).
9. Guaifenesin 100 mg/5 mL Syrup [**Month/Year (2) **]: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day): give 30 min
before breakfast and dinner.
11. Cyanocobalamin 100 mcg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY
(Daily).
12. Lorazepam 2 mg/mL Syringe [**Last Name (STitle) **]: One (1) mg Injection PRN (as
needed) as needed for seizure activity: to be administered prn
seizure activity up to 4 mg over 15 minutes.
13. Sodium Chloride 0.9 % 0.9 % Syringe [**Last Name (STitle) **]: Three (3) ML
Injection PRN (as needed) as needed for line flush: Flush every
8 hours and prn.
14. Ampicillin Sodium 2 gram Recon Soln [**Last Name (STitle) **]: Two (2) gram Recon
Soln Injection Q4H (every 4 hours): day 1 = [**9-17**].
15. Gentamicin 40 mg/mL Solution [**Month/Year (2) **]: 200 mg Injection Q18H
(every 18 hours): overall day 1 = [**9-17**], 160 q 12h [**10-3**], then
200 q12h, then 200 mg q 18 hrs [**10-12**].
16. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Year (2) **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: Flush with
10 mL NS followed by Heparin as above daily and prn per lumen.
17. Potassium Chloride 20 mEq Packet [**Month/Year (2) **]: Sixty (60) mEq PO
twice a day: This dose will need to be adjusted according to
twice daily potassium checks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 80502**] Hospital
Discharge Diagnosis:
Primary:
Listeria Brain Abscess and Cerebritis
Pancytopenia
Seizures
Secondary:
Autoimmune Hepatitis
Discharge Condition:
Fair, tolerating ground diet and thin liquids with chin tuck,
transferring to chair with lift.
Discharge Instructions:
You were admitted to the hospital after a seizure. You had a
head CT and lumbar puncture which showed that you had an
infection around your brain. The neurosurgery team decided that
you did not need surgery. You were started on IV antibiotics,
which have continued for several weeks. You had a breathing
tube, and also a tracheostomy placed to help you breathe. You
also were unable to eat, and had a tube placed into your stomach
to give you food. You were very ill and stayed in the ICU, but
eventually recovered to the point were you could be transferred
to the medical floor.
.
Take your medications as prescribed. It is important that
continue treatment with Ampicillin and Gentamicin as prescribed.
They need to be continued for at least 6 weeks (Day 1 [**2124-9-16**],
6 wks on [**2124-10-28**]). You will need to have an MRI of your brain
performed prior to stopping antibiotics to ensure that your
infection has been appropriately treated. Whether or not to stop
these antibiotics should be discussed with your new Infectious
disease doctor once you have set up follow up.
.
Please call your doctor or return to the ED for any of the
following:
- Seizures
- Changes in strength, sensation, or mental status
- Fever/chills
- Shortness of breath or coughing up blood
- Black or bloody bowel movements
- Any other new or concerning symptoms
Followup Instructions:
Please call your Primary Care Doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow up
appointment.
.
You will need to be followed by an infectious disease doctor as
well as a Neurologist. Please call your Primary Care Doctor to
help [**Last Name (Titles) **] appointments with a new Neurologist and Infectious
Disease specialist. Your PCP or new Infectious disease doctor
can call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**] to discuss the case at
[**Telephone/Fax (1) 457**] if there are any questions.
.
Please follow up with your regular liver doctor.
.
You should discuss with your Primary doctor about having flow
cytometry checked in [**12-22**] months if it is felt to be clinically
indicated given your low blood counts. This may also need to be
discussed with a Hematologist.
.
Please set up a new patient visit with an ENT doctor [**First Name (Titles) **] [**Last Name (Titles) 4656**]
your vocal cord dysfunction if your voice does not improve.
ICD9 Codes: 2760 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8351
} | Medical Text: Admission Date: [**2132-1-21**] Discharge Date: [**2132-2-7**]
Date of Birth: [**2080-12-23**] Sex: M
Service: [**Last Name (un) **]
REASON FOR ADMISSION: The patient is admitted for a
potential liver transplant.
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old
male with HIV diagnosed in [**2115**] with advanced HCC who was
recently evaluated for a hepatic mass. He was status post
chemoembolization of hepatic mass at [**Hospital1 2177**] in the setting of
elevated AFP. CT scans have shown hepatic mass with question
of thrombus in adjacent hepatic vein. CT-guided biopsy of the
involved area did not show tumor. Repeat CT in [**2131-11-18**]
was unchanged. He was subsequently listed for liver
transplant for advanced liver cirrhosis and unresectable HCC.
PAST MEDICAL HISTORY: HIV, well controlled, undetectable
viral load. On [**2131-12-19**], CD4 count was 245. HCV was
diagnosed 5-6 years ago. History of upper GI bleed,
hypertension, hypercholesterolemia, polysubstance abuse,
sober since [**2128**]. History of CVA in [**2129-8-17**] with
residual right leg weakness. DVT. Per report, able to walk 1-
2 blocks prior to claudication.
MEDICATIONS ON ADMISSION: Pravachol 10 mg daily, Diovan 40
mg daily, aspirin 81 mg daily, Reyataz 300 mg daily, Pletal
150 mg b.i.d., Viread 300 mg daily, Pepcid 20 mg daily,
cilostazol 50 mg daily, thalidomide 50 mg q.h.s., Videx 250
mg daily, vitamin E 400 international units daily, vitamin C
and multivitamins.
ALLERGIES: Lisinopril with which the patient gets mouth and
lip swelling.
SOCIAL HISTORY: He lives alone, no children. He smokes half
a pack per day. No alcohol since [**2128**]. No IV drug use since
[**2115**].
REVIEW OF SYSTEMS: He denies recent infections including
fevers, chills, rigors. He denies a change in bowel function.
No change in urinary symptoms. He denies headaches, visual
changes. He reports right leg weakness which is baseline. He
denies chest pain shortness of breath. Recent echocardiogram
in [**2131-7-19**] demonstrated ejection fraction of greater
than 60%, no ventricular septal defects, mild pulmonary
artery systolic hypertension.
EXAMINATION: General: The patient is comfortable in no acute
distress. HEENT anicteric. No nystagmus. Mucosa are clear, no
lesions,. No lymphadenopathy. Lungs are clear to auscultation
bilaterally, no CVA tenderness. CV is regular rate and
rhythm, normal S1 and S2 without murmurs, rubs or gallops.
Abdomen is soft, nontender and nondistended, no organomegaly.
Extremities - no C/C/E, no calf tenderness. Pulses are 2+ AT
and dorsalis pedis. Neuro exam - cranial nerves II through
XII are intact. Upper extremities are [**3-21**] throughout
bilaterally. Right lower extremity is [**1-20**] proximally. No
deficits in the left lower extremity.
LABORATORY DATA: On admission, his labs were the following:
WBC of 4.1, hematocrit 33.8, platelets 145, sodium 137, 3.3,
105, 23, BUN and creatinine of 16 and 1.6, glucose 90. AST
was 118 and ALT 72. Alkaline phosphatase was 229. Total
bilirubin is 1.5. INR is 1.5.
HOSPITAL COURSE: The patient went to the OR on [**2132-1-21**]
in which the patient had a cadaveric liver transplant,
piggyback, portal vein to portal vein anastomosis, common
hepatic artery to common hepatic artery, QDA branch patch,
bile duct to bile duct performed by Doctors [**Last Name (Titles) 816**], [**Name5 (PTitle) **] and
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3446**]. Please see operative note for more details
of the surgery. The patient had 2 [**Doctor Last Name 406**] drains placed to the
right quadrant area, one underneath the right lobe of the
liver and one underneath the liver hilum. The drains were
secured to skin with nylon sutures. The skin was closed with
staples. The patient was transferred, still intubated, to the
intensive care unit in stable condition. The patient was kept
intubated, placed on insulin, Unasyn, ganciclovir, heparin,
MMF and Solu-Medrol 500 IV x1. Ultrasound was performed the
same day demonstrating unremarkable duplex Doppler ultrasound
of the transplanted liver. The patient had a chest x-ray
status post liver transplant for NG tube placement which
demonstrated moderate layering right pulmonary effusion and a
small left pleural effusion. There was a left lower lobe
atelectasis/consolidation.
On the following day, the patient had another ultrasound with
confirmed vascular flow which demonstrated a 13.7 x 7 x 11 cm
subhepatic hematoma, moderate ascites, patent hepatic
vasculature, no evidence of hydronephrosis. The patient was
extubated on postop day 1. LFTs on [**2132-1-22**] were the
following: AST 1324, ALT 566, alkaline phosphatase 126. The
patient was on a Lasix drip. The patient was waiting for
clears. HIV medications were held and subcutaneous heparin
was restarted. It was noted on the chest x-ray on [**2132-1-26**] that the patient had a new right lower lobe infiltrate,
most likely representing pneumonia. In the appropriate
clinical setting, could also represent aspiration or
pulmonary hemorrhage. The patient was started on caspo, levo
and the patient was reintubated for a gas of 7.45, 28, 60, 18
and -4. Dobbhoff was placed for tube feeds. The patient's
antibiotics were changed to Zosyn and vancomycin. Renal and
ID were consulted. On [**2132-1-26**], a bronchoscopy was
performed in the ICU for a presumed diagnosis of pneumonia.
The patient continued to be intubated, sedated with propofol,
p.r.n. morphine, treated for right pneumonia. The patient
continued on tube feeds. Caspo and levofloxacin were started.
The patient extubated on [**2132-1-28**]. The bronchial
washings on [**2132-1-26**] demonstrated that the Gram stain
showed 1+ polymorphonuclear leukocytes, no microorganisms
seen. Respiratory culture was negative with no growth.
Legionella culture was not isolated. Fungus culture was not
isolated. There was no acid-fast bacilli seen on direct smear
nor concentrated smear. Viral culture for cytomegalovirus is
pending. The patient was seen by physical therapy who felt
that the patient would be an excellent candidate for rehab.
On [**2132-1-30**], the patient had the following labs: WBC of
15.1, hematocrit of 36.6, platelets 222, sodium 146, 3.7,
111, 21, BUN and creatinine of 69 and 2.9, glucose 106. AST
was 35, ALT 63, alkaline phosphatase 101, total bilirubin of
4.0. The patient had an AFP of 711. On [**2132-1-30**], the
patient had an ERCP demonstrating that there was a normal
distal pancreatic duct. The cholangiogram revealed a non-
dilated native and donor bile duct. A bile leak was seen at
the level of the anastomosis. The intrahepatic ducts appeared
normal. A 10-French 8 cm Cotton-[**Doctor Last Name **] biliary stent was
placed successfully across the anastomosis into the donor
bile duct and bile was seen draining into the duodenum.
On [**2132-2-1**], the patient returned to the OR for re-
exploration after liver transplant, abdominal washout, Roux-
en-Y hepaticojejunostomy and a wedge biopsy of the liver
performed by Doctors [**Last Name (Titles) **], [**Name5 (PTitle) 816**] and [**Name5 (PTitle) **]. Please see
operative note for more details of the procedure. Of note,
the old JP drains were removed and two fresh [**Doctor Last Name 406**] drains
were placed, one directly underneath the right lobe of the
liver and the other below the biliary anastomosis. The
patient was transferred still intubated to the postop
recovery area. The patient was seen on [**2132-1-31**] by
neurology because of residual right leg weakness and
difficulty with ambulation. They felt that his weakness could
be mechanical due to irritation from pneumo boots. However,
he does have significant weakness in his distal right leg and
they felt that because of the liver transplant, it is
possible to have worsening of old deficits like his residual
stroke. There were no other recommendations per neurology and
they had signed off from the consult. On [**2132-2-6**], the
patient had a routine postop cholangiogram demonstrating
patent hepaticojejunostomy and anastomosis with normal
appearance of the hepatic ducts. There was no extravasation
of the contrast. The patient had continued with TPN post-
surgery from [**2132-2-1**].
On [**2132-2-6**], the patient was introduced to clears,
tolerated it well, and was advanced to a regular diet. So,
post-cholangiogram procedure, the T-tube was capped. On [**2132-2-5**], the patient continued his vanco, Zosyn, caspo and
levo. The patient was on MMF 1000, prednisone 20 mg daily and
tacrolimus 0.5 and hold for a level of 3.6. The patient was
afebrile and vital signs were stable, good I's and O's, JP
drains medial put out 15 and lateral put out 50. Labs on
[**2132-2-5**] were the following: The patient had a WBC of
13.8, 30.6, 276, sodium 142, 3.4, 112, 19, BUN and creatinine
65 and 3.1, glucose 127. AST was 30, alkaline phosphatase 84,
ALT 34, total bilirubin 1.2 and INR 1.1. On [**2132-2-7**],
hospital day 18, continued on vancomycin, Zosyn,
levofloxacin, fluconazole, MMF, prednisone. The patient is
afebrile and vital signs are stable. The T-tube is capped.
The patient is awake and alert. Lungs are clear to
auscultation bilaterally. CVA - regular rate and rhythm.
Abdomen - well-healed incision, distended. Extremities - the
patient had +3 edema bilaterally in lower extremities. Lasix
was increased from 20 b.i.d. to 20 t.i.d. The patient was
placed on a regular diet. Labs on [**2132-2-7**] were the
following: WBC of 19.9, hematocrit of 32.6, platelets 397,
sodium 142, 3.2, 109, 19, BUN and creatinine 61 and 2.7 with
a glucose of 207. ALT was 33, AST 28, alkaline phosphatase
97, total bilirubin 1.1 and albumin 2.4.
So, the patient is potentially going to rehab to [**Hospital1 **] on
the following medications: albuterol nebs, 1 neb q.4 hours
p.r.n., didanosine chewable 125 mg daily, Anzemet 12.5 IV q.8
hours p.r.n., fluconazole 200 mg q.24, Lasix 40 mg IV t.i.d.,
Valcyte 450 mg every other day, heparin 5000 units
subcutaneously b.i.d., insulin sliding scale, levofloxacin
250 p.o. q.48 hours p.r.n., lopinavir-ritonavir 2 tablets
p.o. b.i.d., Percocet 1-2 tablets q.4-6 hours p.r.n., MMF
1000 mg p.o. b.i.d., nystatin oral suspension 5 ml q.i.d.,
Protonix 20 mg daily, Bactrim SS one tablet 3 times a week,
tacrolimus potentially should be 0.5 b.i.d., tenofovir 300 mg
b.i.d. on Sunday, Wednesday. The patient is to follow up with
Dr. [**Last Name (STitle) **] on the following dates: [**2132-2-14**] at 11:20
a.m., [**2132-2-21**] at 10 a.m., [**2132-2-28**] at 11:40 a.m.
The patient is to call transplant surgery immediately at [**Telephone/Fax (1) 28347**] if any fevers, chills, nausea, vomiting, abdominal
pain. Also, if the patient is not able to drink or eat or
having difficulty with urination. The patient should also
call if there is any increased redness to incision, any
discharge or any edema from the incision. The patient should
have labs every Monday and Thursday in which a CBC, Chem-10,
AST, ALT, alkaline phosphatase, albumin, total bilirubin and
Prograf level to be drawn. The patient has been eating well,
urinating without difficulty, and also using the commode and
getting out of bed with physical therapy. So, the patient is
ready to go to rehab.
FINAL DIAGNOSIS: A 51-year-old male with HIV/HCV, cirrhosis,
end-stage liver disease with HCC status post liver transplant
on [**2132-1-21**].
SECONDARY DIAGNOSIS: Biliary leak, biliary aspiration, right
infiltrate seen on the x-rays, treated for pneumonia.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2132-2-7**] 09:18:22
T: [**2132-2-7**] 11:18:04
Job#: [**Job Number 97502**]
ICD9 Codes: 486, 5845, 0389, 3051, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8352
} | Medical Text: Admission Date: [**2115-7-24**] Discharge Date: [**2115-8-3**]
Date of Birth: [**2061-12-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Latex
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea and chest pain
Major Surgical or Invasive Procedure:
[**7-29**] s/p Coronary Artery Bypass Graft x 2 (Lima->LAD/SVG-> OM)
History of Present Illness:
53 yo M with history of VF arrest while working out at gym [**1-12**]
and is s/p LAD PCI. He presented with dyspnea and new chest
pain. Had a +ETT and was taken urgently to the cath lab. He was
found to have 2VD and he was referred for surgery.
Past Medical History:
Coronary Artery Disease w/ VFib arrest [**1-12**]->PCI to LAD,
Diverticulitis, Hypertension, Hyperlipidemia
PSH: s/p Hip replacement x2, s/p Appendectomy, s/p Right knee
surgery x 2, Left knee surgery, Tonsillectomy
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. He works as a
custodian and is married with children. He denies any IVDU.
Family History:
His mother and several maternal uncles had cardiac disease in
their 50-60s. His mother died suddenly on vacation in her early
50s.
Physical Exam:
Admission:
HR 76 RR 18 BP 178/99
Gen: NAD
HEENT: EOMI, PERRL, NCAT
Neck: Supple, FROM, -JVD
Lungs: CTAB -c/r/m/g
Heart: RRR -w/r/r
Abd: NT/ND +BS
Ext: Warm, well-perfused, no edema, 2+pp
Neuro: A&O x 3, MAE, non-focal
Discharge:
VS: T: 98.6 HR: 70's SR BP: 98-112/50-70 Sats: 96% RA
General: NAD
Cardiac: RRR normal S1,S2 no murmur/gallop or rub
Resp: Decreased breath sounds otherwise clear
GI: bowel sounds positive, abdomen soft non-tender/non-distended
Extre: warm no edema
Wound: sternal & left lower extremity c/d/i no erythema
Neuro: non-focal
Pertinent Results:
[**2115-7-24**] WBC-5.1 RBC-4.95 Hgb-15.0 Hct-44.4 MCV-90 MCH-30.3
MCHC-33.8 RDW-13.1 Plt Ct-255
[**2115-7-31**] WBC-8.4 RBC-3.24* Hgb-10.0* Hct-28.5* MCV-88 MCH-30.9
MCHC-35.1* RDW-12.6 Plt Ct-175
[**2115-7-24**] PT-12.9 PTT-26.6 INR(PT)-1.1
[**2115-7-29**] PT-13.9* PTT-35.5* INR(PT)-1.2*
[**2115-7-24**] Glucose-86 UreaN-13 Creat-1.1 Na-142 K-3.9 Cl-102
HCO3-28 AnGap-16
[**2115-7-31**] Glucose-107* UreaN-16 Creat-0.9 Na-136 K-4.2 Cl-97
HCO3-33* AnGap-10
[**2115-8-1**] BLOOD UreaN-19 Creat-0.8 K-3.9
[**7-24**] Cath: 1. Selective coronary angiography of this right
dominant system revealed 2 vessel coronary artery disease. The
LMCA was very short with an approximately 50% narrowing. The
LAD had an ostial 80% stenosis. The mid-LAD was widely patent in
the region of the previously placed stent with a tubular segment
of disease to 50% distally. The LCx and RCA had minimal
disease. 2. Resting hemodynamics revealed normal systemic
systolic and diastolic arterial blood pressures with SBP 130
mmHg and DBP 85 mmHg.
[**7-24**] CARDIAC PERFUSION: 1. Reversible, large, severe perfusion
defect involving the LAD territory. 2. Transient cavity
dilation, consistent with mulit-vessel, left main, or proximal
LAD disease. 3. Mild systolic dysfunction with apical akinesis,
consistent with stunning. Compared with the study of [**2115-3-7**],
the findings are new.
[**7-25**] Vein mapping: 1. Focal areas of non-compressibility,
suggestive of chronic thrombosis in the right greater saphenous
vein at the level of the knee and in the left greater saphenous
vein, at the level of the saphenofemoral junction. 2. Patent
bilateral lesser saphenous veins.
[**7-25**] Carotid U/S: There is less than 40% stenosis within the
internal carotid arteries bilaterally.
[**7-29**] Echo: PRE CPB No spontaneous echo contrast or thrombus is
seen in the body of the left atrium/left atrial appendage or the
body of the right atrium/right atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
top normal/borderline dilated. There is mild to moderate
regional left ventricular systolic dysfunction with moderate
hypokinesis of the mid distal anterior, mid-distal septal,
distal anterolateral, and apical segments. The right ventricle
displays borderline normal free wall function. There are simple
atheroma in the ascending aorta. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There may be a redundant chord intermittently
seen billowing into the left atrium. Physiologic mitral
regurgitation is seen (within normal limits). There is a
trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was
notified in person of the results in the operating room at the
time of the study. POST CPB Low normal right ventricular
systolic function. Initially, after separating from CPB, there
was very severe hypokinesis of the mid to distal septal,
anterior, anterolateral walls and apical segment, bordering on
akinesis. The ejection fraction approximated 25%. About 10
minutes after CPB, these same segments showed much improved
function to the point where there was only very mild
hypokinesis. Ejection fraction improved to 45-50%. Valvular
function remained unchanged from the pre-CPB study. The thoracic
aorta appeared intact.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 99926**] (Complete)
Done [**2115-7-29**] at 3:42:48 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2061-12-7**]
Age (years): 53 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 440.0
Test Information
Date/Time: [**2115-7-29**] at 15:42 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW2-: Machine: AW1
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 35% to 40% >= 55%
Aorta - Sinus Level: *3.8 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.1 cm <= 3.0 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm
Aortic Valve - LVOT diam: 2.3 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. All
four pulmonary veins identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast or
thrombus in the body of the RA or RAA. A catheter or pacing wire
is seen in the RA and extending into the RV. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Top
normal/borderline dilated LV cavity size. Mild-moderate regional
LV systolic dysfunction.
RIGHT VENTRICLE: Borderline normal RV systolic function.
AORTA: Focal calcifications in aortic root. Normal ascending
aorta diameter. Simple atheroma in ascending aorta. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. Mild
mitral annular calcification. No MS. Physiologic MR (within
normal limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE CPB No spontaneous echo contrast or thrombus is seen in the
body of the left atrium/left atrial appendage or the body of the
right atrium/right atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is top
normal/borderline dilated. There is mild to moderate regional
left ventricular systolic dysfunction with moderate hypokinesis
of the mid distal anterior, mid-distal septal, distal
anterolateral, and apical segments. The right ventricle displays
borderline normal free wall function. There are simple atheroma
in the ascending aorta. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There may be a redundant chord intermittently seen billowing
into the left atrium. Physiologic mitral regurgitation is seen
(within normal limits). There is a trivial/physiologic
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results in the operating room at the time of the study.
POST CPB Low normal right ventricular systolic function.
Initially, after separating from CPB, there was very severe
hypokinesis of the mid to distal septal, anterior, anterolateral
walls and apical segment, bordering on akinesis. The ejection
fraction approximated 25%. About 10 minutes after CPB, these
same segments showed much improved function to the point where
there was only very mild hypokinesis. Ejection fraction improved
to 45-50%. Valvular function remained unchanged from the pre-CPB
study. The thoracic aorta appeared intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2115-7-29**] 16:01
Brief Hospital Course:
He was admitted to cardiology. He underwent preoperative work up
and awaited Plavix washout before going to the operating room.
On [**7-29**] he was brought to the operating room where he underwent
a coronary artery bypass graft x 2. Please see operative report
for surgical details, in summary he had CABG x2 with LIMA-LAD
and SVG-OM. Following surgery he was transferred to the CVICU
for invasive monitoring in stable condition. He did well in the
immediate post-op period, was weaned from sedation, awoke
neurologically intact and extubated. On post-op day one he was
started on beta blockers and diuretics and gently diuresed
towards his pre-op weight. Later on this day he was transferred
to the telemetry floor. Chest tubes and epicardial pacing wires
were removed per protocol. He worked with physical therapy while
recovering his strength and mobility. On post-op day 5 he
appeared to be doing well and was discharged home with VNA and
the appropriate follow-up appointments.
Medications on Admission:
Atorvastatin 40, Plavix 75, Metoprolol 25(2), ASa 325,
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
6. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO twice a day.
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2
PMH: VFib arrest [**1-12**]->PCI to LAD, Diverticulitis,
Hypertension, Hyperlipidemia
PSH: s/p Hip replacement x2, s/p Appendectomy, s/p Right knee
surgery x 2, Left knee surgery, Tonsillectomy
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) 1312**] [**Last Name (NamePattern1) 31097**] [**Telephone/Fax (1) 15825**] 2 weeks
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2115-8-28**] 1:40
Dr. [**Last Name (STitle) **] 4 weeks, pt to call to schedule appt
Completed by:[**2115-8-3**]
ICD9 Codes: 4111, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8353
} | Medical Text: Admission Date: [**2159-9-15**] Discharge Date: [**2159-9-17**]
Date of Birth: [**2081-1-28**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
paracentesis
History of Present Illness:
78 M CAD, CHF EF (20%), on pred for gout, h/o leukocytosis to
24-50's, polycythemia, s/p repair of incarcerated RIH [**2159-9-10**]
presents with worsening abdominal pain x4 days. He describes
the pain as severe, crampy pain over his lower abdomen. He
denies having had a BM since Monday and believes his pain is a
result of constipation. He is not sure when he last passed
flatus. He denies nausea, vomiting, fevers or chills.
.
In ED, initial vitals were: T 97.8 R 65 BP 100/39 RR 18 SpO2 97%
RA. Incision c/d/i with surrounding erythema, tender over
incision and throughout abdomen. Patient was given Readi-Cat 2,
Fentanyl Citrate, MethylPREDNISolone Sodium Succ, Ciprofloxacin,
MetRONIDAZOLE, and IV bolus. ARF to 3.4 (baseline 1.9), 1500cc
of fluid, systolic Blood pressure 80-111. Prior to transfer
found to have T 98 HR 62, BP 93/55 RR 22 Sat 96% 4L. CXR showed
increased opacity in LLL.
.
On the floor, patient is stable in mild distress.
.
Review of systems:
(+) Per HPI
Past Medical History:
CAD, s/p CABG [**59**] years ago
Chronic systolic heart failure, EF 20%
Atrial fibrillation, on coumadin, s/p Pacer DDD
HTN
Hyperlipidemia
Chronic kidney disease, baseline creatinine 1.5-1.7
GERD
Chronic shoulder pain
Polycythemia [**Doctor First Name **]
Colonic polyps
Social History:
Lives at home with his daughter in [**Name (NI) 3146**], retired sheet metal
worker, Korean war veteran. Has smoked his entire life, and has
cut back to 4 cigarettes daily. No current ETOH or other drug
use. Daughter is in charge of his medications
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Vitals: T: 98 BP:92/43 P: 61 R: 18 O2: 98% on 5L
General: Alert, oriented, in mild distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, diffusely tender and distended, bowel sounds
present, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS
[**2159-9-14**] 01:00PM BLOOD WBC-53.5* RBC-5.00 Hgb-11.1* Hct-37.7*
MCV-75* MCH-22.1* MCHC-29.3* RDW-20.2* Plt Ct-900*
[**2159-9-14**] 01:00PM BLOOD Neuts-84* Bands-13* Lymphs-1* Monos-1*
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2159-9-14**] 01:00PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-3+
Macrocy-NORMAL Microcy-3+ Polychr-1+ Spheroc-1+ Ovalocy-3+
Schisto-1+ Tear Dr[**Last Name (STitle) **]1+
[**2159-9-14**] 01:00PM BLOOD Plt Smr-VERY HIGH Plt Ct-900*
[**2159-9-14**] 02:00PM BLOOD PT-18.3* PTT-38.2* INR(PT)-1.7*
[**2159-9-14**] 01:00PM BLOOD Glucose-100 UreaN-107* Creat-3.4*# Na-137
K-5.4* Cl-95* HCO3-27 AnGap-20
[**2159-9-14**] 01:00PM BLOOD ALT-5 AST-18 AlkPhos-181* TotBili-1.2
[**2159-9-14**] 01:00PM BLOOD Lipase-43
DISCHARGE LABS
[**2159-9-16**] 04:29AM BLOOD WBC-53.6* RBC-4.93 Hgb-10.9* Hct-37.4*
MCV-76* MCH-22.2* MCHC-29.2* RDW-20.1* Plt Ct-946*
[**2159-9-16**] 04:29AM BLOOD Neuts-94* Bands-4 Lymphs-0 Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2159-9-16**] 04:29AM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-2+
Macrocy-NORMAL Microcy-3+ Polychr-OCCASIONAL Spheroc-1+
Ovalocy-2+ Target-OCCASIONAL Schisto-1+ Burr-1+ Tear Dr[**Last Name (STitle) **]2+
Acantho-OCCASIONAL Ellipto-2+
[**2159-9-16**] 04:29AM BLOOD Plt Smr-VERY HIGH Plt Ct-946*
[**2159-9-16**] 04:29AM BLOOD PT-18.5* PTT-35.2* INR(PT)-1.7*
[**2159-9-16**] 04:29AM BLOOD Fibrino-623*
[**2159-9-16**] 09:50AM BLOOD Na-135 K-5.5* Cl-99
[**2159-9-16**] 04:29AM BLOOD Glucose-92 UreaN-114* Creat-3.8* Na-135
K-6.0* Cl-99 HCO3-19* AnGap-23*
[**2159-9-16**] 04:29AM BLOOD ALT-8 AST-17 LD(LDH)-288* AlkPhos-141*
TotBili-1.0
[**2159-9-16**] 04:29AM BLOOD Albumin-3.0* Calcium-7.9* Phos-7.6*
Mg-2.1 UricAcd-11.7*
[**2159-9-16**] 04:29AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2159-9-16**] 04:29AM BLOOD Vanco-11.5
[**2159-9-16**] 09:54AM BLOOD Lactate-2.2*
[**2159-9-16**] 05:20AM BLOOD Type-[**Last Name (un) **] Comment-GREEN TOP
LABS FROM PARACENTESIS
[**2159-9-15**] 08:50PM ASCITES WBC-[**Numeric Identifier 11039**]* RBC-2300* Polys-92*
Lymphs-1* Monos-6* Eos-1*
[**2159-9-15**] 08:50PM ASCITES TotPro-2.6 Glucose-67 LD(LDH)-2086
Amylase-40 TotBili-0.6 Albumin-1.7
CT Scan
1. 25 x 32 mm gas/fluid collection subjacent to the hernia
repair site. Correlate with surgical implants in this region.
Abscess cannot be excluded.
2. Seroma with air overlying the hernia repair site. There more
air than expected at POD 4. An infectious process in this region
cannot be excluded. There appears to be a small fascial defect
underneath this seroma.
3. Small foci of air within the right inguinal canal.
4. Large amount of intra-abdominal and intra-pelvic ascites.
5. Mild fecalization within the distal small bowel. no evidence
of obstruction.
6. Mild pneumomediastinum may reflect post-surgical changes,
however, this much air is unusual given the type of repair.
Brief Hospital Course:
# Abdominal Pain/Infection: Significant concern for surgical
site infection given CT scan findings and temporal onset of
pain. Pt also had declined surgery as an option. A
paracentesis was done which was consistent with an SBP (organism
grown was enterococcus). He continued to have significant
abdominal distension and tenderness most severe in lower abdomen
near surgical wound. The patient also had
2 of 2 Blood Cultures for the ED + Gram Negative Rods. The
patient's pain was kept under control with Morphine gtt 4 mg/hr
with frequent pain reassessment. When the patient was changed
to CMO status, morphine and scopolamine were used for symptom
control and comfort measures.
.
# Hypotension: Concerning for septic shock in the setting of GNR
bacteremia. Minimal improvement to fluid boluses. These were
stopped when the patient was made comfort measures only (CMO).
.
# Hypoxemia: New O2 requirement, CXR in ED showed increased
opacity in the left lung fields. Now with aggressive fluid
repletion, likely [**3-20**] to pulmonary edema. This intervention was
also stopped [**3-20**] CMO status.
.
# Acute on Chronic Renal Failure: Baseline around 1.7 Likely due
to relative hypoperfusion in the setting of sepsis. Oliguric an
d hyperkalemic. FeNa <1%. Work up and treatment stopped [**3-20**] CMO
status.
.
# Leukocytosis with bandemia: slightly increased from prior,
with bandemia. Peritoneal fluid growing out enterococcus. Labs
were stopped [**3-20**] CMO status.
Medications on Admission:
1. Torsemide 100 mg Tablet PO once a day.
2. Metolazone 2.5 mg Tablet PO q M,W,F.
3. Aspirin 81 mg Tablet, Chewable PO DAILY.
4. Multivitamin PO DAILY.
5. Simvastatin 40 mg Tablet PO DAILY.
6. Sodium Bicarbonate 650 mg PO BID.
7. Calcitriol 0.25 mcg Capsule PO QTUTHUR.
8. Omeprazole 20 mg PO DAILY.
9. Allopurinol 100 mg PO EVERY OTHER DAY.
10. Sevelamer Carbonate 1600 mg Tablet PO TID W/MEALS .
11. Prednisone 5 mg Tablet PO DAILY
12. Levothyroxine 25 mcg Tablet PO DAILY
13. Metoprolol Succinate 200 mg SR PO once a day.
14. Warfarin 2.5 mg PO q Sun/Tue/Thurs/Sat.
15. Warfarin 5 mg PO q Mon/Wed/Fri.
16. Docusate Sodium 100 mg PO BID PRN constipation.
17. Senna 8.6 mg Tablet PO twice a day as needed for
constipation.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
not applicable, patient deceased
Followup Instructions:
not applicable, patient deceased
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2159-9-18**]
ICD9 Codes: 5845, 2762, 5715, 4280, 2767, 2724, 2749, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8354
} | Medical Text: Admission Date: [**2114-1-25**] Discharge Date: [**2114-2-3**]
Date of Birth: [**2036-5-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
77M with hx of COPD, recent admit for COPD flare, ARF (d/c
[**1-20**]), afib, CHF sent to ED from [**Hospital1 1501**] with severe shortness of
breath and desaturation to 86%. Pt states that this am, he woke
up and was feeling well. He got up to go the bathroom but needed
to take his oxygen off because it would not reach. When he got
back from the bathroom, he was severely short of breath. He put
his oxygen back on but it did not help. He states that he could
hear himself wheezing. Later, he again got up to go to the
bathroom and had to take off his O2. Once again, he became
severely short of breath. This time, he sat in his chair because
that makes his breathing better but his O2 does not reach to the
chair. He felt very short of breath and [**Doctor Last Name **] for his nurse. His
O2 sat was checked and found to be 86% on RA. Nursing home notes
state that pt has been coughing up blood tinged sputum. pt
states he has a chronic cough productive of dark brown sputum.
Her cannot walk more than 3 feet without stopping to rest. He
denies chest pain, palpitations.
.
In ED, CXR showed RUL pneumonia and pt was given levaquin and
nebs.
Past Medical History:
* COPD: no PFTs on record, on home O2 3L/m for past 2 weeks
* Interstitial lung disease
* atrial fibrillation (formerly on coumadin; stopped during last
admission)
* CHF: last echo [**12-31**] with LVEF >55%, 2+ MR, 3+ TR, mild AV
stenosis, severe pulm art HTN
* severe pulm art HTN by echo
* DM type II
* CRI: baseline creat 1.6
* BPH
* known bladder mass since [**2108**]
* ? lung mass
* anemia
Social History:
lives with his wife in a 2 story house but is now at a [**Hospital1 1501**] since
recent hospitalization; smoked 150 pack-years, quit 7 years ago;
formerly worked in a battery factory and may have been exposed
to hazardous chemicals during this time; has a h/o asbestos
exposure; no alcohol or illicit drug use. One daughter lives
down the street.
Family History:
Father with CAD.
Physical Exam:
temp 98.2, BP 130/60, HR 102, R 20, O2 94% 4L; wt 187lbs
Gen: NAD, pleasant; moderate resp distress after moving about in
bed; AO x 2
HEENT: EOMI, MMM; +accessory muscle use with resp distress
Neck: no JVD, no bruit
CV: tachy, irreg irreg; difficult to ascultate heart sounds due
to breath sounds; no murmurs detected
Chest: diffuse exp wheezes with prolonged exp phase; crackles at
bilateral bases
Abd: +BS, soft, mildly distended, nontendner; multiple bruises
Ext: venous stasis skin changes; 2+ DP
Skin: multiple abrasions on arms, abdomen, lower ext; on LLE,
4cm area of raw skin; on RLE, 3cm area of raw skin; on top of
right foot, large area of raw skin, tender
Pertinent Results:
[**2114-1-25**] 02:28PM URINE RBC-0-2 WBC-0 BACTERIA-RARE YEAST-FEW
EPI-0
[**2114-1-25**] 02:28PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2114-1-25**] 02:28PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2114-1-25**] 04:05PM PLT COUNT-278
[**2114-1-25**] 04:05PM NEUTS-83* BANDS-2 LYMPHS-3* MONOS-9 EOS-3
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-2*
[**2114-1-25**] 04:05PM WBC-16.5*# RBC-3.14* HGB-9.3* HCT-27.5*
MCV-88 MCH-29.8 MCHC-33.9 RDW-18.6*
[**2114-1-25**] 04:05PM CK-MB-4 cTropnT-0.05* proBNP-969*
[**2114-1-25**] 04:05PM CK(CPK)-144
[**2114-1-25**] 04:05PM GLUCOSE-165* UREA N-45* CREAT-1.5* SODIUM-138
POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-29 ANION GAP-16
[**2114-1-25**] 05:05PM LACTATE-1.2
.
Micro:
- BCX ([**2114-1-25**]) 4/4 bottles No Growth (final)
- Sputum cx ([**2114-1-27**]) contaminated with resp secretions
- Urine legionella Ag negative (final)
.
CXR ([**2114-1-30**]): There is no significant interval change in
multifocal patchy opacities bilaterally since multiple prior
exams, including chest CT dated [**2114-1-26**]. The pulmonary
vasculature is normal. There is no pneumothorax. Tiny
bilateral pleural effusions are slightly smaller than one day
earlier. The cardiac silhouette, mediastinal and hilar contours
are stable. The surrounding soft tissue and osseous structures
are unremarkable.
.
[**2114-1-26**] CT-chest w/o contrast.
IMPRESSION:
1. Poorly defined patchy and nodular airspace opacities seen
bilaterally suggesting multifocal pneumonia. Followup imaging
following treatment to document resolution is recommended.
2. Small bilateral pleural effusions, right greater than left.
3. Pleural calcifications bilaterally, suggesting prior asbestos
exposure.
4. Diffuse coronary artery calcifications and atherosclerotic
calcifications noted within the aorta.
.
ECHO [**2114-1-16**]:
The left and right atria are moderately dilated. The estimated
right atrial pressure is 16-20 mmHg. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal. The
right ventricular cavity is dilated. Right ventricular systolic
function is normal. There are three aortic valve leaflets. The
aortic valve leaflets are moderately thickened. There is mild
aortic valve stenosis (area 1.2-1.9cm2). No aortic regurgitation
is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. The
mitral regurgitation jet is eccentric. Moderate to severe [3+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension.
.
EKG ([**2114-1-29**]): afib at 87 bpm, LAD, flattened T waves in I,
borderline IVCD with left bundyloid pattern; flipped T waves in
avL; no ST changes; overall unchanged from prior tracing [**2114-1-28**].
Brief Hospital Course:
77-yo-man w/ COPD, afib, diastolic CHF, anemia, CKD, admitted
with PNA. He had recently been discharged [**2114-1-19**] after a COPD
exacerbation treated with steroids. He is status post MICU stay
for hypoxia/respiratory distress.
.
# Hypoxia/Resp distress: This was though to be multifactorial,
due to PNA, COPD, and diastolic CHF. His acute dyspnea that
resulted in ICU transfer was felt due to volume overload, and
improved after diuresis with IV lasix. He was diuresed with IV
lasix, treated with IV antibiotics (see below), and round the
clock nebulizers.
.
# PNA: This was multilobar, noted both on chest x-ray and
non-contrast CT scan of the chest. Blood cultures had no growth
(final). Initial sputum culture was contaminated and repeat
grew oropharyngeal flora (not speciated). Initially he was
placed on levofloxacin, with vancomycin added 24 hours later.
The pneumonia was complicated by CHF and COPD exacerbations, so
his progress was slow. After 6 days of levofloxacin and 5 days
of vancomycin, his coverage was broadened to Zosyn instead of
Levofloxacin for presumed nosocomial pneumonia, acquired at the
nursing home. Vanco was continued. He remains afebrile and
his WBC normalized. He should receive an additional 7 days of
Vancomycin and Zosyn. He should follow up with Dr. [**Last Name (STitle) **] (his
primary care physician) in [**12-26**] weeks.
.
# COPD: The patient has no PFTs on record, but he has had a
constant O2 requirement since his last discharge on [**1-19**] of 3L
nasal cannula. His COPD was likely exacerbated by his PNA.
He was continued on Advair and placed on a more extended
prednisone taper (he should begin 20mg x 7 days on [**2114-2-4**],
tapered to 10mg daily for 7 days, then to 5mg daily x 7 days,
then off). He should continue nebulizers, atrovent q6H and
albuterol q4H). Once his acute flair has improved, he should be
referred for outpatient PFTs.
.
# Atrial fibrillation: The patient was rate controlled on
diltiazem which was continued. Coumadin was stopped during his
last admission due to hematuria. He was continued on aspirin.
B-blocker was not given as not to exacerbate his COPD.
.
# DM type 2: The patient was diet controlled until his prior
hospitalization in [**Month (only) 404**]. Since he has been on steroids, he
has required insulin. His fingersticks should be checked four
times a day. He should receive 20 units of NPH insulin each
morning and at bedtime, along with a sliding scale. His doses
of insulin may need to be decreased as his steroids are tapered.
.
# CRI: This is likely from HTN and DM nephropathy. The patient
was at baseline (creat ~ 1.6). His medications were renally
dosed. He has an appointment with his nephrologist in [**Month (only) 958**] as
noted on the discharge paperwork.
.
# Anemia - This is a combination of blood loss and chronic
inflammation. His baseline HCT 26-28. He had hematuria (see
below) and received 4 units total of packed RBCs. His Hct was
stable post transfusion, and he is currently at baseline Hct.
He was noted to have guiac positive stools, and will need
outpatient colonoscopy once his acute respiratory issues have
improved sufficiently. He was started on iron supplements.
.
# Hematuria: Pt has known bladder mass and BPH. Urology was
consulted during last admission, and recommended stopping his
coumadin and outpt Urology followup. Urology was re-consulted
for hematuria after foley insertion. They again recommended
outpatient workup and cystoscopy. Proscar was started as per
Urology and urine cytology sent (can be followed up by Urology
at the outpatient appointment.) The patient had continuous
bladder irrigation and his urine cleared. Bladder irrigation
was stopped 36 hours prior to discharge and the patient's urine
remained clear. On the day of discharge the foley was changed
from a 3-way to an 18-french 2 way catheter. Some hematuria was
again noted but this was felt due to the trauma of foley
replacement. He should follow up with Urology on [**2114-2-27**]
as previously scheduled. He can have a voiding trial in [**12-26**]
days as the catheter is no longer required for medical
management.
.
# LE Wounds: The patient had skin ulcers on his lower
extremities likely secondary to blisters and excoriation by
patient. There was good perfusion on exam and no evidence of
ulcer progression or superinfection. He was followed by the
wound nurse [**First Name (Titles) **] [**Last Name (Titles) 106675**] were changed daily (wound gel and
adaptic, covered with kerlix). The wound care should continue
at rehab and his wounds monitored closely for sign of infection.
.
# FEN: Diabetic/cardiac diet. Electrolytes were stable.
.
# Prophylaxis: SC heparin, bowel regimen, diet
.
# Full code
.
# Communication: [**Name (NI) **] [**Name (NI) 4427**] (Wife) [**Telephone/Fax (1) 106676**]
Medications on Admission:
* Ipraptropium
* Senna/colace
* Levalbuterol prn
* Prednisone 20mg until [**1-27**]
* Furosemide 40 mg qMWF
* Aspirin 325 mg qd
* Lisinopril 2.5 mg qd
* Diltiazem HCl 240 qd
* Tamsulosin 0.4 mg qhs
* Insulin SS
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulized
treatment Inhalation Q4H (every 4 hours).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
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. Diltiazem HCl 240 mg Tablet Sustained Release 24HR Sig: One
(1) Tablet Sustained Release 24HR PO once a day.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty
(20) units Subcutaneous qAM.
11. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty
(20) units Subcutaneous at bedtime.
12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
15. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
17. Piperacillin-Tazobactam Na 2.25 gm IV Q6H
18. Vancomycin HCl 1000 mg IV Q 24H
19. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
20. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days: Then decrease dose to 10mg x 7 days, then 5mg x 7
days, then off.
21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
22. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for For pain with dressing changes.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
1. Pneumonia, nosocomial
2. COPD (Chronic Obstructive Pulmonary disease)
3. CHF (congestive heart failure)
.
Secondary:
1. Bladder Mass
2. Diabetes
3. Atrial Fibrillation
Discharge Condition:
Afebrile, breathing improved. Stable.
Discharge Instructions:
Please take all your medications as prescribed. You were
admitted with pneumonia and need another week of IV antibiotics.
You should continue to use oxygen (3L nasal cannula) at all
times).
.
Call your doctor or return to the hospital if you have fever,
shortness of breath, chest pain, or any other concerning
symptom.
Followup Instructions:
Please call your primary doctor, Dr. [**Last Name (STitle) **], for an appointment
within 1-2 weeks.
.
You should follow up with your kidney doctor, Dr. [**Last Name (STitle) **] as noted
below. You have an appointment with a urologist, Dr. [**First Name (STitle) **], on
[**2114-2-27**] as noted below for work up of your bladder mass.
.
Provider: [**Known firstname **] [**Last Name (NamePattern4) 8941**], MD Phone:[**Telephone/Fax (1) 6317**]
Date/Time:[**2114-2-27**] 10:15
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2114-3-8**] 9:00
Completed by:[**2114-2-3**]
ICD9 Codes: 4280, 486, 496, 5119, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8355
} | Medical Text: Admission Date: [**2163-12-20**] Discharge Date: [**2163-12-28**]
Date of Birth: [**2100-1-19**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
CC:[**CC Contact Info 75401**]
Major Surgical or Invasive Procedure:
craniotomy for tumor resection
History of Present Illness:
HPI:
Pt. is a 63 year old with a history of hypercholesterolemia
who presents for further work up of gait ataxia and mass seen on
Head CT.
He reports that he has been seeing his doctor [**First Name (Titles) **] [**Last Name (Titles) **] that
have been attributed to depression since [**2163-12-6**]. He noted
trouble concentrating at work, making wrong turns when driving
home from work and getting lost, forgetting to turn off the
lights or turn off the TV at home, and problems with his
penmanship, with small, illegible handwriting. He's felt sad,
and he feels that his speech is "flat" with no intonation. He
was started on Celexa for these [**Year (2 digits) **] on [**12-15**], but feels
that
this has made no impact.
Then starting yesterday he started feeling unsteady on his feet.
When he bent forwards to tie his shoes he'd list to the left and
would have to catch himself from falling. He's not actually
fallen. He feels that his left calf is "stiff" and sore, but
not
actually weak that he's noticed. He had a constant,
non-throbbing bifrontal headache at [**Location (un) **] today, but has not
been bothered by headaches prior to that. He's not had any
nausea or vomiting. He presented to his PCP because of the gait
unsteadiness today, and was referred to the ED in [**Location (un) **].
There
a Head CT was performed and showed a 4.3x3.2 complex mass in R
parietal area with contrast enhancement and central necrosis,
and
additional R frontal mass with surrounding edema, and minimal
midline shift. He received Dilantin 1 g load, and was
transferred here. He received 10 mg Decadron here at 18:45.
Past Medical History:
PMHx:
Hypercholesterolemia
Significant rise in PSA
Social History:
SH: Financial consultant (took a leave of absence in the end of
[**11-18**] trouble driving), lives with wife and 16 y/o
daughter, one daughter in college, 2 grown children live in the
area, no tobacco, occ wine with dinner
Family History:
FH: Brother with DVT, no FH of stroke, seizure, CAD, or cancer
Physical Exam:
PHYSICAL EXAM:
T: BP: 160/96 HR:60 R:16 O2Sats: 98% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**5-20**],bilat EOMs: intact, no nystagmus
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect, delayed processing.
Orientation: Oriented to person, place, and date.
Recall: [**2-19**] words at 5 minutes.
Language: Speech delayed, conversant 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, 5 to 4mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
+Left pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 4+ 4 4+ 5 4+ 4+ 5 4+ 4+ 5 5- 5 5- 5
Sensation: Intact to light toucH
Reflexes:
+2 and symmetric throughout.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger on Right, decreased
ability on Left
Pertinent Results:
Labs:
WBC 7.3 Hgb 14.6 Plt 168 Hct 41.7
N:66.2 L:26.2 M:6.1 E:1.2 Bas:0.3
PT: 12.9 PTT: 23.3 INR: 1.1
CT: Pending
OSH CT: 4.3x3.2 complex mass in R
parietal area with contrast enhancement and central necrosis,
and
additional smaller R frontal mass, and minimal midline shift
POSTOP MRI
MR HEAD W & W/O CONTRAST [**2163-12-24**] 9:29 AM
Reason: follow up on postop residual brain tumor. pls do before
midn
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
63 year old man with craniotomy for tumor resection
REASON FOR THIS EXAMINATION:
follow up on postop residual brain tumor. pls do before midnight
[**12-24**]
CONTRAINDICATIONS for IV CONTRAST: None.
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient status post surgery for
post-operative evaluation.
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and
diffusion axial images of the brain were acquired before
gadolinium. T1 sagittal, axial and coronal images were obtained
following gadolinium. Comparison was made with the previous MRI
examinations of [**2163-12-21**] and [**2163-12-23**].
FINDINGS: Since the previous MRI examination the patient has
undergone craniotomy in the right frontal region for right
frontal lobe enhancing mass lesions. There are blood products
seen near the convexity along the midline with foci of air
consistent with recent surgery. Some residual enhancement is
identified on the anterior aspect and also the posterolateral
aspect of the mass. The other enhancing mass lesion seen more
laterally is again visualized unchanged. There is no significant
change in the brain edema identified. There is continued mass
effect on the right lateral ventricle identified without
significant midline shift. There is no hydrocephalus.
Pneumocephalus is identified in the frontal region.
IMPRESSION: Status post resection of frontal mass. Residual
enhancement is seen anteriorly and posterolateral aspect of the
mass with blood products in the region of resection.
Pneumocephalus is identified. No acute infarct is seen.
Previously noted smaller enhancing mass laterally in the right
frontal lobe is again identified unchanged.
****************
postop head CT
CT HEAD W/O CONTRAST [**2163-12-25**] 10:45 AM
CT HEAD W/O CONTRAST
Reason: r/o inc MLS / Mass effect
[**Hospital 93**] MEDICAL CONDITION:
63 year old man with s/p crani for tumor resection
REASON FOR THIS EXAMINATION:
r/o inc MLS / Mass effect
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 63-year-old man with status post crani for tumor
resection. Rule out increased midline shift/mass effect.
COMPARISONS: [**2163-12-23**] CT.
CT HEAD WITHOUT CONTRAST: Patient is status post right frontal
craniotomy for tumor resection. There is interval decrease in
pneumocephalus. There is no new intracranial hemorrhage. No
midline shift. No evidence of major vascular territorial
infarct. Size of ventricles and cisterns is stable.
IMPRESSION: Status post right frontal craniotomy with stable
expected post- surgical changes.
****************
Brain tissue pathology
1. Brain, right frontal, biopsy (including intraoperative
frozen section and smear):
High grade glial neoplasm.
2. Brain, "deep right frontal", biopsy (including frozen
section and smear):
High grade glial neoplasm.
3. Brain, "right frontal deep", resection:
Glioblastoma (WHO grade IV).
Brief Hospital Course:
Mr [**Known lastname 75402**] was admitted to neurosurgery service on [**2163-12-20**] with
diagnosis of brain mass. Upon admission, he was oriented x 3,
but with delayed speech; he has mild left-sided weakness. He
underwent craniotomy for tumor resection on [**2163-12-23**]. No intra-
or postop complications are encountered. He was observed in
surgical ICU postop. Postop CT showed slight bleeding; postop
MRI showed residual brain tumor. He was transferred out of ICU
to regular floor on POD#3.
Neurologically he remained stable with mild left-sided weakness
postoperatively. He is able to ambulate with assistance; his
diet is advanced. He has bladder incontinence.
PT/OT are consulted and he was recommended to be discharged to
rehab facility.
Neuro-oncology is consulted and outpatient followup is
recommended and scheduled.
Upon discharge, neurologically he is oriented times 3, following
commands; mild left-sided weakness (UE/LE, motor 3 to 5-/5);
motor [**5-21**] with RUE/RLE.
His brain tumor pathology reported Glioblastoma (WHO grade IV).
Medications on Admission:
Medications prior to admission:
Aspirin 325 mg QD
Celexa 10 mg QD- started [**12-15**]
Crestor 5 mg QD
Discharge Medications:
1. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Hexavitamin Tablet Sig: Five (5) ML PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed.
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
brain mass
Discharge Condition:
neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after staples have been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 10840**] at [**Hospital3 3765**] for radiation
planning.
[**Hospital 75403**] Cancer Center, 131 ORNAC, [**Location (un) **], [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 75404**]
Building
Please call [**Telephone/Fax (1) 75405**] to make an appointment. Make sure you
bring a CD of your CT images, the CT report and your final
pathology report when you see Dr. [**Last Name (STitle) 10840**].
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN NEXT TUESDAY in clinic. You will have your
staples removed at that time.
PLEASE FOLLOW UP WITH NEURO-ONCOLOGIST DR [**First Name (STitle) 5005**] [**Last Name (NamePattern4) 5342**],
MD ON Date/Time:[**2164-1-2**] 2:00 (Phone:[**Telephone/Fax (1) 44**]). PLEASE CALL
FOR OFFICE LOCATION.
Completed by:[**2163-12-28**]
ICD9 Codes: 2720, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8356
} | Medical Text: Admission Date: [**2101-12-1**] Discharge Date: [**2101-12-5**]
Date of Birth: [**2055-5-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Alcohol intoxication, Suicidal ideation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
46 M with PMHx significant for nephrectomy, and prior admissions
for alcohol intoxication, who presents with suicidal ideation.
Patient has prior history of ED visits with both of these
presentations. Patient reports that he has been on a drinking
binge (vodka & listerine) for the past 2 months, with his last
drink 2 days prior to admission. Patient denies ever having
EtOH withdrawal seizures and just reports having "shakes".
Since stopping alcohol on day prior to admission, he has been
feeling anxiety, depression, nausea with nonbloody bilious
emesis, headache, chills, & tremors. he also reports
lightheadedess and dizziness. He denies any methanol or
ethylene glycol ingestions, fevers, abdominal pain, diarrhea.
He does reports that his last meal was 3 days prior to
admission, and he has consumed essentially nothing but alcohol
since. Patient reports that he's been feeling suicidal for the
past couple days after stopping alcohol. he reports that he has
significant financial, occupational and familial stressors. He
called 911 this am and was brought to the ED. .
.
.
ROS:
Positive: chest rash
Negative: change in vision, oral ulcerations, neck stiffness,
chest pain, abdominal pain, diarrhea, constipation
In the ED, vitals signs were T:96.7, HR:130, BP: 72/44. The
patient was also found to have a significant ETOH intoxication,
as well as an AG acidosis (anion gap 35)and ARF. Tox screen was
positive for only EtOH and LFTs were mildly elevated. he was
given Ativan, 2L fluids, phenergan for nausea, one dose of
ceftriaxone and sent to the floor.
Past Medical History:
1. Alcohol abuse.
2. Right nephrectomy for a mass in his kidney.
3. HTN
4. Dyslipidemia
Social History:
Patient reports that he drinks 1 quart of vodka or listerine per
day. Has been doing this lately for 2 months. Long-standing
drinking history. Patient has had prior visits to [**Hospital1 18**] ED for
suicide attempt and EtOH intoxication. Patient reports smoking
1 pack per week, denies any other illicit drugs.
Family History:
No family history of cancer, no bleeding diathesis
Father - deceased - MI age 70
Mother - recent CVA
Physical Exam:
Physical Exam:
Vitals - T: 100.3 BP: 100/62 HR: 123 RR: 12 02 sat:96RA
Gen: NAD, anxious, cooperative
SKIN: redness to face and upper chest, no excoriations or
lesions
HEENT: AT/NC, bilateral scleral injection without exudate, pink
conjunctiva, PERRL, EOMI, dry MM, poor dentition, no evidence of
oral ulceration
Neck: no masses, no LAD, no JVD, no carotid bruit
CV: tachycardic, S1/S2, flow murmur @ RUSB, nondisplaced PMI
Chest: cta b/l, no crackles or wheezes.
Abd: soft, nd, +bs, no organomegaly, no rebound, no guarding
Extr: no cyanosis, no clubbing; no edema, 2+ pulses b/l.
Neuro: awake, alert, a&ox3, cn ii-xii intact; strength 4/5
bilaterally
Pertinent Results:
[**2101-12-1**] 02:01PM WBC-6.5 RBC-4.65 HGB-15.9 HCT-46.0 MCV-99*#
MCH-34.2* MCHC-34.6 RDW-16.0*
[**2101-12-1**] 02:01PM NEUTS-74.4* LYMPHS-14.3* MONOS-10.9 EOS-0.1
BASOS-0.3
[**2101-12-1**] 02:01PM ASA-NEG ETHANOL-296* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2101-12-1**] 02:01PM CALCIUM-7.8* PHOSPHATE-7.5*# MAGNESIUM-2.1
[**2101-12-1**] 02:01PM CK-MB-21* MB INDX-3.1 cTropnT-<0.01
[**2101-12-1**] 02:01PM LIPASE-71*
[**2101-12-1**] 02:01PM ALT(SGPT)-99* AST(SGOT)-156* CK(CPK)-688* ALK
PHOS-122* AMYLASE-92 TOT BILI-0.4
[**2101-12-1**] 02:01PM GLUCOSE-118* UREA N-37* CREAT-2.1* SODIUM-141
POTASSIUM-4.5 CHLORIDE-91* TOTAL CO2-15* ANION GAP-40*
.
[**2101-12-1**]
CXR: IMPRESSION: No acute pulmonary process.
.
CT HEAD: IMPRESSION: No intracranial hemorrhage or fracture.
No mass effect.
Brief Hospital Course:
Patient is a 46 M with suicidal ideation, EtOH withdrawal,
hypotension, elevated lactate, ARF, metabolic acidosis, &
tachycardia.
.
# EtOH Withdrawal: Patient ceased drinking approximately 24
hours prior to admission. Load with Valium 10mg until
confortable, then Q1hprn per CIWA > 10. the patient initially
required high doses. MVI/Thiamine/Folate were also given.
.
# Hypotension: due to volume depletion in the context of poor po
intake, responded well to fluids.
.
# Tachycardia - Likely due to a combination of etoh withdrawal
hypovolemia. Patient's HR has decreased with fluid challenge.
Fluid hydration.
.
# Fevers - Likely in the setting of alcohol withdrawal.
Cultures negative.
.
# ARF- Cr on admission to 2.0. Baseline is 0.8. Likely
pre-renal renal failure, responded well to fluids. No evidence
of secondary ingestions. Renal was consulted to help with
management.
.
# Metabolic Acidosis: Patient with metabolic acidosis. Likely
due to alcoholic and starvation ketoacidosis as well as renal
failure. Lactate minimally elevated. No evidence of seconday
ingestion. Resolved with IVF hydration.
.
# Suicide attempt- patient currently with 1:1 sitter. Consulted
Psychiatry. Recommended inpatient psychiatry admission.
.
FULL CODE
Medications on Admission:
Paxil
Lipitor 20
Norvasc 20
"Something to stop Alcohol cravings"
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 8063**] - [**Location (un) **]
Discharge Diagnosis:
EtOH withdrawal
Suicide Attempt
Discharge Condition:
Stable
Discharge Instructions:
Please return to the hospital if you experience shortness of
breath, chest pain, fevers/chills.
.
Followup Instructions:
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 3 weeks
of discharge. On this admission, it was noted that you have a
small amount of red blood cells in your urine. This will need to
be followed up with your primary care physician upon discharge.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
ICD9 Codes: 5849, 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8357
} | Medical Text: Admission Date: [**2131-10-19**] Discharge Date: [**2131-10-27**]
Date of Birth: [**2064-7-16**] Sex: M
Service: MEDICINE
Allergies:
Levofloxacin / Cefazolin / Coreg / Dopamine
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
fatigue, shortness of breath
Major Surgical or Invasive Procedure:
Right thoracentesis
History of Present Illness:
A 67 year old gentleman recently discharged [**10-5**] from [**Hospital1 1516**]
service for sepsis [**1-27**] R. BKA site complicated by Refractory VT
s/p ablation with a history of DM, CAD s/p PCI distal RCA '[**03**],
ischemic cardiomyopathy EF 20% who was admitted with lethargy
and fatigue from [**Hospital3 **]. He reports an
increase in fluid collection in his upper extremities, shortness
of breath and constipation and general fatigue over past 4 days.
At [**Hospital1 **], it was presumed that this was an exacerbation of
his CHF so Lasix increased from 20mg PO to 80mg IV BID x2 days.
His UOP was negative 1.5 Liters yesterday but he failed to
respond and was persistantly short of breath. However, on
further review he has not recieved any Lasix over past 18 hours.
(pharmacy error per report). He was subsequently transferred for
further managment.
PT was directly transferred to the floor from [**Hospital1 **] where
his VS: 97.3 77 105/66 17 100% 4L. An initial evaluation was
begun on the floor. EKG showed V paced @69 and no ischemic
changes. CXR revealed evidence of pulmonary edema and possible
pneumonia. CT Chest showed large right pleural effusion and no
evidence of pneumonia, BNP 55, 000. CK 36, Trop 0.35. Cr 2.0 (up
from baseline 1.7)
Pt was subsequently transferred to CCU for further management.
On ROS, He denies chest pain, palpitations, N/V, abdominal pain.
Denies PND or orthopnea. Denies cough, fever or chills. He does
report some constipation x2 days but had some BM today. Reports
mild dysuria 2 days ago now resolved. Denies flank pain. He
endorses poor appetite and PO intake over past 3 days. He
reports a pressure ulcer on coccyx.
Past Medical History:
*CARDIAC HISTORY:
-MI [**2103**]- C.CATH [**2121**] showed 60% distal RCA stenosis at
recanalization site
-Systolic Heart Failure- ECHO [**10-3**] with EF 20%
-Refractory VT (dx [**10-3**] in setting of sepsis) now s/p VT
ablation; currently on Mexilitine and Amiodarone
-Atrial Fibrillation s/p ablation, pacemaker
*Hypertension
*Hyperlipidemia
*DMII
*SMA thrombosis: small&large bowel resection and short gut
*Bacterial peritonitis
*PVD s/p R BKA c/b stump infection- completed 10d Vanc/Zosyn
*Hypercoagulable state, DVTs on Lovenox
*Peripheral neuropathy
*Plantar fasciitis
*CVA
*PV/MDS, baseline 20s
*Nonhealing anal fissure
Social History:
Currently lives at [**Hospital3 **], he is a retired systems
programmer for a management consulting firm. He is married with
no children. He denies alcohol, tobacco or drug use. Prior 3 yrs
of tobbaco use.
Family History:
Family history is negative for hypercoagulable state, PVD
Physical Exam:
PE: VS: 97, BP 96/609 HR 74, RR 18 97% 1.5L
Gen: Cachectic male, fatigued appearing, conversing in full
sentences
Neck: JVP 10cm
Pulm: Rales in Bilateral lower lobes, decreased sounds on right
Cards: S1 & S2 regular without murmur
Abd: Soft, mildly distended, tympanitic, non-tender, no
rebound/guarding
Ext: B upper extremity edema. R BKA, stump with no open wounds
or erythema. Wound on L foot, healing well. 1+ DP on L foot.
Neuro: AAO x3
Pertinent Results:
Admission:
[**2131-10-19**] 05:10PM BLOOD WBC-20.4* RBC-5.22 Hgb-12.4* Hct-39.7*
MCV-76* MCH-23.8* MCHC-31.3 RDW-20.9* Plt Ct-382
[**2131-10-19**] 05:10PM BLOOD Neuts-91.4* Lymphs-5.1* Monos-1.8*
Eos-1.4 Baso-0.3
[**2131-10-19**] 05:10PM BLOOD PT-20.5* PTT-51.4* INR(PT)-1.9*
[**2131-10-19**] 05:10PM BLOOD Glucose-85 UreaN-82* Creat-2.0* Na-140
K-4.8 Cl-101 HCO3-25 AnGap-19
[**2131-10-19**] 05:10PM BLOOD CK(CPK)-36*
[**2131-10-19**] 05:10PM BLOOD CK-MB-NotDone cTropnT-0.35* proBNP-[**Numeric Identifier 103666**]*
[**2131-10-19**] 05:10PM BLOOD Calcium-8.0* Phos-6.8*# Mg-2.0
[**2131-10-20**] 12:09PM BLOOD Lactate-0.9
Admission Chest X-ray:
1) New focal opacity overlying the left mid lung field, which
could represent an area of developing pneumonia. Dedicated PA
and lateral views of the chest is recommended.
2) Persistent large right pleural effusion and mild congestive
heart failure.
3) Unchanged bibasilar atelectasis.
CT CHEST W/O CONTRAST [**2131-10-19**]:
1. Severe right pleural effusion and small left pleural
effusion. The left
pleural effusion is loculated and corresponds to the described
density on the recent chest radiographs.
2. No pericardial effusion is noted.
3. Diffuse ground glass opacities of the lungs is most likely
related to
pulmonary edema. More focal patchy opacities at left apex may
represent
asymmetric pulmonary edema although superimposed infectious or
inflammatory process cannot be excluded.
4. Bibasilar pulmonary calcifications or aspirated barium,
unchanged since
[**2129**].
ECHO [**2131-10-20**]:
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). Left ventricular wall thicknesses are normal.
The left ventricular cavity is moderately dilated. There is
severe global left ventricular hypokinesis with relative
preservation of the anterolateral wall (LVEF = 20 %). The right
ventricular cavity is moderately dilated with severe global free
wall hypokinesis. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. There is at least mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2131-10-1**],
the findings are similar.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2131-10-27**]):
Feces negative for C.difficile toxin A & B by EIA.
Brief Hospital Course:
67 year old gentleman with h/o ischemic cardiomyopathy EF 20%,
Refractory VT s/p ablation, CAD s/p MI'[**03**], who presented from
rehab with increasing SOB c/w acute on chronic systolic heart
failure.
# Systolic CHF exacerbation and dyspnea: On admission, clinical
exam revealed bilateral basilar crackles, JVD 12-13cm and
peripheral edema all consistent with volume overload. BNP 55,260
(previous BNP 22,000). CXR showed effusions (right >left) and
left likely loculated fluid per CT. Pt was also hypotensive,
requiring dobutamine drip which was quickly weaned off. Pt
initially was SOB, attributed to largle right pleural effusion.
Symptoms improved with diuresis to good sats on 2L NC. After
anticoagulation was adequately reversed (Vit K, Lovenox held,
heparin bridge until several hours before procedure), pt was
tapped 2.1L of serous fluid, with LDH and TP consistent with
transudate with additional symptomatic improvement.
Pt was aggresively diuresed with Lasix drip and responded well
symptomatically. PO intake was restricted to low salt and 1L
fluid. He was transitioned to PO lasix at 80 mg [**Hospital1 **]. On
discharge, his oxygen saturation was 98 % on room air.
# Rhythm: Pt has history of VF on recent admission in setting of
sepsis (s/p ablation) and afib (also ablated). Pt was monitored
on telemetry and V Paced with no arrhythmias. He was continued
on Mexilitine and Amiodarone.
Anticoagulation was held for thoracentesis (with a heparin drip
for bridging) and restarted after procedure.
- It was noted that he has a pacemaker rather than an ICD.
Although, there are multiple reasons why he might not be a good
candidate for ICD placement, this issue could be readdressed in
the future.
#CAD: h/o MI. Pt was continued on a statin. BB held while
diuresing since initially was hypotensive, and restarted prior
to DC. Although pt had previous history of bleed while on
Lovenox and [**Hospital1 **], after discussion with his PCP, [**Name10 (NameIs) **] was
restarted as the risk of CAD would exceed the risks of bleeding
on [**Name10 (NameIs) **].
#[**Name (NI) **] Pt was initially very somnolent. Lyrica was DCed given
impaired renal function, Oxycodone was decreased to 10mg q12hrs,
and psychotropic meds were held. He quickly returned to his
baseline level of full alertness and remained there for the rest
of the hospital stay.
#Diarrhea/Constipation: Pt has history of short gut syndrome and
constipation, on psyllum, cholestyramine at home. He was
continued on these and had colace, senna, MOM prn, all separated
by 2 hours from antiarrhythmic meds. Pt initially reported
constipation and after a dose of colace had 7 BMs and then
remained without BM for several days. C Diff was negative and
thus he was started on Immodium. PO intake continued to be
adequate.
#CRI: Pt's baseline creatinine is 1.6-1.8, on presentation
BUN/Cr was 81/2.2. Renal function improved as pt was diuresed
and electrolytes remained stable. Renal team was consulted and
followed.
#Hyperphosphatemia: Pt's phosphate was elevated at 5-6s, likely
a consequence of his CKD and question of vitamin D deficiency.
Levels were sent off but pending at time of discharge an pt
started on weekly vit D supplementation empirically.
#DMII: Blood sugars were well controlled on home dose of NPH and
insulin sliding scale
# Leukocytosis: Pt had a WBC of ~20 throughout admission with
infectious workup initially negative (afebrile, UA neg, no cough
or URI sx, urine and blood cultures negative). Diff with
neutrophil dominance but no early forms. Leukocytosis
attributed to MDS. Prior to discharge, pt's WBCs increased to
30, and UA showed WBCs and leuk esterase so pt was started on
Augmentin for 7 day course and simultaneous PO Vancomycin given
history of recurrent C Diff colitis on antibiotics.
****** Please recheck pt's WBCs, urine analysis and urine
cultures after finishing 1 week course of antibiotics. If
continues to have elevated WBCs after UTI resolves, could
evaluate foot ulcer for possible osteomyelitis.********
# Hypercoagulability Disorder: Pt has a history of multiple
embolic events leading to amputation and GI surgery complicated
by short gut syndrome. He had previously failed coumadin, and
was on lovenox but no aspirin (h/o bleed with lovenox and [**Name (NI) **])
at time of admission. Lovenox was held for thoracentesis and pt
anticoagulated with heparin drip. After thoracentesis, pt was
switched back to lovenox. Prior to discharge, pt was restarted
on [**Name (NI) **] (after discussion with PCP) for cardiovascular risk.
# Depression: Pt initially continued on Citalopram 40mg PO daily
as per rehab records, but was noted to be on 60mg based on outpt
OMR records and increased to 60mg daily.
# Sacral decubetous ulcer: He was seen by wound care who
recommended DuoDerm wound gel to wound bed, to assist with
debriding and to change coccyx dressing q3 days, place Allevyn
foam dressing.
# Neuropathy: Patient has been on neurontin in the past, but was
changed to lyrica and then stopped for volume concerns. Pt had
worsening leg pain but refused Neurontin saying that it did not
sufficiently help in the past. He preferred Oxycontin/Oxycodone
which provided adequate relief but Neurontin could be
reconsidered and uptitrated in the future.
Medications on Admission:
1. Citalopram 40 mg PO DAILY
2. Folic Acid 1 mg PO DAILY
3. Ranitidine HCl 150 mg PO Daily
4. Amiodarone 200 mg PO DAILY
5. Enoxaparin 50mg SQ Q12
6. Hydrocodone-Acetaminophen 5-500 mg [**12-27**] PO Q6h PRN Pain
7. Lyrica 200 mg PO Q8h
9. Psyllium 1.7 g Wafer PO Daily
10. NPH 20U SQ QAM
11. Lidocaine HCl 2 % Gel PRN
12. Oxycodone 20 mg PO Q12
13. Lorazepam 0.5 mg [**12-27**] PO QHS PRN Insomnia
14. Metorprolol Succinate 12.5mg PO Q24
15. Mexiletine 200 mg PO Q8hours
16. Cholestyramine-Sucrose 4 gram PO BID
17. Atorvastatin 10 mg PO QDay
18. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
20. Lasix 20 mg PO Daily
21. Fluconazole 200 mg PO Q24hours until [**10-19**]
22. Maalox 30mL PO Q6h PRN
.
Allergies: Levofloxacin, Cefazolin, Coreg, Dopamine
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Citalopram 40 mg Tablet Sig: 1.5 Tablets PO once a day.
3. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
5. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO once a day.
Wafer(s)
6. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime)
as needed for Insomnia.
7. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
8. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO
BID (2 times a day).
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for pain: for breakthrough pain.
14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO at bedtime as needed.
15. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QTHUR (every Thursday).
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
17. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
18. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
19. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
20. Enoxaparin 60 mg/0.6 mL Syringe Sig: Fifty (50) mg
Subcutaneous Q12H (every 12 hours).
21. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
22. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
23. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
24. Augmentin 250-125 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours for 7 days: Take with food.
25. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary: Acute on Chronic systolic CHF exacerbation
Secondary: Pulmonary effusion, Hypercoagulability, Short gut
syndrome, Diabetes Mellitus type 2, Hypertension,
Discharge Condition:
Stable
Na 135, K 4.9.
BUN
creat
Hct
Pt's dry weight is 49.7 kilos.
Discharge Instructions:
You were admitted to the hospital with an exacerbation of your
heart failure causing back up of fluid in your lungs, which made
it difficult to breathe. You breathing improved with diuresis of
this fluid as well as a thoracentesis (drainage of the fluid
around your lung). Also as the fluid was taken off, your heart
was able to pump more efficiently and your kidneys showed signs
of better perfusion. Prior to discharge your bloodwork and urine
studies showed signs of urinary infection so you were given a 7
day course of Augmentin and started on oral Vancomycin
simultaneously to prevent C Diff diarrhea.
We made the following changes in your medications:
1) Start Augmentin
2) Start Vancomycin
3) Start Lasix at 80mg twice a day
4) Start Aspirin 81mg daily
5) Start Vitamin D
6) Start Oxycontin
7) Start Tylenol
8) Stop Lyrica
9) Stop Percocet
10) Change oxycodone dose
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs,
adhere to 2 gm sodium diet, and restrict your fluid intake to 1L
per day. If you have worsening shortness of breath, chest pain,
lightheadedness or any other concerning symptoms please call
your doctor or return to the hospital.
It was a pleasure taking care of you, we wish you the best!
Followup Instructions:
Primary Care:
Dr [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 250**] Date/Time: Friday [**11-2**] at 2:00pm. With [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP
Cardiology:
Provider: [**Name Initial (NameIs) 2169**]: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2131-11-23**] 2:00
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2131-11-23**]
1:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2131-11-23**]
12:30
Provider: [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 5068**] Date/Time:
[**2131-11-15**] at 10:30am.
Completed by:[**2131-10-27**]
ICD9 Codes: 5849, 5119, 4271, 5990, 4280, 3572, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8358
} | Medical Text: Admission Date: [**2131-7-21**] Discharge Date: [**2131-7-27**]
Date of Birth: [**2071-12-12**] Sex: M
Service: Trauma Surgery
HISTORY OF PRESENT ILLNESS: A 49-year-old male transferred
from outside hospital to the [**Hospital1 188**] status post motorcycle accident with right hip
dislocation and second to third-degree burns to the
extremities.
PAST MEDICAL HISTORY: (Significant for)
1. Paroxysmal atrial fibrillation, status post mitral valve
replacement with [**Doctor Last Name 4726**]-Tex valve.
2. The patient is also status post a right femur fracture
open reduction, internal fixation in [**2115**].
3. Status post Achilles tendon surgery.
4. Status post an appendectomy in [**2079**].
MEDICATIONS ON ADMISSION: The patient was taking
aspirin 325 mg p.o. q.d.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION: Temperature of 100.8,
pulse of 112, blood pressure 142/109. [**Location (un) 2611**] Coma Scale
was 15. Head and neck examination revealed pupils were
equal, round, and reactive, 3 mm to 2 mm bilaterally. There
was periorbital ecchymosis and left forehead swelling. There
was blood in both nares, tenderness over the right mandible
and over the nasal bones. Neck was in a cervical collar.
Trachea was midline. Chest revealed there was no bony
tenderness or crepitus, and lung sounds/breath sounds were
clear and equal bilaterally. Cardiac examination was
irregular. Abdominal examination was soft, nontender, and
nondistended. Rectal examination had normal tone and
heme-positive. Extremities showed left arm second-degree
burn over 1% to 3% of total body surface area in the left
lower extremity with a third-degree burn to approximately 1%
of total body surface area. Neurologic examination revealed
the patient was alert and oriented times three, [**Location (un) 2611**] Coma
Scale of 15 as previously stated. Back revealed no stepoff
or tenderness. Pelvis was stable. Right lower extremity was
obviously dislocated, internally rotated, and shorter than
the left lower extremity.
LABORATORY ON ADMISSION: The patient's laboratories were
significant for a toxicology screen positive for ethanol at a
level of 192. Creatine kinase was 508. Troponin was 0.07.
Chem-7 was within normal limits. White blood cell count
was 13.3, hematocrit 42.3, and platelets 294. Blood gas
was 7.37/36/145/20 and negative 4.5. Coagulations were
normal. Amylase was 73, lactate 4.6, fibrinogen 288.
RADIOLOGY/IMAGING: The patient underwent a trauma series
which showed right posterior hip dislocation and no pelvic
fracture.
A CT of the abdomen was negative. CT of the chest showed
bilateral aspiration pneumonia.
The facial CT showed multiple nasal fractures.
Head CT was questionable for right frontal contusion;
however, on a repeat CT 24 hours later this was felt to be
negative for intracranial injury.
HOSPITAL COURSE: In the trauma bay, the patient had the
right hip dislocation reduced by Orthopaedic Surgery Service
who were consulted immediately. Post reduction films showed
good reduction. Examination also significant for left
peroneal nerve injury and foot drop. Neurosurgery was
consulted for the question of frontal contusions on head CT.
They recommended repeating head CT in 24 hours with frequent
neurologic checks. His repeat head CT 24 hours later showed
no change, and Neurosurgery signed essentially stating that
they did not think there was any intracranial injury.
The patient was admitted to the Cardiothoracic Intensive Care
Unit for close monitoring. He remained hemodynamically
stable. He was noted to be in and out of atrial
fibrillation. He was started on amiodarone. He was also
started on Lopressor.
Plastic Surgery was consulted for the burns to the left arm
and left leg. No debridement was done to the wounds or to
the burns. Essentially, all that was done were dressing
changes with xeroform, gauze, and dry sterile dressings.
Plastic Surgery decided that skin grafting would not be
necessary during this hospitalization and instructed us to
have him follow up with them in the clinic to follow the burn
healing. The patient had TLS films done which were read as
negative. He was taken off precautions at that time. His
cervical spine was cleared.
It should be noted that when the patient was transferred from
the outside hospital, during ambulance ride, the patient
became apneic secondary to narcotic administration. He
received Narcan with good results. The patient was also
electively intubated in the Emergency Department for
reduction of his right hip dislocation. He remained
intubated in the Cardiothoracic Intensive Care Unit, on
hospital day two, and then was extubated without difficulty
on the night of [**2131-7-22**].
Plastic Surgery recommended repeat head CT with facial cuts
to evaluate for orbital injury. This was obtained with
coronal cuts which again showed the nasal fractures
previously described, but there was no evidence of orbital
fracture. Orthopaedics recommended films of the left hip to
rule out fracture secondary to the peroneal nerve injury.
These were obtained with no evidence of fracture.
The patient was transferred to the floor on [**2131-7-24**].
He again remained hemodynamically stable and afebrile for the
rest of his hospital course. Orthopaedics recommended
partial weightbearing with crutches of the right lower
extremity with posterior dislocation hip precautions. He was
instructed to follow up with his own orthopaedist in
approximately two weeks after discharge.
The patient was seen by Physical Therapy who felt he
ambulated reasonably well with crutches, although he had some
minor difficulty getting use to his left foot drop. Physical
Therapy constructed a special brace for his left lower
extremity to assist with this and to facilitate ambulation.
It was felt that he was ready for discharge on [**2131-7-27**],
(hospital days seven).
CONDITION AT DISCHARGE: He was discharged in stable
condition.
DISCHARGE DIAGNOSES:
1. Status post motorcycle accident with right posterior hip
dislocation.
2. Status post reduction.
3. Left upper and lower extremity burns (second-degree and
third-degree, respectively).
4. Nasal fractures.
5. Left peroneal nerve injury with resultant left foot drop.
MEDICATIONS ON DISCHARGE:
1. Lopressor 25 mg p.o. b.i.d.
2. Amiodarone 400 mg p.o. q.d.
3. Percocet one to two tablets p.o. q.4-6h. p.r.n.
4. Colace 100 mg p.o. b.i.d. while taking narcotics.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 33441**]
MEDQUIST36
D: [**2131-7-27**] 08:23
T: [**2131-7-28**] 07:02
JOB#: [**Job Number 34070**]
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8359
} | Medical Text: Admission Date: [**2158-2-22**] Discharge Date: [**2158-2-27**]
Date of Birth: [**2087-6-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Symptomatic Atrial Fibrillation - Shortness of breath, fatigue,
syncope
Major Surgical or Invasive Procedure:
[**2158-2-22**] Bilateral mini thoracotomy with Maze procedure and
resection of left atrial appendage
History of Present Illness:
70 y/o male with a history of paroxysmal atrial fibrillation.
This occurs roughly once per week and last anywhere from 1 to 24
hours. With these episodes he experiences shortness of breath,
fatigue and had one episode of syncope. Now presents for
surgical evaluation for surigcal management.
Past Medical History:
Paroxysmal Atrial Fibrillation, Hypertension, Hemorrhoids,
Benign Prostatic Hypertrophy, s/p Appendectomy, s/p anal abscess
I&D, s/p finger and toe surgery, low testosterone
Social History:
Patient lives with his wife. [**Name (NI) **] is a former tobacco user,
quit in [**2136**], used to smoke ~ 1 PPD x 30 years. Occasional ETOH.
No drugs.
Family History:
Non-contributory
Physical Exam:
VS: 70, 12, 146/90, 72", 210#
General: WDWN male in NAD
Skin, Warm, dry, multiple nevi
HEENT: EOMI, PERRL, OP benign
Neck: Supple, FROM, -JVD, -carotid bruits
Chest: CTAB -w/r/r
Heart: RRR, -c/r/m/g
Abd: Soft, NT/ND. +BS
Ext: Warm, well-perfused, -edema
Neuro: A&O x 3, MAE, non-focal
Discharge
Vitals A/O x3, nonfocal
Pulm CTA SQ emphysema right and left chest into left shoulder
Cardiac RRR no murmur/rub/gallop
Abd soft, NT, ND +BS
Ext warm pulses palpable no edema
Inc rt and lt mini thoracotomy healing, old ct sites with DSD
maintain until [**3-1**] then OTA
Pertinent Results:
[**2158-2-26**] 04:20AM BLOOD WBC-6.6 RBC-4.19* Hgb-12.9* Hct-36.9*
MCV-88 MCH-30.7 MCHC-34.9 RDW-13.4 Plt Ct-160
[**2158-2-22**] 04:58PM BLOOD WBC-14.3*# RBC-4.78 Hgb-14.3 Hct-41.6
MCV-87 MCH-29.9 MCHC-34.3 RDW-13.4 Plt Ct-172
[**2158-2-27**] 10:05AM BLOOD PT-16.9* INR(PT)-1.6*
[**2158-2-22**] 04:58PM BLOOD PT-12.9 PTT-30.6 INR(PT)-1.1
[**2158-2-22**] 04:58PM BLOOD Plt Ct-172
[**2158-2-26**] 04:20AM BLOOD Glucose-132* UreaN-24* Creat-1.2 Na-135
K-4.1 Cl-101 HCO3-31 AnGap-7*
[**2158-2-22**] 04:58PM BLOOD UreaN-21* Creat-0.9 Na-140 Cl-106 HCO3-24
[**2158-2-26**] 04:20AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.7*
CHEST (PA & LAT) [**2158-2-26**] 10:45 AM
CHEST (PA & LAT)
Reason: PTX evaluation
[**Hospital 93**] MEDICAL CONDITION:
70 year old man s/p mini maze
REASON FOR THIS EXAMINATION:
PTX evaluation
CHEST, TWO VIEWS ON [**2-26**].
HISTORY: Mini maze, followup pneumothorax.
FINDINGS: Again noted are bilateral pneumothoraces, left greater
than right, with a large amount of subcutaneous emphysema left
greater than right. There is increased opacity in the right mid
lung laterally that is similar compared to the prior study.
There are small bilateral effusions.
DR. [**First Name (STitle) **] [**Doctor Last Name **]
Approved: SUN [**2158-2-26**] 12:28 PM
Sinus rhythm
Probable left atrial abnormality
Early precordial QRS transition - may be normal variant
Consider pericarditis
Since previous tracing of [**2158-2-22**], findings suggestive of
pericarditis now
present
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
71 164 92 378/400.14 20 -15 6
PATIENT/TEST INFORMATION:
Indication: Pulmonary vein isolation and Left atrial appendage
ligation. Intraoperative echocardiography
Height: (in) 72
Weight (lb): 210
BSA (m2): 2.18 m2
BP (mm Hg): 125/78
HR (bpm): 65
Status: Inpatient
Date/Time: [**2158-2-22**] at 11:19
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW000-0:0
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.7 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.0 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.7 cm (nl <= 5.0 cm)
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.1 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 4.4 cm
Left Ventricle - Fractional Shortening: *0.14 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 55% to 65% (nl >=55%)
Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.6 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 0.7 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 2 mm Hg
Aortic Valve - Mean Gradient: 1 mm Hg
Aortic Valve - Valve Area: 4.5 cm2 (nl >= 3.0 cm2)
Mitral Valve - Peak Velocity: 0.5 m/sec
Mitral Valve - E Wave: 0.5 m/sec
Mitral Valve - A Wave: 0.5 m/sec
Mitral Valve - E/A Ratio: 1.00
Mitral Valve - E Wave Deceleration Time: 203 msec
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement. No spontaneous [**Last Name (NamePattern1) 113**]
contrast is seen in
the LAA. Depressed LAA emptying velocity (<0.2m/s) No thrombus
in the LAA. All
four pulmonary veins identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Lipomatous
hypertrophy of
the interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D
images. Normal LV wall thicknesses and cavity size. Normal LV
wall thickness.
Normal LV cavity size. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in
aortic root. Mildly dilated ascending aorta. Normal aortic arch
diameter.
Normal descending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.
MITRAL VALVE: Normal mitral valve leaflets. No MS. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. The
patient has runs of
a supraventricular tachycardia. Results were personally reviewed
with the MD
caring for the patient.
Conclusions:
Pre-Ablation: The left atrium is moderately dilated. No
spontaneous [**Last Name (NamePattern1) 113**]
contrast is seen in the left atrial appendage. No thrombus is
seen in the left
atrial appendage. All 4 pulmonary veins are seen with normal
flow profile in
each. The right atrium is mildly dilated. No atrial septal
defect is seen by
2D or color Doppler. Left ventricular wall thicknesses and
cavity size are
normal. Left ventricular wall thicknesses are normal. The left
ventricular
cavity size is normal. Overall left ventricular systolic
function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) appear
structurally normal with good leaflet excursion. There is no
aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are
structurally normal. Trivial mitral regurgitation is seen. There
is no
pericardial effusion.
Post Ablation: Flow is seen in all 4 pulmonary veins. The left
atrial
appendage is no longer visible s/p ligation. Biventricular
function is
unchanged. Remaining exam is unchanged. All findings discussed
with surgeons
at the time of the exam.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2158-2-22**] 15:28.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Mr. [**Known lastname 3597**] was a same day admit and underwent all pre-operative
work-up as an outpatient. On day of admission he was brought to
the operative room where he underwent bilateral mini thoracotomy
with Maze procedure and resection of left atrial appendage.
Please see operative report for details. Following surgery he
was transferred to the CSRU for invasive monitoring in stable
condition. Later on op day he was weaned from sedation, awoke
neurologically intact and was extubated. On post-op day one his
right chest tube was removed and he was transferred to the
telemetry floor. There appeared to be a very small left apical
pneumothorax and therefore his left chest tube was removed on
post-op day two. He continued to do well but remained for
evaluation of sq emphysema and apical pneumothorax. He was
ready for discharge home POD 5 with plan for f/u CXR [**3-7**] and
wound check.
Medications on Admission:
Aspirin 325mg qd, Toprol XL 75mg qd, Lisinopril 2.5mg qd, Flomax
0.4mg qd, Androderm 5mg patch qd, HCTZ 25mg qd, Peiostat 20mg
[**Hospital1 **]
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 10 days: please take with food.
Disp:*30 Tablet(s)* Refills:*0*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
Disp:*60 Tablet(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. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
7. Warfarin 3 mg Tablet Sig: Two (2) Tablet PO once a day:
please take 6mg [**2-27**] and [**2-28**] - have INR checked [**3-1**] results to
Dr [**Last Name (STitle) 5444**] goal INR 2-2.5.
.
Disp:*60 Tablet(s)* Refills:*0*
8. Outpatient [**Name (NI) **] Work
PT/INR as needed
goal 2-2.5 first check [**3-1**] with results to Dr [**First Name8 (NamePattern2) 233**] [**Last Name (NamePattern1) 5444**]
([**Telephone/Fax (1) 250**])
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Paroxysmal Atrial Fibrillation s/p Bilateral mini thoracotomy
with Maze procedure and resection of left atrial appendage
PMH: Hypertension, Hemorrhoids, Benign Prostatic Hypertrophy,
s/p Appendectomy, s/p anal abscess I&D, s/p finger and toe
surgery, low testosterone
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive if you take pain medications.
Shower daily, let water flow over wounds, pat dry with a towel.
Leave dressing on until wednesday Am and then remove and leave
open to air
Do not use lotions, powders, or creams on wounds.
Call our office for temp>101.5, drainage from incision, or
shortness of breath
Followup Instructions:
Please schedule the following:
Dr. [**Last Name (STitle) 914**] in 4 weeks
Dr. [**Last Name (STitle) **] in [**12-24**] weeks
Dr. [**Last Name (STitle) 6955**] in [**11-22**] weeks
Wound check and Xray Tuesday [**3-7**] at 1300 - please go to
radiology Clinical center [**Location (un) 470**] for xray then to [**Hospital Ward Name **] 2 for
wound check
PT/INR goal 2-2.5 first check [**3-1**] with results to Dr [**First Name8 (NamePattern2) 233**]
[**Last Name (NamePattern1) 5444**] ([**Telephone/Fax (1) 250**])
Already scheduled appointments:
Provider: [**Name10 (NameIs) **] [**Name10 (NameIs) **] TESTING Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2158-3-1**]
10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5447**], M.D. Date/Time:[**2158-5-19**] 9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2159-1-3**] 2:40
Completed by:[**2158-3-1**]
ICD9 Codes: 5119, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8360
} | Medical Text: Admission Date: [**2140-9-2**] Discharge Date: [**2140-9-18**]
Date of Birth: [**2098-11-11**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10644**]
Chief Complaint:
Abdominal pain.
Major Surgical or Invasive Procedure:
1) US guided paracentesis
2) right IJ
3) ERCP
History of Present Illness:
Ms. [**Known lastname 18323**] is a 41 year old female with history of metastatic
melanoma status post recent spinal fusion surgery for multiple
metastatic spinal lesions, recently discharged from the surgical
service on [**2140-8-31**], who was transferred from an OSH today with
severe abdominal pain. On [**8-31**] (the day of discharge), at around
midnight she was awoken from sleep by the sudden onset of LLQ
abdominal pain which she cannot quantify or qualify, but states
that it felt as though her abdomen was bursting open. Her pain
then migrated to the LUQ and has remained a diffuse pain in the
epigastric region. The pain does not radiate to her back and she
cannot report a certain position which makes the pain better.
She did experience some nausea upon arrival to the ED but she
does not report emesis. She has been constipated, and has
received suppositories. At home she had sweats but not fever per
her sister. She denies cough, chest discomfort, difficulty
urinating, worsening of her back pain, focal weakness, change in
bowel or bladder habits.
She presented to [**Hospital 1562**] Hospital where she was found to have a
WBC = 26K and ALP = 182, amylase = 283, lipase = 772. She
recived NS x 1L, dilaudid 3 mg IV, zofran 4 mg IV, and 4.5 mg IV
zosyn. She was then transferred to the [**Hospital1 18**] ED for further
management. In the ED her vitals on presentation were: 99, 113,
175/103, RR = 20, 97% O2 on room air. She received 8 mg IV
dilaudid, promethiazine, lorazepam 2mg IV, and zosyn 4.5 gm IV x
1. She was also given 4.5 L NS. An NGT was placed. A CT scan
of the abdomen demonstrated a dramatic worsening of disease.
She was evaluated by general surgery who thought that the
patient required ICU monitoring but did not see her as a
surgical patient. She was thus transferred to the [**Hospital Unit Name 153**] for
closer monitoring, pain control and fluid resuscitation. She had
an MRI of her spine prior to transfer, the result of which is
still pending.
Past Medical History:
Oncologic history:
1) Melanoma: s/p wide local excision of melanoma of the left
groin on 02/[**2136**]. Path demonstrated superficial spreading
melanoma, max depth of 1.3 mm, [**Doctor Last Name **] level IV with no ulceration
and lymphovascular invastions. Tumor involved the lateral deep
margins. s/p re-excision on [**2136-3-23**] - no residual melanoma
[**4-18**] LN negative.
Developed back pain 4 mths ago which did not resolve with pain
meds and MRI demonstrated on [**8-9**] demonstrated signal change @
L3 and L4 and a paraspinal mass R iliac creast and metastatic
lesion in S2 vertebral body. Medial LL mass, [**2140-8-12**]- negative
CT of head, bone scan demonstrated increased uptake.
2) Reflux
3) otosclerosis
4) Anorexia
Social History:
She is single, living with her mother. She was living in
[**State 108**], but came to [**Location (un) 86**] recently for further treatment of
her melanoma. She has a long drinking history, but hasn't drank
recently.
Family History:
Non-contibutory
Physical Exam:
Vitals: Tm = 100.4, BP = 154/95, P 125, RR = 22, 97% on RA.
Gen: Slim caucasian female appearing uncomfortable, slightly
obtunded: Falling asleep while talking.
HEENT: Dry mucous membranes, anicteric sclerae, NGT in place.
eEck: Tender to palpation on R aspect of her neck. Firm, fixed
nodule in R lobe of thyroid, approximately 3x3cm. Additionally
tender R anterior cervical LAD. Small LN felt on L lateral
side.
Lungs: Rales at bases b/l.
Cor: RR, tachycardic, no m/r/g.
ABD: Hypoactive bowel sounds, tender to palpation in LUQ/LLQ.
No guarding, mild rebound. Oblique incision with intact sutures
extending across L flank - mild erythema, no exudate.
EXT: No c/c/e, DP present b/l.
NEURO: Moving all extremities.
Pertinent Results:
[**2140-9-1**] 11:00PM BLOOD WBC-31.9*# RBC-3.27* Hgb-10.2* Hct-31.1*
MCV-95 MCH-31.3 MCHC-32.9 RDW-13.6 Plt Ct-691*
[**2140-9-2**] 07:55AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2140-9-1**] 11:00PM BLOOD PT-13.0 PTT-23.7 INR(PT)-1.1
[**2140-9-16**] 12:10AM BLOOD Fibrino-750*
[**2140-9-1**] 11:00PM BLOOD Glucose-99 UreaN-11 Creat-0.4 Na-137
K-4.4 Cl-103 HCO3-22 AnGap-16
[**2140-9-1**] 11:00PM BLOOD ALT-47* AST-38 AlkPhos-159* Amylase-198*
TotBili-0.3
[**2140-9-1**] 11:00PM BLOOD Lipase-489*
[**2140-9-2**] 07:55AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.3*
[**2140-9-1**] 11:00PM BLOOD Albumin-3.3*
[**2140-9-2**] 07:55AM BLOOD Triglyc-140
[**2140-9-1**] 11:19PM BLOOD Lactate-1.3
[**2140-9-2**] 12:15AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.018
[**2140-9-2**] 12:15AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2140-9-2**] 12:15AM URINE RBC-[**12-4**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2140-9-2**] 08:50AM URINE UCG-NEGATIVE
.
MRI Spine [**9-2**]: Soft tissue mass involving L4, L5 and R psoas,
extending into retroperitoneum. spinal canal cannot be assessed
properly due to artifact from metal fusion device.
CT abd/pelvis [**9-2**]: IMPRESSION:
1. Findings consistent with mild pancreatitis by CT with no
drainable collections.
2. Interval laminectomies and spinal fusion hardware spanning
the region of the previously identified pathological fracture of
L4. There is a large amount of associated fluid and foci of gas
anterior to the spine at this level along the left psoas muscle
and in the periaortic region. This is presumably postoperative
in nature but the possibility of infection cannot be entirely
excluded.
3. Redemonstration of numerous metastatic lesions with evidence
for disease progression given slight interval increase in size
over the short time interval. This is best demonstrated by the
increase in size of the pancreatic head mass.
4. Interval increase in development of multiple cysts within the
kidneys. Presumably physiologic follicles.
CXR [**9-2**]: ?LLL infiltrate.
Brief Hospital Course:
## Pancreatitis - pt found to have pancreatitis with elevation
of amylase and lipase. MRCP was done which showed proximal
pancreatic duct obstruction by tumor with distal dilation. Pt
was made NPO and given IVF. After some improvement in abdominal
pain and decrease in amylase and lipase, an ERCP was performed
with stenting of her pancreatic duct. Pt's abdominal pain
gradually improved and amylase and lipase normalized. Patient's
diet was advanced as tolerated however she took in minimal PO.
.
## Pain control - pt was on a dilaudid PCA. An attempt was made
to transition her to a fentanyl patch and PO morphine for
breakthrough in preparation for discharge to rehab however,
patient did not tolerate the change. Patient was resumed on the
PCA.
.
## Abdominal distention - pt developed increasing abdominal
distension thought to be secondary to narctoics for pain control
and bed rest. She was encouraged to ambulate and given an
aggressive bowel regimen. Also patient had ascites thought to
be secondary to malignant spread. Patient was given IV lasix
with good diuresis and underwent US guided paracentesis with
drainage of 1.4 liters of bloody ascitic fluid.
.
## Fever, leukocytosis: pt experienced sporadic low grade fevers
which were attributed to her pancreatitis. Labs did not reveal
a left shift or bandemia. She remained without cough despite
question of pneumonia on a portable X-ray. Initially she was
started on levofloxacin, but this was discontinued due to
abscence of symptoms and she remained without any cough or
clinical worsening following this. Blood cx's were persistently
normal. A UTI with enteroccocus on previous admission resolved
and urine cx was negative. Pt's prior spine surgeyr sites were
monitored and no evidence of infection was found. Urine grew
yeast, foley was removed and patient was encouraged to ambulate.
Patient was restarted on empiric coverage with IV levoquin.
Blood cultures remained negative. Patient's foley was
discontinued secondary to yeast which grew on urine cultures x2.
Repeat urinanalysis was negative for yeast.
.
## Melanoma: patient with dramatic spread of disease over
several weeks since prior hospitalization. Some R neck fullness
initially noted, neck U/S with heterogeneous masses consistent
with metastases. Patient was intially followed in preparation
for initiating biologics however patient was not interested in
rehab in order to regain strength prior to treatment. Plan for
biologics were held off until patient was more stable.
.
## F/E/N: pt initially given IVF with dextrose. Central line
was placed and TPN initiated. Following pancreatic stenting, pt
started taking clear sips and diet was advanced slowly as
tolerated. Triple lumen was placed and was receiving TPN due to
insufficient PO.
.
## Hypertension: Patient was started on PO antihypertensives.
Labetalol was titrated up and the clonidine patches were
transitioned off. Patient's hypertension was thought to be
related to melanoma involvement of her adrenal gland as seen
previously on abdominal CT.
.
## s/p spine surgery - Continued to monitor for possible
infection. Pain was not well controlled on fentanyl patches and
patient was resumed on original dilaudid PCA dosing from [**9-13**]
prior to conversion.
.
## PPx: SQ heparin, bowel regimen.
.
## Family meeting was held with health proxy and oncology team
and patient was made CMO. Patient subsequently passed away with
her family at the bedside [**2140-9-18**].
Medications on Admission:
1. Fentanyl 100 mcg/hr Patch 72HR
2. Lorazepam 0.5 mg Tablet
3. Oxycodone-Acetaminophen 5-325 mg
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release
5. Cyclobenzaprine 10 mg Tablet
6. Zolpidem Tartrate 5 mg Tablet
7. Nystatin 100,000 unit/mL Suspension
8. Docusate Sodium 100 mg Capsule
9. Senna 8.6 mg Tablet
10. Bisacodyl 10 mg Suppository
Discharge Disposition:
Expired
Discharge Diagnosis:
metastatic melanoma
Discharge Condition:
deceased
Completed by:[**2140-10-8**]
ICD9 Codes: 486, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8361
} | Medical Text: Admission Date: [**2153-12-18**] Discharge Date: [**2154-1-1**]
Date of Birth: [**2082-7-24**] Sex: F
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11304**]
Chief Complaint:
Elective nephrectomy for metastatic renal cell carcinoma
Major Surgical or Invasive Procedure:
Left radical nephrectomy
History of Present Illness:
This is a 71 year-old woman with metastatic renal cell
carcinoma diagnosed in [**3-22**] and COPD being transferred to the
[**Hospital Unit Name 153**] s/p left radical nephrectomy for respiratory monitoring.
Patient was hypoxic to the 80's prior to intubation and
therefore aneasthesia and surgery preferred monitoring in ICU
with likely extubation tomorrow AM. History obtained largely
from providers and their notes, patient intubated, sedated.
As per anaesthesia and surgery, surgery was uneventful, no
complications.
On arrival, patient easily arousable, denies pain.
Past Medical History:
Metastatic renal cell carcinoma
COPD, FEV1 2.17-67%predicted
Cholecystectomy.
Status post surgical repair of uterine prolapse, TAH/BSO
Obesity
Heavy Smoker
H/o DVT s/p IVC filter implantation
Social History:
The patient lives with her daughter in [**Name (NI) 8391**]. She
formally worked in a factory, however, denies any chemical or
radiation or asbestos exposure to her knowledge. She also
worked at stop-and-shop briefly. She reports a 80-pack-year
history of tobacco. She quit approximately 9 years ago. She
reports occasional alcohol use, however, none currently
Family History:
Her mother died in her 50s from a postoperative pulmonary
embolus. Father died in his 70s from congestive heart failure.
She reports having 5 siblings. Her brother with esophageal
cancer and there is a prominent family history of type
2 diabetes. She is of Irish descent. She has 6 children all of
whom are in good health. There is no family history of breast,
GYN, colonic, or renal cell cancer in the family.
Physical Exam:
VS: Temp: 98.1 BP:124 /66 HR:75 RR:12 99% O2sat
I/O: 2750/540--last 24 hours/Weight 106.7
Vent setting: AC 12x700 (no spont breaths) FiO2 of 60% PEEP:5
ABG:7.34/51/233
general: intubated, sedated, easily arousable
HEENT: PERLLA, EOMI, anicteric, no sinus tenderness, MMM, op
without lesions, no supraclavicular or cervical lymphadenopathy,
no jvd
lungs: CTA b/l with good air movement throughout
heart: RR, S1 and S2 wnl, distant heart sounds, no murmurs, rubs
or gallops appreciated
abdomen: obese, large ventral hernia, +b/s, soft, nt,
left flank: large dressing in place, NT, without signficant
bleeding
extremities: no edema, pneumoboots
skin/nails: no rashes/no jaundice
neuro: sedated, easily arousable, responsive to commands, moves
all four extremities, wiggles toes and squeezes fingers to
command
Brief Hospital Course:
ICU and hospital course:
Mrs. [**Known lastname **] is a 71 yo F with a PMH of metastatic renal cell
carcinoma, COPD, chronic kidney disease, h/o DVT who presented
to the ICU after a nephrectomy. Prior to the nephrectomy, she
was mildly hypoxic, and it was felt that she would not be easy
to extubate.
## Respiratory failure: The pt arrived to the ICU intubated and
sedated. Her sedation was slowly weaned and she was extubated
successfully on the day after admission. She continued to
require oxygen by nasal canula to maintain O2 sats in the 90s.
Her hypoxia was likley secondary to chronic insufficiecny in the
context of atelectasis and volume overload. She was continued on
her fluticasone/salmeterol 500/50 and albuterol and ipatropium
nebulizer treatments prn. She will need supplemental O2 on
discharge. On discharge she was sating at 95% on 2L (pre-op
88-92% on RA).
## s/p nephrectomy: pt tolerated the procedure well. She
initially had pain at the surgical site which slowly resolved.
Her wound was C/D/I at discharge after staples were removed. Her
final pathology revealed conventional (clear cell) renal cell
carcinoma pT3a: tumor directly invades adrenal gland or
perirenal and/or renal sinus fat but not beyond Gerota's fascia;
spoke with Dr. [**Last Name (STitle) **] regarding her follow-up and the results of
the lung biopsy, which after review are consistent with
metastatic disease obviating the need for a lung biopsy. She
will follow-up with Dr. [**Last Name (STitle) **] in the next week in clinic and is
instructed to call to confirm this appt; in addition she is
scheduled for CT Chest [**1-2**].
## ileus/SBO: patient stopped passing flatus and had worsening
abdominal distention. She then had bilious emesis x 2 for a
total of 600 cc. An NG tube was placed which returned 200 cc of
bilious, nonbloody fluid. Abdominal imaging showed evidence of
small bowel dilation consistent with ileus vs. obstruction. As
patient's operation was not within the peritoneal cavity but
retroperitoneal, it was believed to be more likely ileus in the
setting of increased pain med requirements. Indeed her prolonged
hospital course was secondary to a prostracted ileaus that was
initially managed with NGT/decompression however by POD [**11-28**]
the NG was remvoed, her diet was advanced and she tolerated it
well. Of note, she consistently passed flatus and had BMs
throughout the ileus. Also, C Diff was sent which was negative.
Interval KUBs would show dilated small loops with AFLs, no free
air that would resolve thorughout her course. She was placed on
RTC Reglan toward the end of her course to expedite resolution;
GI was curbsided and beleived she has a protracted ileus that
was responded to conservative measures. In addition surgery was
consulted and recommended similar conservative measures. By the
end of her hospital course she was tolerating a regular diet and
having regular bowel movements.
## CKD: Baseline Cr 1.2-1.4. Normal increase in Cr after
nephrectomy is approximately 30-40%. Her creatinine was 1.6 on
discharge from the ICU. This had settled at 1.3 at time of
discharge. Her lytes were otherwise stable throughout; her
potassim was optimized.
## Hyperglycemia: Likely in setting of stress from surgery and
mild underlying insulin resistance. Was no longer requiring
insulin at time of discharge from the ICU.
## h/o DVT: Should likely be on life-long anticoagulation given
she had a malignancy-associated DVT. Was maintained on heparin
SC TID while in house. Will need to restart warfarin 1-2 weeks
post-op.
## Dispo: PT worked throughout her course and she successfully
ambulated with assistance. She will need to continue aggressive
PT at rehab.
Medications on Admission:
see H&P
Discharge Medications:
1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
2. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
[**12-18**] Disk with Devices Inhalation [**Hospital1 **] ().
3. Acetaminophen 650 mg Suppository Sig: [**12-18**] Suppositorys Rectal
Q6H (every 6 hours) as needed for fever, pain.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze.
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Metastatic Renal Cell Carcinoma
Discharge Condition:
Good
Discharge Instructions:
Please see the nephrectomy discharge instructions
* Increasing pain or persistent pain that is not relieved by
pain medications
*Inability to urinate
* Fever (>101.5 F)
*Nausea or Vomiting that last longer than 24 hours
* Inability to pass gas or stool
* Other symptoms concerning to you
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) 3748**] in [**1-20**] weeks. Call ([**Telephone/Fax (1) 39050**] to make an appointment.
Please follow up with Hematology Oncology, Dr. [**Last Name (STitle) **] at
[**0-0-**]. You have an appt. for next week. This was
confirmed with Dr. [**Last Name (STitle) **]. She is scheduled for CT Chest [**1-2**]
coordinated with Heme-Oncology.
Completed by:[**2154-1-1**]
ICD9 Codes: 496, 5180, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8362
} | Medical Text: Admission Date: [**2191-7-3**] Discharge Date: [**2191-7-14**]
Date of Birth: [**2155-6-10**] Sex: M
Service: SURGERY
Allergies:
Cortisone / Prednisone / Adhesive Tape
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Total Colectomy
History of Present Illness:
36 yo with UC pan colitis found recently to have rectosigmoid
adenocarcinoma, with local extension planned for total colectomy
has been undergoing neoadjuvant chemotherapy, on day 4 of 5FU
and 3 days of XRT presents after significant BRBPR and
lightheadedness.
.
He states that he has had relatively poorly controlled UC over
the past 10 years, complications of rash and perianal fistula in
past but not currently, on salicylates (not tolerated), steroids
(not effective and steroid psychosis) and remicaide in past- now
on rifaximin as well as [**Doctor First Name 130**] and cromolyn to control his GI
symptoms. His UC has been relatively stable recently, a "few"
painful bowel movements in the a.m. with some blood and mucous.
Baseline mild nausea.
.
This morning he awoke and began having LLQ and RLQ abdominal
pain in addition to profusely bloody bowel movements- initially
slightly formed stool then progressing to stool consisting
mainly of blood. He describes it as bright red, without clots,
and roughly 1 liter in total. He felt very lightheaded with the
BMs and needed to lay on the ground to prevent passing out. By
the time he was admitted he states he had about 50 bowel
movements and the bleeding had significantly decreased and his
RLQ and LLQ abd pain was subsiding. Mild nausea. Pain was
cramping and would fluctate in severity.
.
No chest pain, shortness of breath, fevers, chills, or other
symptoms. Currently feels very mildly lightheaded
Past Medical History:
Rectosigmoid Adenocarcinoma- T3 lesion on MRI and enlarged lymph
nodes (not clearly mets vs. IBD associated)- extensive local
extension into mesorectal fat- planned for neoadjuvant chemo and
concurrent chemoradiation. 5FU and XRT with plans for
subsequent surgery- began 5FU on [**6-29**].
Ulcerative Colitis- diagnosed 10 years ago- c/b perianal fistula
Colon CMV infection
Mitral Valve Prolapse
Migraines
Osteoporosis- secondary to steroids
Hyperparathyroidism
Social History:
Lives alone, has PhD in biomedical engineering and molecular
biology, post doc studies at BU. No tob, ETOH or drug use.
Family History:
Father with Ulcerative Colitis. Father w/ CAD, stroke at 69.
Died at 69. Mother alive, hypothyroidism and migraines.
Healthy Brother.
Physical Exam:
Tmax: 37.9 ??????C (100.2 ??????F)
Tcurrent: 37.9 ??????C (100.2 ??????F)
HR: 97 (87 - 97) bpm
BP: 147/66(88) {130/66(85) - 147/71(88)} mmHg
RR: 16 (15 - 16) insp/min
SpO2: 100%
Physical Examination
General Appearance: Well nourished, Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,
(Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Bowel sounds present, No(t) Distended, Tender:
RLQ tenderness without rebound, no masses or organomegaly
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
.
At Discharge:
AVSS
Gen: NAD, A/Ox3
CV: RRR
RESP: CTAB
ABD: +BS, soft, ND, appropriately TTP, RLQ stoma beefy red,
viable with liquid brown stool, +flatus
Incision: midline OTA CDI
Extrem: no c/c/e
Pertinent Results:
[**2191-7-3**] 11:10AM WBC-4.4 RBC-5.38 HGB-12.7* HCT-41.6 MCV-77*
MCH-23.7* MCHC-30.7* RDW-14.4
[**2191-7-3**] 11:10AM NEUTS-80.1* LYMPHS-18.0 MONOS-0.6* EOS-1.1
BASOS-0.2
[**2191-7-3**] 11:10AM PLT COUNT-446*
[**2191-7-3**] 11:10AM PT-12.5 PTT-26.2 INR(PT)-1.1
[**2191-7-3**] 11:10AM LIPASE-22
[**2191-7-3**] 11:10AM ALT(SGPT)-12 AST(SGOT)-24 ALK PHOS-115 TOT
BILI-1.9* DIR BILI-0.2 INDIR BIL-1.7
[**2191-7-3**] 11:10AM GLUCOSE-167* UREA N-15 CREAT-1.1 SODIUM-137
POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-20* ANION GAP-20.
[**2191-7-12**] 04:39AM BLOOD WBC-5.3 RBC-4.00* Hgb-10.3* Hct-31.6*
MCV-79* MCH-25.7* MCHC-32.5 RDW-17.1* Plt Ct-422
[**2191-7-11**] 05:14AM BLOOD Glucose-96 UreaN-6 Creat-0.8 Na-141 K-3.8
Cl-105 HCO3-26 AnGap-14
[**2191-7-11**] 05:14AM BLOOD Calcium-8.1* Phos-3.8 Mg-2.0
.
[**2191-7-3**] CXR - SINGLE UPRIGHT VIEW OF THE CHEST AT APPROXIMATELY
1:40 P.M.:
IMPRESSION: No free air under the diaphragm. No acute
cardiopulmonary abnormalities.
.
Pathology Examination
Procedure date [**2191-7-5**]
DIAGNOSIS:
Colon, abdominal colectomy:
1. Well-differentiated colonic adenocarcinoma, see synoptic
report.
2. Chronic active and inactive colitis, consistent with
ulcerative colitis, with diffuse epithelial atypia, favor
reactive.
3. Focal active enteritis with villous atrophy.
4. Multiple fissures of distal colon with focal perforation and
peri-colic abscess formation.
5. Appendix with fibrous obliteration and focal surface
epithelium with atypia, favor reactive.
Colon and Rectum: Resection Synopsis
MACROSCOPIC
Specimen Type: Colonic resection. Location: Abdominal.
Specimen Size
Greatest dimension: 70.5 cm. Additional dimensions: 6 cm.
Tumor Site: Rectum.
Tumor configuration: Infiltrative.
Tumor Size
Greatest dimension: at least 5.2 cm. Additional
dimensions: 0.6 cm; see comment.
MICROSCOPIC
Histologic Type: Adenocarcinoma.
Histologic Grade: Low-grade (well or moderately
differentiated).
EXTENT OF INVASION
Primary Tumor: At least pT1: Tumor invades submucosa; see
comments.
Regional Lymph Nodes: pN2: Metastasis in 4 or more lymph
nodes.
Lymph Nodes
Number examined: 27.
Number involved: 5.
Distant metastasis: pMX: Cannot be assessed.
Margins
Proximal margin:
Uninvolved by invasive carcinoma: Distance of tumor
from closest margin: 700 mm.
Distal margin: Involved by invasive carcinoma.
Circumferential (radial) margin:
Uninvolved by invasive carcinoma: Distance of tumor
from closest margin: 35 mm.
Lymphatic Small Vessel Invasion: Absent.
Venous (large vessel) invasion: Absent.
Perineural invasion: Absent.
Tumor border configuration: Infiltrating.
Additional Pathologic Findings: Two tumor nodules are found in
peri-colic adipose tissue that lack residual nodal architecture
or capsule.
Comments: The exact size and depth of invasion (T stage) cannot
be determine as the tumor is present at the distal margin and
the entire tumor is not examined.
Clinical: Clinical diagnosis and data: Lower GI bleed.
Patient with history of ulcerative colitis and rectal carcinoma.
Brief Hospital Course:
36 yoM w/ a h/o ulcerative colitis and recent diagnosis of
rectosigmoid adenocarcinoma on neoadjuvant chemo (5FU and XRT x
3-4 days) presents with profuse BRBPR and lightheadedness. Plan
for colectomy but leaving tumor ?????? colectomy will allow for
chemotherapy in setting of severe UC.
.
1. GI bleed: s/p total colectomy- sparing rectum and colon CA
for further neoadjuvand chemo. Hartmanns pouch and ileostomy
on [**2191-7-5**] with Dr. [**Last Name (STitle) **]. Operative course uncomplicated.
Patient remained in [**Hospital Unit Name 153**] for close monitoring of Hct's, and
associated hypotension.
-+ ostomy output and rectal ouput post-op
-hypoactive bowel sounds, no nausea
-pain moderate, not very well controlled, per surgery switched
to morphine pca for more long acting pain control with better
control. Pain control switched to oral agents once tolerating
clear liquids. Reported pain <[**6-11**]. Dishcarged home with pain
medications.
-Diet advanced as bowel function resumed. Tolerated regular diet
without nausea/vomiting prior to discharge.
-Hct followed closely. Treated accordingly with transfusions.
HCT's remained stable for many days prior to discharge. No
further evidence of GI bleeding.
.
2. Ulcerative colitis: patient on a regimen of [**Doctor First Name 130**] 360mg
daily, rifaximin 800mg daily and cromolyn 400mg daily (when he
eats),
-GI and Onc following: Per GI recommendations, d/c'd rifaximin &
restarted on home dose of [**Doctor First Name 130**] & Cromolyn for management of
rectal bleeding.
.
3. Fever
-no clinical evidence of DVT, high fever w/o leukocytosis
however s/p chemo, not neutropenic, continue to follow ANC
-on cipro / flagyl, remained afebrile with normal WBC,
discontinued prior to discharge home.
-Blood cultures all with no growth. Urine cx from [**7-4**] grew
enterococcus which was treated with IV Cipro.
-Medical & radiation Oncology involved-recommended follow-up
Monday after discharge for re-assessment. Plan to resumes
Chemo/XRT depending on physical exam, and labowrk data.
.
Physical Therapy: Due to prolonged ICU stay, and deconditioning,
patient was evaluated by PT. PT worked with patient for a few
sessions, and cleared him for discharge home without PT
services. He continued to ambulate halls of 12 [**Hospital Ward Name **]
independently.
.
Ostomy: Patient followed by ostomy RN specialists during
admission. Competent with emptying pouch. Visiting RN services
set up for home to continue teaching, and assessment of
stoma/surgical wound. In addition to follow-up with Med/Rad
Oncology, patient advised to follow-up with Dr. [**Last Name (STitle) **] in
[**3-6**] weeks.
Medications on Admission:
Zinc
Vitamin D
B complex
Codeine 7.5mg daily prn diarrhea
Cromolyn 400mg daily
[**Doctor First Name **] 360mg daily
Rifaximin 800mg daily
Vitamin D 6000 units qod
MVI daily
Discharge Medications:
1. Cromolyn 100 mg/5 mL Solution Sig: One (1) 20mL PO daily ():
Take with food.
2. [**Doctor First Name **] 180 mg Tablet Sig: Three (3) Tablet PO once a day:
Prevention of rectal bleeding.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain: Do not exceed 4000mg/24hrs.
4. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
5. Centrum 0.4-162-18 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Vitamin D 1,000 unit Tablet Sig: Six (6) Tablet PO every
other day.
7. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours) as needed for pain
for 2 weeks: Take with food.
Disp:*35 Tablet Sustained Release(s)* Refills:*0*
8. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q3-4H () as
needed for breakthrough pain for 2 weeks: Take with food.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Flared ulcerative colitis with low abdominal peritonitis
(perforation of the rectum)
Anemia
.
Secondary:
UC, rectosigmoid adenoca w/CEA 1.9, [**5-25**] sig w/nodular heaped up
mucosa seen in the proximal rectum, PATHT well diff adenoca,
mitral valve prolapse, migraines
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* 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 skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or becoming
progressively worse, or inadequately controlled with the
prescribed pain medication.
* 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.
Incision Care:
*You may shower. Pat incision dry.
*Avoid swimming and baths until further instruction at your
followup appointment.
*Leave the steri-strips on. They will fall off on their own, or
be removed during your followup.
*Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Monitoring Ostomy Output / Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 500mL to 1000mL per day.
*If Ostomy output exceeds 1 liter, take 4mg of Imodium, repeat
2mg with each episode of loose stool. Do not exceed 16mg in 24
hours.
Followup Instructions:
Please call the office of Dr. [**Last Name (STitle) **] to make a follow up
appointment in [**3-6**] weeks. [**Telephone/Fax (1) 9**]
.
Please make a follow-up appointment with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 3613**]
[**Last Name (NamePattern1) 5085**] [**Telephone/Fax (1) **] in 1 week and as needed.
.
You have an appointment on Monday [**7-18**] with Radiation
Oncology service ([**Telephone/Fax (1) 8082**] at 8:30am located in [**Hospital Ward Name 332**]
basement.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2191-7-25**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2191-7-25**] 11:00
Completed by:[**2191-7-18**]
ICD9 Codes: 2762, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8363
} | Medical Text: Admission Date: [**2131-9-21**] Discharge Date: [**2131-10-2**]
Date of Birth: [**2074-12-18**] Sex: F
Service: MEDICINE
Allergies:
Iodine / Sulfa (Sulfonamide Antibiotics) / vancomycin
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
Intubation with mechanical ventilation
History of Present Illness:
Ms. [**Known lastname 6105**] is a 56 year-old woman with developmental delay,
diabetes, asthma, Crohn's disease on prednisone, latent TB on
INH and hepatitis B on lamivudine with recent MRSA bacteremia
initially on vancomycin and transitioned recently transitioned
to daptomycin secondary to drug rash who presented today after
being found unresponsive at her facility with a blood sugar of
40s. Of note 2 days prior to admission, her oral hypoglycemics
including Actos and glipizide were doubled.
.
Initial vital signs in the ED were 97.5 100 97/64 18 100% BG 43.
She received glucagon and 1 amp of D50 and repeat BG was 80. She
then ate dinner and repeat BG was 78. Prior to transfer the
patient was started on D5 1/2 NS at 125mL/hr. Vitals on transfer
were 98.0 84 14 100/49 14 98% on RA.
.
On the medical floor the patient appear comfortable and was
without additional complaint.
.
ROS: Denied fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
Crohns Disease, newly diagnosed, on prednisone
Asthma - never been intubated
glaucoma
DM2 - not on insulin
Barretts Esophagus
Systolic murmur
? s/p cholecystectomy
s/p jaw surgery
Social History:
Pt has cognitive delay; she lives alone and attends an adult day
program at Triangle Day Care (Telephone: [**Telephone/Fax (1) 90811**]) in [**Location (un) 3786**]
5 days a week. Her case manager from Nexus Inc, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28003**]
(office [**Telephone/Fax (1) 90812**], cell [**Telephone/Fax (1) 90813**]) has known her for >20
years and is her HCP. Pt reportedly can shop and cook for
herself, but [**First Name8 (NamePattern2) **] [**Doctor First Name **], the agency that [**Doctor First Name **] works for will
often step in and help with cooking. Even when they help her
cook, she winds up eating out -- mostly tuna subs, macaroni, and
donuts. She has a boyfriend of 11 years who is also
developmentally delayed, and she is very close to him.
Family History:
Her father died of heart disease around age 60; her mother was
reportedly an alcoholic and is still alive, but they have not
been in touch since Ms. [**Known lastname 6105**] was very young. She has many
siblings (5 or 6), and at least 3 of them are also
developmentally delayed / special needs.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals: 98.3 87 70 14 100% on RA
GENERAL: Comfortable in NAD, answers questions appropriately
HEENT: Pupils equal, round, reactive to light. Extraocular
muscles
intact. Sclerae are anicteric. Mucous membranes moist.
Oropharynx is clear. No oral ulcers.
NECK: No lymphadenopathy.
LUNGS: Clear to auscultation bilaterally. No wheezing or
rhonchi noted.
CARDIOVASCULAR: Regular rate, [**4-4**] holosystolic murmur, loudest
at left upper sternal border. Normal S1, S2.
ABDOMEN: Soft, nontender, nondistended, active bowel sounds.
EXTREMITIES: Warm and well perfused.
SKIN: Diffuse morbilliform rash, most prominent on the posterior
aspect of her arms bilaterally. Consistently blanchable. Mild
edema in lower extremities. No ulcers appreciated.
PHYSICAL EXAM ON DISCHARGE:
Unchanged from prior, except with mild degree of bilateral
diffuse wheezing
Pertinent Results:
ADMISSION LABS:
[**2131-9-21**] 12:55AM WBC-14.8* RBC-3.32* HGB-9.4* HCT-28.7* MCV-87
MCH-28.2 MCHC-32.6 RDW-17.6*
[**2131-9-21**] 12:55AM NEUTS-84.3* LYMPHS-10.3* MONOS-2.2 EOS-2.8
BASOS-0.3
[**2131-9-21**] 12:55AM PLT COUNT-419
[**2131-9-21**] 12:55AM GLUCOSE-61* UREA N-55* CREAT-1.8*# SODIUM-136
POTASSIUM-5.8* CHLORIDE-106 TOTAL CO2-22 ANION GAP-14
[**2131-9-21**] 12:55AM ALT(SGPT)-12 AST(SGOT)-14 CK(CPK)-22* ALK
PHOS-68 TOT BILI-0.1
[**2131-9-21**] 12:55AM LIPASE-33
[**2131-9-21**] 12:55AM CORTISOL-8.3
.
PERTINENT LABS:
[**2131-9-21**] 12:55AM BLOOD Glucose-61* UreaN-55* Creat-1.8*#
[**2131-9-28**] 07:00AM BLOOD Glucose-171* UreaN-26* Creat-1.1
[**2131-9-24**] 01:46AM BLOOD CK-MB-26* MB Indx-4.2 cTropnT-0.05*
proBNP-[**Numeric Identifier 37727**]*
[**2131-9-27**] 03:13AM BLOOD proBNP-7626*
[**2131-9-23**] 03:25PM BLOOD Type-ART pO2-62* pCO2-35 pH-7.33*
calTCO2-19* Base XS--6
[**2131-9-26**] 11:43AM BLOOD Type-ART Temp-36.7 Rates-/15 FiO2-50
pO2-84* pCO2-35 pH-7.41 calTCO2-23 Base XS--1 Intubat-NOT INTUBA
Comment-OPEN FACE
[**2131-9-23**] 03:25PM BLOOD Lactate-2.6*
[**2131-9-24**] 04:36AM BLOOD Lactate-1.3
.
.
DISCHARGE LABS:
[**2131-10-2**] 06:35AM BLOOD WBC-13.1* RBC-2.99* Hgb-8.7* Hct-27.3*
MCV-91 MCH-29.0 MCHC-31.7 RDW-17.7* Plt Ct-289
[**2131-10-2**] 06:35AM BLOOD Plt Ct-289
[**2131-10-1**] 06:35AM BLOOD Glucose-96 UreaN-21* Creat-0.7 Na-144
K-4.3 Cl-110* HCO3-23 AnGap-15
[**2131-10-1**] 06:35AM BLOOD ALT-72* AST-32 LD(LDH)-332* AlkPhos-118*
TotBili-0.3
[**2131-10-1**] 06:35AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.7
.
.
MICROBIOLOGY:
[**2131-9-23**] 12:33 am URINE Source: CVS.
**FINAL REPORT [**2131-9-26**]**
URINE CULTURE (Final [**2131-9-26**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S 4 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
.
[**2131-9-24**] 3:06 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
GRAM STAIN (Final [**2131-9-24**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2131-9-26**]): NO GROWTH, <1000
CFU/ml.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2131-9-25**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary):
YEAST.
ACID FAST SMEAR (Final [**2131-9-25**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
[**2131-9-24**] 3:06 pm Rapid Respiratory Viral Screen & Culture
BRONCHIAL LAVAGE.
**FINAL REPORT [**2131-9-27**]**
Respiratory Viral Culture (Final [**2131-9-27**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2131-9-25**]):
Less than 60 columnar epithelial cells;.
Specimen inadequate for detecting respiratory viral
infection by DFA
testing.
Interpret all negative results from this specimen with
caution.
Negative results should not be used to discontinue
precautions.
Refer to respiratory viral culture results.
Recommend new sample be submitted for confirmation.
Reported to and read back by DR [**Last Name (STitle) 90814**] [**Name (STitle) **] [**2131-9-25**]
11:33AM.
[**2131-10-1**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2131-10-1**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2131-9-28**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
NEGATIVE
[**2131-9-24**] CATHETER TIP-IV WOUND CULTURE-FINAL NEGATIVE
[**2131-9-24**] URINE Legionella Urinary Antigen -FINAL
NEGATIVE
[**2131-9-24**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {YEAST}
[**2131-9-24**] BLOOD CULTURE Blood Culture, Routine-FINAL
NEGATIVE
[**2131-9-23**] BLOOD CULTURE Blood Culture, Routine-FINAL
NEGATIVE
[**2131-9-21**] URINE URINE CULTURE-FINAL NEGATIVE
[**2131-9-21**] BLOOD CULTURE Blood Culture, Routine-FINAL
NEGATIVE
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2131-9-27**]):
No Cytomegalovirus (CMV) isolated.
REFER TO VIRAL CULTURE FOR FURTHER INFORMATION.
VIRAL CULTURE (Final [**2131-9-27**]):
RHINOVIRUS. PRESUMPTIVE IDENTIFICATION.
Reported to and read back by DR [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28089**]
[**2131-9-27**] 11:20 AM.
.
DIAGNOSTICS
===========
PA/LAT CXR [**2131-10-1**]
AP and lateral radiographs of the chest were reviewed in
comparison to
[**2131-9-27**] as well as several prior studies dating back
to [**2131-7-23**].
As compared to the most recent prior radiograph from [**9-27**] and
[**2131-9-26**], there is significant improvement in
widespread parenchymal opacities with the current study
representing mild interstitial pulmonary edema. There is small
focal opacity in the left upper lung and left lower lobe which
might reflect partial resolution of the infectious process.
Hilar enlargement is bilateral, unchanged and might potentially
correspond to hilar lymphadenopathy, although pulmonary
enlargement might be another possibility. There is no
appreciable pleural effusion, and there is no pneumothorax.
.
Portable TTE (Complete) Done [**2131-9-24**] at 3:06:14 PM
IMPRESSION: Moderate aortic valve stenosis. Pulmonary artery
hypertension. Right ventricular cavity enlargement with free
wall hypokinesis. Normal left ventricular cavity sizes with
preserved global systolic function. Increased PCWP.
Compared with the prior study (images reviewed) of [**2131-8-17**],
the severity of aortic stenosis has progressed, right
ventricular cavity size is now dilated with free wall
hypokinesis and the estimated PA systolic pressure is much
higher. The severity of mitral regurgitation seems reduced.
These findings are suggestive of an interim acute pulmonary
process, e.g., pulmonary embolism or other acute pulmonary
process..
.
Brief Hospital Course:
A/P: 56 year old woman with a history of cognitive delay, DMII,
recently diagnosed Crohn's disease on prednisone, probable
latent TB on INH, MRSA bacteremia from PICC on daptomycin (last
dose [**2131-9-24**]), who was admitted with hypoglycemia related to an
increase in her antihypoglycemic medications, with course
complicated by viral pneumonia and respiratory distress, now
resolved.
.
ACTIVE ISSUES:
.
# Hypoglycemia: Her presentation was related to aggressive
increase in oral hypoglycemics, after her hypoglycemic
medication dosages had been recently increased. She was treated
with D50 IV and her anti-hypoglycemics were held, glucose
normalized and her mental status returned to baseline. She was
maintained on a sliding scale insulin while in hospital. She
was discharged on antihypoglycemic regimen from prior to
medication increases prior to admission. We recommend continued
monitoring of her finger glucose and gradually increase
glipizide or pioglitazone as needed.
.
# Viral Pneumonia: On [**2131-9-23**], the patient was triggered for
tachypnea and increased work of breathing. Her CXR was
concerning for HCAP as well as vascular congestion. Patient
received 20mg of IV lasix as well as nebs. Antibiotics broadened
to cefepime, but had persistent tachypnea, with CXR
demonstrating worsening bilateral infiltrates. Again received
nebs, Lasix 20mg IV (last dose at MN) with UOP 1L. She continued
to have worsening respiratory function and was transferred to
the MICU in obvious respiratory distress with accessory muscle
use and audible grunting. The decision was made to electively
intubate with anesthesia/respiratory at bedside. During
intubation patient paralyzed with succ with initial transient
hypotension to the 70s. Uncomplicated intubation performed and
patient sedated with propofol and fentanyl. The cause of her
respiratory decompensation was probably multifactorial. Her
antibiotics were broadened to linezolid/cefepime/levofloxacin
for possible multifocal pneumonia. Given CXR evidence of
bilateral pulmonary edema, cardiogenic source was suspected and
she was diuresed. TTE revealed normal left ventricular function
but right ventricular overload thought to be related to her
acute pneumonic process. She underwent bronchoscopy on [**2131-9-24**]
which revealed +yeast, +PMN, and +rhinovirus, but no PCP or
bacteria. Her rhinovirus may have contributed to her diffuse
inflammatory process. PCP was [**Name Initial (PRE) **] concern due to her
unprophylaxed chronic steroid load of 30mg prednisone daily, and
indeed a beta glucan was positive, though this was felt to
represent her candidida from her lung. Her linezolid and
cefepime were discontinued, and she was continued on
levofloxacin 8d course for possible bacterial suprainfection.
She was successfully extubated on [**9-26**] and transferred to the
medicine service on [**9-27**], where she completed levofloxacin
course, oxygen staturation remained in the upper 90's on room
air, she ambulated the [**Doctor Last Name **] without dyspnea. She was discharged
with dextromethorphan-guaifenesin as needed for cough.
.
# Acute kidney injury: Baseline creatinine 0.7, she was admitted
with creatinine 1.8 related to dehydration. Lisinopril was held,
she was treated with intervenous fluids and her creatinine
improved. Lisinopril was resumed.
.
# Rash: Diffuse livido reticularis appearing rash. She was seen
by dermatology and it was felt to be a reaction to her
vancomycin, and she was switched to daptomycin and started on
topical triamcinolone and hydrocortisone and the rash improved.
.
# Urinary Tract Infection: Her urine culture revealed
pan-sensitive E. coli and Klebsiella, which was treated with her
levofloxacin regimen she took for possible bacterial
suprainfection of her viral pneumonia.
.
# MRSA bacteremia: High-grade bacteremia believed to be [**1-31**] to
prior PICC now removed or endocarditis for which she was to
complete a 6 weeks of vancomycin on [**2131-9-24**]. She was switched
to daptomycin on [**9-17**] following the onset of a new rash that
was believed to be vancomycin-related, and completed daptomycin
course on [**9-24**].
.
# Leukocytosis: Throughout hospital course, WBC ranged 9-19, the
day prior to discharge, WBC had trended up to 15 from 13. She
was kept an additional night and a basic infectious workup was
performed. Chest xray looked improved, UA was negative, and
blood cultures showed no growth in 24 hours. The following
morning ([**2131-10-2**]), WBC trended to 13, she was clinically well
appearing and was discharged. Leukocyutosis is likely related to
prednisone.
# Crohns disease: Increased prednisone to 40mg, and have since
resumed home 30mg dose. Started on atovaquone for PCP
[**Name Initial (PRE) 1102**].
.
# TB treatment: Prior to admission, patient had indeterminant
QuantiFERON Gold test.Patient was continued on treatment for
LTBI with isoniazid/B6 Day #1 = [**2131-8-16**] for 9 months. These
medicaitons should be discontinued after the 9 month course is
complete.
.
# Depression: Held home sertraline while on linezolid to prevent
serotonin syndrome. She became progressively anxious and
tearful. Resumed sertraline 250mg after confirming dose with
health care proxy and [**Name2 (NI) **] improved. No signs of serotonin
syndrome.
.
# Hepatitis B: Patient is Hep B surface antigen positive.
Continued home dose lamivudine 100 mg daily.
.
# Hypertension: Held lisinopril briefly due to [**Last Name (un) **]. Lisinopril
was resumed prior to discharge with adequate control.
.
# Asthma: Continued home fluticasone-salmeterol and started on
albuterol nebulizers.
.
# Glaucoma: Continued home Latanoprost
.
.
TRANSITIONAL ISSUES:
-routine follow-up with GI for Crohn's, infliximab treatment
-titration of her diabetes regimen with careful monitoring of
her blood glucose level
-follow-up with hepatology
- Follow up blood cultures [**2131-10-1**] which had shown no growth in
24 hours at the time of d/c
- Follow up acid fast culture from BAL [**2131-9-24**]
Medications on Admission:
Isoniazid 300 mg daily Day #1 = [**2131-8-16**] for 9 months
Pyridoxine 50 mg daily Day #1 = [**2131-8-16**] for 9 months
Omeprazole 20 mg daily
Lamivudine 100 mg daily Day #1 = [**2131-8-14**]
Sertraline 250 mg daily
Daptomycin for MRSA bacteremia Day 1 = [**2131-8-12**] to be complete
[**2131-9-22**]
Lisinopril 10 mg daily
Fluticasone-salmeterol 100-50 mcg 1 puff [**Hospital1 **]
Latanoprost 0.005 % OU HS
Metformin 1000 mg [**Hospital1 **]
Metoprolol succinate ER 75 mg daily
Januvia 100 mg daily
Pioglitazone 30 mg
Glipizide 10 mg daily
Prednisone 30 mg dialy
Pancrealipiase TID
Zyrtec 10 mg daily
Trazodone 50 mg QHS
Discharge Medications:
1. isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
for 9 months, day 1 [**2131-8-16**].
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. sertraline 50 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily): total dose 250mg.
4. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. latanoprost 0.005 % Drops Sig: One (1) Drop(s) in each eye
Ophthalmic HS (at bedtime).
6. prednisone 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily):
total dose 30mg daily.
7. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Day #1 = [**2131-8-14**].
11. atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg daily
PO DAILY (Daily): For PCP [**Name Initial (PRE) 1102**].
Disp:*250 mL* Refills:*2*
12. dextromethorphan-guaifenesin 10-100 mg/5 mL Liquid Sig: [**5-8**]
MLs PO Q4H (every 4 hours) as needed for cough.
Disp:*250 mL* Refills:*0*
13. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
15. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
16. pioglitazone 30 mg Tablet Sig: One (1) Tablet PO once a day.
17. Metoprolol succinate ER 75 mg daily
18. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO DAILY (Daily).
19. pyridoxine 50 mg Tablet Sig: One (1) Tablet PO once a day:
Day #1 = [**2131-8-16**] for 9 months
.
Discharge Disposition:
Extended Care
Facility:
Able Home Care
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Iatrogenic Hypoglycemia
SECONDARY DIAGNOSES:
Pneumonia
Urinary Tract Infection
Acute Kidney Injury
Dehydration
Drug Rash
Depression
Discharge Condition:
Mental Status: Coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 6105**],
You were admitted for treatment of low blood sugars, dehydration
and renal failure. You were treated with glucose infusions and
given fluids, and your condition improved. You were also seen by
our dermatologists who thought your rash might be due to
medication allergy to vancomycin, we treated you symptomatically
with creams and benadryl and your symptoms improved.
While in the hospital you had trouble breathing and had to be
placed on a ventilator. We determined that you had pneumonia,
we treated you with antibiotics and you improved.
.
While in the hospital you completed a 6 week course of
antibiotics for MRSA infection. Please follow up with infectious
disease for your MRSA infection, we have made an appointment for
you.
.
Please also keep your appointment for gastroenterology follow up
of your chron's disease.
The following changes were made to your medications:
- START Atovaquone
- START Albuterol inhaled as needed for wheezing
- START dextromethorphan-guaifenesin as needed for cough
.
- STOP Daptomycin
.
Please continue the rest of your medications without change.
Followup Instructions:
Please follow-up with your PCP at extended care facility
.
Please call ([**Telephone/Fax (1) 8132**] on Monday morning for follow-up
appointment with [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] within one week of your
discharge.
.
Please call([**Telephone/Fax (1) 4170**] on Monday morning for follow-up
appointment with [**Last Name (LF) **], [**Name8 (MD) **] MD within one week of your
discharge.
.
Please also keep the following appointments:
.
Department: LIVER CENTER
When: WEDNESDAY [**2131-10-3**] at 10:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFUSION/PHERESIS UNIT
When: WEDNESDAY [**2131-10-3**] at 2:00 PM [**Telephone/Fax (1) 14067**]
Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2131-10-17**] at 10:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Doctor Last Name **],PINKY
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Apartment Address(1) 90815**], [**Location (un) **],[**Numeric Identifier 90816**]
Phone: [**Telephone/Fax (1) 60787**]
****Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2131-10-24**] at 3:00 PM
With: [**First Name8 (NamePattern2) 4503**] [**Last Name (NamePattern1) 4504**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
ICD9 Codes: 5849, 5990, 7907, 311, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8364
} | Medical Text: Admission Date: [**2138-3-20**] Discharge Date: [**2138-4-7**]
Date of Birth: [**2091-2-17**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old
gentleman with hepatitis C cirrhosis who is high up on the
transplant list, who for the last five days prior to
admission had been having decreased appetite, fatigue,
nausea, and occasional vomiting.
The patient's diuretics were recently increased prior to
admission to Lasix 40 and Aldactone 100, but they were
decreased to Lasix 20 and Aldactone 50 for elevated
creatinines. The patient was found to have acute renal
insufficiency by laboratories in clinic and was asked to come
to the Emergency Department for further evaluation.
In the Emergency Department, laboratories revealed a
potassium of 6.7 and a creatinine of 4.3.
PAST MEDICAL HISTORY: (Significant for)
1. Hepatitis C cirrhosis; requiring liver transplantation,
the patient is currently on liver transplant list.
2. Hypertension.
3. History of nephrolithiasis.
MEDICATIONS ON ADMISSION:
1. Aldactone 50 mg.
2. Lasix 20 mg.
3. Flagyl 250 mg three times per day.
4. Quinine 325 mg once per day.
5. Protonix 40 mg once per day.
6. Magnesium oxide 800 mg twice per day.
7. Oxycodone 2 mg to 4 mg as needed.
ALLERGIES: The patient has allergies to CODEINE (which
causes gastrointestinal upset).
SOCIAL HISTORY: He lives at home with his wife. [**Name (NI) **] is a
past alcohol abuser who now works as a substance abuse
counselor.
FAMILY HISTORY: Significant for father who died of a
myocardial infarction at the age of 38.
PHYSICAL EXAMINATION ON PRESENTATION: On admission, the
patient was afebrile. He had a blood pressure of 130/58, a
pulse of 70, a respiratory rate of 20, and was saturating 97%
on room air. He was in no apparent distress. He was
anicteric. His pupils were reactive. His extraocular
movements were intact. The lungs were clear bilaterally.
His cardiac examination showed normal first heart sounds and
second heart sounds with a 2/6 systolic murmur at the right
upper sternal border. His abdomen was soft, mildly
distended, and nontender. He had no peripheral edema.
PERTINENT LABORATORY VALUES ON PRESENTATION: He had a white
blood cell count of 5.6, his hematocrit was 28.4, and he had
platelets of 101. He had an INR of 1.9. Chemistry-7 showed
an initial creatinine of 4.2 with a potassium of 6.7. After
gentle fluids and treatment for his potassium, he had a
repeat potassium of 5.7 and a creatinine of 3.9. He had an
alanine-aminotransferase of 57, his aspartate
aminotransferase was 166, his alkaline phosphatase was 101,
and his total bilirubin was 3.7.
PERTINENT RADIOLOGY/IMAGING: An electrocardiogram showed a
normal sinus rhythm. There were no peaked T waves.
Otherwise, his electrocardiogram was normal.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted
for his acute renal insufficiency. His Lasix and his
Aldactone were held. His hyperkalemia responded well to his
Kayexalate therapy.
The patient was noted to have some mild periorbital erythema
and edema on the right side of his face. He was initially
started on doxycycline for this presumed preseptal
cellulitis.
The patient's creatinine did initially improve; however, it
started to increase again slowly during the course of his
hospital stay. Initially, it was felt that the patient's
initial presentation of acute renal insufficiency was
secondary to aggressive diuresis; however, in the setting of
his diuretics being held and his continued increase in his
creatinine, it was possible that he could have the initial
stages of hepatorenal syndrome. The patient has had elevated
creatinines on previous hospitalizations, presumed to be
related to hepatorenal syndrome. The patient was started on
octreotide and midodrine.
Also in the setting of his acute renal insufficiency, his
tetracycline was held as it was possible that this could be a
contributing factor.
An Ophthalmology consultation was obtained which showed just
some very mild preseptal cellulitis with no orbital signs or
symptoms suggestive of an orbital cellulitis. The patient's
doxycycline was discontinued in favor of Keflex.
The patient did have urine eosinophils and sediment checked.
He had bland sediment which was not consistent with an acute
tubular necrosis type picture. The patient was also
transfused with 2 units of packed red blood cells for a low
hematocrit early on during the course of his hospital stay.
The patient did not have any upper endoscopy as his anemia
was not suspected to be secondary to esophageal varices.
The patient's creatinine continued to rise in the setting of
his octreotide and midodrine therapy. Because of this,
albumin 25 grams intravenously once per day was also started.
On [**2138-3-29**], the patient became encephalopathic. Blood
cultures and urine cultures were sent, and he did have an
episode of occult-blood positive stools.
In the setting of his encephalopathy, his renal function did
improve; however, he was transferred to the Unit for further
observation. A nasogastric lavage was done in the setting of
his occult-blood positive stool. The nasogastric lavage was
negative for blood. He did have a STAT head computed
tomography which was negative for bleed. All sedatives were
discontinued, and he was started on lactulose therapy. A
chest x-ray there was negative for a pneumonia. The patient
did have serial blood cultures done. He did have a total of
[**6-26**] blood cultures positive for methicillin-resistant
coagulase-negative Staphylococcus. His mental status did
improve on lactulose therapy.
The origin of his staphylococcal bacteremia was still
uncertain. In this setting, he did have a diagnostic
paracentesis done which was negative for spontaneous
bacterial peritonitis. The patient was started on vancomycin
for his high-grade bacteremia. He did have a transesophageal
echocardiogram done which was negative for endocarditis. Per
the Infectious Disease staff, it was recommended that he be
treated with four to six weeks of vancomycin from the date of
his last positive blood cultures which were [**2138-3-30**].
The patient was transferred back to the floor with an
improved mental status and improved renal function. He did
well on the floor. His hematocrit remained stable. He
remained afebrile on vancomycin. The patient also completed
a course of levofloxacin for his preseptal cellulitis. For
his preseptal cellulitis, he received a total of 10 days of
antibiotics which included doxycycline, Keflex, and
levofloxacin. The patient did have good nutritional intake
while on the floor. His creatinine remained in the 1.6 to
1.9 range on the floor and stable. His baseline creatinine
is around 1. He was not started on diuretics at discharge.
A peripherally inserted central catheter line was placed for
administration of intravenous vancomycin for his high-grade
methicillin-resistant Staphylococcus epidermitis bacteremia.
The patient was seen by Physical Therapy and was discharged
from their service as he had no acute physical therapy needs.
The patient did have a candidal infection of his groin area
which was treated with topical anti-fungal medications, to
which he responded well to.
Toward the end of his hospital stay, the patient did have
increased diarrhea. His lactulose was held which improved
his diarrhea somewhat; however, he did complain of increased
diarrhea. He did have Clostridium difficile toxins times
three days which were sent. These were negative for
Clostridium difficile.
The patient was discharged on no diuretics; however, the
possibility of restarting Aldactone 50 mg will be considered
as an outpatient. He will be discharged with a total course
of four to six weeks of vancomycin. The start date on his
vancomycin was [**2138-3-30**].
CONDITION AT DISCHARGE: Fair.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. Hepatitis C cirrhosis; awaiting liver transplantation.
2. Acute renal failure.
3. Methicillin-resistant coagulase-negative staphylococcal
bacteremia; on vancomycin.
MEDICATIONS ON DISCHARGE:
1. Miconazole nitrate powder applied three times per day as
needed to groin rash.
2. Protonix 40 mg q.12h.
3. Lactulose 30 mL by mouth three times per day (titrated to
four to five bowel movements per day).
4. Vancomycin 1 gram intravenously q.12h. (for a total of
six weeks); his vancomycin dose will be changed per trough
levels and his renal function.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up in the Liver Clinic in two days from discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], M.D. [**MD Number(2) 22654**]
Dictated By:[**Last Name (NamePattern1) 11207**]
MEDQUIST36
D: [**2138-4-7**] 15:21
T: [**2138-4-9**] 07:33
JOB#: [**Job Number 25451**]
ICD9 Codes: 5849, 7907, 2767, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8365
} | Medical Text: Admission Date: [**2137-6-8**] Discharge Date: [**2137-6-18**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
Right hip pain s/p fall
Major Surgical or Invasive Procedure:
Nasogastric tube insertion
History of Present Illness:
Ms. [**Known lastname 69629**] is an 89 year-old woman with a past history of total
hip replacement, osteoporosis, hypothyroidism and Zencker's
diverticulum that initially presented to the ED after a fall in
the grocery store on [**6-7**]. In the ED she denied loss of
consciousness, head strike and other neurological deficits
(headache, seizures). She complained of headache and R hip pain.
Exam showed normal VS, limited ROM R hip, multiple ecchymoses
and chipped teeth. Negative head CT. Initial x-rays of R hip and
knee showed no evidence of fracture. Urinalysis was positive for
white cells; given 1 dose of ciprofloxacin. She was admitted to
medicine for workup of mechanical fall vs. possible syncope.
Past Medical History:
1. GERD
2. Hypothyroidism
3. [**Doctor Last Name 933**] disease
4. Incontinence
5. Osteoporosis
6. Spinal stenosis
7. Carpal tunnel syndrome
8. R hip replacement
9. Previous episodes of small bowel obstruction
10. Zencker's diverticulum
Social History:
Lives alone, retired; used to work in medical records department
at [**Hospital1 18**].
Denies ETOH, Tobacco, or recreational drug use.
She walks with a cane at baseline and lives at home and is
fairly independent.
Family History:
Son is handicapped and lives in a group home. No known family
history of heart disease or malignancy.
Physical Exam:
Admission Exam:
Vitals: T=96.7, BP=136/66, HR=80, RR=21, O2sat=93% on nasal CPAP
General: Alert, oriented, no acute distress on nasal CPAP. The
patient had several bruises on her face (over right eye and
right side of chin) and damaged teeth (post-fall) on the left
side.
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Bibasilar crackles posteriorly R>L, with no wheezes,
rales, ronchi. No use of accessory muscles.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. Capillary refill was normal.
Abdomen: Distended, soft, non-tender with little to no bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: Foley's catheter not inserted
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
ICU-->Floor Transfer Exam:
Vitals: T 97.2, BP 102/47, HR 73, RR 15, O2sat=96%/4L x nasal
cannula
General: Alert, oriented, no acute distress. ecchymoses over
right eye and chin, chipped teeth. NGT in place.
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear.
Neck: supple, JVP not elevated, no LAD
Lungs: Bibasilar crackles posteriorly R>L and bronchial breath
sounds heard mostly in the posterior left lower lung. No
wheezes, rales, ronchi. No use of accessory muscles.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. Capillary refill was normal.
Abdomen: Distended (decreased from admission), soft, non-tender
with some bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: Foley catheter inserted
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2137-6-14**] 05:10 7.6 4.06* 12.9 37.7 93 31.7 34.1 12.6 185
[**2137-6-13**] 04:19 8.2 3.95* 12.8 36.3 92 32.3* 35.2* 12.9 216
[**2137-6-12**] 04:55 10.7 4.80 15.4 44.0 92 32.0 34.9 12.8 253
[**2137-6-11**] 05:45 8.0 4.55 14.4 41.2 91 31.7 35.1* 12.9 239
[**2137-6-9**] 06:30 6.3 4.32 13.9 39.3 91 32.3* 35.5* 12.8 189
[**2137-6-7**] 23:50 9.6 4.94 15.4 44.51 90 31.2 34.6 13.5 228
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2137-6-7**] 23:50 77.4* 17.2* 3.7 1.0 0.6
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2137-6-14**] 05:10 185
[**2137-6-13**] 04:19 216
[**2137-6-12**] 13:00 52.3*
heparin dose: 650
[**2137-6-12**] 04:55 253
[**2137-6-12**] 04:55 13.0 23.7 1.1
[**2137-6-11**] 05:45 239
[**2137-6-9**] 06:30 189
[**2137-6-7**] 23:50 228
LAB USE ONLY
[**2137-6-14**] 05:10
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2137-6-15**] 07:05 120*1 9 0.4 137 3.6 103 23 15
[**2137-6-14**] 05:10 981 12 0.5 138 3.6 103 29 10
[**2137-6-13**] 04:19 113*1 31* 0.7 136 4.2 104 28 8
[**2137-6-12**] 04:55 166*1 35* 0.8 137 4.5 100 26 16
[**2137-6-11**] 05:45 158*1 21* 0.7 139 4.0 99 29 15
[**2137-6-9**] 06:30 101*1 20 0.8 139 4.2 105 28 10
[**2137-6-8**] 01:10 114*1 18 0.7 139 3.4 103 29 10
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2137-6-15**] 07:05 Using this1
Using this patient's age, gender, and serum creatinine value of
0.4,
Estimated GFR = >75 if non African-American (mL/min/1.73 m2)
Estimated GFR = >75 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2137-6-13**] 04:19 14 15 20*1 35 0.5
[**2137-6-12**] 07:29 16 17 361 47 0.7
[**2137-6-11**] 18:13 421
[**2137-6-11**] 05:45 14 16 561 47 0.4
NEW REFERENCE INTERVAL AS OF [**2135-11-28**];UPPER LIMIT (97.5TH %ILE)
VARIES WITH ANCESTRY AND GENDER (MALE/FEMALE);WHITES 322/201
BLACKS 801/414 ASIANS 641/313
OTHER ENZYMES & BILIRUBINS Lipase
[**2137-6-12**] 07:29 19
[**2137-6-11**] 05:45 20
CPK ISOENZYMES CK-MB cTropnT
[**2137-6-13**] 04:19 2 <0.011
[**2137-6-12**] 07:29 3 <0.011
[**2137-6-11**] 18:13 3 <0.011
[**2137-6-11**] 05:45 3 <0.011
<0.01
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2137-6-15**] 07:05 1.7* 2.1
LAB USE ONLY LtGrnHD GreenHd HoldBLu
[**2137-6-7**] 23:50 HOLD1
[**2137-6-7**] 23:50 HOLD
[**2137-6-7**] 23:50 HOLD2
HOLD
DISCARD GREATER THAN 24 HRS OLD
HOLD
DISCARD GREATER THAN 4 HOURS OLD
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS Intubat
[**2137-6-12**] 06:43 ART 65* 42 7.43 29 2 NOT INTUBA1
NOT INTUBATE
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Lactate
[**2137-6-13**] 11:35 1.1
.
Micro
- URINE CULTURE (Final [**2137-6-10**]): MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
.
Imaging:
[**6-7**] - CT Head: IMPRESSION:
1. No acute intracranial traumatic injury. No acute intracranial
hemorrhage.
2. Minimal fluid in the right mastoid air cells.
.
[**6-7**] - Knee/Hip X-ray: IMPRESSION:
1. Status post total hip arthroplasty, without periprosthetic
fracture or
other evidence of traumatic sequelae.
2. Degenerative changes at the lumbosacral junction and right
knee
.
[**6-10**] - CT Pelvis:IMPRESSION:
1. Nondisplaced periprosthetic fracture of the right femur
extending from the
intertrochanteric to the subtrochanteric region.
2. Right trochanteric bursitis.
.
[**6-11**] - Abdomen X-ray:IMPRESSION:
1. No evidence of free air.
2. Small and large bowel dilation which could be consistent with
obstruction
or ileus.
.
[**6-12**] - CT Chest:IMPRESSION:
1. No CT evidence of simple pulmonary embolism
2. Collapsed bilateral lower lobes with dilated bronchi having
irregular walls - suggestive of bronchiectasis with chronicity
3. Zenker's diverticulum
4. Diffuse wall thickening of the cervical and mid thoracic
esophagus
5. Grossly distended and fluid filled stomach
.
[**6-12**] - Chest X-ray:IMPRESSION:
- Severe bibasilar atelectasis and low lung volumes persist.
There is no
pneumoperitoneum. The degree of gastric distension cannot be
assessed. The
large Zenker's diverticulum shown on the chest CTA is not
evident on
conventional radiographs. No pneumothorax.
.
[**6-12**]
IMPRESSION:
1. Interval worsening of bibasilar atelectasis.
2. No evidence of acute cardiac decompensation.
3. Severely distended stomach.
4. Possible pneumoperitoneum. Findings and need for additional
imaging
discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] by telephone at the time of
dictation.
.
EKG:IMPRESSION:
- Sinus rhythm. First degree A-V delay. Probable left atrial
abnormality.
Non-specific anterolateral ST-T wave changes. No change compared
to [**2136-9-6**]
.
Echo:IMPRESSION:
- Normal global and regional biventricular systolic function. No
pulmonary hypertension or pathologic valvular disease seen.
- Compared with the resting images of the prior study of
[**2133-5-14**], the findings are similar.
.
CT abdomen-IMPRESSION:
1. Incomplete partial/early small-bowel obstruction, with a
transition point in the right lower quadrant of the abdomen,
could be related to adhesions. The transition point is in a
similar level as the prior study. No evidence of ischemia or
free air.
2. Bibasilar consolidations, likely represent atelectasis.
.
EKG-[**Known lastname **],[**Known firstname 94790**] [**Age over 90 94791**] F 89 [**2047-9-27**]
Cardiology Report ECG Study Date of [**2137-6-13**] 11:26:44 PM
Sinus rhythm. Borderline P-R interval prolongation. Diffuse T
wave flattening
which is non-specific. Compared to the previous tracing of
[**2137-6-12**] there is no
significant diagnostic change.
Brief Hospital Course:
Brief Hospital Course:
.
#R hip injury s/p fall
Pt suffered multiple injuries during her fall. In addition to
broken teeth (some cemented in the ED) and ecchymoses over her
chin and R temple, there was persistent concern for R hip
fracture given limited range of motion on exam. Therefore,
despite initial negative plain films of her R hip and leg in the
ED, a follow-up CT was obtained and showed a peri-prosthetic
proximal femur fracture. Ortho trauma recommended non-operative
management of her right hip fracture, with outpatient follow-up
with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**12-27**] weeks with repeat x-rays of her
right hip. Pain was controlled with standing tylenol and a
lidocaine patch.
Initially anticoagulated with Sq heparin alone, changed to
lovenox per discussions with ortho.
.
#Small Bowel Obstruction
On the medicine service on hospital day 4 the pt developed acute
epigastric pain associated with nausea, nonbloody vomiting, and
dyspnea. Abdominal x-ray showed a distended stomach and small
bowel with multiple air-fluid levels with no free air,
consistent with possible small bowel obstruction. In the ICU, an
NGT tube was placed (required left lateral decubitus positioning
given known Zenker's diverticulum) with >2L bilious gastric
fluid drainage. Surgery was consulted to evaluate her recurrent
small bowel obstruction; they recommended non-operative
management, keeping patient NPO with NGT/IV fluids. She also
received an agressive bowel regimen to relieve obstruction, and
was passing gas within 24 hours. Her symptoms improved, NGT was
removed on [**6-14**] and her diet advanced to regular.
#Acute Hypoxia/severe atelectasis with lung collapse.
Vital signs obtained at the onset of nausea/vomiting showed
oxygen desaturation to 84% with tachypnea to RR 24. Pt denied
chest pain and palpitations. ABG pH 7.43 pCO2 42 pO2 65.
Supplemental oxygen via non-rebreather improved O2sats to
91-94%. SErial EKG's were monitored. EKG performed at 3am on
morning prior to hypoxic episode showed possible STE in v3-v4
(performed as pre-op for possible OR but not reviewed by
overnight physician). Repeat EKG at 6am did not show this
finding. However, serial cardiac enzymes ruled out MI. Reviewed
EKG with cardiology. Pt was empirically started on heparin gtt,
PR aspirin, statin and beta-blocker and transferred to the ICU
for stabilization of her respiratory status. She was afebrile,
without elevated WBC or consolidation/infiltration on CXR or
cough. Negative CTA ruled out pulmonary emboli, but showed
bilateral lower lobe collapse due to lobar atelectasis. Echo
showed normal biventricular function and no evidence of
pulmonary hypertension. Cardiac enzymes were negative. As ACS
and PE were ruled out, BB, statin, heparin were discontinued.
After transfer to the ICU she denied SOB but continued to
require 5-6L supplemental oxygen to keep O2 sats>90%. Used
frequent incentive spirometry to promote re-inflation of
collapsed lower lobes. Pt required no further oxygen on day of
discharge and had clinical improvement in crackles in right base
*******PT SHOULD HAVE STRESS TESTING AS AN OUTPT GIVEN ISOLATED
TRANSIENT V3-4 STE ON EKG***
.
# Hypothyroid - Treated with home levothyroxine.
.
# GERD - Treated with home omeprazole.
#UTI-s/p course of PO cipro x3 days. Cx with mixed flora.
.
#osteoporosis-continued calcium
.
FEN:adat to clears
.
PPX: hep SC, bowel regimen (PR dulcolax/enemas)
.
#CODE: Full (confirmed)
.
#Contact: [**Name (NI) **] (handicapped. per patient he is not able to make
decisions for the patient. Patient has no one who she says can
make decisions for her.
Medications on Admission:
levothyroxine 88mcg po daily
oxybutynin chloride 5mg po daily
ASA 325mg po daily
Calcium carbonate 750mg po TID
MVI
Discharge Medications:
1. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO once a
day.
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain.
7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
11. multivitamin Tablet Sig: One (1) Tablet PO once a day.
12. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once
a day for 3 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Urinary tract infection
Fall
periprosthetic hip fracture
severe atelectasis
bowel obstruction and markedly dilated stomach
zenkers diverticulum
hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted with Right hip pain after a fall and found to
have a fracture near your hip replacement. For this, you were
evaluated by the orthopedic surgery team who felt that you did
not require a surgery, but would need continued follow up in
orthopedic clinic. In addition, you were found to have a bowel
obstruction and low oxygen levels. For your bowel obstruction,
you initially had an NG tube and were given bowel rest with
improvement in your symptoms. The NG tube was removed and your
diet was advanced. Your low oxygen levels were likely due to
lung collapse related to your distended stomach. This was also
improving with using incentive spirometry and getting up to a
chair.
please discuss the need for a stress test with your PCP after
discharge.
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Department: [**Hospital3 1935**] CENTER
When: THURSDAY [**2137-7-11**] at 3:00 PM
With: [**Doctor Last Name **] OPTOMETRY [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2137-7-2**] at 3:00 PM
With: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: FRIDAY [**2137-8-9**] at 11:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5447**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5990, 5180, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8366
} | Medical Text: Admission Date: [**2142-1-29**] Discharge Date: [**2142-1-30**]
Date of Birth: [**2088-10-16**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Worst Headache of Life
Major Surgical or Invasive Procedure:
[**1-29**] Conventional Cerebral Angiogram
History of Present Illness:
Pt is a 53M who experienced sudden onset of the worse
headached of his life at 4pm yesterday. Headache was occiptal
and
accompanied by some neck stiffness. He was evaluated at an OSH
where a non-contrast head CT was reportedly negative but LP was
bloody and did not clear through 4 tubes with cell counts as
follows: tube 1- rbcs 125,920 wbcs 80 diff 87 polys 1 band p
lymphs 2 monos 1 eo; tube 4- rbcs 75,920 wbcs 80. He was
transferred to [**Hospital1 18**] for further evaluation. He is
neurologically
with a mild occipital headache at present.
Past Medical History:
HLD
Social History:
Works as a production manager does use alcohol
Family History:
NC
Physical Exam:
Vitals: 100.5 84 141/93 16 96%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERLA
Gen: WD/WN, comfortable, NAD.
HEENT: atraumatic, normocephalic
Pupils: bilaterally 4-3mm EOMs: intact
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-24**] 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 are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-28**] throughout. No pronator drift
Sensation: Intact to light touch
Handedness Right
On Discharge:
Nonfocal
Pertinent Results:
[**2142-1-29**] CTA head and neck: Again noted prepontine density
possibly representing subarachnoid hemorrhage. No evidence of
aneurysm or AVM.
[**2142-1-29**] MRI cervical spine:
1. Degenerative changes of the cervical spine as described in
detail above,worse at C3-4 and C4-5.
2. Limited evaluation of the vasculature demonstrates no gross
evidence of
vascular malformation.
Brief Hospital Course:
Patient presented to [**Hospital1 18**] from an OSH with the Worst Headache
of his life. At the OSH he had a lumbar puncture which showed
gross blood which was the impetus for the trasnfer. Imaging of
the head and neck has been negative. On mornign rounds on [**1-29**] he
was neurologically intact and awaiting conventional angiogram to
assess his vessels and r/o vascular anomaly. Cerebral
angiogram was negative for aneurysm or vascular malformation.
His exam remained stable and intact and on [**1-29**] he was deemed
stable for trasnfer to the floor. He was awaiting a bed into
[**1-30**]. His exam remained stable and after discussion with patient
and team it was determined he could be discharged from the
Intensive Care unit to home. He was given instructions for
post-discharge.
Medications on Admission:
Lovastatin
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
2. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**12-25**]
Tablets PO Q4H (every 4 hours) as needed for Headache.
Disp:*45 Tablet(s)* Refills:*0*
3. lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Medications:
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
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:
You do not require neurosurgical follow-up. We recommend
contacting your PCP and being seen in the near future especially
if you continue with your minor headaches.
Completed by:[**2142-1-30**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8367
} | Medical Text: Admission Date: [**2110-9-23**] Discharge Date: [**2110-9-24**]
Date of Birth: [**2038-6-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 3646**] is a 71 year old man with a history of diastolic heart
failure (EF 40-45%), critical aortic stenosis, multiple myeloma,
amyloidosis, and chronic renal insufficiency who presents with
exertional dyspnea worsening over the last 2 weeks or so. He has
noticed increased abdominal girth over this period, without any
abdominal discomfort. He has had some associated poor energy,
limited appetite, and nausea. He vomited once yesterday, and has
had some loose stools without melena or hematochezia. He thinks
he has gained weight but is unsure of the amount. He can ascend
[**1-28**] flights of stairs before having to stop due to dyspnea which
he says is his baseline. His wife however notes that he seems
out of breath just walking across a small room. He has stable 3
pillow orthopnea, but denies any PND. He denies any difficulties
with taking his medications as prescribed, or any increased salt
intake. He denies fevers, chills, sweats, palpitations,
lightheadedness/fainting, chest discomfort, wheezing, leg pains
or history of thrombosis. He does have a chronic cough not
recently worse productive of white sputum, without any
hemoptysis.
.
In the ED, his triage vitals were T98.1, P 98, Bp 104/64, RR 18,
99% on RA. He received 80mg lasix IV x1. On the floor, he was
noted to be "extremely short of breath" tachypneic to the 30's
and wheezing with O2 saturation dipping to 79. He was placed on
a non-rebreather facemask, given 2mg morphine, started on a
nitroglycerin drip, and subsequently transferred to the CCU.
Past Medical History:
CHF EF 40-45%, diastolic HF
AS - valve area <0.8cm2 on [**2110-8-25**] echo
CAD
DM2
HTN
CKD
Hyperlipidemia
Left atrial appendage thrombus
Social History:
The patient is married, lives with wife has children. Retired
from working for Polaroid. Social history is significant for the
absence of current tobacco use, previous use x 50 years, quit 5
years ago. There is no history of alcohol abuse. There is no
family history of premature coronary artery disease or sudden
death.
Family History:
M: suicide. F: died at age 51, is unsure of what cause. No
family
history of premature coronary artery disease or sudden death.
Physical Exam:
T101.8 P 132 BP 108/55 RR 22 O2 100% on nonrebreather
General: Thin elderly man in mild respiratory distress. Able to
speak in short sentences
Neck: JVP 10cm. Carotid upstroke brisk bilaterally
Pulm: Lungs with slightly decreased breath sounds on R, +wheezes
without rales
CV: Regular rate S1 S2 II/VI SEM base
Abd: Soft +BS, +fluid wave, nontender
Extrem: Warm, well perfused with 1+ pitting edema. 2+ distal
pulses bilaterally.
Neuro: Alert and oriented
Lines: Has R PICC
Pertinent Results:
[**2110-9-23**] 11:46AM WBC-15.0*# RBC-3.17* HGB-10.5* HCT-33.0*
MCV-104* MCH-33.1* MCHC-31.8 RDW-17.3*
[**2110-9-23**] 11:46AM PLT SMR-NORMAL PLT COUNT-184
[**2110-9-23**] 11:46AM NEUTS-93* BANDS-3 LYMPHS-1* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2110-9-23**] 11:46AM PT-29.8* PTT-33.9 INR(PT)-3.1*
[**2110-9-23**] 11:46AM ALBUMIN-3.3* CALCIUM-9.3
[**2110-9-23**] 11:46AM proBNP-[**Numeric Identifier 71895**]*
[**2110-9-23**] 11:46AM ALT(SGPT)-90* AST(SGOT)-167* ALK PHOS-236*
AMYLASE-110* TOT BILI-2.4*
[**2110-9-23**] 11:46AM GLUCOSE-99 UREA N-52* CREAT-2.7* SODIUM-131*
POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-24 ANION GAP-15
[**2110-9-23**] 12:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2110-9-23**] 12:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2110-9-23**] 12:45PM URINE RBC-0 WBC-[**3-31**] BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2110-9-23**] 06:42PM LACTATE-10.6*
.
CXR [**9-23**]
Right-sided pleural effusion, possibly slightly decreased in
size compared to the previous study. Patchy density at the right
lung base likely reflects atelectasis.
.
RUQ Ultrasound [**9-23**]
IMPRESSION: Moderate to large ascites with no ultrasound
evidence suggestive of acute cholecystitis. There is, however
re-demonstration of previously noted gallbladder sludge.
Moderate to large amount of ascites again noted. Doppler
waveform consistent with right heart failure.
.
EKG [**9-23**]
Sinus rhythm 94bpm. Upper limits of normal rate. P-R interval
prolongation. Marked left axis deviation. Low voltage
throughout. Borderline intraventricular conduction delay. Late R
wave progression. ST-T wave abnormalities. Since the previous
tracing of [**2110-8-27**] probably no significant change. Clinical
correlation is suggested.
.
Renal Ultrasound [**9-24**]
1. Limited. Right kidney not visualized. The left kidney appears
normal.
2. Abundant ascites.
.
MICROBIOLOGY
[**2110-9-23**] 9:14 pm BLOOD CULTURE Source: Line-PICC SET #2.
**FINAL REPORT [**2110-9-28**]**
AEROBIC BOTTLE (Final [**2110-9-27**]):
REPORTED BY PHONE TO FA6B [**Last Name (NamePattern4) 71896**] [**2110-9-24**] 930AM.
ESCHERICHIA COLI. FINAL SENSITIVITIES.
PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
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
_________________________________________________________
ESCHERICHIA COLI
| PSEUDOMONAS AERUGINOSA
| |
STAPHYLOCOCCUS, COAGULASE N
| | |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S 2 S
CEFTAZIDIME----------- <=1 S 4 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
CLINDAMYCIN----------- <=0.25 S
ERYTHROMYCIN---------- <=0.25 S
GENTAMICIN------------ <=1 S <=1 S <=0.5 S
IMIPENEM-------------- <=1 S <=1 S
LEVOFLOXACIN---------- <=0.12 S
MEROPENEM-------------<=0.25 S <=0.25 S
OXACILLIN------------- <=0.25 S
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S 8 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC BOTTLE (Final [**2110-9-27**]):
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.
PSEUDOMONAS AERUGINOSA.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE.
AEROBIC BOTTLE (Final [**2110-9-27**]):
REPORTED BY PHONE TO FA6B [**Last Name (NamePattern4) 71896**] [**2110-9-24**] 930AM.
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
236-2195B
[**2110-9-23**].
PSEUDOMONAS AERUGINOSA.
SENSITIVITIES PERFORMED ON CULTURE # 236-2195B [**2110-9-23**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
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
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
PENICILLIN------------ =>0.5 R
ANAEROBIC BOTTLE (Final [**2110-9-27**]):
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
236-2195B
[**2110-9-23**].
PSEUDOMONAS AERUGINOSA.
SENSITIVITIES PERFORMED ON CULTURE # 236-2195B [**2110-9-23**].
Brief Hospital Course:
1. Septic shock, likely secondary to spontaneous bacterial
peritonitis: The patient was transferred to the CCU for dyspnea,
initially thought to be due primarily to heart failure. He had
received intravenous furosemide in the emergency room as well as
empiric levofloxacin. The CCU team was concerned about the
presence of spontaneous bacterial peritonitis, therefore we
broadened his antibiotic coverage and planned to do a diagnostic
paracentesis. This was not performed immediately due to concern
for an elevated INR, as well as hemodynamic instability with
systolic blood pressures in the 80's. In addition, his urine
output was poor, so he was administered fluid boluses. He had a
limited renal ultrasound that did not visualize the left kidney
adequately, but showed no evidence of ureteral obstruction or
hydronephrosis on the right that wound account for his poor
urine output. It became clear that his poor urine output was
likely due to poor renal perfusion in the setting of sepsis. His
tachynea had been somewhat improved following admission to the
CCU, but was worsened by the next morning. Given his elevated
lactate, it is likely his tachypnea was at least in part a
compensatory response to his lactic acidosis. A discussion with
the patient and his family resulted in the decision not to place
him on mechanical ventilation. He was started on a morphine drip
and his status was changed to Care Measures Only. The patient
passed away on [**2110-9-24**]. The family declined an autopsy.
Medications on Admission:
Toprol Xl 25 mg PO daily
Allopurinol 100 mg PO daily
Calcitriol 0.25 mcg PO daily
Prilosec 20 mg PO daily
Lasix 80 mg IV daily
Ambien 5 mg PO QHS prn insomnia
Warfarin 5 mg PO daily
Insulin NPH 6 units QAM
Discharge Medications:
N/A, patient deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary
1. Septic shock, likely secondary to spontaneous bacterial
peritonitis
2. Congestive heart failure, diastolic, acute on chronic
3. Acute on chronic renal failure
Secondary
4. Amyloidosis in setting of multiple myeloma
5. Aortic stenosis, severe
Discharge Condition:
Deceased
Discharge Instructions:
Not applicable
Followup Instructions:
Not applicable
ICD9 Codes: 5849, 4241, 5859, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8368
} | Medical Text: Admission Date: [**2169-3-14**] Discharge Date: [**2169-3-23**]
Date of Birth: [**2085-6-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
Fevers, altered mental status
Major Surgical or Invasive Procedure:
- ERCP
- Placement of PICC line
History of Present Illness:
Mrs. [**Known lastname 10840**] is a pleasant 83 year old female, followed by
biliary service at [**Hospital1 18**] for biliary obstruction status-post
stenting for likely malignancy, though not biopsy proven, as
well as a history of cholangitis. She was at home with her
husband, who noted on morning of admission she was much less
responsive than usual, and that she felt warm to the touch. He
describes that she was slightly more somnolent the day prior to
admission. He was concerned and called EMS. She was brought to
[**Hospital3 3583**]. There, she was noted to have a white blood cell
count of 26 with bands, a total bilirubin of 2.4, no acute chest
process on chest x-ray, and a mildly positive urine analysis
with 1+ LE. She was given vancomycin, ceftriaxone, and flagyl
over concern of cholangitis. Her INR was over 8, and she was
given 10 mg of intravenous vitamin K. Blood and urine cultures
were drawn prior to administration of antibiotics. She was then
transferred to [**Hospital1 18**].
.
In the [**Hospital1 18**] [**Last Name (LF) **], [**First Name3 (LF) **] abdominal ultrasound was completed, which
demonstrated no change in known intrahepatic dilatation, two
common bile duct stents in place, and no obvious abscesses. Her
vitals at that time were: temperature of 101.4 rectal, stable
blood pressure (never hypotensive, lowest 120/40) 160/70, RR 24,
Sat 98% on NRB. She was noted to be rigoring and was somnolent
but somewhat arousable. Her laboratories were notable for a
transaminitis AST >ALT, lactate 2.4, INR 7.7. She received more
vitamin K, was seen by surgery and was admitted to [**Hospital Unit Name 153**] for plan
to ERCP in AM.
.
Of note, patient had recent admission to [**Hospital Unit Name 153**] for polymicrobial
sepsis in setting of biliary stent obstruction due to tumor. She
underwent ERCP with successful flushing of stents. Her course
was complicated by afib with RVR, DVT and liver abscesses not
amenable to drainage.
.
Blood cultures at that time grew: enterococcus sensitive to
gent and streptomycin; E.coli sensitive to gent, imipenem, and
cephalosporins; Klebsiella pansensitive except to amp.
.
Upon arrival to the [**Hospital Unit Name 153**], she would open her eyes to tactile
stimuli and would squeeze her hand when ask; she was not
otherwise interactive.
Past Medical History:
Biliary obstruction/malignant stricture s/p ERCP X 2 and 2 metal
stents--last placed in [**9-12**]. Thought to be cholangiocarcinoma,
no clear pathologic diagnosis made. By report, evaluated by
surgical team, thought not to be a surgical candidate. Now with
peritoneal carcinomatosis.
-Diabetes mellitus, type 2
-Hypertension
-Coronary artery disease
-Parkinson's disease
-diastolic CHF
-Vaginal Carcinoma
-s/p Cholecystectomy
-Urosepsis d/t E. coli and Proteus
-Bacteremia due to VRE in [**9-12**] treated with 2 week course of
Linezolid
-Bacteremia due to E. coli in [**9-12**] treated with 2 week course of
Ceftriaxone.
-Atrial fibrillation
-Hyperlipidemia
Social History:
She lives with husband in [**Name (NI) 3320**], and has no children.
Dependent for ADLs--has VNA and husband cares for her, no
tobacco or drugs, occassional alcohol. Retired tax examiner for
the state.
At baseline, she eats pureed foods with some assistance from her
husband depending on how bad her Parkinsons tremor is. Her
primary care physician describes she has a good baseline quality
of life.
Family History:
Per records, her mother died of heart disease.
Physical Exam:
On Admission:
T= 101.9 axillary BP=125/59 HR=103 RR=? O2= 100% on 50% shovel
mask
Gen: elderly female, very warm, somnolent but follows with eyes.
HEENT: Dry mucous membranes, OP clear
Neck: No JVP
Car: Tachycardic, irregular, no murmurs appreciated
Resp: course BS bilaterally transmitted from O2.
Abd: soft, +BS, ND, unclear if tenderness pain in [**Name (NI) 25714**] - pt opens
eyes wide.
Ext: strong distal pulses, bilateral edema
Neuro: somnolent, unable to participate in neuro exam.
Skin: No rashes or lesions noted
Pertinent Results:
Ultrasound:
IMPRESSION:
1. No significant interval change in intrahepatic biliary duct
dilatation,
most severe within the left lobe.
2. Echogenic material within both common bile duct stents is
nonspecific, and
could represent debris, but tumor involvement is not excluded.
3. Patent main portal vein, however, the patient's known right
posterior
portal venous branch occlusion is not visualized on current
examination.
4. Small amount of perihepatic fluid.
5. 1.1-cm pancreatic mid body lesion, stable from the prior
studies.
6. No new hepatic abscess identified.
Chest x-ray:
IMPRESSION: No acute cardiopulmonary abnormality. Patchy opacity
within the
retrocardiac region is felt to represent atelectasis and/or
scarring.
Brief Hospital Course:
Mrs. [**Known lastname 10840**] is an 83 year old female with history of biliary
obstruction, polymicrobial bacteremia from cholantitis
presenting with fever, altered mental status concerning for
ascending cholangitis.
#. Sepsis: Pt presented with altered mental status, fevers,
tachycardia and leukocytosis. Symptoms were presumed to be due
to cholangitis and obstruction of known biliary stent, given
elevated white blood cell count, fevers, and elevated liver
function tests. There were no other clear sources of infection
on admission. A RUQ ultrasound showed no change in biliary
dilitation but ERCP showed sludge and stones obstructing the
stent which were successfully cleared out. Pt was initially
empirically treated linezolid, ceftriaxone and flagyl given
prior h/o VRE and resistent bacteria, and transitioned to only
high dose ceftriaxone once blood cultures grew Klebsiella. She
was also treated with IVF boluses via PICC and did not require a
CVL or pressors. The biliary surgery and ERCP team followed
along during her stay. The infectious disease team helped guide
appropriate antibiotic choice: as she did not have evidence of
active hepatic abscesses on abdominal CT, a 2 week course was
deemed sufficient (last day [**3-28**]). Her mental status returned to
baseline, and her fevers resolved within a few days of
hospitalization. Her blood cutlures checked after the initial
positive results remained sterile.
#. Coagulopathy: On presentation pt's INR was 8, likely in
setting of poor hepatic clearance of coumadin. She had no signs
of active bleeding. She recieved several doses of Vitamin K and
FFP to reverse her INR for ERCP and was NOT restarted on
anticoagulation post procedure, out of concern for needing
future procedures. Benefits and downsides of anticoagulation can
be discussed with pt's PCP given ongoing goals of care.
#. [**Name (NI) 20472**] Pt's home home glyburide was held and pt was
monitored and treated with a sliding scale of insulin. This was
not restarted after her procedures due to generally good blood
sugar control; however, this can be restarted when necessary at
rehab depending on her blood sugars.
#. Coronary artery disease: Patient's last echo was in [**Month (only) 404**]
[**2169**], which demonstrated an EF of >55%, normal systolic
function, mild MR. She was continued on her home statin, while
her home anti-hypertensives were initially held in the setting
of concern of hypotension while septic. Her metoprolol was
started after her BP recovered.
#. Atrial fibrillation: Pt supratherpeutic on coumadin on
arrival. This was not restarted due to ongoing discussions about
goals of care. Metoprolol was restarted and titrated up to 50mg
tid given episodes of afib with RVR in the ICU. This was backed
down to 25mg [**Hospital1 **] after she was noted to be in sinus brady in the
50s on the floor. Digoxin was not restarted.
#. HTN: held home BP regimen on admission. Metoprolol was added
back as above and lisinopril and HCTZ were added and titrated up
after she became hypertensive on the floor. This can continue to
be titrated as needed at rehab.
#. Parkinsons: continued Sinimet and Pramipexole
#. Concern for aspiration/goals of care: the patient failed a
video speech and swallow study after being called out of the
ICU. The speech and swallow team discussed the possibility of a
feeding tube with the patient and family in order to be able to
provide adequate nutrition, but she and her husband were
adamantly against this, as quality of life and being able to
have the comfort of eating food were deemed to be more
important; thus, speech and swallow recommended nectar thick
liquids and pureed solids per her husband's request. The patient
and husband acknowledged the risks that she will likely
aspirate. Goals of care should continue to be discussed at rehab
and any concern for aspiration should be discussed with the
patient and husband before she is sent to the hospital in the
event that she does aspirate, to see if they may decide not to
hospitalize her in that situation.
## CODE STATUS: DNR/DNI
EMERGENCY CONTACT: [**Name (NI) 4906**] [**Name (NI) **] [**Telephone/Fax (1) 105717**]
Medications on Admission:
Albuterol
Sinemet 25-100 TID
Lasix 40 mg [**Hospital1 **]
glyburide 5 mg daily
lisinopril 5 mg [**Hospital1 **]
singulair 10 mg daily
protonix 40 mg daily
pramipexole 0.375 mg tid
prazosin 2 mg [**Hospital1 **]
simvastatin 10 mg daily
(Although not confirmed with patient at time of admission--per
discharge from [**1-/2169**], was also on digoxin, metoprolol, and
coumadin)
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
2. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
7. Pramipexole 0.125 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
8. Prazosin 2 mg Capsule Sig: One (1) Capsule PO twice a day.
9. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
13. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
14. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
Two (2) g Intravenous Q24H (every 24 hours) for 5 days.
15. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous ASDIR (AS DIRECTED).
16. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center
Discharge Diagnosis:
Primary: biliary obstruction, bacteremia
Secondary: likely cholangiocarcinoma, hypertension, atrial
fibrillation, diabetes mellitus Type 2, coronary artery disease,
Parkinson's disease, chronic diastolic CHF
Discharge Condition:
good, stable, at baseline mental status, afebrile
Discharge Instructions:
You were evaluated for fevers and lethargy and improved after
ERCP. You are being treated for a bloodstream infection and will
continue IV antibiotics for a few more days. You were evaluated
by speech and swallow and were found to be at risk for
aspiration; however, after discussion you declined a feeding
tube and would rather eat despite the risk of aspiration.
If you have fevers, chills, chest pain, shortness of breath,
confusion, episodes of loss of consciousness, or any other
concerning symptoms, have the doctors at rehab [**Name5 (PTitle) 4656**] you.
Followup Instructions:
Follow up with your primary care physician 1-2 weeks after
discharge from rehab.
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8369
} | Medical Text: Admission Date: [**2111-4-16**] Discharge Date: [**2111-4-23**]
Date of Birth: [**2111-4-16**] Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname 60813**] was born at 32 4/7 weeks with
respiratory and issues of prematurity.
The mother is a 37 year-old gravida 6, para 3 woman with
prenatal screens; B positive, hepatitis B surface antigen
negative, RPR nonreactive, Rubella immune, antibody negative.
Prenatal course significant for the following:
1. Severe polyhydramnios with a maximum AFI of 53. Normal
stomach was noted and a normal abdominal wall was noted.
2. Large for gestational age. Fetal ultrasound results were
as follows. Ultrasound at 20 showed an AFI for 20 with an
estimated fetal weight of the 84th percentile. At 23 weeks
AFI was 45 with an estimated fetal weight in the 94th
percentile. At 26 weeks AFI of 40, estimated fetal weight
of 87th percentile. At 29 weeks AFI of 46, estimated fetal
weight in 98th percentile.
3. Mild ventriculomegaly noted at 26 week ultrasound with
lateral ventricles measuring 11 mm. A 29 week ultrasound
also showed mild ventriculomegaly with lateral ventricles
measuring 13 mm bilaterally and a prominent cavum septum
pellucidum. An MRI on [**3-3**] which was at 29 weeks was
consistent with ultrasound report and frontal horns were
noted to be slightly squared in appearance. There was an
unclear etiology of the ventriculomegaly. No other abnormal
brain findings were noted.
4. Mother was on bed rest at 27 weeks and admitted at 28
weeks with preterm labor. At that point she received
magnesium and was made betamethasone complete and the
preterm labor stopped.
5. Advanced maternal age. However, declined triple screen and
amniocentesis.
6. Anticardiolipin antibody weekly positive and treated with
heparin until 14 weeks gestation followed by baby aspirin
until 24 weeks gestation.
Mother now presents with lower abdominal pain with an
ultrasound showing bulging membranes elected to deliver infant
in the setting of severe polyhydramnios.
Infant was admitted to the NICU:
PHYSICAL EXAMINATION: On admission weight 2680 grams, length
48 cm, head circumference 33.25 cm. These are all over the
90th percentile. Heart rate 160s, respiratory rate in the
60's, oxygen saturation on room air 75%, blood pressure of
83/47 with temperature of 97.8. Infant is pink and active,
nondysmorphic facies. Anterior fontanelle is open and full.
Palate is intact. Petechiae were noted on the hands. There is
normal S1 and S2, no murmur. Moderate to severe intercostal
and subcostal retractions with poor aeration, grunting.
Abdomen was slightly distended yet soft, no masses. Three
vessel cord was noted. Very large umbilical cord. Extremities
were well perfused. Tone was slightly increased in legs. Anus
was patent. Testes descended bilaterally. Spine was intact
and no bruising was noted.
HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: Patient was intubated and received 2 doses of
surfactant due to severe respiratory distress. On day of li
fe #1 patient was extubated to room air and has remained on room
air since day of life #1 with saturations greater than 93%.
2. CARDIOVASCULAR: The patient has been hemodynamically
stable throughout his admission.
3. FLUID, ELECTROLYTES AND NUTRITION: Patient was initially
n.p.o. on total fluid of 60 cc per kilo per day. Over the
course of the first three days of life patient was noted
to have an approximately 20 percent weight loss with urine
output between 5 to 7 cc per kilo per hour. On day of life
#2 the infant was started on feeding of 30 cc per kilo per
day. Total fluids were advanced by day of life #4 to 160
cc per kilo per day due to persistent weight loss. Patient
is currently on full feedings of breast milk 20 at 160 cc
per kilo per day. Over the past three days he has had good
weight gain, (currently is 2200 grams) and the polyuria has
improved. Because of the weight loss and polyuria a renal
consult was obtained. A renal ultrasound was performed
which showed a dual collecting system but was otherwise
normal.
On day of life #6 a set of electrolytes were obtained and t
he
potassium was found to be 6.9. At that point endocrine
consult was obtained due to concerns of congenital adrenal
hyperplasia. On repeat testing of the electrolytes they wer
e
found to be normal with a potassium of 5.4. Repeat again th
is
morning showed a potassium of 5.1. State screen, however, h
as
returned with a 17-hydroxyprogesterone value above the
cutoff value and therefore the state screen was resent. A
17-hydroxyprogesterone as well as plasma renin activity and
aldosterone were also sent to [**Hospital3 1810**] for [**Doctor Last Name **]
er
investigation. These results are pending at time of
dictation.
4. GASTROINTESTINAL: Patient was started on phototherapy on
day of life #3 for a bilirubin of 14.0/0.5. Phototherapy
was stopped on day of life #6 and rebound bilirubin was
8.5/0.3.
5. INFECTIOUS DISEASE: Patient was initially started on
ampicillin and Gentamicin due to preterm labor. CBC and
blood culture were obtained. CBC was benign and blood
culture was negative at 48 hours and therefore antibiotics
were discontinued.
6. NEUROLOGIC: Due to ventriculomegaly noted on prenatal
ultrasound a head ultrasound was performed on day of #1
and was essentially normal with the exception of a large
septum cavum pellucidum.
CONDITION ON DISCHARGE: Good.
NAME OF PRIMARY CARE PEDIATRICIAN: Unknown at this time.
FEEDINGS AT DISCHARGE: Patient is currently on break milk 20
calories per ounce at 160 cc per kilo per day.
MEDICATIONS: Patient is currently receiving no medications.
STATE NEWBORN SCREENING: Initial newborn screen returned
with an elevated 17-hydroxyprogesterone and therefore
screening was resent on day of this dictation.
DISCHARGE DIAGNOSIS:
1. Prematurity at 32 4/7 weeks.
2. Polyhydramnios.
3. Respiratory distress syndrome, resolved.
4. Hyperbilirubinemia, resolved.
5. Rule out sepsis, resolved.
6. Weight loss of nearly 20 percent from birth.
[**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) 37305**], MD [**MD Number(2) 59540**]
Dictated By:[**Last Name (NamePattern1) 58671**]
MEDQUIST36
D: [**2111-4-23**] 12:15:05
T: [**2111-4-23**] 14:09:46
Job#: [**Job Number 60814**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8370
} | Medical Text: Admission Date: [**2129-4-8**] Discharge Date: [**2129-4-15**]
Date of Birth: [**2059-3-27**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 70-year-old female
with a history of coronary artery disease suffered an acute
myocardial infarction in [**2128-4-14**], and she was taken to
catheterization laboratory and found three vessel disease
with successfully stented left anterior descending artery,
found to have left ventricular diastolic dysfunction with a
preserved ejection fraction of 57% with anterior apical
dyskinesis and anterolateral hypokinesis.
In [**2128-11-14**], the patient returned to [**Hospital3 **] for
chest pain. Catheterization revealed totally occluded left
anterior descending artery with brachytherapy.
Echocardiogram in [**2128-11-14**] showed an ejection
fraction of 50%, mild symmetric left ventricular hypertrophy
with hypokinetic anterior wall and kinetic anteroseptal wall,
hypokinetic anterior apex, akinetic septal apex, and lateral
apex and akinetic apex, 1+ mitral regurgitation.
The patient was admitted to an outside hospital for a GI
bleed, where aspirin and Plavix were discontinued upon the
outside hospital. The patient is found to have "several
ulcers". EGD performed with cauterization of lesions. The
patient is discharged home 48 hours.
On the morning of admission, she awoke, had a bowel movement,
and shortly after that, she developed severe substernal chest
pain [**6-23**] radiating to the back, positive diaphoresis, no
nausea or vomiting. The patient took nitroglycerin x3 with
no relief and called EMS. Electrocardiogram was 3-[**Street Address(2) 1755**]
elevations in leads V2 through V4. Morphine, Heparin drip,
and nitroglycerin drip were started.
REVIEW OF SYSTEMS: The patient with one pillow orthopnea.
No change in weight. She has dyspnea on exertion with
walking one block, no stairs.
FAMILY HISTORY: Mother has diabetes. Father has coronary
artery disease. Died at age 56 of a myocardial infarction.
SOCIAL HISTORY: A half pack per day smoker. No alcohol,
seven children, divorced, former telephone operator.
PAST MEDICAL HISTORY:
1. Coronary artery disease in [**2129-11-14**], received
brachytherapy through a restented left anterior descending
artery, instent restenosis in [**2128-4-14**], stented left
anterior descending artery.
2. Lower back pain.
3. Congestive obstructive pulmonary disease/asthma, O2
dependent at night.
4. Gastrointestinal bleed status post
esophagogastroduodenoscopy with cauterization.
5. Hyperlipidemia.
6. Peripheral vascular disease status post aorto-bifemoral
bypass.
7. Congestive heart failure.
8. Hypothyroidism.
9. Hypertension.
ALLERGIES: She has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg po q day.
2. Prednisone 10 mg po q day.
3. Atenolol 25 mg po q day.
4. Lisinopril 5 mg po q day.
5. [**Year (4 digits) **] prn.
6. Flovent two puffs q hs.
7. Serevent two puffs [**Hospital1 **].
8. Diltiazem.
9. Lipitor 10 mg q day.
10. Compazine.
11. Plavix 75 mg q day.
12. Lasix 25 mg q day.
13. Vicodin.
14. Buthalital.
15. Isosorbide 30 mg q day.
16. Trazodone 100 mg q hs.
17. Prevacid 40 mg [**Hospital1 **].
LABORATORY VALUES ON ADMISSION: White blood cell count 16.5,
hematocrit 29.7, platelets 250. Sodium 140, potassium 3.8,
chloride 107, CO2 23, BUN 11, creatinine 0.6, glucose 97,
calcium 8, phosphate 4, magnesium 1.6.
On coronary artery catheterization, she had a 60% right
coronary artery proximal lesion, 60% right coronary artery
distal lesion, right posterolateral 100% stenosis, left
anterior descending artery 100% occlusion proximal to
previous stent, LCX without significant lesion.
A postcatheterization electrocardiogram showed atrial
flutter/fibrillation, left axis deviation, [**Street Address(2) 4793**] elevations
in V2 through V4, T-wave inversions in V2 through VI, poor
R-wave progression.
VITALS ON ADMISSION: Temperature 99.0, heart rate is 82,
blood pressure 98/48, respiratory rate 16, and oxygen 94% on
4 liters nasal cannula. In general, this is a frail
appearing woman in no apparent distress, alert and oriented
times three. HEENT: No lymphadenopathy, no jugular venous
distention. Pupils are equal, round, and reactive to light.
Cardiovascular: Faint heart sounds. Pulmonary: Bivalve
sounds secondary to emphysematous changes. Abdomen is soft,
nontender, nondistended no hepatosplenomegaly. Extremities:
No edema, no pulses, dopplerable, no cyanosis or clubbing.
HOSPITAL COURSE BY SYSTEMS:
1. Coronary artery disease/ischemia: The patient was found
to have a large acute myocardial infarction. She received
successful cardiac catheterization with stenting of the left
anterior descending artery. In the post myocardial
infarction period, she did have a period of tachycardia to
160s, which was found to be VT. For this she was bolused
with lidocaine and put on a lidocaine drip. EP was consulted
to assess the need for further EP studies and also
defibrillator placement.
The patient was talked to extensively and declined EP study,
and pacemaker, and AICD placement at this time. To lower the
risk of recurrent VT, she was placed on amiodarone 400 mg po
q day, and additionally, she was sent home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of
Hearts monitor for which strips will be examined over the
next two weeks by EP. She has an outpatient with this EP in
approximately four weeks from discharge for followup and
further discussion of risk of morbidity and mortality from
cardiac arrhythmias.
Nevertheless, after the first 24 hours, she did not have any
recurrence of ventricular arrhythmias. She was kept on the
lidocaine for the first 48 hours. The lidocaine drip was
weaned off for 72+ hours prior to discharge, she was off
lidocaine and had no further arrhythmic events.
Pump: The patient had repeat echocardiogram in-house, which
showed an ejection fraction of 25-35% reduced from the 50%
before. This should be followed up. It is unclear how much
of this is from damage versus myocardial stunning. It is
possible the patient will recover from significant amount of
ejection fraction in the future.
Other systems: GI: She has a history of gastrointestinal
bleed. We followed her hematocrit. There was no drop in
hematocrit. No recurrent gastrointestinal bleed. She was
kept on proton-pump inhibitor, and stool softeners.
Heme: The patient did receive 1 unit of packed red blood
cells for a decreased hematocrit, which was most likely
secondary to the prior gastrointestinal bleed. She had no
need for blood and her hematocrit was stable.
Renal: The patient's renal function was stable. No acute
issues.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg po q day.
2. Plavix 75 mg po q day.
3. Prednisone 10 mg po q day.
4. Atenolol 25 mg po q day.
5. Lisinopril 5 mg po q day.
6. Fluticasone two puffs [**Hospital1 **].
7. Salmeterol 1-2 puffs [**Hospital1 **].
8. Lipitor 10 mg po q day.
9. Lasix 20 mg po q day.
10. Lansoprazole 30 mg po q day.
11. Levothyroxine 75 mcg po q day.
12. Spironolactone 12.5 mg po q day.
13. Amiodarone 400 mg po q day.
14. Levofloxacin 250 mg po q day for three days.
15. Prochlorperazine 25 mg prn.
16. Vicodin prn.
17. Bubatol prn.
18. Ativan prn.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Acute anterior myocardial infarction.
3. Congestive heart failure.
4. Ventricular arrhythmia.
5. Congestive obstructive pulmonary disease.
6. Hypertension.
7. Hyperlipidemia.
[**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**]
Dictated By:[**Last Name (NamePattern1) 1737**]
MEDQUIST36
D: [**2129-4-14**] 15:24
T: [**2129-4-20**] 08:53
JOB#: [**Job Number 34496**]
ICD9 Codes: 5990, 4280, 4271, 496, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8371
} | Medical Text: Admission Date: [**2125-4-4**] Discharge Date: [**2125-4-25**]
Date of Birth: [**2057-12-8**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF THE PRESENT ILLNESS: The patient is a 67-year-old
gentleman transferred from [**Hospital 1474**] Hospital after a cardiac
catheterization performed at that institution demonstrated
severe aortic stenosis. He was initially seen there for
increased shortness of breath over the past two months that
was progressive with just about any activity, including tying
his shoes. He was not complaining of chest pain but stated
that he does have chest pressure that occasionally awakes him
from sleeping. He has a two to three pillow orthopnea. He
has not seen a doctor in a number of years prior to this
presentation.
PAST MEDICAL HISTORY: He, therefore, has no known past
medical history of significance.
REVIEW OF SYSTEMS: Negative for syncope, palpitations,
shortness of breath at rest, stroke. He has no diabetes. No
hypertension. No history of cancer.
At the outside hospital, he underwent an echocardiogram that
demonstrated an aortic valve area of 0.8 cm squared and a
peak gradient of 79. The EF was 10-20%, mild left
ventricular hypertrophy, moderate aortic stenosis, and
moderate aortic regurgitation. He also had moderate mitral
regurgitation and pulmonary hypertension. Cardiac
catheterization demonstrated normal coronaries with PA
pressures of 83/36 and a wedge of 52. By catheterization,
his [**Location (un) 109**] was 0.5 cm squared with a peak gradient of 88 and a
mean gradient of 61.
At the outside hospital, his white count was 8.4, hematocrit
47.2, platelets 265,000. Coagulation studies were within
normal limits as were his chemistries. He had a carotid
ultrasound that demonstrated no lesions. The patient was
subsequently transported to the [**Hospital6 2018**] for further workup.
TRANSFER MEDICATIONS:
1. Enteric coated aspirin 325 mg p.o. q.d.
2. Lansoprazole 30 mg p.o. q.d.
3. Lasix 60 mg IV q.d.
4. Colace 100 mg p.o. b.i.d.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Afebrile at
97.8, heart rate 72, blood pressure 120/70, respiratory rate
18, saturating 95% on 2 liters nasal cannula. General: The
patient was in no acute distress. HEENT: The mucous
membranes were moist. There was no erythema. The pupils
were equal, round, and reactive to light and accommodating,
anicteric. Neck: Supple with no lymphadenopathy or jugular
venous distention. Lungs: Clear. Heart: Regular. He had a
III/IV systolic murmur radiating to the carotids. Abdomen:
Soft, nontender, nondistended. Extremities: Warm, well
perfused with trace edema.
HO[**Last Name (STitle) **] COURSE: The patient was initially admitted to the
Medical Service where he was optimized on his cardiac
medications prior to going to the Operating Room on [**2125-4-6**] with Dr. [**Last Name (Prefixes) **] where he underwent an uncomplicated
aortic valve replacement with a #23 pericardial tissue valve
as well as a mitral valve repair with a #20 annuloplasty
band. The intraoperative echocardiogram demonstrated mild to
moderately depressed right ventricle.
He was transported to the CRSU intubated on milrinone at 0.5
and Levophed at 0.04. He stayed intubated and his pressors
were slowly weaned but he remained on the milrinone. The
first couple of days postoperatively, he had several episodes
of atrial fibrillation for which he was started on an
Amiodarone drip.
By postoperative day number three, he was just on the
Amiodarone as well as Lasix to help with his diuresis. At
one point, he actually required nitroprusside in order to
bring down his pressure.
He developed a high fever and without an identifiable source
the Infectious Disease Service was consulted. They
determined that one possible source could be an infected
tooth and, therefore, recommended a Dental consult. The
decision was made to anticoagulate the patient.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 3801**]
MEDQUIST36
D: [**2125-4-25**] 04:10
T: [**2125-4-25**] 18:30
JOB#: [**Job Number 49543**]
ICD9 Codes: 4280, 9971, 5119, 5849, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8372
} | Medical Text: Admission Date: [**2126-11-13**] Discharge Date: [**2126-12-4**]
Date of Birth: [**2072-5-27**] Sex: M
Service: MEDICINE
Allergies:
Rocephin
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
transfer from outside ICU
Major Surgical or Invasive Procedure:
none
History of Present Illness:
54 yo gentleman with a history of DM type I, recent pna, and
probable lymphoma who presented to OSH after being d/c'd on home
oxygen and abx on [**10-26**] for pna, during that admission large
axillary and supraclavicular lymph nodes were noted and biopsied
[**10-21**] (frozen section w/reactive ln's, final path still
pending?), represented on [**11-4**] after 4 days of fatigue, dyspnea
and cough, also having loose stools. Was admitted on [**11-4**] with
? post obstructive pna, treated with gatiflox. CXR showed
bilateral infiltrates with left effusion and wbcc of 23. Sputum
cx showed rare normal flora and yeast, repeat stain showed rare
gram positive rods. Ambisome was started [**11-7**] for yeast in
sputum. Was tx to ICU on [**11-10**] and intubated on [**11-11**] after
desating 80%'s on 100% NRB and tiring, he also had increased
secretions at that time, tachycardic. On [**11-11**] after intubation
and sedation w/propofol, bp had to be supported with neo, abx
zosyn and vanomycin were added with steroids. Was paralyzed with
norcuron [**1-7**] to labile sats w/motion and for bronch done [**11-12**],
BAL pending. Per OSH they were concerned with PIP's in the high
30's low 40's and started pressure control ventilation, with
rate of 14, pressure of 28, peep 10, FiO2 0.9 was as low as 0.6
at one point, hct dropped from 31.8 to 25.2 and recieved 1 u
prbc's. High glucose likely [**1-7**] steroids and was briefly on
insulin gtt. Tx to [**Hospital1 **] ICU for "more intensive care".
Past Medical History:
diabetes
b total knee replacements
abdominal wall abcesses drained
Social History:
smoked two packs of cigarettes qd for 35 years quit on 2nd
admission, words as courier, no h/o EtOH or illicits
documented. One dtr w/[**Name2 (NI) **] bifida in nursing home, finace [**Doctor First Name **]
is hcp [**Telephone/Fax (1) 59440**].
Family History:
mother w/ br ca, father w/ [**Name2 (NI) **]a and cad
Physical Exam:
VS: 98.3, 130, 143/69, 18, 97% on PCV of 30, PEEP 8, rr 18, FiO2
0.6, TV's 490's
Gen: intubated, paralyzed
HEENT: scleral edema, perrl, mmd
Neck: L supraclavicular lymph node palpable, RIJ in place,
dressing c/d/i
CV: rrr, tachycardic, no m/r/g
Pulm: coarse bs bilaterally, very decreased on L as compared to
R
Abd: s, nd, no bowel sounds
Groin: R inguinal lymph nodes palpable
Extr: trace edema to feet bilaterally, warm, +2 dp bil
Skin: rash to inner thighs and interrigenous folds
Neuro: paralyzed
Pertinent Results:
[**2126-11-13**] 11:14PM BLOOD WBC-29.0* RBC-4.62 Hgb-11.7* Hct-38.5*
MCV-83 MCH-25.4* MCHC-30.4* RDW-15.9* Plt Ct-394
[**2126-11-13**] 11:14PM BLOOD Neuts-96.2* Lymphs-2.4* Monos-1.3* Eos-0
Baso-0.1
[**2126-11-13**] 11:14PM BLOOD Plt Ct-394
[**2126-11-13**] 11:14PM BLOOD PT-14.3* PTT-22.4 INR(PT)-1.3
[**2126-11-13**] 11:14PM BLOOD Ret Man-PND
[**2126-11-13**] 11:14PM BLOOD ALT-50* AST-55* LD(LDH)-303* CK(CPK)-24*
AlkPhos-128* Amylase-25 TotBili-1.0
[**2126-11-13**] 11:14PM BLOOD Lipase-14
[**2126-11-13**] 11:14PM BLOOD Albumin-2.9* Calcium-9.1 Phos-6.1* Mg-2.5
Iron-123
[**2126-11-13**] 11:14PM BLOOD calTIBC-176* Ferritn-1342* TRF-135*
[**2126-11-13**] 11:14PM BLOOD TSH-0.66
[**2126-11-14**] 02:58AM BLOOD Type-ART Rates-26/4 Tidal V-400 PEEP-8
FiO2-100 pO2-127* pCO2-62* pH-7.31* calHCO3-33* Base XS-3
AADO2-534 REQ O2-88 -ASSIST/CON Intubat-INTUBATED
[**2126-11-13**] 11:55PM BLOOD Type-ART Temp-37 Rates-14/ Tidal V-600
PEEP-10 FiO2-97 pO2-88 pCO2-77* pH-7.26* calHCO3-36* Base XS-3
AADO2-536 REQ O2-88 Intubat-INTUBATED
*
Brief Hospital Course:
A: 54 yo man with h/o type I diabetes mellitus and 50pack year
tobacco use transferred from outside hospital with hypoxic
respiratory failure. During hospitalization the following
problems were addressed:
1) respiratory distress: The cause of his respiratory failure
remains undiagnosed, but his presentation is concerning for
infection vs. malignancy with lymphangetic spread. Lymph node
biopsy from the OSH was read as polyclonal T cell proliferation
consistent with reactive lymphadenopathy. Later, the pleural
fluid from the OSH came back as concerning for malignancy. He
underwent bronchoscopy 3 times, which showed no infection,
cytology negative. Bacterial, AFB cultures negative, stain for
PCP and AFB were also negative. He had CT scan of his abdomen,
chest, and pelvis, which showed diffuse lymphadenopathy but of
only modestly enlarged size and not typical of lymphoma, chest
wall hypodensities of unknown etiology, abdominal wall
hypodensities c/w hematoma, and a small right adrenal
hyperdensity. On day 7 of hospitalization after the pleural
fluid came back concerning for malignancy, a bone marrow biopsy
was done. He was treated with a ______ day course of
levofloxacin, vancomycin, and azithromycin for a possible
post-obstructive pneumonia. Although he continued to produced
copious thick sputum, cultures were nondiagnostic. On day 6 of
hospitalization, and day 8 on the ventilator he was evaluated
for tracheostomy. He did not recieve one as his resp status
contiued to decline and is overall prognosis was poor
2. Hypotension: On day two of hospitalization the patient
became acutely hypotensive requiring pressor support.
Echocardiogram showed increased pulmonary artery pressure and a
lesion in the PA that was confirmed by CT. PA-gram was done to
rule out an evolving PE; it was negative. He was treated
initially with levophed, then for a day with neosynephrine and
vasopressin on day #3 when he became acutely tachycardic and
went transiently into A-fib. He converted back to sinus rhythm,
neosynephrine was weaned off and levophed started. Cardiac
output as determined by mixed venous O2 saturation was found to
be adequate, suggesting his hypotension was due more to
distributive physiology than cardiogenic shock, despite his
obvious right sided failure due to pulmonary artery
hypertension. It was felt that the PAH resulted from the
intrapulmonary process.
3. Lymphadenopathy: biopsy from [**2126-10-21**] at [**Hospital 1474**] Hospital
showed reactive nodes of polyclonal T cell morphology. RPR was
nonreactive, HIV negative, HTLV pending. Oncology was consulted
for recommendations of further work-up and treatment.
4. Tachycardia: The patient was tachycardic on day 2 and
transiently in atrial fibrillation. On day 5 of admission, he
developed transient episodes of multifocal atrial tachycardia.
5. Type I diabetes mellitus: He was maintained on an insulin
gtt
6. Nutrition: he received tubefeeds by OG tube. On day ___ he
had a PEG placed for continued tubefeeds.
7. Communication: the patient's fiance [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9418**] is
his designated health care proxy, official documentation noted.
8. Sedation: he was maintained on versed and fentanyl.
Initially off sedation the patient became very agitated resulted
in tachycardia and decreased oxygen saturation.
9. Access: the patient came with a R IJ from the OSH. A-line
placed on the morning following admission.
10. Skin rash: On day 2 the patient developed what appeared to
be a drug reaction on his abdomen. The rash spread to his
thighs bilaterally, feet and hands. On day 4 he was found to
have pustular lesions on his right foot, and desquamation on his
thighs and backside. Dermatology was consulted and suggested he
had tinea cruris. He was treated with topical antifungals and
improved.
11. Care Plan: The family and attending had a meeting on [**12-3**]
and decided to make the paitent CMO since his overall prognosis
was poor. He was extubated in the presence of his family on
[**12-4**] and expired shortly thereafter.
Medications on Admission:
tequin 400 mg iv qd
zosyn 3.375 mg iv q 6
vanco 1.5g iv q 12
pepcid 20 mg iv q 12
solumedrol 80 mg iv q 8
propofol gtt to sedation
vecuronium gtt to paralysis
ambisome 300 mg iv qd
MSO4 2 mg iv q4 hr prn
regular insulin sliding scale
Discharge Disposition:
Expired
Discharge Diagnosis:
respiratory failure
diffuse large B cell lymphoma
Discharge Condition:
expired
Followup Instructions:
none
ICD9 Codes: 486, 4280, 4271, 5180, 2760, 4589, 4168, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8373
} | Medical Text: Admission Date: [**2128-10-21**] Discharge Date: [**2128-10-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Change in mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a [**Age over 90 **] year old gentleman with a history of high blood
pressure and possible lung cancer who presented from his nursing
home today with change in mental status. The patient was noted
to be lethargic at his nursing home today. His grandson came to
visit him and reported the patient could not speak. He was sent
to the ED where a blood sugar was 25. Patient was given one amp
of D50 and a subsequent blood sugar was 300. Potassium was 6.3
and the patient was given one amp of D50, 10 units of insulin,
calcium gluconate and bicarbonate. One hour later her blood
sugar was 37. He received one amp of D50 and his blood sugar was
113. He was started on D10 at 150 an hour. One hour later his
blood sugar was 80. His nursing home was called and reported
that his roomate took sulfonylureas. In the ED the patient also
received vancomycin, ceftazadime, one liter of normal saline and
kayexalate.
[**Hospital1 336**] was called and gave the patient's pmhx and med list.
[**Name (NI) **] grandson reports that the patient has been living in a
nursing home since [**Month (only) **]. Prior to that he lived with his
daughter, but he has become harder to care for at home, and his
family does not feel that he is safe at home without constant
supervision. According to his grandson his memory is good, but
he is sometimes forgetful. He does not wander. He feeds himself
but does not cook or prepare food. He has been walking less and
less. He is DNR/DNI and would not want any aggressive measures
or surgery. He has had several recent hospitalizations at [**Hospital1 336**]
for GI bleed and hyponatremia.
ROS: Denies abdominal pain, fevers, shortness of breath.
Past Medical History:
1. Hypertension
2. Probable lung cancer (not biopsy proven)
3. Bronchitis
4. Hyponatremia
5. Dementia
6. GI bleed [**7-9**]
Social History:
Lives in a nursing home. Widowed. Has two children who are very
supportive. No alcohol. Remote tobacco use.
Family History:
Noncontributory
Physical Exam:
VS: T 97.3 HR 82 BP 184/81 RR 18 O2 sat 100% RA
Gen: Well appearing, thin, comfortable, lying in bed in NAD.
HEENT: PERRL, EOMI, sclera anicteric, MMM.
Neck: No LAD, JVD or thyromegly.
CV: RRR with no m/r/g
Lungs: CTA bilaterally
Abd: soft, NT, ND active BS, no hepatosplenomegly.
ext: No clubbing, cyanosis or edema.
Neuro: back to baseline per daughter
Pertinent Results:
[**2128-10-21**] 04:46PM BLOOD WBC-12.8* RBC-3.85* Hgb-12.1* Hct-34.9*
MCV-91 MCH-31.4 MCHC-34.6 RDW-16.0* Plt Ct-299
[**2128-10-21**] 04:46PM BLOOD Plt Ct-299
[**2128-10-21**] 04:46PM BLOOD PT-12.0 PTT-24.2 INR(PT)-1.0
[**2128-10-21**] 04:46PM BLOOD Fibrino-503*
[**2128-10-21**] 04:46PM BLOOD UreaN-47* Creat-2.5* K-6.3*
[**2128-10-21**] 04:46PM BLOOD ALT-14 AST-23 LD(LDH)-226 CK(CPK)-21*
AlkPhos-113 Amylase-258* TotBili-0.2
[**2128-10-21**] 04:46PM BLOOD Lipase-108*
[**2128-10-21**] 04:46PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2128-10-21**] 04:46PM BLOOD Albumin-3.7 Calcium-9.3 Phos-3.1 Mg-2.2
[**2128-10-21**] 04:46PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2128-10-23**] 05:00AM BLOOD WBC-11.7* RBC-2.89* Hgb-9.6* Hct-26.7*
MCV-92 MCH-33.3* MCHC-36.0* RDW-17.3* Plt Ct-235
[**2128-10-23**] 05:00AM BLOOD Plt Ct-235
[**2128-10-23**] 05:00AM BLOOD Glucose-153* UreaN-35* Creat-1.7* Na-134
K-4.2 Cl-101 HCO3-24 AnGap-13
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2128-10-21**] 6:43 PM:
RIGHT UPPER QUADRANT ULTRASOUND: Examination limited secondary
to patient's inability to follow breath-hold instructions. The
liver is grossly normal in echotexture and contour. No focal
liver lesions are identified. There is no intrahepatic biliary
ductal dilatation. The gallbladder is not distended. Several
gallstones are identified. There is no gallbladder wall edema.
There is no pericholecystic fluid or ascites identified. The
common bile duct measures 6 mm which in a patient of age [**Age over 90 **] is
normal. Limited assessment of the hepatic vasculature shows
patent hepatic and portal veins with normal direction of flow.
The visualized pancreas shows a 2-mm pancreatic duct.
IMPRESSION:
1. Limited examination secondary to patient's inability to hold
his breath.
2. Patent hepatic vasculature as described above.
2. Cholelithiasis without evidence for cholecystitis.
CHEST (PORTABLE AP) [**2128-10-21**] 5:20 PM:
FINDINGS: Cardiac and mediastinal contours are normal. The aorta
is tortuous and calcified. Patchy opacity is seen at the left
lung base with obscuration of the medial left hemidiaphragm.
Pulmonary vasculature appears normal. There is no pneumothorax.
Osseous structures are unremarkable.
IMPRESSION:
Patchy left lower lobe opacity may represent atelectasis or
early pneumonia.
CT HEAD W/O CONTRAST [**2128-10-21**] 4:46 PM:
FINDINGS: No acute intra- or extra-axial hemorrhage is
identified. There is no mass lesion, shift of normally midline
structures, or evidence for major vascular territorial
infarction. There is prominence of the ventricles and sulci
consistent with age-appropriate involutional change.
Hypodensities are seen in the periventricular white matter
consistent with chronic small vessel infarction. A small
hypodensity is seen in the right side of the pons consistent
with old infarction. The remainder of the brain parenchyma has
normal density with preservation of the [**Doctor Last Name 352**]-white matter
differentiation. No fractures are identified. There is bilateral
maxillary sinus mucosal thickening versus fluid. The remaining
visualized paranasal sinuses and mastoid air cells are well
pneumatized. The soft tissue structures are unremarkable.
IMPRESSION: No evidence for intracranial hemorrhage or mass
lesion. Old right pontine infarction. Periventricular small
vessel ischemic changes.
CHEST (PORTABLE AP) [**2128-10-22**] 5:06 AM:
The patient's right arm obscures the lower chest. There is a
suggestion of consolidation at the right lung base, which may
represent an evolving pneumonia. Upper lungs are clear. The
heart is top normal size. There is no large pleural effusion or
indication of pneumothorax or central adenopathy. Leftward
deviation of the trachea at the thoracic inlet could be due to
tortuous head and neck vessels and/or enlargement of the right
lobe of the thyroid gland.
Brief Hospital Course:
[**Age over 90 **] year old man with history of hypertension and possible lung
cancer presents with change in mental status and persistent
hypoglycemia.
1) Change in mental status: Most likely due to hypoglycemia.
Head CT was negative for any acute intracranial process.
Resolved quickly with glucose replacement. Patient is Cantonese
peaking and was able to communicate effectively with his family
members and through the translator.
2) Persistent hypoglycemia: Differential includes erroneous
medications (patient may have taken his roomate's sulfonylurea
or insulin), paraneoplastic phenomenon, salicylates, tumor
producing insulin like growth factor, sepsis, adrenal
insufficiency, or insulinoma. Most likely would be a medication
error resulting in sulfonylurea dosing. Would expect this to
cause prolonged hypoglycemia since the patient has renal
impairment. Pt was treated with octreotide to reverse
hypoglycemia. Hypoglycemia corrected over the next 10 hours. As
patient remained stable, additional labs such as serum insulin,
C peptide, and proinsulin levels to evaluate for insulinoma vs
surreptitious insulin dosing were not obtained. Sulfonylurea
levels were not sent. [**Last Name (un) **] stim test to r/o sepsis and adrenal
insufficiency was not performed as patient's hypoglycemia
resolved. Patient will be discharged back to his skilled nursing
facility. Extra precautions should be taken to avoid medication
errors.
3) Renal insufficiency: Patient's Cr was 2.5 on admission,
however, it was unclear if this is patient's baseline.
BUN/creatinine ratio c/w pre renal etiology. Pt was hydrated;
urine lytes were obtained. FeNa based on the urine electrolytes
was 1.5%. Patient's Cr trended down during his admissiona and
was 1.7 on day of discharge. Unfortuntely we were not able to
speak to patient's PCP about his baseline renal function prior
to discharge, but patient should be directed to follow-up with
his PCP after he returns to the skilled nursing facility and
have a serum creatinine level checked.
4) Hypertension: Chronic. Restarted outpatient medications.
Patient's BP remained slightly elevated so we added HCTZ 25 mg
po qd for tighter control.
5) Prophylaxis: Patient received pantoprazole for GI prophylaxis
and wore pneumoboots for DVT prophylaxis while in-patient.
Medications on Admission:
1. Aspirin
2. Llidocaine
3. Cardizem
4. Lopressor
5. Potassium
6. moxifloxacin
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Lidocaine HCl 2 % Solution Sig: Ten (10) ML Mucous membrane
DAILY (Daily).
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Calcium Carbonate 1,250 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
10. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
Hypoglycemia
Secondary diagnosis:
Question of new renal insufficiency
Hypertension
Dementia
Discharge Condition:
Stable
Discharge Instructions:
1. Please keep all follow up appointments.
2. Please take all medications as prescribed.
3. Seek medical attention for fevers, chills, chest pain,
shortness of breath, change in mental status, or any other
concerning symtpoms.
Followup Instructions:
Please follow up with the physician at your nursing home within
one week of discharge.
ICD9 Codes: 5849, 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8374
} | Medical Text: Admission Date: [**2112-6-1**] Discharge Date: [**2112-6-8**]
Date of Birth: [**2039-7-15**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 72-year-old female
with a history of type 2 diabetes mellitus and hypertension
who presented with confusion, lightheadedness, and malaise.
The patient reported some visual hallucinations for
approximately 10 months which were not mentioned during her
earlier hospitalization in [**2111-12-12**]. She reports
feeling thirsty but not urinating frequently. She admits to
a 50-pound weight loss, increased fatigue, weak legs with
minimal ambulation during the past two months.
By report, the patient was a somewhat poor historian on
initial evaluation. Initially, the patient was thought to
have significant mental status changes, lethargy, and
borderline unresponsiveness.
In the Emergency Department, she was noted to be in acute
renal failure with a creatinine increased to 5.8 from a
baseline of 0.7. Her arterial blood gas was notable for a
bicarbonate of 8. The patient was initially transferred to
the Intensive Care Unit for immediate care and management.
In the Intensive Care Unit, the patient was treated with
Kayexalate with resolution of her hyperkalemia. The Renal
team was consulted for acute renal failure and acidosis.
Initially, there was some question if the patient had a renal
tubular acidosis, specifically type 1, given her
metabolic derangements. However, the patient responded
immediately to intravenous fluids with her creatinine
decreasing from 5.8 to 2 quickly, making prerenal acute renal
failure the most likely diagnosis.
Further history revealed the patient had some question of
increased ostomy output, although there was no reported
decrease in oral intake. Gastroenterology was consulted,
.................... nongap acidosis possibly related to
increased ostomy output. In addition, the patient had been
on an ACE inhibitor prior to admission.
PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus times 12 years.
2. Hypertension.
3. Lower gastrointestinal bleed secondary to diverticulosis;
failed embolization requiring subtotal colectomy with
ileostomy in [**2111-12-12**].
4. Uterine fibroids.
5. Colonic polyps.
MEDICATIONS ON ADMISSION:
1. Glipizide 10 mg once per day.
2. Glucophage 500 mg twice per day.
3. Lisinopril 5 mg once per day.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on initial
presentation revealed a temperature of 98.1, her blood
pressure was 125/52, her heart rate was 78, her respiratory
rate was 11, and 97% on room air. An elderly female,
lethargic. Head, eyes, ears, nose, and throat examination
revealed atraumatic. The pupils were equal, round, and
reactive to light. The mucous membranes were moist. The
neck was supple. No lymphadenopathy. No thyromegaly. No
jugular venous distention. Cardiovascular examination
revealed a regular rate and rhythm. Normal first heart
sounds and second heart sounds. A [**2-16**] diastolic murmur.
Her lungs were clear to auscultation bilaterally. No
crackles, wheezes, or rhonchi. Her abdomen was soft,
nontender, and nondistended. Active bowel sounds. The
ostomy was clean and intact. There was no costovertebral
angle tenderness bilaterally. Her extremities were without
edema. Her skin showed several seborrheic keratoses over the
back, face, and chest. Her neurological examination was
alert and oriented times three without asterixis.
PERTINENT LABORATORY VALUES ON PRESENTATION: Notable for a
creatinine of 5.8, her potassium was 7.5, and her lactate was
0.8. Urinalysis showed a specific gravity of 1.000,
leukocyte esterase was negative, nitrites were negative,
protein was negative, and glucose was negative. The
patient's serum osmolalities were 322. Her urine creatinine
was 0, sodium was less 10, urine osmolalities were 3. Her
fractional excretion of sodium was initially greater than 1.
RADIOLOGY/IMAGING FINDINGS: The patient had an
electrocardiogram with a normal sinus rhythm in the 60s,
normal axis, first-degree AV block, flat T waves in aVL,
biphasic in V5 and V6. No ST segment changes. Read as
unchanged from prior.
Her renal ultrasound showed no hydronephrosis, stones, or
masses.
BRIEF SUMMARY OF HOSPITAL COURSE: This is a 72-year-old
female with a past medical history of hypertension and type 2
diabetes times 12 years who presented with confusion and was
noted to have acute renal failure.
1. ACUTE RENAL FAILURE ISSUES: The patient was initially
evaluated in the Intensive Care Unit. There was some concern
the patient had type 1 renal tubular acidosis; however, the
patient responded quickly to intravenous hydration, and it
was felt that this picture was most likely consistent with
prerenal acute renal failure.
The patient's creatinine returned to the 1.3 to 1.4 range
from a peak of 5.8 quite quickly over several days with
intravenous fluids. The patient was deemed stable enough to
be transferred to the general medical floor on [**2112-6-3**]. At the time of transfer, her creatinine had improved
to 2.
The patient had several kidney studies including the renal
ultrasound which was negative for obstruction. She had a
serum protein electrophoresis and urine protein
electrophoresis sent which were normal; to rule out multiple
myeloma. In addition, she had urine eosinophils sent to
evaluate for allergic interstitial nephritis which were
negative. The patient had a urinalysis sent and a urine
culture which was no growth to date.
It was felt that the prerenal state was likely induced
secondary to increased ostomy output. The ostomy output was
followed closely and was noted to be in the normal range;
approximately 1 liter to 1.5 liters per day. It was felt
that the patient was likely just not keeping up with the by
mouth fluid requirements given her ostomy output. The
patient was encouraged to continue to take adequate by mouth
hydration.
The Gastroenterology Service had been consulted to further
evaluate the ostomy. This will be discussed further down.
2. EXCESSIVE OSTOMY OUTPUT ISSUES: There was a concern
raised that the patient was actually having excessive ostomy
output which was causing her prerenal state. However,
further observation revealed that the patient was simply not
keeping up with her output.
Gastroenterology did evaluate the patient with an ileoscopy
and did not note any abnormalities. In addition, the patient
had an endoscopy performed which noted several duodenal
ulcerations. The patient was begun on a higher dose of
Protonix 40 twice per day for eight weeks. She will continue
this medication for eight weeks and then decrease to 40 mg by
mouth every day.
3. TYPE 2 DIABETES MELLITUS ISSUES: The patient's by mouth
hypoglycemics were discontinued on admission given her acute
renal failure. As her renal failure improved, the patient
was restarted on glipizide at initially 5 mg and then
titrated up to 10 mg by mouth once per day. At the time of
discharge, the patient was not taking her metformin. Her
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10208**], was contact[**Name (NI) **] and was
aware that the patient will need to have her fingerstick
glucoses followed and will likely need to restart her
Glucophage as an outpatient.
4. HYPERTENSION ISSUES: The patient had been on an ACE
inhibitor which may have contributed to the prerenal picture.
The ACE inhibitor was held during this admission. She was
started on a beta blocker; 50 mg by mouth twice per day was
the dose she was discharged on. This was also communicated
to her primary care physician (Dr. [**Last Name (STitle) 10208**].
5. ANEMIA ISSUES: The patient had iron studies sent which
were borderline for anemia of chronic disease. The patient
was continued on by mouth liquid iron. She did have one
guaiac-positive stool during this hospital stay. It was felt
that this was likely secondary to her duodenal ulcerations.
The Gastroenterology Service stated that the patient should
not need a small-bowel follow-through to further evaluate her
anemia.
6. MENTAL STATUS CHANGES: The patient's mental status
significantly improved with improvement of her renal failure.
On discharge, the patient was alert and oriented. She felt
nearly back to herself; not quite 100% but was ambulating
without difficulty and eating a good by mouth diet.
CONDITION AT DISCHARGE: Stable, eating a full diet, and
ambulating without difficulty.
DISCHARGE STATUS: To home with [**Hospital6 407**]
services. [**Hospital6 407**] for home safety
evaluation, blood pressure checks, fingerstick checks, and
blood draw to check her creatinine.
DISCHARGE DIAGNOSES:
1. Acute renal failure; prerenal.
2. Status post ileostomy.
3. Type 2 diabetes mellitus.
4. Hypertension.
5. Duodenal ulcerations.
MEDICATIONS ON DISCHARGE:
1. Tylenol 325 mg one to two tablets by mouth q.4-6h.
2. Iron sulfate 300-mg liquid 5 mL by mouth twice per day.
3. Pantoprazole 40 mg one tablet by mouth twice per day
times eight weeks then decrease to 40 mg by mouth once per
day ongoing.
4. Glipizide 10 mg by mouth once per day.
5. Metoprolol 50 mg by mouth twice per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with her primary care
physician (Dr. [**Last Name (STitle) 10208**].
2. She was aware that she needs to call Dr. [**Last Name (STitle) 10208**] for an
appointment in the next week.
3. In addition, she will have followup by the [**Hospital6 1587**] for home blood pressure checks, as well as
fingerstick checks to follow her glucose level, and a
laboratory draw two days after discharge to follow up on her
creatinine.
4. The [**Hospital6 407**] were advised that they
should call these results to Dr. [**Last Name (STitle) 10208**] (her primary care
physician) [**University/College 45471**] Health Center. Dr.
[**Last Name (STitle) 10208**] can be contact[**Name (NI) **] at [**Telephone/Fax (1) 35879**].
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Name8 (MD) 3482**]
MEDQUIST36
D: [**2112-6-8**] 15:23
T: [**2112-6-8**] 18:01
JOB#: [**Job Number 45472**]
ICD9 Codes: 5849, 2765, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8375
} | Medical Text: Admission Date: [**2147-7-4**] Discharge Date: [**2147-8-23**]
Date of Birth: [**2103-7-19**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Left lower leg swelling
Major Surgical or Invasive Procedure:
hemodialysis
left internal jugular hemodialysis catheter placement and
removal
right upper extremity PICC placement
chemotherapy: 1st cycle fludarabine (50% dose due to renal
function), 2nd cycle CHOP
R Nephrosotomy and L renal stent placement
R Nephrostomy and L stent removal
History of Present Illness:
43 y.o women with a history of hepatitis C, recent lymph node
biopsy on [**2147-6-9**] at [**Hospital3 **] hospital who presents today
with left lower extremity redness and pain, who was then found
to have severe hyperkalemia and acute renal failure.
The patient recently was admitted to [**Hospital3 417**] hospital
from [**2147-6-9**] to [**2147-6-13**] for an elective excisional biopsy of
diffuse lymphadenopathy, most prominent in her left groin.
Based on limited records, her creatinine was 0.9 at that time.
She was then discharged from the hospital to a [**Hospital1 1501**] due to
inability to ambulate, where she has been residing ever since.
Today, at the [**Hospital1 1501**] her labs were checked and she was found to
have a K of 7.8 and a creatinine of 9.9. The patient herself
reports that she feels that her urine output has been decreasing
lately along with some increased generalized edema.
In the ED, initial VS were: 98.9 92 146/90 18 95% RA. On labs,
her K was 8.6 and her creatinine was 10.6. She was given 10U of
regular insulin and 1 amp of D50W for her hyperkalemia. She was
also given a dose of vancomycin for a possible cellulitis. A
left lower extremity ultrasound was negative for clot. Other
notable labs include a uric acid level of 10.1 and a phosphate
of 6.7. Nephrology was consulted and recommended that she be
admitted to the MICU for medical management of her hyperkalemia.
Her K after the above interventions dropped to 6.3, and given
an EKG that did not show evidence of cardiac toxicity, dialysis
was not initiated.
On arrival to the MICU, patient's VS were 97.4 79 118/82 15 98%
on RA
Past Medical History:
Hepatitis C
hypertension
Anxiety
Depression
myocardial infarction
Bilateral lower extremity edema
Irritable bowel syndrome
Hemorrhoids
Heroin abuse
Borderline personality disorder
Social History:
IVDA, quit years ago according to patient, during a search of
her belongings a significant amount of drug paraphenelia was
found including a spoon, wrapping papers, and syringes. Current
1ppd smoker. No EtOH.
Family History:
NC
Physical Exam:
ADMISSION EXAM:
General: somlenent, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, PERRL
Neck: supple, JVP not elevated, mild left anterior cervical
lymphadenoapthy
CV: Regular rate and rhythm, normal S1 + S2, mild [**3-20**] mid
systolic murmur best heard at RUSB.
Lungs: Bibasilar crackles, R>L
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or
guarding. Dressing at inguinal site c/d/i. Significant
bilateral inguinal lymphadenopathy.
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, significant bilateral LE
edema Neuro: GCS 14, oriented x3, moving all 4 extremities,
otherwise unable to cooperate with neuro exam.
DISCHARGE EXAM:
General: alert, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, PERRL
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no MRG
Lungs: CTAB
Abdomen: soft, slightly distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or
guarding.
GU: nephrostomy stent and
Ext: Warm, well perfused, 2+ pulses, 1+ bilateral LE edema
Neuro: alert and oriented x3, CN II-XII grossly intact, normal
gait, normal muscle tone and buk
Pertinent Results:
ADMISSION LABS:
[**2147-7-4**] 09:25PM BLOOD WBC-3.9* RBC-3.50* Hgb-9.4* Hct-30.2*
MCV-86 MCH-26.9* MCHC-31.2 RDW-13.0 Plt Ct-266
[**2147-7-4**] 09:25PM BLOOD Neuts-66.6 Lymphs-23.2 Monos-8.5 Eos-1.5
Baso-0.1
[**2147-7-4**] 09:25PM BLOOD PT-10.0 PTT-30.9 INR(PT)-0.9
[**2147-7-5**] 03:02AM BLOOD Ret Aut-1.2
[**2147-7-4**] 09:25PM BLOOD Glucose-80 UreaN-70* Creat-10.6* Na-135
K-8.6* Cl-98 HCO3-22 AnGap-24*
[**2147-7-4**] 09:25PM BLOOD CK(CPK)-169
[**2147-7-4**] 09:25PM BLOOD Calcium-9.0 Phos-6.7* Mg-3.2*
UricAcd-10.1*
[**2147-7-5**] 07:01AM BLOOD calTIBC-247* VitB12-578 Ferritn-200*
TRF-190*
[**2147-7-5**] 03:02AM BLOOD Osmolal-305
[**2147-7-5**] 03:02AM BLOOD Valproa-47*
[**2147-7-4**] 09:25PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2147-7-4**] 09:49PM BLOOD Lactate-1.2
URINE:
[**2147-7-5**] 12:25AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004
[**2147-7-5**] 12:25AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-MOD
[**2147-7-5**] 12:25AM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-1
TransE-<1
[**2147-7-5**] 12:25AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
STUDIES:
[**2147-7-4**] Lower extremity ultrasound:
No DVT of the left lower extremity.
[**2147-7-4**] CXR:
1. Retrocardiac opacity compatible with pneumonia or
atelectasis
2. Prominence of the right hilus may be secondary to low lung
volumes or
hilar opacity. Suggest follow up radiographs, ideally with
better
inspiration.
[**2147-7-5**] CXR:
1. Left IJ catheter in the mid SVC.
2. Mild pulmonary edema.
[**2147-7-6**] 3:26 PM # [**Telephone/Fax (1) 103896**] CT CHEST, ABD & PELVIS W/O CON
1. Infiltrative soft tissue mass surrounding the retroperitoneal
region, including the aorta, IVC, and presumably the ureters.
This is likely secondary to lymphoma and would be expected to be
the cause of the patient's bilateral renal obstruction. However,
given the cortical thinning on the left, this is likely a
chronic process. 2. Ground-glass opacities seen within the right
upper lobe and right middle lobe suggestive of atypical
infection. The typical consolidations seen with bacterial
pneumonia are not evident on this examination. 3. Bilateral
pleural effusions are moderate in size, slightly greater on the
right and on the left, with associated atelectasis.
[**2147-7-12**] 12:20 PM # [**Numeric Identifier 103897**] INTRO CATH RENAL
1. Successful uncomplicated placement of a left-sided 8 French
x22 cm nephroureteral stent. 2. Successful uncomplicated
placement of an 8 French nephrostomy tube in the right kidney.
3. A future study is recommended in [**3-17**] weeks to try to attempt
reconversion of the right-sided nephrostomy tube to a
nephroureteral stent and to try to further characterize the
filling defect seen in the right renal pelvis, which could be an
air bubble.
[**2147-7-18**] 11:23 AM # [**Telephone/Fax (1) 103898**] RENAL U.S.
IMPRESSION: Complete resolution of left hydronephrosis.
Near-complete resolution of right hydronephrosis with only
minimal residual hydronephrosis noted.
[**2147-7-19**] Cardiovascular ECHO
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. No masses or
vegetations are seen on the aortic valve. Mild (1+) aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is high normal. There is no pericardial effusion. IMPRESSION:
Mild aortic regurgitation with normal valve morphology. Normal
biventricular cavity sizes with preserved global and regional
biventricular systolic function. If clinically indicated, a
transesophageal echocardiographic examination is recommended to
assess aortic valve morphology. CLINICAL IMPLICATIONS: Based on
[**2142**] AHA endocarditis prophylaxis recommendations, the echo
findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
[**2147-7-19**] Radiology MRI PELVIS W/O & W/CONT
1. 3.6-cm lymph node in the left external iliac chain has
features concerning for a necrotic lymph node with probable
secondary infection (suppurative lymph node). An 1.8-cm lymph in
the left common iliac chain has similar characteristics, and
also is concerning for a suppurative lymph node. 2. Edema and
swelling of the left iliacus and obturator internus muscles is
suggesting of an ongoing inflammatory or infectious process. 3.
Compression of the left external iliac artery and vein due to
the enlarged external iliac chain lymph node without evidence of
thrombus or occlusion. 4. Extensive pelvic and inguinal
lymphadenopathy.
[**2147-7-21**] Radiology US UPPER EXTREMITY, SOFT TISSUE NODULE
IMPRESSION: Multiple subcutaneous soft tissue nodules in the
right and left upper extremity, suggestive of lymphomatous
deposits/ lymph nodes in the soft tissues. If desired, these can
be FNAed/biopsied under imaging guidance.
[**2147-7-24**] Radiology MR THIGH W&W/O CONTRAST
1. Left inguinal lymphadenopathy, slightly progressed since the
recent MRI one week ago. No new lesion identified, and no distal
lymphadenopathy in the thigh. 2. Diffuse subcutaneous soft
tissue swelling and edema is nonspecific but may represent
lymphedema or cellulitis. Fluid tracks along the superficial
fascia, but this is unlikely to represent fasciitis given the
lack of fascial enhancement. Mild inter- and intramuscular edema
representing mild myositis. 3. Diffuse patchy bone marrow signal
abnormality likely represents red marrow, but osseous
lymphomatous involvement is not excluded especially in the
intertrochanteric regions bilaterally.
[**2147-7-25**] Pathology Tissue: RIGHT ARM NODULE.
Hematoma with early organization. No evidence of lymphoma.
[**2147-7-27**] Radiology CT CHEST W/O CONTRAST
IMPRESSION: No findings to suggest pulmonary infection with
unchanged prominent lymph nodes as above.
[**2147-8-12**] Abdomen and Pelvis
IMPRESSION:
1. Decreased size of left retroperitoneal lymph node
conglomerates and
bilateral inguinal lymphadenopathy.
2. Right nephrostomy tube and left nephroureteral stent
appropriately
positioned with interval resolution of bilateral hydronephrosis.
[**2147-8-21**] Antegradge nephrogram
IMPRESSION:
1. Left antegrade nephrostogram demonstrated brisk passage of
contrast
through the left ureter into the urinary bladder. Mildly
dilated left
interpolar to lower pole calices, likely as a result of
caliectasis. No left
UPJ obstruction. Left NU stent was removed.
2. Right antegrade nephrostogram did not demonstrate
hydroureteronephrosis.
Brisk passage of contrast through the reter into the bladder.
Right
nephrostomy catheter was removed.
----------
MICRO:
[**2147-7-5**] IMMUNOLOGY HCV VIRAL LOAD-FINAL -
23,720,478 IU/mL.
[**2147-7-8**] IMMUNOLOGY HIV-1 Viral
Load/Ultrasensitive-FINAL HIV-1 RNA is not detected.
[**2147-7-12**] STOOL C. difficile DNA amplification
assay-FINAL -NEGATIVE
----
[**2147-7-19**] 9:46 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2147-7-21**]**
C. difficile DNA amplification assay (Final [**2147-7-19**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final [**2147-7-21**]):
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final [**2147-7-21**]): NO CAMPYLOBACTER
FOUND.
Cryptosporidium/Giardia (DFA) (Final [**2147-7-21**]):
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
---
BLOOD CULTURES: 5/22,26,27 all negative. 6/4,5,6,7,8,9,13 all
negative
-----
ECG - [**2147-7-31**]
Sinus rhythm. Precordial T wave inversions of uncertain
significance. Since the previous tracing of [**2147-7-28**] ventricular
premature beat is not seen, the lateral T waves are improved,
early precordial T wave abnormalities persist.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
82 144 86 [**Telephone/Fax (2) 103899**] 35
-------
Brief Hospital Course:
43 yoF with h/o hepatitis C, HTN, IV drug use, and recent
diagnosis of follicular lymphoma who initially presented with
acute obstructive renal failure (s/p HD and R nephrostomy and L
nephroureteral stent) with course complicated by fevers and left
necrotic iliac lymph nodes.
# Follicular Lymphoma: Final pathology showed follicular
lymphoma, follicular growth pattern, cytological grade 1 of 3.
New subcutaneous nodules were concerning for lymphomatous
transformation, supported by increasing LDH. Pt had an
excisional biopsy of R upper extremity subcutaneous nodule by
general surgery on [**2147-7-25**], but these only showed organizing
hematoma, perhaps from prior drug use. Choices for treatment
were initially limited by Pt's profound obstructive renal
failure. Pt was treated with fludarabine D1-5, dose-reduced to
50% normal and completed 2 cycles of R-CHOP when renal function
resolved. [**2147-8-12**] CT abdomen showed interval improvement in
retroperitoneal masses and improvement of bilateral
hydronephrosis. Pt was discharged with acyclovir, fluconazole,
and bactrim ss for ppx. She has an appointment with Oncologist
Dr [**Last Name (STitle) 21628**] (ph:1-[**Telephone/Fax (1) 71494**] fax: [**Telephone/Fax (1) 83170**] address [**Last Name (NamePattern1) 103900**]. [**Hospital1 1474**], Mass) on [**9-11**].
# Healthcare associated pneumonia: Patient presented with fever
and infiltrate on CXR. Pt was treated with vancomycin and
pip/tazo 4.5g iv q6h d1 = [**7-10**] for full 8 day course with
complete resolution of symptoms and radiographic resolution on
repeat CXR.
# Acute renal failure/obstructive uropathy: Pt presented in
profound obstructive renal failure with Cr 10.6 and potassium
8.6. Pt was initally admitted to ICU, initially medically
managed, then dialyzed and transferred to BMT service for
further managment. Pt had uneventful placement of R nephrostomy
tube and L nephro-ureteral stent placed by IR on [**2147-7-12**]. Pt had
little urine output from L nephro-ureteral stent (~250mL over 16
hrs) but plentiful urine output from R nephrostomy (~2.4L over
16 hrs). L nephro-ureteral stent was capped per IR on [**2147-7-13**].
Given rapid improvement in Cr, down to 2.5 on [**2147-7-13**] morning
w/out dialysis, further decreasing to 2.0 on [**2147-7-14**], Pt's HD
line was discontinued w/out issue. Pt's Cr continues to improve
to 1.1 on [**2147-7-24**] and ultimately down to baseline. Repeat renal
ultrasound showed complete resolution of L hydronephrosis and
almost complete resolution of R hydronephrosis. R nephrostomy
was capped on [**2147-7-27**], On [**2147-8-21**], pt had IR evaluate the
nephrostomy tubes via nephrostogram which showed no obstruction
of R or L ureter, the nephrostomy tube and stents were removed
without complication.
Patient with good UOP and creatinine of 1.1 at time of discharge
# UTI. Patient with positive UA. Ucx + E.Coli. Patient placed on
macrobid 100 mg twice per day with instruction to take thru
[**2147-9-7**]
# Hyperkalemia - Secondary to the acute renal failure, treated
with Kayexalate, insulin, and calcium gluconate prior to
initiation of HD. No e/o EKG changes. Resolved with HD. K at
time of discharge 5.5
# Altered mental status. Noted on admission. Differential
diagnosis: uremia, hypoglycemia (although she was quite sleepy
prior to getting insulin in the emergency room), accumulation of
drugs including klonopin and dilaudid that she had been
receiving due to her renal failure. Resolved with HD and
mentating at baseline.
# Chronic back pain / abdominal pain with possible
radiculopathy. Pt is an active cocaine and heroin user.With
initial pain consult evaluation, Pt was placed on hydromorphone
IV, PO, and methadone, gabapentin, and lidocaine patch. Pt was
titrated to methadone 10mg po tid, hydromorphone to 4mg po q4hrs
prn. QTc monitored and within normal limits. Pt was strongly
opposed any effort to taper her pain medications but after pt
was rejected by facilities for having a much too high daily
dilaudid requirement, patient was willing to half her Dilaudid
dose from 8mg to 4mg every 4 hours. Will need outpatient pain
medication taper.
# Anxiety / agitation: Very labile behavior with hypothesized
underlying personality disorder per psych. Pt was started on
divalproex 250 mg PO BID, olanzapine 5mg po tid standing per
psychiatry; clonazepam 1 mg PO TID for anxiety and lorazepam 1mg
po tid prn. These medications should be tapered as an
outpatient. She will follow up with her primary care doctor
after discharge.
# Normocytic Anemia: Hct initially downtrending, hemolysis labs
negative. Nadir of 21.1 on [**2147-7-10**]. Likely related to
underproduction in setting of underlying lymphoma/renal failure.
Iron studies suggestive of anemia of chronic disease. No
evidence of bleeding. HCT 26.8 on discharge.
# HCV: HCV viral load 23 million. Pt has not been exposed to
HBV. Pt's LFT have been normal. She will need outpatient
hepatology follow up for active hepatitis C.
# Drug abuse - Patient with current IV drug use. Pt was also
using drugs in while hospitalized. Social work was consulted.
Will need outpatient support program. Patient will follow up
with PCP and pain specialist.
# Disposition issues: Pt was homeless prior to admission. Her
husband is also at [**Name (NI) 10246**], and they had a significant
altercation while at [**Hospital1 18**]. Patient has been barred from several
shelters/rehabs due to issues with continued heroin abuse and
altercations w/ other residents. Rejected by [**Hospital1 10246**], [**Hospital **]
hospital, [**Doctor Last Name **] house. As patient did not meet inpatient
criteria after lengthy discussion patient was discharged to live
with a friend in [**Name (NI) 5110**], MA per her request.
# Follow-up
The patient will follow up with her PCP, [**Name10 (NameIs) **] [**Name (NI) 103901**] (ph:
[**Telephone/Fax (1) 10216**] fax:[**Telephone/Fax (1) 103902**] address:64 Main [**Location (un) 103903**] Mass)on
[**2147-8-28**].
She will also meet with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12967**] for pain management.
She will meet with Oncologist Dr [**Last Name (STitle) 21628**] in [**Hospital1 1474**] on [**9-11**], [**2147**].
TRANSITIONAL ISSUES:
-needs continued chemotherapy for treatment of lymphoma
-will need outpatient hepatology follow up for active hepatitis
C
-will need referral to drug abuse cessation program
-taper pain medications
-taper sedatives including lorazepam, clonazepam
Medications on Admission:
Dilaudid 2-4mg PO q3h prn pain.
multivitamin 1 tab daily
fluconazole 100mg daily
depakote 250mg [**Hospital1 **]
ativan 0.5mg [**Hospital1 **] prn
kayexalate 30mg PO once on [**7-4**]
klonopin 1mg tid
colace 100mg [**Hospital1 **]
hydroxyzine 100mg qhs
Discharge Medications:
1. Scalp prosthesis
Scalp Prosthesis
Dispense: 1
2. docusate sodium 100 mg capsule Sig: One (1) capsule PO BID (2
times a day).
3. senna 8.6 mg tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
4. clonazepam 1 mg tablet Sig: One (1) tablet PO TID (3 times a
day): anxiety.
Disp:*12 tablet(s)* Refills:*0*
5. divalproex 250 mg tablet,delayed release (DR/EC) Sig: One (1)
tablet,delayed release (DR/EC) PO BID (2 times a day).
Disp:*30 tablet,delayed release (DR/EC)(s)* Refills:*0*
6. fluconazole 200 mg tablet Sig: One (1) tablet PO Q24H (every
24 hours).
Disp:*30 tablet(s)* Refills:*0*
7. hydroxyzine HCl 25 mg tablet Sig: Four (4) tablet PO at
bedtime as needed for pruritis.
Disp:*30 tablet(s)* Refills:*0*
8. acyclovir 400 mg tablet Sig: One (1) tablet PO Q8H (every 8
hours).
Disp:*30 tablet(s)* Refills:*0*
9. sulfamethoxazole-trimethoprim 400-80 mg tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. olanzapine 5 mg tablet Sig: One (1) tablet PO TID (3 times a
day).
Disp:*15 tablet(s)* Refills:*0*
11. lorazepam 0.5 mg tablet Sig: One (1) tablet PO twice a day
as needed for anxiety.
Disp:*8 tablet(s)* Refills:*0*
12. nitrofurantoin monohyd/m-cryst 100 mg capsule Sig: One (1)
capsule PO Q12H (every 12 hours): End date [**2147-9-7**].
Disp:*30 capsule(s)* Refills:*0*
13. hydromorphone 4 mg tablet Sig: One (1) tablet PO every [**5-19**]
hours as needed for pain.
Disp:*16 tablet(s)* Refills:*0*
14. gabapentin 300 mg capsule Sig: One (1) capsule PO TID (3
times a day).
Disp:*30 capsule(s)* Refills:*0*
15. allopurinol 100 mg tablet Sig: Two (2) tablet PO DAILY
(Daily).
Disp:*30 tablet(s)* Refills:*0*
16. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Transdermal
once a day: Do not use with tobacco. If you are going to smoke,
you must remove this patch due to risk of cardiovascular
complications and death.
Disp:*4 4* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
pneumonia
hyperkalemia, now resolved
obstructive renal failure, now resolved
follicular lymphoma
Secondary:
hepatitis C
heroin use
chronic back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **],
You were admitted to the hospital because you had leg swelling
and shortness of breath. You were found to have a large mass in
your abdomen, later discovered to be follicular lymphoma, a type
of cancer. This mass compressed both of your ureters and caused
your kidneys to fail. When you arrived, you had dangerous high
levels of potassium in your blood. You were treated with
hemodialysis, and your condition stabilized. You then received a
urinary stent in your left kidney and a nephrostomy in your
right kidney. Your left kidney did not show much improvement in
function, likely due to the chronic nature of the urinary
obstruction. Your right kidney recovered very well. You were
treated with chemotherapy, and you responded well to the initial
two cycles. You were also treated for a pneumonia and had a full
recovery. Your left leg and abdomen remain swollen, likely due
to blockage of lymphatic drainage systems by your cancer. This
should improve as your cancer responds to the chemotherapy. The
kidney stent and kidney drain (nephrostomy) were removed and
your kidney function has improved.
Changes to your medications:
To treat your pain, the following changes were made:
Dilaudid 4 mg every 4-6 hours to treat pain
Methadone will be dispensed at methadone clinic
Gabapentin 300 mg three times per day
**Do not take these medications while driving or drinking
alcohol or using recreational drugs as these will cause sedation
and possible death if used in combination
**Please take stool softeners while taking narcotics because
this can cause constipation**
For smoking cessation, please take:
Nicotine patch 14 mg, replace once daily
** Do not take nicotine patch with cigarettes due to
cardiovascular risk and possible death.
To prevent infection, the following changes were made:
fluconazole 200 mg daily
acyclovir 400 mg every 8 hours
bactrim single strength tablet daily
To treat your urinary tract infection,
macrobid 100 mg twice per day, please take through [**2147-9-7**]
To treat your mood,
continue on olanzapine 5 mg three times per day
Please take all your other medications as prescribed.
Followup Instructions:
1) [**Hospital **] Clinic: 7 [**Hospital Ward Name 1826**] Outpatient Clinic @[**Hospital1 18**] Time: 12
pm (noon) tomorrow [**8-24**]
2) Dr. [**Last Name (STitle) **] (PCP): Monday [**8-28**] 2:00 pm
[**Hospital1 1474**] Neighborhood Health
[**Location (un) **] [**Hospital1 1474**], MA
3) [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 103904**] (pain management): will see at [**Hospital1 1474**]
Neighborhood Health
4) Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 21628**] (oncologist): [**9-11**]
[**Hospital1 1474**] Neighborhood Health
phone [**Telephone/Fax (1) 71494**]
ICD9 Codes: 5849, 486, 2767, 412, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8376
} | Medical Text: Admission Date: [**2162-1-31**] Discharge Date: [**2162-2-6**]
Date of Birth: [**2103-7-7**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
female with a past medical history significant for
insulin-dependent diabetes, hypertension,
hypertriglyceridemia likely causing chronic pancreatitis, and
peripheral vascular disease who was transferred from a
outside hospital with an inferolateral ST-elevation
myocardial infarction.
The patient had no known prior coronary artery disease. She
had a recent vascular surgery in [**2161-11-2**] for a left
femoral to posterior tibialis bypass. Prior to that surgery,
the patient had a preoperative stress test done with a
Persantine MIBI and noted to have borderline
electrocardiogram changes with no perfusion defects with a
calculated ejection fraction of 62%. The patient had
recovery of 0.5 mm to [**Street Address(2) 100598**] depressions
during that stress test.
On the morning prior to admission, the patient developed
substernal chest pain which the patient describes as her
first episode ever of chest pain that radiated to her back
and her left arm. She denied any associated symptoms related
to that.
She called Emergency Medical Service and was sent to an
outside hospital. Her electrocardiogram there showed
inferior and lateral ST elevations with creatine kinases in
the 400s, positive MB, and positive MB index with a troponin
I of 15.5.
The patient was transferred to [**Hospital1 188**] for emergent catheterization. On cardiac
catheterization, the patient was noted to have 3-vessel
disease including a 30% left main, 90% left anterior
descending artery, 100% left circumflex, 50% right coronary
artery, and occluded posterior descending artery and was
treated with angioplasty. The patient's posterior descending
was treated with percutaneous transluminal coronary
angioplasty and noted to have normal flow with
moderate-to-severe dissection requiring prolonged inflation.
No stent was placed during the procedure, and the patient was
sent to the Coronary Care Unit with an intra-aortic balloon
pump with a plan for Cardiac Surgery to do a coronary artery
bypass graft procedure in the next 48 to 72 hours.
PAST MEDICAL HISTORY: (The patient's past medical history is
as described in addition to)
1. Anemia of uncertain etiology.
2. Insulin-dependent diabetes.
3. Peripheral vascular disease; status post left femoral to
posterior tibialis bypass.
4. Chronic pancreatitis.
5. No known coronary artery disease.
6. Peripheral neuropathy.
7. Hypothyroidism.
8. History of deep venous thrombosis.
9. History of methicillin-resistant Staphylococcus aureus
to a left thigh wound in [**2161-12-3**].
10. She is status post cholecystectomy.
11. Status post thyroidectomy.
12. She has had right shoulder surgery for a vascular and
infected necrosis.
MEDICATIONS ON ADMISSION:
1. Lopressor 25 three times per day.
2. Zestril 40 once per day.
3. Synthroid 75 mcg once per day.
4. Pepcid 20 twice per day.
5. Lantus 60 at hour of sleep.
6. Humalog sliding-scale.
7. Hydrochlorothiazide 12.5 once per day.
Apparently the patient was suppose to be on Tricor, but was
not taking that medication.
MEDICATIONS ON TRANSFER: The patient was transferred on a
nitroglycerin drip, heparin drip, given 25 mg of Demerol, 5
mg of intravenous Lopressor times three, Phenergan,
Integrilin, and Plavix 300 times one.
ALLERGIES: The patient's allergies include PERCOCET,
question to MORPHINE, question of HEPARIN (per patient), and
BACTRIM.
SOCIAL HISTORY: She is a single female. Denies any current
alcohol abuse. Denies any other drug use. She quit smoking
30 years ago.
FAMILY HISTORY: Her mother had a myocardial infarction at
the age of 26. Her maternal grandmother had a fatal
myocardial infarction at uncertain age. The patient's
religion is Jehovah Witness and refused blood products.
PHYSICAL EXAMINATION ON PRESENTATION: She was febrile at
102.4, her blood pressure was 140/90, her heart rate was 100,
her respiratory rate was 20, and she was 219 pounds. In
general, she was in no apparent distress. Awake, alert, and
oriented. Her pupils were equal, round, and reactive to
light. Her extraocular muscles were intact. Moist mucous
membranes. Her neck had no evident jugular venous
distention. No thyromegaly. Her chest was clear to
auscultation bilaterally. Heart examination revealed she had
a [**1-8**] holosystolic murmur at the apex. Otherwise, slightly
tachycardic. No rubs or gallops appreciated. Her abdomen
was soft, nontender, and nondistended with positive bowel
sounds. Extremity examination revealed she had no lower
extremity edema. She had nonpalpable distal pulses in her
lower extremities, but dopplerable distal pulses. On
neurologic examination, she had 2+ deep tendon reflexes
throughout and 5/5 strength throughout.
PERTINENT LABORATORY VALUES ON PRESENTATION: Her creatine
phosphokinase on admission was 486, with a MB fraction of 30,
and MB index of 6.2. Her second set showed a creatine
phosphokinase of 646, with a MB fraction of 42, and a MB
index of 6.5. Her troponin I showed an initial value of 15.5
at the outside hospital to 13.8. Her Chemistry-7 showed a
sodium of 136, potassium was 3.9, chloride was 102,
bicarbonate was 26, blood urea nitrogen was 29, creatinine
was 1.2, and blood glucose was 230. Complete blood count
showed a white blood cell count of 11.4, hematocrit was 27.3,
and platelets were 222. INR was 1.1. Calcium was 8.7,
magnesium was 1.7, and phosphate was 3.7.
PERTINENT RADIOLOGY/IMAGING: Her electrocardiogram from the
outside hospital noted 3-mm ST elevations inferiorly and ST
elevations of 1 mm to 2 mm in V2 through V6. Status post
catheterization, the patient still had inferior ST elevations
of 2 mm to 3 mm and 2-mm to 3-mm ST elevations in V4 through
V5.
An echocardiogram on [**2161-11-4**] showed an ejection
fraction of greater than 65%, left atrium was mildly dilated,
trivial mitral regurgitation, trivial pericardial effusion,
and normal left ventricular wall motion.
On cardiac catheterization, as described above, status post
percutaneous transluminal coronary angioplasty of her
posterior descending artery with normal flow with dissection
with inflation. Her hemodynamics showed a right atrial
pressure with a mean of 9, right ventricular of 40 systolic
and 10 diastolic, with a PA mean pressure of 33, pulmonary
capillary wedge pressure of 18, and a cardiac index of 2.
BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. CARDIOVASCULAR ISSUES: (a) Ischemia: For
cardiovascular ischemia, the patient had noted 3-vessel
disease likely related to her longstanding insulin-dependent
diabetes, and a coronary artery bypass graft was recommended
given her persistent electrocardiogram changes and 3-vessel
disease as well as her diabetes.
The patient was maximally treated with medication including
Lopressor which was titrated for a goal heart rate of 60. In
addition, she was placed on a statin as well as aspirin and
ACE inhibitor.
The plan was for the patient to go to cardiothoracic surgery
for a coronary artery bypass graft. Cardiothoracic Surgery
evaluated the patient and recommended the patient have a
hematocrit of 45 prior to getting the coronary artery bypass
graft procedure given her high risk for blood loss during
this procedure. Given the patient's religious beliefs of
Jehovah Witness, she refused any blood products. The
coronary artery bypass graft surgery was postponed due to
that reason.
The patient's iron studies were checked, and she was noted to
be profoundly iron deficient with a mixed picture of iron
deficiency and chronic disease. She was given one dose of
intravenous iron and started on Epogen to help increase her
hematocrit to a goal preoperative level of 40 to 45. The
patient was not put on Plavix secondary to the thought that
she was likely going to coronary artery bypass graft in the
near future. In addition, the data suggests that it is more
efficacious for patients with stent procedures to be placed
on Plavix, and this patient did not have a stent procedure,
she only had angioplasty done to her posterior descending
artery.
(b) Pump: The patient had elevated right-sided filling
pressures on hemodynamics during catheterization and was
diuresed when in the Intensive Care Unit with small amounts
of intravenous Lasix, and she responded to 10 mg to 20 mg of
intravenous Lasix and diuresed well over the two days status
post catheterization.
The patient had a repeat echocardiogram done on her second
hospital day and was noted to have apical hypokinesis with an
ejection fraction decreased to 40%, mild LVH, and mild
pulmonary artery hypertension.
(c) Rhythm: The patient was in a normal sinus rhythm and
was placed on a beta blocker for heart rate control in the
60s, and she maintained most of her heart rates in the 60s to
70s while in the Intensive Care Unit.
The patient was discharged from the Coronary Care Unit on
[**2-6**] and was chest pain free at that time. She was not
requiring any nitrates.
2. HEMATOLOGIC/INFECTIOUS DISEASE ISSUES: Given the
patient's religion of Jehovah Witness, she would not accept
any blood transfusions for her anemia. Therefore, she was
started on intravenous iron therapy as well as by mouth iron
therapy and given Epogen 20,000 units once per day. Her iron
studies noted a low ferritin and low iron level as well as a
low total iron-binding capacity, giving a mixed picture of
iron deficiency and chronic disease state. Her hematocrit
remained basically stable while in the Coronary Care Unit,
ranging from 24 to 28.
The patient was febrile on admission; however, she had no
evidence of infection. Her urinalysis, chest x-ray, and
blood cultures remained negative. She never required
antibiotics and was afebrile for the rest of her hospital
stay with a stable white count.
3. PULMONARY ISSUES: The patient had an oxygen requirement
while in the Coronary Care Unit likely secondary to her high
filling pressures and pulmonary edema noted on chest x-ray
and on examination. She was diuresed gently with intravenous
Lasix 10 mg to 20 mg as needed.
Upon leaving the Coronary Care Unit, she was on 4 liters
nasal cannula and saturating well. During her first two days
on the floor, her oxygen requirements decreased, and she no
longer needed Lasix for diuresis.
4. RENAL/FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient
was noted to have a rising creatinine while in the Coronary
Care Unit; likely secondary to dye nephropathy and was
initially treated with Mucomyst status post catheterization
and intravenous hydration. A renal ultrasound was done to
evaluate for obstruction which was negative. Her creatinine
resolved slowly; likely secondary to acute tubular necrosis
related to contrast dye.
5. GASTROINTESTINAL ISSUES: The patient had recurrent
nausea while in the Coronary Care Unit, and it was thought it
may have been related to ongoing ischemia. However, her
cardiac enzymes remained stable, and her electrocardiogram
showed no new changes. She was treated symptomatically with
Zofran and Compazine and given Demerol for her epigastric
pain.
The patient stated that her pain was similar to past episodes
of pancreatitis, which are acute flares on her chronic
problem. The patient no long has amylase or lipase
elevations secondary to a "burned out pancreas." The patient
is treated with pain medication, nothing by mouth status, and
low-flow intravenous fluids.
6. ENDOCRINE ISSUES: The patient was continued on her
outpatient dose of Lantus 60 units and a Humalog
sliding-scale, and that was adjusted per her oral intake.
Her hemoglobin A1c was checked which was greater than 8, and
she was continued on her outpatient Levoxyl dose of 75 mcg
for her hypothyroidism.
7. DISPOSITION ISSUES: The patient was transferred to the
Medicine Service on [**2-6**] for management of her
pancreatitis and her anemia. Please refer to Dr.[**Name (NI) 42300**]
Discharge Summary for the remainder of the hospital course
and discharge medications and plan.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D. [**MD Number(1) 15177**]
Dictated By:[**Last Name (NamePattern1) 3480**]
MEDQUIST36
D: [**2162-2-9**] 15:13
T: [**2162-2-9**] 15:16
JOB#: [**Job Number 100599**]
ICD9 Codes: 5845, 4280, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8377
} | Medical Text: Admission Date: [**2169-1-27**] Discharge Date: [**2169-1-31**]
Date of Birth: [**2095-10-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Rapid Afib, Pulmonary Embolus, Dyspnea
Major Surgical or Invasive Procedure:
Expired
History of Present Illness:
This is a 73 yo F with a past medical history significant for
NSCLC s/p resection, in remission for 5 years, and marked COPD,
who presents to the ED after experiencing progressive dyspnea
over the last several weeks, requiring oxygen therapy around the
clock rather than just with exertion. In the ED she was found to
be in afib (new for this patient) with RVR to 170's. She was
sent for CTA and was found to have a small subsegmental PE and
was started on a heparin gtt. She was given a dose of
levofloxacin for ?infectious process given leukocytosis on CBC
to 26 and she was initiated on a dilt gtt after two doses of IV
dilt did not affect her HR that much.
She also notes swelling in her legs bilaterally and her left
arm, as well as a new mass in the left side of her neck which
per the patient grew in entirety over the last two weeks. Of
note, she also had knowledge of a breast mass, which had not yet
been worked up. Last mammogram seems to be in [**2161**]. Per the
patient's PCP [**Last Name (NamePattern4) **] [**6-13**], "She has adamantly refused all screening
and followup testing at this time. We discussed follow up chest
x-rays and CT scans for example and also mammograms, but she
refuses that. She refuses colon cancer screening. At this
point, she feels that she would not accept or take any further
medications or any further
therapies for any further diseases."
She is admitted to the MICU for further evaluation of her afib
with RVR and dyspnea.
Currently in the MICU, the patient is hemodynamically stable
with a HR in the 140's-150's. She is breathless on supplemental
O2. She denies fevers/chills, n/v or nightsweats. She admits to
some weight loss, and although does not entertain palpitations,
she felt something was wrong and attributed it to her chronic
anxiety. She denies calf tenderness, chest or abdominal pain.
She is refusing blood draws and foley catheter.
Past Medical History:
Status post stage III lung cancer s/p left upper lobe lobectomy,
with chemo/rads
COPD
glaucoma
Major depressive disorder
Anxiety
Social History:
2 ppd x 40 years, just quit several months ago. Was real estate
[**Doctor Last Name 360**], frequently travels to [**State **] for vaction. Has two
daughters, one is in [**Name (NI) 745**] who is HCP.
Family History:
non-contributory
Physical Exam:
VS: Temp: 97.6 BP:146/72 HR: 137 RR: 13 O2sat 99% on 4L NC
GEN: cachectic, comfortable, NAD but breathless when talking
HEENT: PERRL, EOMI, but right strabismus and left eyelid ptosis,
anicteric, MM dry, op without lesions. dentures in place.
NECK: large left sided nontender, nonmobile hard mass just
lateral to the thyroid, no jvd, no carotid bruits. RIJ in place.
RESP: No breath sounds at the right base. Scattered crackles and
+expiratory wheeze with prolonged E:I ratio.
CV: Tachcardic and irregularly irregular. No murmurs.
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: nonpitting 2+ edema in the ext bilaterally, right UE with
1+ nonpitting edema. warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 4/5 strength throughout
(generally weak). No sensory deficits to light touch
appreciated. Essential tremor present. DTR's normoreflexive.
Breast exam refused.
Pertinent Results:
[**2169-1-27**] 11:20AM
WBC-25.3*# RBC-4.01* HGB-12.1 HCT-38.9 MCV-97 MCH-30.2 MCHC-31.1
RDW-14.4
NEUTS-96.4* BANDS-0 LYMPHS-1.4* MONOS-1.6* EOS-0.5 BASOS-0
[**2169-1-27**] 11:20AM GLUCOSE-212* UREA N-24* CREAT-0.8 SODIUM-141
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-29 ANION GAP-19
[**2169-1-27**] 11:20AM CALCIUM-8.9 PHOSPHATE-3.8 MAGNESIUM-2.0
EKG: Afib with RVR to 170's.
CXR:
1. Hazy opacity in the right lung base may represent a layering
pleural effusion, although pneumonia cannot be excluded; a
lateral view is recommended.
2. Stable emphysematous changes and volume loss on the left
related to left upper lobectomy.
CTA Chest:
1. Right lower lobe subsegmental pulmonary embolism. No
evidence of compression of the SVC.
2. Moderate-to-severe emphysema with interstitial septal
thickening consistent with underlying CHF. Small left greater
than right pleural effusions, with atelectasis in the right
lower lobe.
3. Status post left upper lobectomy with stable left volume
loss and post-radiation changes.
4. Interval development of hypodense mass likely arising from
the left lobe of the thyroid. Two left upper quadrant soft
tissue masses. Multiple mediastinal and hilar lymph nodes as
described above. Soft tissue nodule in the left breast and
subcentimeter likely lymph node in the presternal soft tissues.
Given the patient's history of lung cancer, these findings are
suspicious for malignancy.
Brief Hospital Course:
73 yo F with a past medical history of NSCLC status-post
chemo-radiation and right upper lobectomy admitted with
progressive dyspnea in the setting of multiple new masses, new
atrial fibrillation with RVR, and subsegmental PE.
# Dyspnea: Etiologies for the patient's dyspnea include atrial
fibrillation with RVR with decreased forward flow, progression
of COPD, interstitial lung disease secondary to radiation
therapy, metastasis and infection. Although she had a
leukocytosis, and possible effusion at the right base, she was
afebrile during her inpatient stay. She does have a very small
subsegmental PE, which could have also contributed to dyspnea.
Was rate controlled with a esmolol drip. Patient then became
suddenly hypoxic with short duration asystole the afternoon of
[**2169-1-31**], thought to be secondary to possible mucous plugging.
Daughter was [**Name (NI) 653**] concerning the event and her mother's
poor prognosis. At that time, she requested she be CMO. All
medications were stopped and she was given morphine IV for
comfort. She expired at 8:15pm on [**2169-1-31**] due to
cardiopulmonary arrest.
# Afib with RVR: Unclear if her known small subsegmental PE
would actually cause the patient's Afib with RVR. Other possible
causes could be dehydration in the setting of poor PO
intake/infection. Also rapidly growing mass contiguous with the
thyroid could be causing a relative thyroiditis, or be producing
thyroid hormone itself. TSH was check and was low normal. Rate
was controlled with an esmolol drip until the events immediately
preceding her death.
# Pulmonary Embolus: Known small subsegmental PE. Thus, she was
maintained on a heparin gtt. ED confirmed with Oncology that it
was okay to start heparin gtt without head imaging as long as
initiated without a bolus. PE thought to be likely [**3-11**] to
tumor. Heparin gtt was discontinued once patient was made CMO
on [**2169-1-31**].
# Neck Mass: Concerning for malignancy. Patient had a breast
mass noted on a mammogram from [**2163**] and has since refused follow
up screening. Concerned that this could represent a breast
primary with metastases to her thyroid and mediastinal nodes.
Unclear what left upper quadrant masses are at this time. Other
possibility is recrudescence of NSCLC, but this is unlikely
although she continued to smoke until this year. With poor oral
intake, fatigue and weight loss, malignancy was high on the
differential. Associated hoarseness could be secondary to
recurrent laryngeal nerve compression. Heme-onc was consulted
and recommended obtaining tissue for a diagnosis. General
surgery was consulted but determined she was too unstable during
her stay for tissue biopsy. Patient expired without clear
diagnosis and family declined autopsy.
# Anxiety/Depression: While inpatient was continued on
antidepressants and Ativan PRN.
# COPD: This ongoing issue likely contributed to her overall
respiratory distress while inpatient. She was treated with
Atrovent and Albuterol was used only minimally secondary to
concern for tachycardia.
Patient become increasingly dyspneic during the day of [**2169-1-31**].
At approximately 4pm, physicians were called to the bedside for
pulselessness and respiratory arrest thought to be secondary to
mucous plugging. Was treated with atropine and epinephrine and
subsequently regained a heart rhythm, blood pressure and pulse.
Pupils were noted to be unresponsive at that time. Her family
was notified of the acute change and poor prognosis and decided
to make her CMO status. All medications were discontinued
beyond those for comfort. Patient expired on [**2169-1-31**] at 8:15pm
secondary to cardiopulmonary arrest.
Medications on Admission:
Trazadone
Buspar
Wellbutrin
Triazolam
Atrovent
PPI
Veranicicline
Reglan TID
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Non-Small Cell Lung Cancer
Secondary: COPD, neck mass
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 496, 4275, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8378
} | Medical Text: Admission Date: [**2165-2-14**] Discharge Date: [**2165-2-17**]
Date of Birth: [**2100-11-15**] Sex: M
Service: [**Hospital Unit Name 196**]
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 64-year-old male
with history of coronary artery disease status post recent
non-ST elevation myocardial infarction at the end of [**Month (only) 404**]
as well as stenting of the left anterior descending artery
with two stents, who presents with left sided chest
pain/pressure beginning approximately 10 pm on the night
before admission. Onset of the chest pain was at rest, and
the pain was somewhat improved with Protonix and one
sublingual nitroglycerin, but the sensation persisted, and
the patient eventually called EMS. He was given aspirin and
sublingual nitroglycerin by EMS with resolution of his
symptoms.
Patient says that the pain/pressure is the same sensation he
had at the time of his non-ST elevation myocardial
infarction. Patient denied radiation of the pain, shortness
of breath, back, or abdominal pain, cough, nausea, or
vomiting, palpitations. Patient was pain free at the time of
evaluation in the Emergency Department. Heparin was started
in the Emergency Department.
PAST MEDICAL HISTORY:
1. Recent non-ST elevation myocardial infarction with a
troponin of 29 and a CK peak of 90. Catheterization [**1-16**]
showed three-vessel disease and two stents were placed in the
left anterior descending artery. He had chest pain after
this procedure, and was taken back to the catheterization
laboratory, but the catheterization was cut short by a GI
bleed. Catheterization on [**1-16**] showed 70% proximal and 95%
mid left anterior descending artery stenosis, 70% left
circumflex lesion, 80% OM-2 lesion, and 80% right coronary
artery lesion. Echocardiogram [**1-18**] showed left atrial
enlargement, right atrial enlargement, left ventricular
hypertrophy, ejection fraction greater than 55%, and 1+
aortic regurgitation.
2. Hyperlipidemia.
3. End-stage renal disease with dialysis on Monday,
Wednesday, Friday.
4. Pancreatitis.
5. Congestive obstructive pulmonary disease.
6. Hypertension.
7. Diverticulosis.
8. Cerebrovascular accident in [**2159**] with residual left sided
weakness.
9. Prior history of upper gastrointestinal bleed at [**Hospital6 11241**].
10. Fistula repair [**2165-1-15**].
MEDICATIONS:
1. Plavix 75 mg po q day.
2. Enalapril 20 mg po q day.
3. Labetalol 200 mg po q day.
4. Isordil 20 mg tid.
5. Clonidine patch q Monday.
6. Renagel.
7. Nephrocaps.
8. Protonix 40 mg [**Hospital1 **].
9. Sublingual nitroglycerin.
ALLERGIES: None.
SOCIAL HISTORY: Patient comes from [**Country 2045**], and he lives with
his daughter and his wife. [**Name (NI) **] denies any smoking.
PHYSICAL EXAMINATION: The patient is a well-developed, thin,
elderly appearing man. Temperature is 99.0, blood pressure
88/63, heart rate of 81, respiratory rate of 16, and sating
98% on 3 liters. Oropharynx was clear. Mucous membranes
were moist. There was no jugular venous distention. Lungs
were clear bilaterally except for a few crackles at the
bases. Heart rate was irregularly, irregular. There were no
murmurs, rubs, or gallops. Abdomen was soft, nontender, and
nondistended. Extremities had no peripheral edema. Rectal
was guaiac negative with no masses.
At the time of admission, electrocardiogram showed Q waves in
lead III, atrial fibrillation at a rate of approximately 70,
possibly alternating with flutter with variable block.
Chest x-ray showed no infiltrates and no effusions.
CK was 46 and troponin was 1.8.
HOSPITAL COURSE:
1. Cardiac: The patient's history was suggestive of unstable
angina, and the patient was continued on a Heparin drip and
underwent cardiac catheterization, which showed significant
three vessel disease with 80% instent restenosis in the
proximal left anterior descending artery stent and 50% in the
distal stent. At this point, the patient was pain free and
the case was discussed with Cardiothoracic Surgery.
At the time of this dictation, Cardiothoracic Surgery was
planning a coronary artery bypass graft after evaluation of
the carotid arteries by ultrasound. Patient's blood pressure
was treated with labetalol, clonidine, enalapril, and
Norvasc. Patient had a second episode of chest pain on
[**2165-2-16**] that had a component of radiation to his back. He
therefore underwent CT scan of his chest and abdomen to rule
out any dissection of his aorta. These examinations were all
negative for dissection.
Patient presented in atrial fibrillation, with a relatively
slow ventricular response. The patient spontaneously
converted to a normal sinus rhythm while in the hospital
without any further intervention.
2. Renal: Renal service was consulted to assist in the
management of this patient with end-stage renal disease.
Patient received dialysis after his cardiac catheterization
and then returned to his normal schedule of hemodialysis.
His Renagel was increased to 1600 mg tid.
3. GI: Patient's stool was guaiacked on admission and after
his Heparin had been running for a day. Both of these stools
guaiacks were negative, and he was continually followed for
evidence of bleeding. The GI service was consulted, and felt
that the patient should be catheterized from a cardiac
standpoint despite any possible concerns over
gastrointestinal bleeding. They suggested treating
gastrointestinal bleeding as it grows and not delaying
treatment of the patient's coronary artery disease because of
considerations of gastrointestinal bleeding.
4. Hematologic: The patient was noted to have a baseline
anemia at the time of admission, and this was thought to be
due to a combination prior gastrointestinal bleeding as well
as end-stage renal disease. At the time of this dictation,
iron studies were pending, and there was no evidence of
gastrointestinal bleeding. Discharge was still in the
planning stage at the point of this dictation.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Last Name (NamePattern1) 4706**]
MEDQUIST36
D: [**2165-2-17**] 21:03
T: [**2165-2-18**] 09:09
JOB#: [**Job Number 32514**]
ICD9 Codes: 4111, 4241, 496, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8379
} | Medical Text: Admission Date: [**2149-12-17**] Discharge Date: [**2149-12-31**]
Date of Birth: [**2075-3-13**] Sex: F
Service: MEDICINE
Allergies:
Altace
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
shortness of breath, increased angina
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
Ms. [**Known lastname **] is a 74 year-old woman with a history of CAD s/p
CABG in 10/84 with redo in 11/84, stent to left subclavian in
[**6-17**] and repeat dx cath without intervention in [**10-18**], EF of 35%
on echo in [**2145**], atrial fibrillation diagnosed in [**2146**] managed
with rate control and anti-coagulation, hypertension, lipids and
asthma/possible COPD (no PFT's noted in record/no smoking
history) admitted now with SOB/unstable angina. The patient's
current symptomatology began last friday [**12-12**] when she
developed URI symptoms including nasal congestion and cough.
Since then she has noted increased dyspnea, increased episodes
of her anginal pain including at rest and cough productive of
yellow/celery colored sputum. Dyspnea has increased to point
where she has trouble with stairs now where recently she has
not. Has dry cough at baseline attributed to Mavik, but her
current cough is different. Has also had significantly
increased fatigue over this time. Takes combivent or albuterol
with some relief of shortness of breath. Her SOB brought her to
see her PCP [**Name Initial (PRE) 1262**]. CXR was obtained and revealed no acute
process. Other history from that visit is unobtainable.
Last night she had palpitations and her shortness of breath
subsequently worsened which ultimately brought her to [**Hospital1 18**]
today.
Reports taking all her medications. Has had some dietary
indiscretion recently including salted fish last friday and
dining out recnetly.
Also reports increased stress and exposure to dogs at family
members house.
Denies fever or chills. Denies feeling dizzy, syncope. NO
weight loss. Appetite has been good.
Past Medical History:
CAD as above
atrial fibrillation
htn
increased lipids
asthma
?COPD(non-smoker)
GERD
Anemia
Social History:
No history of smoking. Occasional alcohol and no IVDU. Lives in
[**Location 86**] area with excellent support from family.
Family History:
non-contributory
Physical Exam:
VS: T: 97.5 BP 124/63 HR: 90's RR 18 95% 3l (on nitro)
general: No distress but mildly increased work breathing resting
pleasant,
HEENT: PERLLA, EOMI, MMM, no pharyngeal exudate, no conj
injection, sclarae anicteric, no lymphadneopathy. JVP to about
12cm. No carotid bruits. Neck is supple
lung: wheezing throughout the lung fields
heart: tachy, irregular, S1 and S2 wnl, no murmurs/rubs or
gallops
abd; +b/s, soft, non-tender, non-distended, no masses
extr: +2 pitting edema bilaterally,swelling is symmetric in
lower extremities. non-tender. DP and femoral pulses are 1+.
no femoral bruits.
neuro; Alert and oriented x 3. no focal deficits
appreciated--strength appropriate for age, normal cerebellar and
reflexes. CNII-XII intact
Pertinent Results:
[**12-17**] chest x-ray:
PA AND LATERAL VIEWS OF THE CHEST: The patient is S/P CABG.
There is a
vascular stent projecting above the aorta again demonstrated and
unchanged.
The cardiac and mediastinal contours are stable. No evidence of
failure. The
lungs are clear. There is no pleural effusion.
IMPRESSION: No evidence of pneumonia. No evidence of CHF.
(pulmonary vascular congestion, cardiomegaly)
Admit labs:
[**2149-12-17**] 12:10PM WBC-8.8 RBC-3.84* HGB-11.7* HCT-34.6* MCV-90
MCH-30.3 MCHC-33.6 RDW-14.4
[**2149-12-17**] 12:10PM NEUTS-83.9* LYMPHS-9.4* MONOS-5.6 EOS-1.1
BASOS-0.1
[**2149-12-17**] 12:10PM PLT COUNT-237
[**2149-12-17**] 12:10PM GLUCOSE-180* UREA N-15 CREAT-1.1 SODIUM-138
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-27 ANION GAP-16
[**2149-12-17**] 01:45PM PT-21.3* PTT-31.7 INR(PT)-2.9
Ischemia labs:
[**2149-12-17**] 12:10PM CK(CPK)-95
[**2149-12-17**] 12:10PM cTropnT-<0.01
[**2149-12-17**] 06:00PM CK(CPK)-147*
[**2149-12-17**] 06:00PM CK-MB-6 cTropnT-0.06*
Last cath:
PROCEDURE DATE: [**2147-11-15**]
INDICATIONS FOR CATHETERIZATION:
Chest pain. Prior CABG. S/P subclavian stent.
FINAL DIAGNOSIS:
1. Native three vessel coronary artery disease with extensive
bridging
collaterals of the RCA.
2. Known occluded saphenous vein grafts.
3. Patent LIMA to LAD.
4. Patent left subclavian stent.
5. Mild mitral regurgitation.
6. Mild systolic ventricular dysfunction.
7. Mild right common-femoral vascular disease.
COMMENTS:
1. Coronary arteriography in this right dominant system showed
native
three-vessel coronary artery disease. The LMCA had mild luminal
irregularities. The LAD artery was occluded in the mid-vessel.
The left
circumflex artery was proximally occluded with two distal OMs
with a
"jump" segment filling via left to left collaterals. The RCA was
proximally occluded with many bridging collaterals supplying the
distal
RCA and posterior LV branches.
2. Saphenous vein grafts were known to be occluded from a prior
catheterization dated [**6-17**] and were therefore not visualized.
3. Graft angiography showed a widely patent LIMA to LAD,
supplying the
distal [**1-18**] of the LAD and large collaterals to the RCA and
r-PDA.
4. Left subclavian angiography showed a widely patent left
subclavian
stent.
5. Resting hemodynamics showed normal left-sided filling
pressure.
6. Left ventriculography showed mild global hypokinesis with
more
pronounced hypokinesis of the inferior wall. There was trace
mitral
regurgitation. The calculated LVEF was 45%.
7. Limited left ilio-femoral peripheral angiography showed a
mild 30%
stenosis of the common femoral artery.
EKG: afib, left axis deviation, ST depression and TWI in V2-V6.
[**12-19**] Echo:
Study continues from Tape [**2149**] W487 to tape [**2149**] W 509, starting
at 0:15 for an additional seven minutes of recording.
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV cavity size. Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. Depressed LVEF. Cannot assess LVEF.
RIGHT VENTRICLE: RV not well seen.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Mild [1+] TR. Mild PA systolic hypertension.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions
1. The left atrium is mildly dilated.
2. The left ventricular cavity size is normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. LV systolic function appears depressed. Overall
left ventricular systolic function cannot be reliably assessed.
3. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
4. There is mild pulmonary artery systolic hypertension.
[**12-26**] cath:
PROCEDURE DATE: [**2149-12-26**]
INDICATIONS FOR CATHETERIZATION:
EKG changes.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent LIMA-LAD
COMMENTS: 1. Selective coronary angiography of this right
dominant
system revealed three vessel disease. The LMCA was diffusely
disease.
The LAD was occluded mid-vessel and filled distally via the
LIMA. The
LCX was occluded proximally, and filled distally from
collaterals from
the LCX. The RCA was occluded proximally and filled distally via
bridging collaterals.
2. Graft angiography revealed a patent LIMA-LAD. The SVGs were
not
imaged as they were known to be occluded.
3. Left ventriculography was not performed.
4. The left subclavian stent was widely patent.
LIVER OR GALLBLADDER ULTRASOUND.
INDICATION: 74 year old female with abdominal pain, increased
LFTs. Evaluate
for gallstones, or liver disease.
There are no prior studies for comparison.
The patient is status post cholecystectomy. The common bile duct
measures 5
mm, and is within normal limits status post cholecystectomy. The
liver shows
no focal abnormalities. The liver parenchyma is mildly
hyperechoic in
echotexture, consistent with fatty infiltration. The right
kidney measures
8.3 cm. There is a mild hyperechoic focus within the interpolar
right kidney,
with no evidence of posterior shadowing, possibly representing a
small
parenchymal calcification Within the lateral aspect of the right
kidney, in
the interpolar region, there is a 1.2-cm anechoic focus, most
likely
representing a simple cyst. The left kidney measures 8.1 cm,
with no focal
abnormalities.
IMPRESSION:
1) Patient is status post cholecystectomy.
2) The liver is echogenic, consistent with fatty liver. However,
other forms
of liver disease, and more advanced liver disease, including
significant
hepatic fibrosis/cirrhosis cannot be excluded on this study.
[**12-24**] chest x-ray:
INDICATION: Shortness of breath, s/p extubation. Check status.
FINDINGS: A single AP semi-upright image. Comparison study dated
[**2149-12-21**]. The heart shows slight left ventricular enlargement. There
is evidence of
a prior CABG procedure. A vascular stent is noted in the left
brachiocephalic
vessel. The pulmonary vessels are normal. No pulmonary
infiltrates are seen.
There is slight blunting of the right costophrenic angle and
slight widening
of the minor fissure consistent with a small effusion. The hila
and
mediastinum are otherwise unremarkable. The ETT and the NG line
remain well
positioned.
IMPRESSION: Possible small right pleural effusion. No other
acute
cardiopulmonary abnormality. Prior CABG surgery noted and prior
left
brachiocephalic stent in place.
Brief Hospital Course:
72 year-old woman with CAD s/p CABG in [**2129**], stent to left
subclavian in [**6-17**], re-cath in 02 as above, history of CHF,
depressed EF, hypertension, afib astham/COPD who presents now
with increasing SOB and anginal episodes after URI last Friday.
Cardiovascular:
a)ischemia: Concerning past history, very high risk and now with
good story for unstable angina [**Female First Name (un) **] admit. Patient was ruled out
for MI on admission. After stabilization of her pulmonary
issues, given her history and an echo which could not fully
assess LVEF and could not rule out RWMA, she went for cardiac
catherterization and found to have no new lesions, patent LIMA
to LAD.
Patient maintained on ACE, beta-blocker, statin, aspirin, imdur.
Imdur and beta-blocker titrated up. D/ced calcium channel
blocker with likely systolic dysfunction and definite diastolic
CHF. Sublingual nitro as needed. Had been on Mavik for unclear
reason, tolerating ACE here--would titrate up for heart failure
as below.
Continues to have seom angina with stress.
b)pump: Patient noted to have depressed EF in past-35%? but no
recent echo on admission. Echo here showed: 1. The left atrium
is mildly dilated.
2. The left ventricular cavity size is normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. LV systolic function appears depressed. Overall
left ventricular systolic function cannot be reliably assessed.
3. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
4. There is mild pulmonary artery systolic hypertension. On
admission, the patient was felt to be euvolemic to slightly
volume overloaded and gently diuresed but her SOB was primarily
due to astham/copd exacerbation. AFter transfer to ICU(see
below) patient received lots of fluids and needed to be
diuresed. Diuresed adequately for discharge--felt to be dry for
discharge by exam and labs. Given that she was acutely
decompensated from pulmonary perspective and volume overloaded
when echo was done, it was not felt to be fully accurate of
baseline status. Maintained on beta-blocker, ACE for ischemia
and HF. Should titrate ACE/beta to HF goals based on repeat
echo (lisinopril 20/toprol 150).
c)rhythm; afib: has always been rate controlled, never
cardioverted. POor control now and had sensation of
palpitations on night PTA. Unclear if ratelead to CHF or CHF
lead to increased rate and component of ischemia?--Increaed
demand leading to ischemia vs. ischemia leading to tachy--
Patient maintained on metoprolol for rate control with good
affect. Had been on dilt but with ? heart failure, systolic-held
and went up on beta-blocker for control.
Concerning anti-coagulation, we are holding coumadin until
patient has outpatient colonoscopy-had guiac positive stools and
crit drop (also with neck hematoma after central line
placement.) Scheduled for outpatient colonoscopy and then to
re-start coumadin then.
Shortness of breath/hypoxemia: CHF vs. post URI Reactive airways
disease vs. COPD vs. PE vs. pneumonia--ON admission, SOB felt
secondary to astham exacerbation-Patient acutely decompensated,
wheezy on exam, sent to unit on day 2 of admission for
intubation. Treated with predniesone, flovent, azithromycin
then levaquin as well as nebs/inhalers. HAd 5 day ICU stay and
then was transferred out. By discharge, not wheezy satting well
on room air. Felt to be RAD post bronchitis. Was not fluid
overloaded on admit--was diuresed after ICU stay with lots of
fluids. On discharge satting well on room air.
Anemia at baseline/Crit drop/guiaic positive: Patient had crit
drop while in ICU. She had a hematoma after central line
placement as well as guiac positive stools. Was on heparin
during this time for her afib, stopped at this time. She
stabilized after transfusion in ICU, and needed no further
transfusions. Neck hematoma is resolving. Guiac positive
stools-she is scheduled for outpatient colonoscopy. Re-address
anti-coagulation for afib after this. Do not want her on iron
until after colonoscopy.
Elevated LFT's, tbili and PTT: After being off heparin (on it
for afib), stopped for crit drop in [**Name (NI) 102488**] PTT remained
elevated. WAs on subcu heparin, lft's obtained which showed
mild transaminase elevation and t bili elevation. Subcu heparin
stopped, RUQ U/S obtained showed fatty liver/h/o
cholecystectomy. Lft's, t. bili and PTT trended down on
discharge. Patient will need follow -up of these studies as an
outpatient. ? MEd affect. Lipitor was increased from 10 to 40
given significant coronary disease--although unlikely to cause
acute elevations.
Hsitory of DM: Not on meds prior to admission. Needs primary
care follow-up.
Hypothyroidism: Levoxyl continued, TSH normal
GERD: PRotonix continued, no acute issues.
General care: VIT D, calcium, multi-vitamins
FULL CODE
Medications on Admission:
cardizem 120
levoxyl 75
warfarin 1/2/2 3 day rotation
protonix 40
lipitor 10
HCTZ 25
Imdur 45
metoprolol 12.5 [**Hospital1 **]
Mavick O.5
multi-vitmain
citrate
ferrous gluconate
aspirin 81
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay - [**Hospital1 392**]
Discharge Diagnosis:
newly depressed EF- systolic Heart failure
acute renal failure
hypercoagulability
neck hematoma
cad
diabetes
reactive airway disease s/p bronchitis
transaminitis
Discharge Condition:
stable, ambulating with assistance
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2l
Call your doctor if you experience any further chest pain,
shortness of breath.
All medications as prescribed.
You will need to follow up with Dr. [**Last Name (STitle) 14069**] and Dr. [**Last Name (STitle) 120**] this
week. Please call to make appointments.
They will decide about re-starting coumadin after you [**1-7**]
colonscopy. Will also need to have [**Name (NI) 53324**], PT/PTT checked at
that time.
Please check ast, alt, alk phos and total bilirubin every few
days and trend results. If increasing dramatically then [**Name8 (MD) 138**] MD
for further work up.
Outpatient doctor to re-institute coumadin over next few weeks.
Followup Instructions:
Dr. [**Last Name (STitle) 14069**] within one week. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 37171**]
Follow-up appointment should be in 1 week
Call Dr. [**Last Name (STitle) 120**] this week to set up appointment.
Need to repeat echo in 3 monthsProvider: RADIOLOGY Where: [**Hospital 4054**] RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2150-1-2**]
4:00
Date/Time:[**2150-1-7**] 10:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD Where: [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **] COMPLEX)
Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2150-1-7**] 10:30
You are scheduled for colonscopy on [**1-7**].
Provider: [**Name10 (NameIs) **] WEST,ROOM FIVE GI ROOMS Where: GI ROOMS
Date/Time:[**2150-1-7**] 10:30
ICD9 Codes: 5849, 4589, 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8380
} | Medical Text: Admission Date: [**2149-5-13**] Discharge Date:
Date of Birth: [**2102-12-9**] Sex: F
Service: MEDICAL ICU
REASON FOR TRANSFER: Management of liver failure.
HISTORY OF PRESENT ILLNESS: The patient is a 46 year old
woman with past medical history as listed below who was
transferred from [**Hospital 8**] Hospital for further management of
acute hepatitis. She was in her usual state of health until
four days prior to admission there when she developed right
upper quadrant/epigastric pain, nausea and vomiting. Family
members also reported that they thought that she looked
jaundiced. Additionally, she reported chills and temperature
to 101 at home. She denied any hematemesis, saying that when
she vomited that it was bilious. Her stools were noted to be
[**Male First Name (un) 1658**] colored and smaller in caliber than usual. She denied
any sick contacts or recent travel. She had started no new
medications and denied the use of alcohol or intravenous drug
use. Of note, she reported that her ex-husband (divorced
three years ago) had a history of hepatitis C.
At [**Hospital 8**] Hospital, right upper quadrant ultrasound on the
day of admission was initially normal. Her transaminases
rose rapidly to the range of [**2146**] to 3000 with INR of 2.1 at
the time of transfer. Hepatitis serologies and autoimmune
studies were sent, most of which were still pending at the
time of transfer.
At the time of admission to [**Hospital1 188**], she complained of continuing right upper quadrant
pain. She denied further nausea, vomiting, chills or fever.
In addition, she reported a thirty pound weight gain over the
previous few months as well as increased abdominal girth over
the previous week.
PAST MEDICAL HISTORY:
1. Open cholecystectomy in [**2124**].
2. Status post appendectomy.
3. Depression.
4. Multiple benign breast masses.
ALLERGIES: Codeine.
MEDICATIONS AT THE TIME OF TRANSFER:
1. Protonix.
2. Morphine p.r.n.
3. Klonopin 0.5 mg three times a day.
SOCIAL HISTORY: The patient lives with her 21 year old
daughter and her father. She reports ongoing smoking with
greater than thirty pack year history. She has a history of
suicide attempts in the past by overdose with benzodiazepines
but denied again any active drug use.
MEDICATIONS AT HOME:
1. Effexor.
2. Percocet.
3. Remeron.
4. Vicodin.
5. Trazodone.
6. Neurontin.
7. Compazine.
This list was obtained from the patient's local pharmacy.
PHYSICAL EXAMINATION: On admission, vital signs revealed the
patient was afebrile at 98.2., heart rate 74, blood pressure
113/55, respiratory rate 12, oxygen saturation 97% in room
air. Pertinent physical findings included that she was obese
and jaundiced. She had scleral icterus. Her heart and lung
examinations were without significant findings. Her
abdominal examination revealed tenderness over the right
upper quadrant, liver palpable approximately 3.0 centimeters
below the costal margin. Cholecystectomy scar was noted.
She had no stigmata of chronic liver disease or elevated
portal pressures. She had no asterixis on examination.
Extremities revealed no palmar erythema, cyanosis, clubbing
or edema.
LABORATORY DATA: On admission, complete blood count was
unremarkable. Chem7 revealed sodium of 136, potassium 5.1,
blood urea nitrogen and creatinine within normal limits. INR
on admission was 2.1. Liver function tests revealed ALT
2481, AST 3416, alkaline phosphatase 203, total bilirubin
16.3, direct bilirubin 9.9, total protein 5.3, albumin 2.9.
Numerous serologies looking at possible causes of her liver
disease were still pending at the outside hospital at the
time of transfer.
HOSPITAL COURSE:
1. Acute hepatitis - Upon admission, blood was sent for
numerous studies to determine the etiology of her acute
hepatitis. Things that were examined included hepatitis A, B
and C serologies, hepatitis B and C viral loads, EBV, CMV,
HSV serologies, HIV, varicella, RPR, toxoplasma and
ceruloplasmin. Ultimately, these results yielded an etiology
consistent with acute hepatitis B as her hepatitis B surface
antigen returned positive. All other studies were negative.
She was treated supportively for her acute hepatitis B with
coagulation studies being followed very closely. Her liver
enzymes remained stable. On [**2149-5-16**], without any signs of
hepatic encephalopathy, the patient was transferred out of
the Intensive Care Unit to the medical floor. While still in
the Intensive Care Unit and upon transfer to the floor, the
patient had been treated with Morphine including a PCA for
her severe abdominal pain. On [**2149-5-18**], the patient became
acutely more encephalopathic and was transferred to the
Surgical Intensive Care Unit, placed on the transplant list
for possible liver transplant. While awaiting a liver, the
patient admitted to recent intravenous drug use, specifically
the use of Heroin. Her admission of illicit drug use
precluded her from getting a liver transplant and she was
transferred out of the Surgical Intensive Care Unit back to
the Medical Intensive Care Unit. In the Medical Intensive
Care Unit, she continued to decline neurologically with
worsening encephalopathy, increasing asterixis and eventually
significant lethargy and obtundation. Her INR continued to
elevate and, at the time of readmission to the Medical
Intensive Care Unit, her INR was 6.8. On [**2149-5-22**], the
patient's INR reached its highest point of 25.0. At that
time, hematology was consulted regarding reversal of her INR.
It was recommended that she be given daily Vitamin K , fresh
frozen plasma, and cryoglobulins for fibrinogen less than 150
and Factor VII-A was suggested for acute bleeding or if any
procedure was needed to be performed.
On [**2149-5-24**], the patient's mental status deteriorated further
and she was ultimately intubated for airway support.
Neurosurgery was consulted at that time. After reversal of
INR to normal levels, intracerebral pressure monitor (BOLT)
was placed for monitoring of her intracranial pressure. Her
intracranial pressure was solid and maintained at level of
less than 25 with a cerebral perfusion pressure greater than
50. At one point, her intracranial pressure rose to a level
of 24 at which time she was treated with 20 grams of
intravenous Mannitol. In the interim, the patient had
developed acute renal failure and was essentially anuric
becoming incredibly volume overloaded with all the blood
products she was receiving. Once the BOLT was placed, it was
necessary to maintain an INR of less than 1.5. For this, she
received very frequent transfusions of fresh frozen plasma,
Factor VII-A, cryoglobulins and platelets for levels that
were less than 70,000. Renal was consulted and CVVH was
instituted in the Intensive Care Unit for volume removal as
well as to help with the elevation in intracranial pressure.
This treatment continued until [**2149-5-30**], in that the patient
received frequent blood products and CVVH for volume removal.
The patient's platelets were found to fall precipitously and
Heparin dependent antibodies were checked finding that she
was HIT positive. For this, Heparin could not be used in the
CVVH and the CVVH filter clotted. Citrate was used
alternatively as an anticoagulant (see renal below) and
ultimately as the patient showed no signs of improvement in
her hepatic function, it was decided after a family meeting
on [**2149-5-30**], that once the CVVH filter clotted off again that
it would not be restarted. That was the case on [**2149-5-30**],
after which time, CVVH was not restarted. The patient had
her BOLT removed and has since been monitored for progressive
neurologic decline. At the time of this dictation, there is
evidence of cerebral herniation in that her pupils are fixed
and dilated bilaterally. She continues to be sedated on the
ventilator so the neurologic examination is difficult beyond
that, however, without any improvement in her liver synthetic
function, her prognosis is grime. The patient was made "Do
Not Resuscitate" after a family meeting.
Liver enzymes have trended downward and are actually below
normal limits suggesting that hepatic function is not showing
any signs of return.
2. Renal - As stated above, the patient developed acute
renal failure likely hepatorenal syndrome versus HEN as
microscopic examination of the urine reveals casts suggestive
thereof. As above, CVVH was instituted to help with volume
overload as well as to aid in the treatment of intracranial
pressure with the administration of Mannitol. Again, the
CVVH filter had clotted off and the patient was not receiving
Heparin. Citrate was instituted as anticoagulant. While on
Citrate, the patient's free calcium was noted to become very
low due to the binding of Citrate and she was repleted with a
constant infusion of Calcium Gluconate as well as Calcium
Chloride on a p.r.n. basis. Daily laboratories revealed that
her body's total calcium was as high as 18.0 as it was
measuring the calcium bound to Citrate and though her free
calcium was within the normal range of 1.0 to 1.2. When the
CVVH filter clotted on [**2149-5-30**], as above, it was decided
that it would not be restarted as the patient's prognosis and
hope for recovery was minimal. Since CVVH has been
discontinued, the patient's creatinine has risen very rapidly
from 2.5 on the day of discontinuation to 4.5 on the day of
dictation. She continues to be volume overloaded with
increasing potassium.
3. Hematology - With worsening liver synthetic function, the
patient's coagulopathy was as above with her INR ultimately
reaching a level of 25. With the placement of the
intracranial pressure monitor, it was necessary to keep the
patient's INR less than 1.5, platelets greater than 70,000,
fibrinogen greater than 150. Appropriate blood products were
transfused on a p.r.n. basis to maintain those goals with
Factor VII-A being used frequently for INRs greater than 2.0
to 2.5. Because of its expense, Factor VII-A was reserved
only for when fresh frozen plasma was unable to correct the
INR on its own which was a frequent occurrence. After the
intracranial pressure monitor was removed, reversal of INR
was continued for 24 hours to minimize the chance of an
intracranial bleed. Since discontinuation of INR control,
her INR has already risen to 6.1 eight hours after her last
dose of Factor VII-A. No further blood products will be
given at this time unless the patient shows signs of active
bleeding. On the day of this dictation, the patient's
hematocrit was 19.0, status post one unit of packed red blood
cells the day prior for the same hematocrit. A source of
bleeding is unclear at this time. It is possible the patient
is hemolyzing. She will be transfused further packed red
blood cells today on [**2149-6-1**].
4. Hypotension - With the patient's worsening encephalopathy
and liver failure as well as likely component of her
sedation, the patient was persistently hypotensive requiring
pressors to maintain her blood pressure. Specifically, it
was important to maintain her cerebral perfusion pressure
(MAT minus intracranial pressure) of greater than 50. For
this, she was on Levophed, Neo-Synephrine and Vasopressin.
The Neo-Synephrine was able to be weaned and the patient has
been continued to date on Levophed and Vasopressin. After
the family meeting on [**2149-5-30**], it was determined that no
further pressors would be used, i.e., Neo-Synephrine would
not be restarted but Vasopressin and Levophed would be
continued and titrated as needed.
5. Pulmonary - Once intubated, the patient developed
worsening oxygenation but chest x-ray was consistent with
adult respiratory distress syndrome. She was ventilated with
low tidal volumes at high respiratory rates, as high as 34
for a number of days, with continuing poor oxygenation. Over
time, her oxygenation did improve and at the time of this
dictation, she is still ventilated on assist control with a
tidal volume of 600 with a rate of only 22, pCO2 in the mid
30s and pO2 in the 80s to 100s.
6. Acid base - The patient had a triple acidotic disturbance
with both a gap and nongap metabolic acidosis as well as
respiratory acidosis. In order to compensate for this, she
was ventilated as above with respiratory rates as high as 34
to try to decrease her pCO2.
7. FEN - As above, the patient was persistently volume
overloaded and her total volume in was minimized by
concentrating all fluids that she received. Her calcium was
complicated by the Citrate and the CVVH fluid as above. At
the time of this dictation, her potassium is rising since
CVVH has been off. For nutrition, the patient had been
receiving tube feeds but was having problems with high
residuals. Therefore, she has been maintained on TPN.
8. Endocrine - The patient was found to be adrenally
insufficient by random cortisol and is being treated with
Hydrocortisone 100 mg intravenous q8hours. In addition,
because of her decrease in hepatic synthetic function,
decreased gluconate agenesis, the patient has had q2hour
fingerstick and treated with initially a D10 infusion
replaced by increased dextrose in her TPN with p.r.n. of D50
as needed for hypoglycemia.
The dictation covers the [**Hospital 228**] hospital course from
admission through [**2149-6-1**]. The remainder of the [**Hospital 228**]
hospital course will be dictated by the intern taking over
the Medical Intensive Care Unit service tomorrow.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
Dictated By:[**Name8 (MD) 3491**]
MEDQUIST36
D: [**2149-6-1**] 08:41
T: [**2149-6-1**] 10:39
JOB#: [**Job Number 49613**]
ICD9 Codes: 5849, 5185, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8381
} | Medical Text: Admission Date: [**2120-8-3**] Discharge Date: [**2120-8-13**]
Date of Birth: [**2052-9-12**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Self-transferred from [**Hospital 1474**] Hospital for further workup
Major Surgical or Invasive Procedure:
1. Bone marrow aspirate
History of Present Illness:
67 yo M, PMH of DM, CAD (CABG), DJD (disc surgery), COPD,
presents with epistaxis, purpura, lymphadenopathy, back pain,
anemia, thrombocytopenia, fevers, fatigue x 2.5 months, 30 lb
weight loss over past month. Pt developed persistent epistaxis
at 2 pm today, still bleeding 7 hours later. Pt states 30 lb
weight loss over past month. His back pain has been so severe
that he has not been able to walk properly for the past 2.5
months. The back pain projects down in and along the spinal
canal, from the shoulder blades down to his buttocks, worst in
disc surgery site in lower thoracic/upper lumbar spine. The
pain radiates to his buttocks bilaterally, and radiates down his
leg posterolaterally bilaterally. The pt has experienced motor
weakness in both legs for the past 2.5 months, no tingling, no
sensory loss. No bladder or rectal incontinence. No erectile
dysfunction. Pt has felt fatigued and short of breath for the
past few months. Pt has never had a bone marrow biopsy.
.
Pt also has 50 pk yr smoking hx and COPD, and chronic dyspnea on
exertion. His PPD test has been negative, he has not traveled
out of the country, been in shelters, or been incarcerated over
the past several years. Pt has had unprotected sex with his
girlfriend for the past 3 years.
.
Pt has been hospitalized in [**Hospital 1474**] Hospital for the past 4
weeks, for intractable back pain, bilateral hilar and
mediastinal adenopathy, anemia, thrombocytopenia, pneumonia,
MRSA. Mediastinoscopy and bronchoscopy were performed to sample
lymph node tissue, which yielded benign findings. Bronch sample
found MRSA in the sputum. Pt was placed on regimen of Vanco and
Zosyn for coverage.
.
Pt had a fine needle aspiration of a right lower lung lesion,
but before FNA, pt was noted as having low plts and hct of 19.
The patient had hemoptysis with small amounts of bloody sputum.
Pt received plts and red cell transfusions. Path for the needle
biopsy is still pending.
.
Pt was in constant pain at [**Hospital1 1474**], and needed his pain regimen
adjusted constantly until placed on a PCA pump. He is allergic
to codeine. He wished a second opinion for his medical
problems.
.
ROS: +30 lb weight loss, +fatigue, +weakness, +shortness of
breath, +constipation, all other negative
Past Medical History:
PMH:
1. DM
2. HTN
3. DJD
4. CAD
5. Emphysema
.
PSH:
Spinal fusion surgery [**30**] years ago.
Social History:
50 pk yr smoking hx (nicotine patch), stopped drinking 35 yrs
ago, lives with his children, getting married soon, 4 children.
Enjoys hunting, fishing now. Strong social support.
Family History:
Healthy, uncle may have had cancer, no family member had or have
similar symptoms
Physical Exam:
Vitals: 98.9 / 92 / 28 / 96% sat on 2 L / 132/70
Gen: Ambulatory, breathing loudly
HEENT: No JVD, PERRL
Lungs: CTAB
Chest: No pain on palpation, purpura on chest, barrel-chested
Heart: RRR, no m/r/g, clear S1/S2, no S3/S4
Abdomen: Distended, firm, bumpy on palpation, NT, +BS, purpura
and petechiae on abdomen, hepatosplenomegaly is difficult to
appreciate due to distension of abdomen and bowel
Back: Tenderness to palpation along spine from shoulder blades
down to buttocks, most tenderness in T8 area of disc surgery,
tenderness with palpation of buttocks, less tenderness in
cervical spine
LYMPH: No anterior/posterior cervical/supraclavicular LN, no
axillary or inguinal LN
Genital: Vesicle/wart in suprapubic area, discomfort on
palpation
Extremities: 1+ pitting edema bilaterally
Neuro: [**6-13**] motor, sensory equal and intact throughout, good
rectal tone and sensation, leg raise to 80 degrees bilaterally
without pain, 2+ pulses throughout, PERRL
Pertinent Results:
[**2120-8-3**] 08:15PM PT-12.7 PTT-20.4* INR(PT)-1.1
[**2120-8-3**] 08:15PM PLT SMR-VERY LOW PLT COUNT-56*
[**2120-8-3**] 08:15PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ STIPPLED-1+ HOW-JOL-1+
[**2120-8-3**] 08:15PM NEUTS-52 BANDS-12* LYMPHS-19 MONOS-6 EOS-0
BASOS-1 ATYPS-1* METAS-5* MYELOS-3* PROMYELO-1* NUC RBCS-7*
[**2120-8-3**] 08:15PM WBC-5.6 RBC-3.46* HGB-10.4* HCT-29.3* MCV-85
MCH-30.2 MCHC-35.6* RDW-15.9*
[**2120-8-3**] 08:15PM calTIBC-235* FERRITIN-GREATER TH TRF-181*
[**2120-8-3**] 08:15PM ALBUMIN-3.6 CALCIUM-9.4 PHOSPHATE-2.9
MAGNESIUM-2.0 URIC ACID-4.8 IRON-57
[**2120-8-3**] 08:15PM ALT(SGPT)-38 AST(SGOT)-90* LD(LDH)-4712* ALK
PHOS-105 TOT BILI-0.8
[**2120-8-3**] 08:15PM GLUCOSE-114* UREA N-23* CREAT-0.7 SODIUM-133
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-25 ANION GAP-15
Brief Hospital Course:
A/P:
67 yo M, PMH of DM, CAD (CABG), DJD (disc surgery), COPD,
presents with epistaxis, purpura, lymphadenopathy, severe back
pain, anemia, thrombocytopenia, fevers, fatigue x months, 30 lb
weight loss over past month.
.
1. MEDIASTINAL AND ABDOMINAL LAD:
Diff Dx: LAD could be due to myeloma, lymphoma, primary lung
ca, TB (no apparent exposure), granulomatous diseases, HIV
(unprotected sex for 3 years, STD), fungus. Other possibilities
are Wegener's (hemoptysis, but no renal failure), sarcoidosis
(but unusual patient profile, and Ca is 9.4).
.
In [**Hospital 1474**] Hospital, the pt had undergone a CT Chest, which
showed mediastinal LAD and a RLL lesion. Mediastinoscopy was
performed, and the [**Hospital1 1474**] pathologist (Dr. [**First Name (STitle) **] reported
"benign findings" (detailed [**Hospital1 1474**] pathology report and phone
numbers included in the chart). FNA of a RLL lesion was
performed, and Dr.[**Name (NI) 16211**] initial impression was small cell ca
of the lung.
.
At [**Hospital1 18**], a CT Torso was performed, demonstrating diffuse giant
LAD throughout the mediastinum and abdomen, as well as a RLL
lesion, 2 small liver lesions (one in caudate lobe, one in left
lobe), and no splenomegaly. Since the patient had SOB, chest
pain, and a R apical pneumothorax after his mediastinoscopy at
[**Hospital1 1474**], it was decided that the giant lymph nodes found on CT
Torso, the lung lesion, and 2 liver lesions would not be
biopsied, in case the results of the bone marrow aspirate were
sufficient for diagnosis. HIV and ANCA were negative.
.
2. BACK PAIN:
Diff Dx: Back pain could be due to myeloma (lytic lesions),
colon ca (pathologic fx), mets to bone from lung ca (pathologic
fx), slipped disc.
.
Metastases to the spine were suspected. T- and L-spine XR
showed neither a pathologic fracture nor lytic lesions.
SPEP/UPEP and PSA were negative. During admission, the pt
experienced a fall, in which he was "walking normally, and then
all of a sudden my legs went numb, and I went to take a step and
my legs buckled like the batteries had been taken out of them".
Neurologic findings showed R LE weakness. Pt was started on
steroids with communication with Hem-Onc. MRI of the Head, C-,
T-, and L-spine ruled out cord compression, but a possibility of
an epidural tumor was noted at T10/T11. The next day,
neurologic findings progressed to R LE and R UE weakness and
decreased pinprick sensation, and decreased R lower face
pinprick sensation. MRI Head showed a possible subacute pontine
infarct. Pt has a h/o spinal fusion surgery [**30**] years ago, and
an LP under fluoro was attempted to rule out carcinomatous
meningitis. 2 units plts were transfused before LP. However,
while attempting to lie on his abdomen, the pt was in
excruciating pain and his O2 sat dropped to 90%, and the LP
could not be performed.
.
3. EPISTAXIS:
Diff Dx: Epistaxis that does not stop after several hours, with
a plt count of 56, in a non-uremic pt is unusual, and suggestive
of myeloma, lymphoma, bone marrow aplasia, DIC, qualitative plt
defects.
.
The pt presented with plts 56 and profuse epistaxis that did not
respond to Afrin, pressure, tilting of his head. Epistaxis
ceased only after infusion of 1 unit plts. Hct remained stable
throughout admission. Epistaxis was on and off when pt had plts
78.
.
4. PURPURA:
Diff Dx: Purpura diffusely over the chest, abdomen, and legs,
with a plt count of 56, in a non-uremic pt is unusual, and
suggestive of myeloma, lymphoma, bone marrow aplasia, DIC,
qualitative plt defects.
.
The pt presented with green-yellow purpura on his chest and
abdomen, as well as petechiae on his abdomen with no h/o trauma.
Purpura continued to resolve during admission.
.
5. ANEMIA:
Diff Dx: Anemia of Hct 29.3 suggests colon ca in a 67 yo male
(but no black stools, normal bore stools), myeloma, lymphoma,
hemolytic anemia, splenomegaly and reticuloendothelial system
can be destroying RBC. With fever and thrombocytopenia, TTP is
a possibility, but no renal failure or neuro changes (although
these are late developments).
.
Results of uric acid, haptoglobin, retics, total bili, and no
schistocytes indicated that a hemolytic anemia or TTP was
unlikely. No splenomegaly was found on CT Abd.
.
CBC with diff twice showed selectively early myeloid precursors
in the peripheral blood. Basophilic stippling and [**Location (un) **]-Jolly
body was noted on erythrocyte examination. A peripheral smear
(showing erythroblasts and no tear drop cells) and bone marrow
aspirate was performed by Hem-Onc (Dr. [**First Name4 (NamePattern1) 16212**] [**Last Name (NamePattern1) **] and Dr.
[**Last Name (STitle) **]. A bone marrow biopsy could not be performed due to pt's
"panic attack" during two attempts. The results of the BM
aspirate revealed a diagnosis of small cell carcinoma of the
lung with squamous morphology, an undifferentiated tumor.
.
6. THROMBOCYTOPENIA:
Diff Dx: Plts of 56 with epistaxis and purpura indicates a
functional, qualitative thrombocytopenia, suggesting bone marrow
suppression, production problem (liver failure and tpo, but bili
is WNL), destruction by splenomegaly (should be increase in
megakaryocytes).
.
7. SOB:
Pt's baseline SOB was attributed to COPD (emphysema), as CXR
taken for possibility of post-obstructive pneumonia showed no
infiltrates. Exacerbated SOB was attributed to R pneumothorax.
Pt maintained >95% O2 sat on high flow 5L nasal cannula, and R
pneumothorax was resolving.
.
Echo and daily CXR had not been performed on the day before
transfer to OMED, due to more emergent testing. Echo had also
been planned as preparation for possible future cancer therapy.
.
8. PAIN:
Both at [**Hospital 1474**] Hospital and [**Hospital1 18**], pt's pain was difficult to
control. Pt's pain is diffuse, "all over", in the chest, and
localized especially on the spine from T4 to the sacrum and down
the LEs. Pt's pain is episodic, at times [**3-21**] to 10+/10, feels
like "sharp, electric shock pain", helped by position of sitting
or lying down on his back, and precipitated by muscle use. Pt's
pain was successfully controlled on a morphine PCA pump at a
maximum of 10 mg/hr.
.
9. CAD:
Pt's CAD is chronic. He had been maintained on Metoprolol and
ASA, but no ACE-I or [**Last Name (un) **]. Pt's ASA was discontinued due to pt's
bleeding tendency.
.
10. HTN:
Pt's HTN is chronic, and well-controlled on Metoprolol.
.
11. DM:
Pt was maintained on Insulin SS.
.
12. COPD (Emphysema):
Pt has a 50 pk-yr smoking history and emphysema, and was
maintained at >95% O2 sat on 2L O2 nasal cannula alone. High
flow 5L O2 nasal cannula was maintained to help resolve pt's
pneumothorax.
.
13. FEN:
Due to pt's 30 lb weight loss over the past month, decreased
appetite, and possible cachexia, a house diet and periodic IVFs
of D5 0.45NS were provided.
.
14. PROPHYLAXIS:
Due to pt's bleeding tendency, pneumoboots and no heparin sc
were used. PPI was given for GI protection.
.
.
15. FAMILY CONTACTS:
Have permission of the pt to have open communication with:
[**Name (NI) **] (son), [**Name (NI) 6480**] (daughter): [**Telephone/Fax (1) 16213**]
[**Name (NI) 1328**] (sister).
.
The patient was kept comfortable until his family could arrive.
He was then made CMO and expired on [**2120-8-13**].
Medications on Admission:
Morphine Sulfate SR 15 mg PO Q12H
Oxycodone 5 mg PO Q4-6H:PRN pain
Nicotine Patch 21 mg TD DAILY
Pantoprazole 40 mg PO Q24H
Insulin SC (per Insulin Flowsheet) Sliding Scale
Multivitamins 1 CAP PO DAILY
Metoprolol 50 mg PO BID
Albuterol 0.083% Neb Soln 1 NEB IH Q6H
Ipratropium Bromide Neb 1 NEB IH Q6H
Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] use with spacer
Acetaminophen 1000 mg PO Q6H
traMADOL 50 mg PO Q4-6H:PRN pain
Zolpidem Tartrate 5 mg PO HS:PRN insomnia
Oxymetazoline HCl 1 SPRY NU [**Hospital1 **] Duration: 3 Days
for epistaxis
Discharge Medications:
None - patient expired
Discharge Disposition:
Expired
Facility:
[**Hospital1 18**]
Discharge Diagnosis:
Respiratory Failure
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 2875, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8382
} | Medical Text: Admission Date: [**2196-1-7**] Discharge Date: [**2196-1-18**]
Date of Birth: [**2139-6-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
CABGx3(LIMA->LAD< SVG->OM, PDA) [**2196-1-8**]
Cardiac Catheterization [**2196-1-7**]
History of Present Illness:
Mr. [**Known lastname 32283**] is a 56 year old gentleman with no known coronary
artery disease. In [**2191-8-5**], he was diagnosed with thyroid
cancer and underwent a thyroidectomy and radiation therapy. In
[**2194-2-1**] a routine CT scan revealed coronary artery
calcification and he was therefore referred for further
evaluation. An exercise tolerance test on [**2195-12-18**] was positive
with fatigue, dyspnea and ST depressions in the inferolateral
leads. Scans showed a moderate reverisble defect in thebasilar
and mid-inferior wall. His ejection fraction was predicted to be
66%. Mr. [**Known lastname 32283**] reports intermittant dyspnea on exertion for
the past few months but denies ever experiencingany chest pain.
He was admitted today [**2195-12-7**] for a cardiac catheterization which
revealed an 80% stenosed left main, an 80% stenosed left
anterior descending artery and a 90% stenosed right cronary
artery. His ejection fraction was normal. Mr. [**Known lastname 32283**] is now
being referred for surgical revascularization.
Past Medical History:
Hypercholesterolemia
Thyroid cancer
S/P Thyroidectomy
Gout
Right eye styes
Glaucoma
Past tonsillectomy
Eye surgery to relieve pressure
Social History:
Live sin [**Location 17448**] with wife. Three children. WOrks full-time
as a buisness analyst. Never smoked. Occasional alcohol use.
Family History:
Father with myocardial infarction and CABG in his 60's. Aunts
and [**Name2 (NI) 32284**] with coronary artery disease.
Physical Exam:
Ht 68" Wt 160 Temp- 98.1 128-147/70's 64 SR 100% room air
sats
GEN: Overall good health. Appears well in no acute distress.
NEURO: Alert and oriented x3. Appropriate. Flat affect.
Nonfocal.
LUNGS: Bibasilar rales
HEART: RRR, normal S1-S2. No murmur
ABDOMEN: Soft, round, nontender, nondistended, normoactive bowel
sounds
EXTREMITIES: Warm, well perfused, no edema, no varicosities.
PULSES: 1+ radial, dorsalis pedis and posterior tibial
bilaterally.
Pertinent Results:
[**2196-1-7**] 09:30AM PT-12.9 PTT-28.9 INR(PT)-1.1
[**2196-1-7**] 09:30AM WBC-3.6* RBC-4.39* HGB-13.7* HCT-37.7* MCV-86
MCH-31.3 MCHC-36.4* RDW-12.8
[**2196-1-7**] 09:30AM ALT(SGPT)-32 AST(SGOT)-16 ALK PHOS-38*
AMYLASE-35 TOT BILI-0.7
[**2196-1-7**] 09:30AM GLUCOSE-208* UREA N-19 CREAT-1.0 SODIUM-135
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-25 ANION GAP-11
[**2196-1-7**] 11:53AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2196-1-7**] CXR
No acute cardiopulmonary disease
[**2196-1-7**] Cardiac Catheterization
1. Selective coronary angiography of this right dominant
system revealed severe three vessel and left main coronary
disease. The
LMCA contained an 80% ostial lesion. The LAD contained an 80%
osital
lesion before giving off two large septals and a large diagonal
branch.
The LCX contained 40% ostial disease. The RCA was a large,
domiant
vessel and contained a mid vessel 90% lesion and a distal 90%
just
before the PDA takeoff.
2. Left ventriculography revealed a calculated ejection fraction
of 55%
with not mitral regurgitation or wall motion abnormalities seen.
3. Limited resting hemodynamics revealed a central aortic
pressure of
161/70 with an elevated LVEDP of 23mmHg. There was no gradient
across
the aortic valve on pull-back.
[**2196-1-7**] EKG
Sinus rhythm. Right ventricular conduction delay. No previous
tracing available for comparison. Rate 57.
[**2196-1-14**] EKG
Sinus rhythm 74. Short PR interval. Nonspecific inferolateral T
wave changes, RSR' in V1. Since last ECG some T wave changes
[**2196-1-15**] ECHO
1. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is moderately depressed. Anterior, septal, and
apical
hypokinesis to akinesis is present.
2. The aortic valve leaflets (3) are mildly thickened.
3. The mitral valve appears structurally normal with trivial
mitral
regurgitation.
4. Compared with the findings of the prior report (tape
unavailable for
review) of [**2195-7-7**], LV function has decreased.
Brief Hospital Course:
Mr. [**Known lastname 32283**] was admitted to the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical
Center on [**2196-1-7**] and underwent a cardiac catheterization. This
revealed an 80% stenosed left main coronary artery, an 80%
stenosed left anterior descending artery, a 90% stenosed right
coronary artery and a normal left ventricular ejection fraction.
Heparin was started for anticoagulation. Due to the severity of
his disease, the cardiac surgical service was consulted for
surgical revascularization. Mr. [**Known lastname 32283**] was worked-up in the
usual preoperative manner. On [**2196-1-8**], Mr. [**Known lastname 32283**] was taken to
the operating room where he underwent coronary artery bypass
grafting to three vessels. Postoperatively, he was taken to the
cardiac surgical intensive care unit for monitoring. On
postoperative day one, Mr. [**Known lastname 32283**] [**Last Name (Titles) 5058**] neurologically intact
and was extubated. Neo-Synephrine continued for hypotension. The
endocrinology service was consulted in regards to his
difficultly coming off pressors and a thyroid study and cortisol
levels were sent. He was gently diuresed towards his
preoperative weight. He was transfused with packed red blood
cells for postoperative anemia. The physical therapy service was
consulted for assistance with his postoperative strength and
mobility. His drains and epicardial pacing wires were removed
per protocol. An echocardiogram was obtained which ruled out any
evidence of tamponade. Ultimately his neo synephrine was weaned
off. On postoperative day eight, Mr. [**Known lastname 32283**] was transferred
to the step down unit for further recovery. His cortisol level
returned mildly elevated at 27.7 micrograms per deciliter and
his thyroid studies showed a mildly elevated free T4 and a low
thyroid stimulating hormone on Synthroid. Follow-up thyroid
studies were recommended in 2 to 4 weeks as an outpatient. Mr.
[**Known lastname 32283**] continued to make steady progress and was discharged
home on postoperative day ten. He will follow-up with Dr.
[**Last Name (STitle) **], his cardiologist and his primary care physician as an
outpatient.
Medications on Admission:
Synthroid 150mcg daily
Timoptic one drop to both eyes at bed time
Travatan one drop to both eyes at bed time
Lipitor 20mg once daily
Toprol XL 50mg once daily
Doxycycline 50mg once daily
Valium 5mg as needed at bed time
Ecotrin 81mg once daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
Disp:*1 bottle* Refills:*2*
4. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed.
Disp:*120 Tablet(s)* Refills:*0*
7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*250 ML(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Coronary artery disease.
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 32285**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 2-3 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Completed by:[**2196-2-2**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8383
} | Medical Text: Admission Date: [**2197-3-15**] Discharge Date: [**2197-3-20**]
Date of Birth: [**2137-5-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Dyspnea, palpitations
Major Surgical or Invasive Procedure:
[**2197-3-15**] Tricuspid Valve repair utilizing a 34mm annuplasty ring
with LV lead placement
.
[**2197-3-17**] Insertion of [**Company 1543**] dual chamber permanent pacemaker,
model # ADDRL1
History of Present Illness:
This is a 59 year old female with history of polymyositis, who
was recently sent in for evaluation of tachy-brady syndrome.
Over past month prior to admission, she reported having
intermittent chest tightness and palpitations. These episodes
lasted approximately 10-40 minutes. She also complained of
intermittent dyspnea and decreased exercise tolerance. She also
reported episodes in which she feels lightheaded and a sensation
of warmth, but denies any dizziness or loss of consciousness.
Subsequent cardiac MRI revealed worsening tricuspid
regurgitation with RA/RV enlargement and also some mitral
regurgitation. Given above findings, cardiac surgery was
consulted and further evaluation was performed. After routine
preoperative evaluation, she was eventually cleared to proceed
with surgical intervention.
Past Medical History:
- Gallbladder polyps
- Polymyositis - biopsy proven. Has refused treatment in the
past due to side effects of prednisone
- Recent Pneumonia, one month prior to admission
- Tricuspid Regurgitation
- Sick Sinus Syndrome
Social History:
Lives with her son [**Name (NI) **]. Nonsmoker. Denies ETOH or drug use.
Daily hour long walks per family.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
PREOP EXAM:
BP 103/56 Pulse:54 Resp:18 O2 sat:95/RA
Height:66" Weight:59.1 kgs
General: WDWN female in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] No edema
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: none Left: none
Pertinent Results:
Admission labs:
[**2197-3-15**] WBC-7.4 RBC-2.71*# Hgb-8.1*# Hct-24.5*# RDW-14.2 Plt
Ct-64*#
[**2197-3-16**] WBC-11.5* RBC-2.84* Hgb-8.3* Hct-25.2* RDW-15.2 Plt
Ct-173
[**2197-3-17**] WBC-15.5* RBC-3.14* Hgb-9.1* Hct-27.7* RDW-15.5 Plt
Ct-120*
[**2197-3-18**] WBC-8.9 RBC-2.95* Hgb-8.6* Hct-26.7* RDW-15.0 Plt
Ct-104*
[**2197-3-19**] WBC-9.4 RBC-2.99* Hgb-8.6* Hct-27.1* RDW-15.2 Plt
Ct-111*
[**2197-3-15**] UreaN-9 Creat-0.4 Na-142 K-3.4 Cl-109* HCO3-28 AnGap-8
[**2197-3-16**] Glucose-100 UreaN-7 Creat-0.3* Na-138 K-4.1 Cl-106
HCO3-30
[**2197-3-17**] Glucose-112* UreaN-8 Creat-0.5 Na-135 K-4.1 Cl-99
HCO3-33*
[**2197-3-18**] Glucose-99 UreaN-6 Creat-0.3* Na-138 K-3.8 Cl-101
HCO3-31 AnGap-10
[**2197-3-19**] UreaN-7 Creat-0.3* Na-140 K-3.8 Cl-101
[**2197-3-16**] Mg-2.0, [**2197-3-19**] Mg-2.0
.
Discharge labs:
[**2197-3-19**] 06:40AM BLOOD WBC-9.4 RBC-2.99* Hgb-8.6* Hct-27.1*
MCV-91 MCH-28.9 MCHC-31.9 RDW-15.2 Plt Ct-111*
[**2197-3-19**] 06:40AM BLOOD Plt Ct-111*
[**2197-3-17**] 03:52AM BLOOD PT-12.7* PTT-26.7 INR(PT)-1.2*
[**2197-3-19**] 06:40AM BLOOD UreaN-7 Creat-0.3* Na-140 K-3.8 Cl-101
[**2197-3-19**] 06:40AM BLOOD Mg-2.0
[**2197-3-18**] Chest x-ray:
Pulmonary edema has not recurred and pulmonary vascular
engorgement has improved. Severe cardiomegaly is stable. Small
right and moderate left pleural effusion are stable, left lower
lobe collapse is more pronounced. No pneumothorax. Transvenous
right ventricular pacer lead may pass into the coronary sinus,
but it does not traverse the ring of the tricuspid valve
prosthesis
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 55% >= 55%
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal regional LV
systolic function. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV
free wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal descending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to
moderate ([**2-6**]+) MR.
TRICUSPID VALVE: Moderate to severe [3+] TR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Written informed consent was obtained from the
patient. The patient was under general anesthesia throughout the
procedure. No TEE related complications. The patient appears to
be in sinus rhythm. Results were personally reviewed with the MD
caring for the patient.
Conclusions
Prebypass
No mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses are normal. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is moderately dilated with mild global free wall
hypokinesis. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**2-6**]+) mitral regurgitation
is seen. Moderate to severe [3+] tricuspid regurgitation is
seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in
person of the results on [**2197-3-15**] at 945am.
Post bypass
Patient is AV paced and receiving an infusion of phenylephrine.
LVEF= 50%. Annuloplasty ring seen in the tricuspid position. It
appears well seated . There is trivial tricuspid regurgitation
and no stenosis. Aorta is intact post decannulation. The mitral
regurgitation is trivial.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2197-3-15**] 14:04
Brief Hospital Course:
Mrs. [**Known lastname **] was a same day admission to the operating room for
tricuspid valve repair along with placement of a left
ventricular lead, please see operative report for details. In
summary patient had:
1. Tricuspid repair using an [**Doctor Last Name **] MC3 annuloplasty ring,
model number 4900.
2. Left ventricular epicardial lead placement x2.
3. Atrial tissue biopsy.
4. Mediastinal reexploration
Her bypass time was35 minutes with a crossclamp time of 24
minutes.
Following re-operation, she was brought to the CVICU for
invasive monitoring. Within 24 hours, she awoke neurologically
intact and was extubated without incident. She maintained stable
hemodynamics and underwent placement of dual chamber [**Company 1543**]
pacemaker on postoperative day two. She tolerated the procedure
well without complication. Following pacemaker implantation, she
transferred to the cardiac stepdown floor for further care and
recovery. She experienced brief episodes of paroxysmal atrial
fibrillation but ultimately was apaced. Beta blockade was
started and advanced as tolerated. Over several days, she
continued to make clinical improvement with diuresis and she was
medically cleared for discharge to rehabilitation on
postoperative day five. Prior to discharge, pacemaker underwent
interrogation and was found to be functioning within normal
limits. At discharge, incisional pain was well controlled on
Ultram.
Follow up appointments were outlined in discharge paperwork.
Medications on Admission:
metoprolol XL25 mg daily, several Chinese herbal medications
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin [**Hospital1 1926**] 81 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
Disp:*90 Tablet, Chewable(s)* Refills:*2*
4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
5. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain management .
Disp:*30 Tablet(s)* Refills:*0*
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 days: please take with KCL.
Disp:*10 Tablet(s)* Refills:*0*
7. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 10 days:
please take with Lasix.
Disp:*10 Tablet, ER Particles/Crystals(s)* Refills:*0*
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for dyspnea.
9. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5481**] TCU
Discharge Diagnosis:
Tricuspid regurgitation- s/p Tricuspid repair
Tachy-brady syndrome, s/p Permanent pacemeker implantation
Polymyositis
Postop Bleeding, s/p re-exploration
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Tramadol
Incisions:
Sternal - healing well, no erythema or drainage
Edema-trace bilat LE
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 170**]) on [**4-20**] @1pm phone:[**Telephone/Fax (1) 4044**]
EP service/Cardiologist:Dr. [**First Name (STitle) 900**] [**Name8 (MD) 901**], M.D.
Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2197-3-30**] 1:40
Provider: [**Name10 (NameIs) **] CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2197-3-28**]
10:00
Device Clinic- [**Hospital Ward Name 23**] 7: [**2197-3-23**] @ 10AM [**Telephone/Fax (1) 62**]
Please call to schedule appointments with:
Primary Care: Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 10349**] in [**5-11**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2197-3-20**]
ICD9 Codes: 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8384
} | Medical Text: Admission Date: [**2146-2-14**] Discharge Date: [**2146-2-18**]
Date of Birth: [**2082-7-27**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 63-year-old gentleman who
is relatively asymptomatic from his coronary artery disease
had a murmur detected on a physical exam this past [**Month (only) 359**]
prior to admission. The workup revealed a dilated ascending
aorta of 5.2 cm and 3-vessel disease. Cardiac catheterization
performed at [**Hospital6 3872**] on [**2145-12-29**]
showed a LAD 80% lesion, a circumflex 80% lesion, a PDA 80%
lesion, mild aortic insufficiency, and an ejection fraction
of 76%. An echocardiogram performed on [**2145-9-30**]
showed an EF of 60%, an aortic root of 4.2 cm, mild AI, and
mild MR.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Raynaud disease.
3. Hypertension.
4. Hyperlipidemia.
5. Osteoma of the left leg, status post removal in [**2135**].
6. Status post deviated septal repair in [**2115**].
7. Wisdom teeth removal in [**2110**].
8. He also has a history of herniated disc with occasional
lower leg paresthesia.
MEDICATIONS PRIOR TO ADMISSION: Procardia XL 30 mg p.o.
daily, atenolol 25 mg p.o. daily, aspirin 325 mg p.o. daily,
and Zocor 20 mg p.o. daily.
ALLERGIES: He had no known allergies.
CARDIOLOGIST: His cardiologist is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 32255**].
PRIMARY CARE PHYSICIAN: [**Name10 (NameIs) **] primary care is Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 5263**].
FAMILY HISTORY: He has a positive family history. His father
had a stroke and a CVA.
SOCIAL HISTORY: Mr. [**Known lastname 91245**] is a retired engineer. He lives
with his wife who has early dementia, and he is the primary
caregiver to his wife. [**Name (NI) **] has no tobacco history whatsoever
and rarely uses alcohol.
REVIEW OF SYSTEMS: He denied any CVA symptoms, TIA, or
syncope, as well as claudication; but he did have a positive
history with Raynaud's which improved with the treatment with
Procardia.
PHYSICAL EXAMINATION: He was 5 feet 11 inches, 152 pounds,
his pulse was regular at 60, blood pressure on the right was
120/80, on the left 118/78. He was in no apparent distress
and was well appearing. His skin was warm and dry. He had no
lesions or rashes. His pupils were equally round and reactive
to light and accommodation. His EOMs were intact. His neck
was supple with no JVD. His lungs were clear bilaterally. His
heart was regular in rate and rhythm with a loud S2 and a
grade [**11-25**] to 2/6 systolic ejection murmur. His abdomen was
soft, nontender, and nondistended with bowel sounds present.
He had no peripheral edema. He had a mild paresthesia on the
lateral aspect of his left thigh and lower leg. He had some
venous dilation of his left lower extremity, but the left leg
vein appeared suitable for a possible conduit with no
varicosities present. He was alert and oriented x 3 with 5/5
strength and a steady gait. He had 2+ bilateral femoral, DP,
PT, and radial pulses. No carotid bruits were appreciated.
PREOPERATIVE LABORATORY DATA: White count of 5.8, hematocrit
of 44.2, and platelet count of 245,000. PT of 13.4, PTT of
33.1, and INR of 1.1. Sodium of 140, K of 4.1, chloride of
99, bicarbonate of 33, BUN of 21, creatinine of 1.0, with a
blood sugar of 74. His urinalysis was negative. ALT of 25,
AST of 25, alkaline phosphatase of 66, amylase of 77, total
bilirubin of 0.7, total protein of 7.0, albumin of 4.5,
globulin of 2.5, and HBA1C of 5.2%.
RADIOLOGIC STUDIES: Preoperative EKG revealed a sinus
bradycardia at 51 with an intraventricular conduction delay,
and left axis deviation, and a question of an old
anteroseptal myocardial infarction.
Preoperative chest x-ray revealed evidence of emphysema with
no pneumonia or congestive heart failure.
HOSPITAL COURSE: The patient was referred to Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] for coronary artery bypass grafting with possible
ascending aortic replacement for his dilated ascending aorta.
He was admitted on the [**10-17**] and underwent a coronary
artery bypass grafting x 2 with a LIMA to the diagonal, and a
vein graft to the OM1, and an ascending aortic replacement
with a 28-mm Gelweave 2 graft as well as resuspension of his
aortic valve.
He was transferred to the cardiothoracic ICU in stable
condition on a Levophed drip at 0.05 mcg/kg/min and a
propofol drip at 30 mcg/kg/min. In the cardiothoracic ICU
that evening he was quickly weaned off his Levophed as his
SBPs were rising into the 130s, and nitroglycerin and Nipride
were added in and titrated up to keep his systolic blood
pressure below 110. He received a blood transfusion with PA
diastolic pressures in the teens with a CVP of 13. He also
received 4 units of FFP and 2 packs of platelets from
anesthesia due to an INR of 2.5, and when he came out of the
OR he received an additional 2 units of fresh frozen plasma
and 2 units of packed cells for a hematocrit of 23.8. He also
received repletion of his low potassium. Over the course of
the evening, he was weaned from his propofol slowly in
preparation for extubation and was sedated overnight. He did
have a postoperative rash and was administered some Benadryl.
The following morning he was on a nitroglycerin drip at 4. He
was in a sinus rhythm at 72 with a blood pressure of 119/73.
Postoperative laboratories showed a BUN of 17, a creatinine
of 1.0, a K of 4.6, a hematocrit of 29 (after 2 units of
packed red blood cells). His PA line was removed. He began
Lopressor beta blockade as well as Lasix diuresis and
remained in the cardiothoracic ICU. He was also seen by the
case manager.
On postoperative day 2, his Lopressor was increased. His
heart rate was 77. He was hemodynamically stable. His
creatinine rose only slightly to 1.2. His pacing wires were
discontinued. His mediastinal tubes were discontinued. His
pleural tube remained in place, and he was transferred out to
the floor where he was seen and evaluated with physical
therapy to begin his ambulation. He immediately made
excellent progress with ambulating and progressing his
activity level on the floor.
On postoperative day 3, he was alert and oriented. His
hematocrit remained stable at 28.9. He was restarted on his
oral medications including aspirin and continued to finish
his perioperatively vancomycin. His sternum was stable. His
incision was clean, dry, and intact. His left endoscopic vein
harvest incision was clean and dry with no erythema, and his
pleural tube was removed. Case management arranged for VNA
services for the patient.
DISCHARGE STATUS: On postoperative day 4, he did do a level
V ambulation. He was doing extremely well postoperatively,
and he was ready for home to home with VNA. On the day of
discharge his blood pressure was 116/64, in sinus rhythm at
77, saturating 94 percent on room air. His incisions were
clean, dry, and intact.
DI[**Last Name (STitle) 408**]E FOLLOWUP: He was instructed to follow up in our
postoperative wound clinic at 2 weeks post discharge and to
see Dr. [**Last Name (Prefixes) **] in the office at 4 weeks post discharge.
Also, the patient was instructed to follow up with his
primary care physician [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 3613**] [**Last Name (NamePattern1) 5263**] - in approximately
3 weeks post discharge.
DISCHARGE DISPOSITION: He was discharged to home with VNA
services on [**2146-2-18**].
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting x 2 with
resuspension of aortic valve and replacement of ascending
aorta.
2. Coronary artery disease.
3. Raynaud disease.
4. Hypertension.
5. Hyperlipidemia.
6. Status post osteoma of left leg.
7. Status post deviated septal repair.
8. Wisdom teeth removal.
9. Herniated disc.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. once a day (for 10 days).
2. Potassium chloride 20 mEq p.o. once a day (for 10 days).
3. Colace 100 mg p.o. twice a day.
4. Enteric coated aspirin 81 mg p.o. once a day.
5. Percocet 5/325 1 to 2 tablets p.o. q.4-6h. as needed (for
pain).
6. Zocor 20 mg p.o. once a day.
7. Metoprolol 50 mg p.o. twice a day.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2146-3-22**] 08:51:56
T: [**2146-3-22**] 10:49:03
Job#: [**Job Number 103185**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8385
} | Medical Text: Admission Date: [**2124-5-10**] Discharge Date: [**2124-5-18**]
Date of Birth: [**2043-5-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81 yo M w/h/o CHF w/EF 22%, CAD, CABG x2, complete AV block with
DDD Pacer presented to his Cardiologist's office, Dr. [**Last Name (STitle) **]
on [**5-9**] with increasing DOE. His lasix was increased from 40mg
daily to 80mg daily without improvement in DOE. Over the past 2
days PTA pt noticed increasing DOE with limitation in
ambulating. At baseline pt can walk ~1block and can go up 5-7
stairs without SOB or having to stop secondary to fatigue or
SOB. Pt denies any CP/Palpitations or SOB at rest. Pt also
denies PND, and orthopnea.
.
Pt presented to ED with increasing DOE. In [**Name (NI) **], pt was hypoxic
with O2Sats 86%RA, BNP [**Numeric Identifier 27074**], CXR c/w mild pulmonary edema. Pt's
O2 Sats did not improve on 4LNC-sats remained 86% on 4LNC. Pt
was then started on BIPAP, O2 sats improved to 100%.
Approximately 1 hour after presenting to ED received 80mg IV
Lasix x1, and ASA 600mg PR. Pt's VSS at that time 112/66 88 RR
36 100%Sats on BIPAP, with 400cc UOP. Pt was to be started on
Nitro gtt but due to BP 94/50 was held. Pt's SOB improved, BIPAP
removed and placed on NRB with 100%sats, comfortable breathing,
and transferred to CCU for closer monitoring.
.
On further ROS: Pt denied any constitutional symptoms, no
F/C/Cough. No dysuria, no hematuria, no diarrhea, no BRBPR. No
LH/Dizziness-had 1 episode 2 weeks ago of LH and fatigue while
gardening. Has not had any recent recurrence of LH/Dizziness.
Denies any testicular pain, no penile discharge, itchiness or
discomfort (completed course of levofloxacin for testicular
infection)
Past Medical History:
-CAD s/p MI and CABGx2(last CABG-[**2111**])-->Subsequent EF 22%
-Complete AV Block s/p DDD Pacer-Atrial sensed, V paced
-CHF
-HTN
-CRI (Baseline Cr 1.7-2.0)
-SAH ([**2120**])
-Testicular infection (levofloxacin last week)
Social History:
-Pt is retired, lives with wife in [**Name (NI) **].
-Denies any h/o TOB use and no ETOH use. No h/o IVDU.
Family History:
NC
Physical Exam:
-Afebrile, BP 94/50 HR 74 RR 18 100%NRB
-GEN: NAD, pleasant elderly male speaking in full sentences
-HEENT: Cataract surgery b/l, EOMI, Anicteric sclera, MMM
-RESP: Crackles 2/3 up b/l, no wheezing
-CV: Reg Nml S1, S2, 2/6 SEM at LLSB, elevated JVP up to
mandible, sternotomy scar, pacer SC-L sided
-ABD: Soft ND/NT +BS
-EXT: 2+pitting edema b/l up to knees, warm, 1+DP pulses B/L
-NEURO: A&OX3, no confusion
Pertinent Results:
[**2124-5-10**] CXR:
IMPRESSION: Cardiomegaly and findings consistent with mild
congestive heart failure
.
[**2124-5-11**] ECHO:
Conclusions:
The left atrium is moderately dilated. The right atrium is
moderately dilated.
The inferior vena cava is dilated (>2.5 cm). Left ventricular
wall thicknesses
are normal. The left ventricular cavity is mildly dilated. There
is severe
global left ventricular hypokinesis (ejection fraction [**10-6**]
percent). No
masses or thrombi are seen in the left ventricle. There is no
ventricular
septal defect. The right ventricular cavity is dilated. Right
ventricular
systolic function appears depressed. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. Moderate to severe [3+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. Significant pulmonic regurgitation
is seen. The main pulmonary artery is dilated. The branch
pulmonary arteries are dilated. There is no pericardial
effusion.
Tissue velocity imaging and tissue synchrony imaging
demonstrates < 50 msec opposing wall delay to peak velocity in
all apical windows (dyssynchrony not present).
.
Brief Hospital Course:
AP: 81 yo M w/CAD, s/p CABG, HTN, CHF p/w CHF exacerbation and
respiratory distress
.
#. CHF exacerbation: Pt's CHF exacerbation most likely in
setting of increased fluid intake due to testicular infection.
Pt presented with worsening SOB with recently increased Lasix 80
mg PO daily without improvement in symptoms. EF 22% on P-MIBI,
no recent ECHO. Received 80 mg IV Lasix in ED with good UOP >800
cc UOP, off BIPAP on NRB w/100% O2 sats. In CCU he received
another 80IVLasix x1 with his cardiac meds, including Carvedilol
12.5, lisinopril 5mg and Dig 0.125. His SBP dropped in to the
70s. Pt was asymptomatic, however MAPs dropped to 40s. SBP
minimally improved with 100cc IVF bolus. Pt was started on Dopa
gtt and subsequently started on lasix gtt for better perfusion
and diuresis. Pt diuresed well with -1L per day. He was noted to
have severely depressed EF on ECHO 10-20% with 3+TR, 2+MR,
Moderate Pulmonary Regurg. He was also noted to have elevated
PAD pressures, elevated PCWP 26. With lasix gtt, Wedge decreased
to 18, Dopa was weaned off on [**5-13**] as well as lasix gtt. His
BB/ACE-I/Dig were held while on Dopa gtt. He was further
diuresed on furosemide 80 mg po qd. Eventually his dose was
further decreased to 40 mg po qd with ins and outs remaining
roughly even. He will be discharged on furosemide 40 mg qd. His
respiratory status improved during his hospitalization. He was
encouraged to use BiPAP at night to augment his respiratory
status.
.
#. CAD: Pt denies any CP/palpitation. No indication of ischemia
on ECG or with CE. CE remained Negative. He was continued on low
dose ASA, and statin. Patient needs to have follow-up with
cardiology. Would have PCP recommend [**Name Initial (PRE) **] local out-patient
cardiologist to follow the patient. He should see cardiology in
[**1-21**] weeks.
.
#. Rhythm: NSR, v-paced. Had an episode of VT on Tele. On ECHO
no dy synchrony noted. Pt with DDD Pacer. No further episodes.
.
#. RESP: Pt with persistent respiratory acidosis with initial
ABG 7.27/70S/90S. Noted to have elevated PaCO2. Upon arrival to
CCU remained on NRB while diuresing. Pt was started on BIPAP the
following morning for the above notable ABG. A respiratory
consult was obtained for his respiratory hypercarbia. Per PCP pt
noted to have empyema as child with restructured R-sided
pulmonary anatomy. R-sided parenchyma with pleural thickening.
He was aggressively diuresed with improvement of respiratory
status ABG improved 7.40/56/121, the Lasix gtt was turned off
and continued on Lasix IV. Patient developed metabolic alkalosis
in response to his ongoing respiratory acidosis. Patient was
encouraged to wear his BiPAP at night and while napping,
however, he often refused as he does not like the machine. Would
continue to encourage use of BiPAP. Patient should follow-up
with Dr. [**Last Name (STitle) 575**] in the pulmonary clinic. He has an
appointment for [**2124-7-17**] but the clinic will call him if an
earlier appointment becomes available. A sleep study can be
arranged to evaluate for sleep apnea after he has been
officially seen in the pulmonary clinic.
.
#. HTN: Baseline SBP low 100s. Reinitiated BB, ACE-I and
titrated as BP tolerated once off the dopamine drip. Patient
had SBPs in low 100s during most of his stay. He was discharged
on carvedilol 6.25 mg [**Hospital1 **] and lisinopril 7.5 mg QD. Meds,
particularly the ace inhibitor, should be titrated up if blood
pressure tolerates.
.
# Testicular infection: Pt had recently completed 1 week course
levofloxacin for testicular infection. He remained afebrile,
normal WBC, testicular exam normal. Spoke with PCP which
confirmed the 1 week course of ABX. Urine culture was negative.
No additional antibiotics were administered during his stay.
.
#. CRI: Cr baseline 1.7-2.0, currently at 1.8. Renally dose
meds, avoid nephrotoxins
Follow UOP and Cr and electrolytes weekly while taking
furosemide.
.
# Gout: Had been allopurinol as an out-patient, which was not
continued during his admission. Developed some R great toe pain
on [**5-17**] and was started on colchicine for symptom control ([**Hospital1 **]
dosing). Would plan to restart allopurinol in the future after
acute symptoms have subsided. Renal function should be followed
on colchicine and allopurinol. Allopurinol should be renally
dosed. If flare does not improve with colchicine, could use
NSAID like sulindac, steroids, or intra-articular steroids.
.
#. Thrombocytopenia: Plts in low 100s during admission. On
review of records, PLTs 100 in [**3-22**], etiology is unclear. HIT
(PF4) ab was negative. Would follow in out-patient setting.
Consider evaluation by out-patient hematology.
.
Medications on Admission:
MEDS (at home):
-Lasix 40mg daily
-Lisinopril 5mg daily
-Dig 0.125mg daily
-Carvedilol 12.5mg [**Hospital1 **]
-Lipitor 20mg daily
-ASA 81mg
Discharge Medications:
1. Atorvastatin 20 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. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-20**]
Puffs Inhalation Q6H (every 6 hours).
5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Lisinopril 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
11. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 weeks: for acute gouty flare.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
CHF exacerbation
Pulm HTN
CO2 retention
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1 Liter
*
Call your doctor or return to the emergency department if you
develop shortness of breath, chest pain, you cannot eat, drink
or take your medications or you develop any other symptoms that
are concerning to you.
Followup Instructions:
Please follow-up in pulmonary clinic with Dr. [**Last Name (STitle) 9504**].
*
Provider: [**Name10 (NameIs) 2052**],[**First Name3 (LF) **] [**Location (un) 2788**] CARDIOLGY PPS (SB)
Date/Time:[**2124-7-4**] 2:00
ICD9 Codes: 4280, 2762, 2749, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8386
} | Medical Text: Admission Date: [**2201-3-25**] Discharge Date: [**2201-3-28**]
Date of Birth: [**2139-2-27**] Sex: F
Service: MEDICINE
Allergies:
Tylenol-Codeine #3
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
nausea, abdominal pain
Major Surgical or Invasive Procedure:
PICC
History of Present Illness:
62 year old female with past history of HTN, pancreatitis,
hyperlipidemia, insulin-dependent diabetes who complains of
shortness of breath and a bloated feeling. Bloated feeling
started 2 weeks prior to presentation to ED, characterized as
umbilical dull ache, [**7-12**] severity, no pain like this
previously, no exacerbating or relieving factors. Last bowel
movement was at least 5 days ago and small. The patient
endorses a foul taste in her mouth for the past day. She notes
that she has been nauseous for the past two days, with 2
episodes of vomiting up soda that she tried to drink today. Pt
denies EtOH use, reports she has taken her usual lantus 20u qd
per usual. Denies chest pain or palpitations. Pt was seen at
the [**Hospital 2287**] clinic on [**3-25**], with complaints of abdominal
discomfort. Blood drawn at that visit detected a very elevated
glucose (400s), hyperkalemia and metabolic acidosis. Patient
notes that her fingerstick last night was in the 200s.
.
The patient was diagnosed with diabetes in [**2199**]. She had an
episode of a "diabetic coma" in [**2199**] in [**State 19827**]. She was in
the ICU for nearly a week, per patient and family. This was the
time she was first diagnosed with diabetes and also the first
time she was diagnosed with pancreatitis. The patient and
family unaware of reason/cause for diabetes.
.
Pt denies fevers or chills, no diarrhea, subjective abdominal
distention, one day of shortness of breath and increased
respiratory rate, no chest pain, no headache or change in
vision, no neck pain, no dysuria or change in urinary frequency,
no lower extremity edema or focal numbness tingling weakness.
.
In the ED inital vitals were, 96.8 139 101/65 30 99%
Non-Rebreather. Per sign-out, PE remarkable for tachycardia,
tachypnea, no abd TTP despite complaints of distention and
discomfort per pt.
The patient received:
-3L NS bolus
-18 EJ, 22 peripheral
-10u SC x1 for hyperK and glucose > 600
-insulin gtt initiated at 7u/hr
-Albuterol neb x1
-Kayexalate 60g PO x1
-Repeat EKG in 10 min post above: continues with no peaked T
waves
EKG: sinus 155, varrying QRS pattern, STD in V3, TWI III, no
prior
CXray: no acute CP process identified (wet read pending)
Bedside US: near complete resp compression of IVC which may
represent hypovolemia or distribution shock; no pericard
effusion, hypodynamic heart
-Empiric Abx given 1d of SOB/cough: levofloxacin
-ABG pending
Vitals on transfer were: Temp: 97.5, Pulse: 140, RR: 29, BP:
109/67, Rhythm: st, O2Sat: 100, O2Flow: 2.5 liters
.
On arrival to the ICU, vital signs were: 97.5 148 130/75 24
99% 4L. Patient was alert, oriented, and continued on insulin
drip and IVF.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies wheezing. Denies chest pain, chest pressure,
palpitations. Denies nausea, vomiting, diarrhea or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
-DM (diabetes mellitus), type 2, uncontrolled
-Pancreatitis
-OBESITY UNSPEC
-HYPERCHOLESTEROLEMIA
-RHINITIS - ALLERGIC, UNSPEC CAUSE
-LOW BACK PAIN
-HTN
Social History:
- Tobacco: none
- Alcohol: none
- Illicits: none
Family History:
glaucoma in mother; DMII in many members of family (mother, son,
aunt/uncle)
Physical Exam:
ADMISSION PHYSICAL EXAM:
97.5 148 130/75 24 99% 4L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, mucous membranes extremely dry
Neck: supple, JVP flat, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, dopplerable pedal pulses, no clubbing,
cyanosis or edema
.
Discharge Exam:
AVSS
Lungs clear
Abdomen benign
Pertinent Results:
Admission Labs;
[**2201-3-25**] 10:40AM BLOOD WBC-12.5* RBC-5.03 Hgb-15.0 Hct-47.6
MCV-95 MCH-29.7 MCHC-31.4 RDW-13.7 Plt Ct-422
[**2201-3-25**] 10:40AM BLOOD Neuts-90.0* Lymphs-7.2* Monos-2.4 Eos-0.1
Baso-0.4
[**2201-3-25**] 10:40AM BLOOD Plt Ct-422
[**2201-3-25**] 03:19PM BLOOD Glucose-285* UreaN-19 Creat-0.9 Na-155*
K-4.6 Cl-128* HCO3-8* AnGap-24*
[**2201-3-25**] 10:40AM BLOOD Glucose-664* UreaN-28* Creat-1.8* Na-146*
K-7.7* Cl-107 HCO3-5* AnGap-42*
[**2201-3-25**] 10:40AM BLOOD ALT-15 AST-25 AlkPhos-86 TotBili-0.2
[**2201-3-25**] 10:40AM BLOOD Lipase-239*
[**2201-3-25**] 10:40AM BLOOD cTropnT-<0.01
[**2201-3-25**] 03:19PM BLOOD CK-MB-3 cTropnT-<0.01
[**2201-3-25**] 10:40AM BLOOD Albumin-4.6 Calcium-9.9 Phos-7.3* Mg-2.3
[**2201-3-25**] 03:19PM BLOOD Calcium-7.2* Phos-1.1*# Mg-1.5*
[**2201-3-25**] 10:40AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2201-3-25**] 02:32PM BLOOD Type-ART pO2-138* pCO2-12* pH-7.14*
calTCO2-4* Base XS--22
[**2201-3-25**] 12:35PM BLOOD Glucose-470* Lactate-3.4* Na-152* K-5.4*
Cl-127*
PERTINENT INTERVAL LABS:
[**2201-3-25**] 03:19PM BLOOD Glucose-285* UreaN-19 Creat-0.9 Na-155*
K-4.6 Cl-128* HCO3-8* AnGap-24*
[**2201-3-25**] 06:22PM BLOOD Glucose-213* UreaN-14 Creat-0.8 Na-150*
K-4.1 Cl-127* HCO3-11* AnGap-16
[**2201-3-25**] 11:14PM BLOOD Glucose-220* UreaN-11 Creat-0.8 Na-147*
K-3.8 Cl-126* HCO3-12* AnGap-13
[**2201-3-26**] 03:45AM BLOOD Glucose-88 UreaN-9 Creat-0.7 Na-143 K-4.2
Cl-121* HCO3-14* AnGap-12
[**2201-3-25**] 03:19PM BLOOD Calcium-7.2* Phos-1.1*# Mg-1.5*
[**2201-3-25**] 06:22PM BLOOD Calcium-7.5* Phos-0.5* Mg-1.3*
[**2201-3-25**] 11:14PM BLOOD Calcium-7.3* Phos-1.0* Mg-3.1*
[**2201-3-26**] 03:45AM BLOOD Calcium-7.4* Phos-1.4* Mg-2.7*
[**2201-3-25**] 11:31PM BLOOD freeCa-1.17
URINE:
[**2201-3-25**] 11:15AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.018
[**2201-3-25**] 11:15AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2201-3-25**] 11:15AM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE
Epi-<1
[**2201-3-25**] 11:15AM URINE CastHy-15*
MICRO:
blood cultures ([**3-25**]): NGTD
urine culture ([**3-25**]): NGTD
IMAGING:
CXR ([**3-25**]):
FINDINGS: The lungs are clear without focal consolidation.
Previously
questioned lucency at the left lung base is not long seen and
was likely
artifactual. The cardiomediastinal and hilar contours are
unremarkable.
There is no pleural effusion or pneumothorax. Degenerative
changes about both AC joints are noted.
IMPRESSION: No evidence of acute cardiopulmonary process.
KUB ([**3-25**]):
FINDINGS: Supine and left decubitus views of the abdomen were
obtained.
There is a non-obstructive bowel gas pattern. Moderate colonic
fecal loading is seen throughout. No evidence of free air is
seen. Amorphous calcification projecting over the right renal
shadow could be artifactual, however, raises concern for
possible staghorn calculus.
IMPRESSION: No evidence of bowel obstruction or free air.
Amorphous calcification projecting over the right renal calculus
raises
concern for staghorn calculus.
WBC RBC Hgb Hct MCV MCH MCHC RDW PLT
[**3-27**] 4.9 3.27* 9.3* 27.7* 85 28.6 33.7 14.0 175
[**3-26**] 7.3 3.35* 9.7* 28.4* 85 29.0 34.0 14.1 191
[**3-26**] 8.8 3.66* 10.5* 31.2* 851 28.6 33.6 14.0 202
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**3-27**] 106 5* 0.5 144 3.4 116* 20* 11
[**3-26**] 198 9 0.6 141 3.7 116* 18* 11
[**3-26**] [**Telephone/Fax (2) 98122**] 4.0 115* 14*2 13
[**3-26**] 161 6 0.6 137 4.1 115* 15* 11
[**3-26**] 881 9 0.7 143 4.2 121*3 14*3 12
Brief Hospital Course:
62 year old female with past history of pancreatitis,
hyperlipidemia, insulin-dependent diabetes who complains of
shortness of breath and abdominal pain and was found to be in
diabetic ketoacidosis. The patient was admitted to the [**Hospital Ward Name 332**]
ICU, initiated on an insulin drip, repleted with IVF and
electrolytes, and recovered from DKA. Patient was called out
from ICU on [**2201-3-27**].
ACTICE ISSUES:
#Diabetic Ketoacidosis:
Likely cause of this DKA either URI and/or constipation/poor PO
intake. Pt does have hx of pancreatitis and pt has elevated
lipase. Lipase, however, is not sensitive for pancreatitis in
the setting of DKA, and pt has no clinical signs of pancreatitis
(no abd pain to palpation). Although pt has dyspnea, pt CXR
looks clear and no production of sputum. No e/o cardiac
ischemia as pt has neg trop x1 and EKG w/ non-specific changes.
Urine tox sent. On admission, pt has anion gap of 34, ketones in
urine and a HCO3 of 5. Pt received 3L NS in ED, 10U SC insulin
and initiated on insulin drip at 7u/hr. Received 10+ liters of
fluid plus insulin drip. In the ICU, transitioned to
subcutaneous insulin and clear diet. Anion gap has closed and
patient is no longer acidotic. NGTD on blood and urine cxs.
Have continued glargine 20u qhs and HISS, fingersticks q4hrs. Pt
tolerating POs. Held metformin while here. [**Last Name (un) **] was consulted
and sent an anti-GAD ab to discern type I vs type II. The
patient has been advanced to regular diet and will be discharged
on Insulin regimen that included an increase in her Lantus from
20 to 24 units daily, and a sliding scale.
- Patients Lantus should be titrated up as needed.
- The pt was instructed to hold his metformin until seen by her
PCP.
.
# Tachycardia: pt w/ sinus tachycardia to 150 on day of
admission, which quickly responded to IVF. On transfer from
ICU, pt's HR was 90s.
.
# Constipation: Pt states hasn't had BM in at least 5 days, per
pt. Likely secondary to combination of gastroenteritis and poor
fluid intake. colace/senna standing and miralax, bisacodyl PR
PRN. No BM by HD #2.
.
# HTN: pt's BP in 100s in ICU. held losartan for now
considering BPs in 90-110s. continued ASA when taking POs.
Losartan continued on outpatient.
- This should be adjusted as an outpatient.
.
# hypercholesterolemia: restarted simvastatin
.
# GERD: continued omeprazole 20mg qd
.
# Abdominal calcification -- confirmed w/ PCP office was not a
new finding. Raises question of staghorn calculus, though urine
not suggestive and patient without recurrent UTIs typical of
this. PCP to consider further imaging as outpatient.
=========================
Transitional Issues
=========================
1. [**Last Name (un) **] recommended checking anti-GAD (sendout) to
differentiate between type I and type II DM. Lab ordered. Will
need to be followed up.
2. Pt w/ ? staghorn calculus (R renal hilus) on KUB. No e/o
infection this admission. Will need outpt urology f/u.
3. pt's PCP [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **] emailed on [**3-26**]
4. Pt will be sent home with a VNA for insulin teaching.
Medications on Admission:
-Omeprazole 20 mg Oral Capsule, Delayed Release(E.C.) Take 1
capsule 30 minutes before first meal of day
-Insulin Syringe-Needle U-100 (BD INSULIN SYRINGE ULT-FINE II)
0.3 mL 31 x [**6-17**]" Miscellaneous (Misc) Syringe use as directed,
up to three times daily
-Insulin Needles, Disposable, (BD INSULIN PEN NEEDLE UF SHORT)
31 X [**6-17**] " Misc.(Non-Drug; Combo Route) Needle USE AS DIRECTED
with lantus pen
-Lipase-Protease-Amylase (CREON) 6,000-19,000 -30,000 unit Oral
Capsule, Delayed Release(E.C.) TAKE 1 CAPSULES by mouth 3 times
a day with meals
-Blood Sugar Diagnostic (FREESTYLE LITE STRIPS) Misc.(Non-Drug;
Combo Route) Strip Use as directed 4 times daily pls dispense no
substitution
-Losartan 50 mg Oral Tablet Take 1 tablet daily
-Blood-Glucose Meter (FREESTYLE FREEDOM LITE) Misc.(Non-Drug;
Combo Route) Kit Use as directed
-Insulin Glargine (LANTUS SOLOSTAR) 100 unit/mL (3 mL)
Subcutaneous
-Insulin Pen inject 20 units under the skin every night or as
directed
-Simvastatin 40 mg Oral Tablet Take one-half tablet = 20 mg
every evening for cholesterol
-Metformin 500 mg Oral Tablet take 1 tab twice daily
-Aspirin 81 mg Oral Tablet None Entered
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
4. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
5. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: One (1)
24 Subcutaneous at bedtime.
6. insulin lispro 100 unit/mL Cartridge Sig: One (1) As directed
Subcutaneous four times a day.
7. losartan 50 mg Tablet Sig: One (1) Tablet PO once a day.
8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Creon 6,000-19,000 -30,000 unit Capsule, Delayed
Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO
three times a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis
-Diabetic Ketoacidosis
-Diabetes Mellitus type 2
-Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with diabetic ketoacidosis after a few weeks
of abdominal symptoms. With treatment this normalized. You
were found to have anemia, and this should be addressed with Dr.
[**Last Name (STitle) **]. Please speak with him about the abdominal radiology
findings seen on your abdominal xray -- calcification. It
appears they are old as per records at [**First Name9 (NamePattern2) 98123**] [**Location (un) **], and perhaps
comparison with older records from [**State 19827**] will confirm this.
Please follow the insulin regimen.
A visiting nurse will visit to make sure you are doing well.
Please hold your Metformin until instructed to restart it.
Followup Instructions:
Name: [**Last Name (LF) 38584**],[**First Name3 (LF) **] P.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
Appointment: Thursday [**2201-4-2**] 10:00am
.
Please make an appointment to follow-up with the [**Last Name (un) **] Diabetes
Center as needed.
ICD9 Codes: 2859, 5849, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8387
} | Medical Text: Admission Date: [**2103-8-13**] Discharge Date: [**2103-8-30**]
Date of Birth: [**2021-11-16**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
fluent perseverative speech, confusion
Major Surgical or Invasive Procedure:
Intubation [**2103-8-13**] ([**Hospital6 302**])
History of Present Illness:
[**Known firstname **] [**Initial (NamePattern1) **] [**Known lastname 7710**] is an 81-year-old man with history of HTN, HLD,
prostate [**Hospital 4699**] transferred from OSH for seizure.
History is obtained via chart review as patient is intubated.
He was at physical therapy this AM for his left shoulder when he
became confused, repetitive, and could not follow commands.
This started at 09:40. When asked his name, he would respond,
"[**Last Name (un) 46536**], my name," and would move all extremities on his own and
speech was clear although he remained "confused." He was taken
via EMS to [**Hospital3 **] ED and en route he had a seizure lasting
45-60 seconds and then was thought to be post-ictal afterwards.
His FS was 90 and was thought to be in afib with a possible run
of vtac per EMS while en route.
Upon arrival to [**Hospital3 **] ED, T 96.7 P 80 RR 16 BP 140/67 100%
on NRB. He was noted to be non-verbal, un-arousable, and
unresponsive, with gaze to the right. After arrival he had
another witnessed seizure in the ED, possibly lasting 30
seconds. He received a total of 4 mg ativan, 1 g dilantin, and
then was intubated receiving etomidate, succinylcholine and
propofol. A CT head prior to transfer was unrevealing. BP was
transiently up to 216/99 P 119 prior to transfer.
Per his PCP (Dr. [**First Name4 (NamePattern1) 5279**] [**Last Name (NamePattern1) 90800**]) he has no history of seizure,
stroke, or CNS infections and is a bright and independent person
at baseline. Per EMS note he may have had a similar episode
last month and was seen at [**Hospital6 302**] for that.
Past Medical History:
[] Cardiovascular - HTN, HLD
[] Oncologic - Prostate CA (treated > 10 years ago)
Social History:
Lives with wife.
Family History:
Not known
Physical Exam:
At admission:
Gen; lying in bed, intubated
HEENT; NC/AT, ETT in place
CV: RRR, II/VI SEM
Pulm; CTA anteriorly
Abd; soft, nt, nd
Extr; no edema
Skin; multiple ecchymoses on arms
Neuro;
MS; (off propofol x5 minutes) eyes closed but grimaces and
briefly opens eyes to noxious. Does not follow any commands or
attempt to speak.
CN; eyes conjugate in midposition, pupils 3mm and minimally
reactive. does not blink to threat. brisk corneals b/l. face
obscured by ETT. + gag.
Motor; normal bulk, increased tone in legs b/l. spontaneously
moves arms and briskly withdraws all extremities to noxious
stimuli.
Reflexes; 1+ and symmetric at biceps, brachioradialis, and
patellars. Toes upgoing b/l.
__________________________________________________________
At discharge:
Pertinent Results:
[**8-13**] EEG - IMPRESSION: This extended routine video EEG telemetry
captured no pushbutton activations. Automated and routine
sampling captured several
brief runs of sharp and slow wave discharges but no clinical
correlate.
The interictal period showed one every 1-1.5 second periodic
epileptiform discharges over the left hemisphere. The background
otherwise showed a well-organized posterior predominant rhythm
on the
right and generalized delta and theta frequency slowing over the
left
hemispheric leads.
[**8-13**] CXR - IMPRESSION: Endotracheal tube ends approximately 5 cm
above the carina. Given low lung volumes, bibasilar opacities
likely represent atelectasis, although pneumonia cannot be
excluded.
[**8-14**] EEG - IMPRESSION: This is an abnormal continuous ICU video
EEG telemetry due to a few brief electrographic seizures with no
clinical correlation all occurring between 9:00 and 10:00 a.m.
The interictal period showed one every 1-1.5 second periodic
lateralized epileptiform discharges (PLEDs) over the left
hemisphere. The background otherwise showed a well- organized
posterior predominant rhythm on the right and generalized delta
and theta frequency slowing over the left hemispheric leads.
These findings are consistent with an epileptogenic focus in the
left hemisphere related to an underlying structural lesion. The
EEG was
improved compared to previous day's recording as the
electrographic
seizures were shorter and less frequent.
[**8-14**] MRI Brain c/s contrast - IMPRESSION:
1. T2 hypointense focus in the posterior aspect of the left
thalamus with
slowed diffusion and mild contrast enhancement, most likely
representing a
subacute infarct. With regard to enhancement, a followup study
should be
scheduled in four to six weeks to definitely rule out underlying
mass such as lymphoma.
2. Evidence of global cerebral volume loss as well as sequela of
chronic small vessel ischemic disease.
[**8-16**] MRI/MRA/MR [**Month/Year (2) **] - BRAIN MRI:
There are now new acute infarcts identified in the left
posterior temporal and occipital regions since the previous
study. The previously seen left thalamic infarct has evolved.
There are no definite new infarcts identified in the right
cerebral hemisphere. Previously noted changes of small vessel
disease and brain atrophy are seen. There is no midline shift.
There is no evidence of abnormal parenchymal, vascular, or
meningeal enhancement seen.
The MR [**First Name (Titles) 15758**] [**Last Name (Titles) 4059**] increase in time to peak in the
left occipital lobe, corresponding to the region of infarct. No
definite decreased blood volume is appreciated. Subtle increase
in the time to peak is identified in the right occipital lobe.
IMPRESSION:
1. Acute infarcts are now seen in the left posterior temporal
and occipital lobes. No definite new infarcts are seen in the
right cerebral hemisphere.
2. No enhancing brain lesions or mass effect is seen. Otherwise,
the MRI of the brain is not changed since the previous study.
3. Increased time to peak is identified in the left posterior
temporal and
occipital lobes corresponding to the infarcts seen and could
indicate ischemia. Subtle increased time to peak is identified
in the right occipital lobe which could indicate ischemia in the
right occipital region. However, no definite new infarct is seen
in this region.
MRA HEAD:
The head MRA [**Last Name (Titles) 4059**] normal flow signal in the arteries of
anterior and posterior circulation without stenosis or
occlusion.
IMPRESSION: Normal MRA of the Head.
[**8-16**] EEG
IMPRESSION: This is an abnormal continuous ICU video EEG
telemetry due
to two electrographic seizures in the right hemisphere maximum
at T4 and
P4 correlating with no clinical correlation on video. Also there
were
periodic lateralized epileptiform discharges (PLEDs) over the
left
hemisphere. The background otherwise was markedly suppressed and
slow
over both hemispheres occasionally reaching low amplitude theta
frequency intermixed with delta. These findings are consistent
with
independent epileptogenic foci in both hemispheres likely
related to
underlying structural lesions. After 21:00, a burst suppression
of
background was seen related to midazolam administration.
Compared to
prior day's EEG, there were fewer and shorter electrographic
seizures.
[**8-17**] TTE w/bubble study
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler; single bubble contrast injection
negative for right to left shunt at atrial level. No late
contrast is seen in the left heart (suggesting absence of
intrapulmonary shunting). There is mild symmetric left
ventricular hypertrophy. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF 70%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (valve area 1.2 cm2). The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion. If clinically indicated, a transesophageal
echocardiographic examination is recommended.
IMPRESSION: Suboptimal image quality. No obvious intracardiac
mass or shunt. However, due to the technically suboptimal nature
of this study, a cardiac source of embolus cannot be excluded.
If clinically indicated, a transesophageal echocardiogram (with
or without bubble study) is recommended to exclude cardiac
source of embolus.
[**8-17**] Carotid Duplex Series
Impression: Right ICA with stenosis 40-59%.
Left ICA with stenosis 60-69%.
Antegrade bilateral vertebral artery flow.
[**8-17**] EEG
[**Known lastname **],[**Known firstname **] [**Medical Record Number 90801**] M 81 [**2021-11-16**]
Neurophysiology Report EEG Study Date of [**2103-8-17**]
OBJECT: ROE, EKG, VIDEO, [**8-17**] TO [**2103-8-18**].
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **]
FINDINGS:
ABNORMALITY #1: The background is markedly abnormal. It shows,
for
the vast majority of the record, that the two hemispheres appear
to be
working relatively independently of each other. Over the left
hemisphere, there is a fairly persistent pseudoperiodic spike
and wave
and sharp slow wave discharge broadly present across the left
posterior
quadrant maximum in the region of the occipital pole. These
discharges
occur every two to four seconds and interposed between them is a
period
of marked electrical suppression. The bursts, themselves, in
addition
to having an epileptiform transient have frontal central
irregular theta
and suppression of electrical activity except for the spike wave
discharge posteriorly. The right hemisphere has similar
pseudoperiodic
bursting but no clearly identified epileptiform transients. The
periods
vary from two to six seconds in duration and appear to be
occurring
relatively independently of the activity on the left. There is
also
marked suppression of electrical activity in the posterior
quadrant on
the right when the bursts themselves occur. At about 2:30 in the
morning, the amplitude of the background bursts seem to increase
slightly and there appeared to be more frequent synchronization
between
the two hemispheres.
SLEEP: No cycling of sleep activity was identified.
PUSHBUTTONS: There were no pushbuttons.
SEIZURE DETECTIONS: Did not detect any sustained events.
AUTOMATED INTERICTAL FILES: Almost all of the occipital sharp
discharges from the left were detected.
CARDIAC MONITOR: Shows a regular rhythm.
IMPRESSION: This EEG gives evidence for an extremely severe
diffuse
encephalopathy that, curiously, appears independently in the two
hemispheres. The right hemisphere appears to be a burst and
burst
suppressive pattern with no clear epileptic features. The left
is a
similar pattern seen with a different periodicity to the right
and with
an occipitally predominant broadly based epileptiform discharge
seen
with most of the bursts. There were no sustained seizures and
most of
the effect in the burst and burst suppressive pattern may very
well
reflect the effects of systemic medication.
[**8-18**] UE US - IMPRESSION: Left distal cephalic venous thrombosis.
[**8-18**] EEG
IMPRESSION: This EEG continues to show a severe diffuse
encephalopathy.
In comparison to the previous 24 hours, most of this record was
synchronous over the two hemispheres and there was little
epileptiform
activity from the left after 22:00 and, overall, it appears to
be a
slight improvement to the record. The pattern is still most in
keeping
with drug effect.
[**8-19**] EEG
IMPRESSION: This tracing still shows a fairly significant
diffuse
encephalopathy although the suppressive bursts appear to be
somewhat
shorter, particularly near the end of the record, on the morning
of the
15th. On the morning of the 14th, there was one brief
electrographic
seizure from the right central temporal region that was not
associated
with a clinical accompaniment.
[**8-20**] EEG
IMPRESSION: This EEG did not capture any electrical evidence for
sustained seizure discharges. A few isolated left occipital
discharges
were still seen but they occur very infrequently. The tracing is
still
compatible with a moderate to moderately severe diffuse
encephalopathy
with a bursting pattern of electrical activity and suppressive
bursts.
No clear laterality, except for the occipital discharges, was
noted.
[**8-21**] EEG
IMPRESSION: This EEG gives evidence still for a moderately
severe
diffuse encephalopathy with suppressive bursts and intervening
activity
that appears more normal than on previous studies but still
shows
leftsided slowing, particularly over the more posterior aspects
of the
left hemisphere admixed with interictal sharp and epileptic
spike
discharges relatively infrequently in the left occipital pole.
It
should be noted that there was one brief electrographic seizure
discharge from the right temporal central region lasting about
30+
seconds that appeared to be without any electrographic
correlate.
[**8-22**] EEG
IMPRESSION: This EEG gives evidence for both encephalopathic as
well as
multifocal abnormalities. The encephalopathic features are loss
of
normal background and suppressive bursts. The epileptiform
activity was
seen in the left occipital pole and right mid-temporal and there
appears
to be fairly discrete right lateral temporal slow wave
abnormality
suggestive of additional structural pathology in that region.
[**8-22**] NCHCT - IMPRESSION:
1. No evidence of hemorrhage, mass effect or shift in normally
midline
structures.
2. Evolution of known left parieto-occipital infarction,
compared to previous studies.
3. Poorly-defined hypodensities in the superficial aspect of the
right
posterior occipital lobe; additional infarction (presumably,
embolic) at this site is not excluded.
[**8-23**] EEG
IMPRESSION: This 24-hour recording shows a fairly persistent
posterior
left temporal slow wave focus suggestive of a subcortical
structural
lesion. The left occipital relatively rare epileptiform
transients seem
to increase significantly throughout the course of the record,
both in
their frequency of occurrence as well as their distribution. No
sustained seizures, however, were identified and the background
continues to be a diffusely abnormal encephalopathic pattern.
Brief Hospital Course:
81 yo M h/o HTN, HL, prostate CA p/w perseverative and fluent
speech disturbance and two convulsive seizures with post-ictal
lethargy and confusion and left hemisphere seizure activity,
likely secondary to a subacute posterior thalamic ischemic
stroke.
[] Status Epilepticus - At the OSH, he was given 4 mg of
lorazepam, 1000 mg of phenytoin, was intubated at the outside
hospital, and was sedated with Propofol. Phenytoin was switched
to Fosphenytoin at transfer, and he was given an additional 500
mg IV since his Phenytoin was subtherapeutic. He had evidence of
20 second runs suggesting left hemisphere seizure activity and
PLEDS despite the second loading dose. Valproate sodium was
added for further seizure suppression. He was initially treated
empirically for HSV encephalitis, but his LP cell counts were
not suggestive of infection and his HSV PCR was negative. His
MRI revealed a subacute left posterior thalamic ischemic stroke
which may correlate with an antecedent event three weeks prior
to admission when he was noted to be confused with right arm
symptoms (described as pain at that time). He was started on
aspirin and continued on his home medications for hypertension.
A second [**Doctor Last Name 360**], valproate sodium, was added for further
suppression as he was continuing to have frequent PLEDs. His
Propofol was then weaned for possible extubation but he remained
quite lethargic. Overnight on [**8-15**], he had
electroencephalographic seizures affecting the right hemisphere
as well as report of nonrhythmic arm and leg movements. We opted
to switch from Propofol to Midazolam (as the patient was
requiring IVF boluses to maintain blood pressure) and uptitrate
for burst suppression. Concerned for new lesions, we obtained a
repeat MRI with MRA and MR [**Month/Year (2) **] to identify a seizure focus
(MR Spectroscopy was not readily available due to requirements
to transfer the patient to another campus for which the patient
was not stable enough). While the patient's Midazolam was being
uptitrated, he had one 60 second right hemisphere
electroencephalographic seizure at 20 mg/hr overnight on [**8-16**],
but seizures where suppressed at 25 mg/hr. He had additional
electroencephalographic evidence of seizures on [**8-17**], so
Levetiracetam 500 q12h was started as a third antiseizure [**Doctor Last Name 360**].
He did not have any more EEG evidence of seizures over [**8-18**] and
[**8-19**] but did on [**8-20**]; Epilepsy recommended to wean off the
Midalazom infusion and Valproate Sodium. He was successfully
weaned from the Midazolam infusion with gradually returning
background activity, and we started simplifying his antiseizure
regimen under close observation in the ICU. He was maintained on
Fosphenytoin and Levetiracetam. His EEG gradually showed more
return of background activity but continued to show sharp
discharges from the left occipital lobe. His clinical exam very
slowly recovered, first with brainstem reflexes and subsequently
increased motor response to noxious stimuli and then eye
opening. However, he never recovered the ability to attend to
the examiner or follow commands.
[] Acute Subacute Ischemic stroke - His initial MRI revealed a
subacute stroke, likely affecting the left posterior choroidal
artery. We suspected this event was likely the result of small
vessel disease (hypertension), but artery-to-artery and
cardioaortoembolic etiologies are also possible. As this event
was subacute, he was started on an antiplatelet and kept
normotensive. However, in light of the additional seizure
activity, we pursued further imaging with a repeat MRI which
revealed an acute ischemic infarction of the left occipital and
temporal lobes, possibly the event that triggered the initial
series of seizures. This was more strongly suggestive of
artery-to-artery or [**Last Name (LF) 90802**], [**First Name3 (LF) **] we pursued a
carotid/vertebral artery ultrasound and TTE. We increased his
aspirin from 81mg to 325mg and kept him normotensive. Given the
distribution of strokes suggesting an embolic source and normal
vessel imaging with a report of AFib en route to the OSH, he
will likely need anticoagulation for stroke prevention; he has a
CHADS of 4. He started him on a Heparin GTT.
[] Klebsiella pneumonia - On [**8-21**], the patient had two episodes
of O2 desaturations in the setting of fever. He was found to
have 4+ GNR which were identified as pan-sensitive Klebsiella.
He was treated with Cefepime 2gm q12h initially, but his
antibiotics were broadened to Cefepime, Vancomycin and
Tobramycin due to worsening of his infection with increased
leukocytosis.
[] Acute Kidney Injury/Acute Tubular Necrosis - The patient's
renal function worsening from [**Date range (1) 90803**] (peak of 2) in the
setting of relative hypotension in the setting of his pulmonary
infection requiring pressors and fluid boluses. His renal US was
negative for obstruction or hydronephrosis and his FE Urea was
most consistent with ATN, likely from hypoperfusion. His fluid
status was monitored closely and his blood pressure stabilized.
His antihypertensives were held. His renal function improved
back to Cr 1.3 and he required further diuresis but continued to
show signs of [**Last Name (un) **] (to Cr 3.1) whenever diuresis was pursued. He
had anasarca and significant volume overload including pulmonary
congestion which did not permit downtitration of his ventilator
settings, yet his kidneys would not tolerate pharmacologic
diuresis.
[] Liver Dysfunction - The patient has a noted mild coagulopathy
and synthetic dysfunction (low albumin), likely contributing to
his third-spacing and peripheral edema. His wife agreed that as
a young man it is likely that he had consumed excess amounts of
alcohol, and he most recently was still drinking [**2-8**] glasses of
hard liquor at a time. This baseline liver dysfunction has
likely contributed to both his volume overload as well as his
prolonged sedation from Midazolam.
[] Goals of Care - Several discussions with the wife [**Name (NI) 17301**], [**First Name3 (LF) **]
[**Name (NI) **], and other family members were held which revealed hope
regarding the patient's prognosis but also understanding of the
severity of his illnesses. In discussions with the family on
[**8-29**], it was found that he actually had a living will which
indicated that he would want to be DNR/DNI. The family came to
the hospital on [**8-30**] and decided to make the patient DNR/DNI
with goals of care directed toward Comfort Measures Only. He was
extubated and placed on a morphine infusion for pain and air
hunger. He passed away on [**2103-8-30**] at 3:30 PM of hypoxic
respiratory failure. His family was notified and declined
autopsy.
Medications on Admission:
-tricor 145 mg daily
-zocor 80
-lisinopril 20 daily
-folate 1 mg [**Hospital1 **]
-norvasc 5 mg daily
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Seizures, Status Epilepticus
Subacute ischemic stroke
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 5845, 2760, 5119, 2724, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8388
} | Medical Text: Admission Date: [**2170-9-19**] Discharge Date: [**2170-10-12**]
Date of Birth: [**2099-5-5**] Sex: F
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
Weight gain, weakness
Major Surgical or Invasive Procedure:
Colonoscopy-no apparent bleeding lesion.
History of Present Illness:
71 y.o Russian speaking female with extensive PMH including CAD,
CHF, afib and chronic anemia. She was recently admitted in [**6-3**]
for anemia work-up and found to have a bleeding gastric ectasia
on EGD which was removed. Colonoscopy revealed a benign polyp.
Pt presents today after feeling increased fatigue at home.
Denies CP or increasing SOB. On home O2 at 2L and has not
required increased amounts. Pt also notes that she has been
unable to walk around her apartment as much, but is limited by
weakness vs shortness of breath. She does not feel that her
breathig has changed. Her symptoms began approx 3 weeks ago.
Denies, cough, cold symptoms, fever, chills, nausea, vomting,
change in diet or medication. Pt reports that she was told by
her PCP that she had gained a lot of weight due to fluid and
needed to come into the hospital for diuresis.
Past Medical History:
CAD
h/o CHF
AFib on coumadin
anemia
Restrictive lung disease
Social History:
married, no alcohol or tobacco
Family History:
non-contributory
Physical Exam:
VS: 97.5, 97/50, 57,16, 95 on 2l NC
GEn: Morbidly obese, pale, pleasant, speaking in full sentences.
HEENT: Ophx clear, MMM, PERRLA, conjinctiva pale, no icterus
CV: distant HS, reg [**Last Name (LF) 20687**], [**First Name3 (LF) **], III/VI SEM radiating to
carotids.
Pulm: Distant BS, good inspiratory effort, bibasilar crackles
1/3 up, no rhonchi or wheezing.
Abd: obese, NT, ND, +BS
Ext:4+ woody edema to the knee bilat, warm, erythematous,
non-tender
Neuro: occ resting tremor which is not new. No focal deficits.
A&O x3
Pertinent Results:
ECHO:
Left Atrium - Long Axis Dimension: 3.7 cm (nl <= 4.0 cm)
Aortic Valve - Peak Velocity: *4.1 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 64 mm Hg
Aortic Valve - Mean Gradient: 40 mm Hg
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 1.2 m/sec
Mitral Valve - E/A Ratio: 0.92
Mitral Valve - E Wave Deceleration Time: 270 msec
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV cavity size. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Moderate AS.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular
calcification.
PERICARDIUM: No pericardial effusion.
Conclusions:
1. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is very difficult to assess but it may be
normal (LVEF>55%).
2. The aortic valve leaflets are severely thickened/deformed.
There is
moderate aortic valve stenosis.
3. The mitral valve leaflets are mildly thickened.
4. Compared with the findings of the prior study (tape reviewed)
of [**2167-12-7**], LV
function may have improved.
COLONOSCOPY:
(Rectal polyp, polypectomy):
Distorted fragment of benign colonic mucosa with melanosis coli;
no
adenomatous change seen (multiple levels examined).
Brief Hospital Course:
71 yo Russian speaking female with extensive PMH presents with
weight gain and increased fatigue over the past 3-4 weeks.
1)Anemia: Pt was recently admitted in [**2170-5-31**] for anemia
work-up and found to have a bleeding gastric ectasia on EGD
which was removed. Colonoscopy at that time revealed a benign
polyp. Pt was found to have Hct of 18 on this admission. Pt
was transferred to the CCU for monitoring and received 8 units
of PRBC with appropriate increase from 18 to 33. The anemia was
thought to be subacute since she was never hemodynamically
unstable. GI was consulted. Coumadin was held for suspected GI
bleed. Colonoscopy was scheduled but held for persistent high
INR which was reversed with vitamin K. Pt was a difficult prep
and required almost 4-5 days of prepping with Golytely and other
laxative. Pt finally underwent colonoscopy which revealed no
source of bleed. Since pt's Hct was stable 25 34-35, no further
diagnostic procedure was done. If pt were to develop another
acute/subacute anemia, capsule study was recommended.
2) CHF: Pt has a long hx of CHF per old records. Last echo
before admission was from [**2168**] which showed EF of 35-40%. She
got an echo on [**9-20**] which showed EF>55%. Pt was initially
started on niseritide and lasix for diuresis for suspected CHF
exacerbation before her initial Hct of 18 came back. Pt
received lasix between transfusions. Lisinopril was held for
increased creatinine. Pt's wt was stable and CHF status was
stable initially. However, after 5 days of prep for the
colonoscopy, pt started to gain weight everyday and was net
positive daily. Pt was refractory to standing IV Lasix and
Diuril. She got PICC line placed under IR and Natrecor gtt was
started with still net positive daily. Lasix gtt was added and
was titrated up to 10-15mg/hr which gave some reponse initially
but again became refractory to it. Dopamine gtt was tried but
showed no improvement in UOP. Pt lost PICC access. However one
day, she started to respond extremely well with lasix gtt at
10mg/hr and IV Diuril 250 mg [**Hospital1 **] only (without Natrecor). Pt's
admission weight was 130 kg (128 kg in a clinic note) and has
gotten up as high as 139 kg. However, she was able to diuresis
1-2L/day and her weight came down to 130kg which is her
baseline. The diuretics were changed to po form (Lasix po 120
mg [**Hospital1 **] and Diuril po 125 mg [**Hospital1 **]) and pt continued to diuresis
with net negative daily. Pt's CHF was thought to be possibly
from AS. If that is the case, valve replacement could improve
her symtoms. Review of the aortic valve orifice and
consideration of valve replacement should be discussed as
outpatient. Pt needs to follow up with a [**Hospital 1902**] clinic within 1
week.
3) Afib: Pt with hx of atrial fibrillation but now in sinus
rhythm. Rate is bradycardic. Pt noted to have pauses on tele up
to 2 seconds. Pt was continued on amiodarone 200 mg po qd.
Coumadin was held in a setting of GI bleed and also for high INR
prior to colonoscopy. Coumadin was restarted with goal INR of
[**1-2**]. Pt needs to be seen by her PCP to check her INR level.
4) COPD/restrictive lung dz: Pt was continued on 2 L of oxygen
which is her baseline. Pt was getting nebulizer prn for
wheezing and SOB. Pt is on home O2.
5) DM: Pt was initially continued on home meds of avandia and
glyburide and was cover with RISS. However, avandia was held
while she was NPO. She will be discharged with her home
regimen.
9) CODE: DNR/ DNI- this was re-discussed with patient and
husband to determine if pt still wants to be DNI/DNR as she has
been DNR/DNI on prior admissions.
Medications on Admission:
avandia 4 [**Hospital1 **]
amaryl 2 mg prn FS > 250
protonix 50 qd
coumadin 2 qhs- on HOLD
amiodorone 200 qd
lasix 160 qam, 40 qpm
zaroxyln 2.5 qd 30 minute before am lasix
lipitor 40 qd
iron 325 tid- don't give w/ protonix
vit c tid with iron
lisinopril 5 qd
levoxyl 0.050 mg qd
albuterol/atrovent MDI
epogen 3000 units 2x per week.
Discharge Medications:
1. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO QD ().
Disp:*30 Tablet(s)* Refills:*2*
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO QD
().
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD ().
Disp:*30 Tablet(s)* Refills:*2*
5. Epoetin Alfa 4,000 unit/mL Solution Sig: Two (2) Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*qs * Refills:*2*
6. Albuterol Sulfate 0.083 % Solution Sig: [**12-1**] Inhalation Q6H
(every 6 hours) as needed.
7. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical
HS (at bedtime).
Disp:*1 tube* Refills:*2*
8. 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*
9. Avandia 4 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
10. Amaryl 2 mg Tablet Sig: One (1) Tablet PO as needed as
needed for FS>200.
Disp:*30 Tablet(s)* Refills:*0*
11. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Iron 325 (65) mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO three times a day.
Disp:*90 Capsule, Sustained Release(s)* Refills:*2*
13. 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*
14. Chlorothiazide 250 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
15. Furosemide 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
16. Pramoxine-Zinc Oxide in MO 1-12.5 % Ointment Sig: One (1)
Appl Rectal Q4-6H (every 4 to 6 hours) as needed.
Disp:*qs qs* Refills:*0*
17. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 20688**] Home Health
Discharge Diagnosis:
Acute anemia from GI bleed
CHF
Discharge Condition:
Hemodynamically stable, stable Hct, no chest pain, no symptoms
of dizziness.
Discharge Instructions:
Patient was instructed to take all of the medications as
instructed. Pt was instructed to seek medical attention if shed
develops fatigue, dizziness, SOB, Chest pain, bloody stool,
melena, bloody emesis. Pt should see her PCP [**Last Name (NamePattern4) **] [**12-1**] weeks after
the discharge.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2170-10-30**] 1:30
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
Completed by:[**2170-10-12**]
ICD9 Codes: 4280, 2851, 4241, 5849, 5990, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8389
} | Medical Text: Admission Date: [**2117-4-14**] Discharge Date: [**2117-5-9**]
Date of Birth: [**2117-4-14**] Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname 61155**] is a 32 [**3-15**] week gestation infant
born to a 41-year-old G6 P2 mom. Prenatal screens, 0
positive, antibody negative, hepatitis surface antigen
negative, RPR nonreactive and Rubella immune. Prenatal
course is significant for placenta previa and probable
abruption presented with large vaginal bleeding at
approximately 26 weeks. She received 2 doses of betamethasone
and was admitted to the hospital on bedrest with a few
bleeding episodes. Fetus well. Hepatitis B in the past,
resolved. Due to risk for further bleeding and gestational
age, over 32 weeks, elected to deliver by C-section. She
received second course of betamethasone. The infant
delivered by repeat cesarean section with Apgar's of 8 and 9.
He emerged active and well-appearing.
PHYSICAL EXAMINATION: Infant active, moderate to severe
respiratory distress. Anterior fontanelle open and flat.
Normal S1 and S2, no murmur. Breath sounds distant
bilaterally. Abdomen, soft nontender, nondistended.
Extremities well perfused, tone appropriate for gestational
age.
HISTORY OF HOSPITAL COURSE BY SYSTEMS: Respiratory -
[**Known lastname **] was placed on CPAP for mild respiratory distress
and remained on CPAP for a total of 3 days at which time he
was transitioned to nasal cannula for a brief 4-hour period
of time. He has been stable on room air throughout the rest
of his hospital course. He did not require any
methylxanthines for apnea or bradycardia of prematurity
although he did have mild apnea and bradycardia of
prematurity. His last documented episode was on [**5-2**].
Cardiovascular - He has been cardiovascularly stable
throughout the hospital course.
Fluids and electrolytes - Birthweight was 2.435 kg. He was
initially started on 80 cc/kg/day of D10 W. Enteral feedings
were initiated on day of life #2. Full enteral volumes were
achieved by day of life #5. Maximum enteral intake was 150
cc/kg/day of breast milk 24 calorie and he continues to ad
lib feed with a minimum of 150/kg of breast milk 24,
concentrated with Similac powder. His discharge weight is
Gastrointestinal - Peak bilirubin was 12.9/0.3 on day of life
#4 and he was treated with phototherapy and was discontinued
and this issue has since resolved.
Infectious disease - CBC and blood culture obtained on
admission, CBC was benign and blood cultures remain negative
at 48 hours at which time antibiotics were discontinued. He
has not required any further sepsis evaluations during this
hospital course.
Neurology - He has been appropriate for gestational age.
Sensory - Hearing screen has not yet been performed, it
should be done prior to discharge.
Psychosocial - A social worker has been involved with this
family and can be contact[**Name (NI) **] at [**Telephone/Fax (1) 61156**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
PEDIATRICIAN:
CARE/RECOMMENDATIONS: Feeding - Continue ad lib feeding,
breast milk 24 calorie, concentrated with Similac powder.
Medications - Tri-Vi-[**Male First Name (un) **] and Fer-In-[**Male First Name (un) **].
Car seat position screening - Not yet performed, but should
be done prior to discharge.
State newborn screens - Sent per protocol and have been
within normal limits.
Immunizations received - Received hepatitis B vaccine on
[**2117-4-28**].
DISCHARGE DIAGNOSIS: Premature infant born at 32 3/7 weeks.
Mild respiratory distress syndrome. Mild apnea and bradycardia
of prematurity. Hyperbilirubinemia. Mild anemia. Status post
rule out sepsis with antibiotics.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2117-5-8**] 00:05:37
T: [**2117-5-8**] 07:00:19
Job#: [**Job Number 61157**]
ICD9 Codes: 769, 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8390
} | Medical Text: Admission Date: [**2199-3-8**] Discharge Date: [**2199-3-14**]
Date of Birth: [**2134-1-20**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Bactrim / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 5301**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
65 F c COPD, HTN p/w malaise, diaphoresis, SOB for 1 week. Also
c nausea, but no vomiting/diarrhea. No cough, chest pain,
palpitations, LE edema, orthopnea, PND. In ED, vitals were T
98.5, HR 87, BP 172/101, RR 24, sat 94% on 2L NC. Noted to be
in resp. distress, unable to speak in full sentences.
Significant wheezing. ABG showed pCO2 60, p02 71; placed on
BiPAP. CXR clear by radiology report. Treated with nebulizers,
solumedrol, levofloxacin. Also treated for hypertensive urgency
(BP to 200/100 in ED after presentation) with lisinopril and
amlodipine.
.
At baseline, pt has home O2 2.5L NC for daily use & BiPAP at
night. Pt has never been intubated. Pt reports not using her
supplemental 02 during the day, though she says she always uses
her BiPAP for sleep. Has not been using Nebs recently. No
known sick contacts.
.
MICU course: Thought to have COPD flare from non-compliance with
home 02. Hypertension thought [**2-15**] COPD flare and non-compliance
with medications. Treated overnight with BiPAP and nebulizers.
BP well controlled and did not require additional meds.
Past Medical History:
COPD/emphysema
OSA
HTN
hyperlipidemia
GERD
schizophrenia
depression
s/p R ankle ORIF
obesity
s/p T & A
Social History:
Lives alone, close friend [**Doctor First Name **] is very supportive. Former
tobacco 1ppd x 40 years, now "occasional smoking" few
cigs/monthly. Has an estranged brother in FL.
Family History:
mother-deceased brain CA
father-deceased suicide
sister-deceased PE
Physical Exam:
98.6, 193/119, 66, 18, 97% on BiPAP
GEN: BiPAP on, appears well, speaking in largely full sentences
HEENT: MM dry, Left eye w/purulent discharge & matting, PERRL,
no conjunctival irritation. EOMI. No LAD.
CV: RRR, distant sounds. No JVD. Good pulses peripherally.
PULM: diminished bilaterally w/expiratory wheezes throughout. No
focal crackles or consolidations noted.
ABD: soft, NT/ND. +BS. Obese.
EXT: cool feet bilaterally but palpable DP pp x2. No edema.
NEURO: A&Ox3, MAE, CN III-XII intact grossly, strength 5/5 upper
and lower extremities bilaterally, sensation intact to light
touch. Reflexes not tested.
Pertinent Results:
[**2199-3-8**] 02:30PM WBC-16.7*# RBC-5.98* HGB-15.4 HCT-48.8*
MCV-82 MCH-25.7* MCHC-31.5 RDW-15.4
[**2199-3-8**] 02:30PM CK-MB-NotDone cTropnT-<0.01
[**2199-3-8**] 02:30PM CK(CPK)-56
[**2199-3-8**] 02:30PM GLUCOSE-119* UREA N-22* CREAT-0.6 SODIUM-146*
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-33* ANION GAP-14
[**2199-3-8**] 02:47PM LACTATE-1.6 K+-4.2
.
[**2199-3-8**]
CXR: Study is mildly compromised secondary to body habitus. No
superimposed consolidations or effusions are noted. There is
minimal ectasia of the thoracic aorta with atherosclerotic
disease. The cardiac silhouette remains enlarged but stable. No
pleural effusion or pneumothorax is evident.
IMPRESSION: No acute pulmonary process.
Brief Hospital Course:
65 F w/long history of COPD, OSA, and HTN admitted to MICU on
[**2199-3-8**] with COPD exacerbation. The following issues were
investigated during this hospitalization:
.
#. COPD exacerbation: Pt's respiratory distress was likely from
COPD exacerbation triggered by a viral URI. Additionaly,
patient reported non-compliance w/ daytime supplemental 02 which
likely contributed to her presentation. She was treated with an
initial dose of IV solumedrol on admission, then transitioned to
a PO steroids taper. She also received nebs which were
transitioned to an MDI. She continued on BiPAP at night and 02
by NC during the day and was improving, however, it was noted
that her bicarbonate was slowly trending up. An ABG on room air
showed values of 7.37/68/46. This was compared to an ABG in the
MICU with a CO2 of 68. Given the hypoxia, a repeat ABG on 3 L NC
showed values of 7.34/86/86. The pulmonary consult team was
curbsided and advised placing the patient on BiPAP during the
day for a few hours each day in order to allow the patient to
ventilate her CO2. She remained awake and alert with good
mentation despite the readings of the ABG. Additionally, it was
confirmed with the respiratory team that knows the patient, that
the patient's CO2 baseline is close to that reflected in the
initial ABG. She was discharged to pulmonary rehabilitation on 1
L of O2 with a satisfactory O2 saturation of 92%.
.
#. HTN: Patient was found to have several episodes of
hypertensive urgency for which she received one time doses of
Amlodipine and Lisinopril. Both of these medications, which the
patient had been taking as an outpatient, were increased to
maximum values of 10 and 40 mg respectively. A beta blocker was
not an ideal 3rd option given the patient's COPD and while HCTZ
would have been an ideal choice, a sulfa drug allergy prevented
her from safely receiving it. Since increasing Lisinopril, the
patient's BP has been better controlled with a sytolic BP range
between 150s - 160s.
.
#. SCHIZOPHRENIA/DEPRESION: Stable during this hospitalization.
Pt. is followed at Mass Mental as an outpatient. She was
continued on her outpatient regimen of Risperdal, Trazodone and
Prozac.
.
#. GERD: Pt. was maintained on her outpatient PPI.
.
#. HYPERLIPIDEMIA: Pt. was maintained on her outpatient statin.
.
#. OSA: Pt. with known pulmonary artery hypertension and large
body habitus, on BiPAP ([**10-18**] w/ 3L 02) at home, which was
maintained during this hospitalization.
.
# Conjunctivitis L eye: Noted while in MICU, but resolved with
Erythromycin OPH TID.
Medications on Admission:
Prozac 80 mg'
Risperdal 2 mg'
Lisinopril 20 mg'
Norvasc 5 mg'
Trazodone 200 mg po HS
Protonix 40 mp po'
Lipitor 20 mg'
Albuterol
Advair
Combivent
Nebulizers
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
2. Risperidone 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours).
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): use for DVT
prophylaxis; can discontinue if ambulating.
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
12. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 doses: Start on [**2199-3-15**].
13. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: Start on [**2199-3-18**].
14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
3 days: Start on [**2199-3-21**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
COPD exacerbation
.
Secondary:
OSA
HTN
Mild aortic valve stenosis on echo
hyperlipidemia
GERD
schizophrenia
depression
obesity
Discharge Condition:
Afebrile, Mentating well
Discharge Instructions:
You were admitted to the hospital with COPD/emphysema attack.
This was due to possible viral infection. It is critical that
you use your home oxygen and BiPAP as directed.
.
You are being discharged to [**Hospital **] rehab for further management
of your breathing status. They may adjust your BiPAP settings,
please follow these recommendations on discharge to home.
.
It is very important that you stop smoking, please see your
primary care doctor if you need assistance with this.
.
Please take your medications as prescribed.
Followup Instructions:
Please see your primary care doctor [**Last Name (Titles) **],[**First Name8 (NamePattern2) **] [**Doctor First Name **]
[**Telephone/Fax (1) 693**] within 2wks of discharge from the hospital. You
should have pulmonary function tests done; please discuss this
with Dr. [**Last Name (STitle) **].
ICD9 Codes: 4241, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8391
} | Medical Text: Admission Date: [**2127-7-22**] Discharge Date: [**2127-7-29**]
Date of Birth: [**2053-7-1**] Sex: F
Service: [**Hospital Unit Name 14178**]
REASON FOR ADMISSION: Admission for hypertrophic obstructive
cardiomyopathy alcohol septal ablation.
HISTORY OF PRESENT ILLNESS: This is a pleasant 74-year-old
female with a history of hypertrophic obstructive
cardiomyopathy with a left ventricular outflow tract gradient
of 60, congestive heart failure, severe mitral regurgitation,
paroxysmal atrial fibrillation, and diabetes, who has been
admitted multiple times ([**2127-6-17**], [**2127-7-9**], [**2127-7-11**]) with a
CHF exacerbation. She now complains of increasing symptoms
of congestive heart failure (orthopnea, paroxysmal nocturnal
dyspnea at rest and with exertion, peripheral edema) over the
past five days. She denies dietary indiscretion. During her
last admission, her Zaroxolyn was discontinued.
She has had some edema of her lower extremities bilaterally
for the past few weeks. Of note, she was started on
ciprofloxacin p.o. b.i.d., now on day five of 10 for left
upper extremity cellulitis. She has not taken Coumadin since
[**2127-7-21**].
REVIEW OF SYSTEMS: Ten systems were reviewed and were
negative as above. The patient denies cough, fever, chest
discomfort, palpitations, or lightheadedness.
PAST MEDICAL HISTORY:
1. Hypertrophic obstructive cardiomyopathy diagnosed in [**2117**]
with the most recent ejection fraction of 60%, left
ventricular outflow tract of 60, [**11-21**]+ mitral regurgitation
during echocardiogram in [**2127-3-20**].
2. Congestive heart failure as above.
3. Diabetes mellitus type 2.
4. Mitral regurgitation.
5. Paroxysmal atrial fibrillation on Coumadin.
6. Hypertension.
7. Status post DDD pacemaker to induce left ventricular delay
compared to the right ventricle in order to decrease the
outflow tract obstruction.
8. Left upper extremity cellulitis on day five of 10 on
Cipro.
ALLERGIES: Penicillin induces hives.
MEDICATIONS AT TIME OF ADMISSION:
1. Toprol XL 100 mg q.d.
2. Spironolactone 25 mg q.d.
3. Verapamil 240 mg p.o. b.i.d.
4. Trazodone 50 mg q.h.s.
5. Glipizide 5 mg q.d.
6. Metformin 850 mg one p.o. q.d.
7. Amiodarone 200 mg one p.o. q.d.
8. Lasix 80 mg one p.o. b.i.d.
9. Potassium chloride 40 mEq one p.o. b.i.d.
10. Ciprofloxacin 500 mg p.o. b.i.d. day five of 10.
SOCIAL HISTORY: The patient quit smoking 10 years prior to
admission. She uses alcohol occasionally less than once per
week. She is from [**Country 4754**]. Denies drug use or toxic
exposures.
FAMILY HISTORY: Mother has diabetes mellitus. Brother had a
CABG, the details of which are unknown.
PHYSICAL EXAM AT TIME OF ADMISSION: Blood pressure was
134/41, heart rate was 68 and regular, respiratory rate is
14, temperature of 98.1, oxygenation of 93% on room air.
General: Pleasant female sitting up in no apparent distress
alert and oriented times three. HEENT: Pupils are equal,
round, and reactive to light and accommodation. Extraocular
movements are intact. Moist mucous membranes. Oropharynx
benign. Anicteric sclerae. No jugular venous distention was
noted. Lungs: Minimal crackles [**11-23**] of the way up
bilaterally. Cardiovascular: Nondisplaced point of maximal
impulse, regular, rate, and rhythm with a normal S1 greater
than S2, [**1-23**] blowing systolic ejection murmur at the apex and
[**1-23**] holosystolic murmur at the base that increased with
Valsalva maneuvers. Abdomen is soft, nontender, nondistended
with positive bowel sounds, no hepatosplenomegaly or bruits.
Extremities: 1+ pitting edema to the ankles bilaterally.
Skin: Consistent with mild sunburn over the upper chest, no
bruises or rashes.
STUDIES: Laboratories: White blood cell count 11.6, 80.2%
neutrophils, 14.3% lymphocytes, 4.3% monocytes, 0.8%
eosinophils, hematocrit 36.9. INR was 4.8, glucose 66, BUN
55, creatinine 1.4. Sodium 134, potassium 2.9, chloride 90,
bicarb 31.
CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted
to the [**Hospital Unit Name 196**] Service, placed on telemetry. Cardiac enzymes
were cycled. Patient was placed on standard CHF protocol
with a low sodium fluid-restricted diet. Head of the bed
elevated at 45 degrees. Lower extremities elevated while
patient in bed.
1. Coronaries. In preparation for the HOCM septal ablation,
the coronary arteries were imaged with cardiac
catheterization and were found to have no significant
lesions. The patient's cardiac enzymes were stable prior her
septal ablation.
CHF: The patient had daily weights and ins and outs
monitored. She was continued on Toprol XL, Lasix,
spironolactone, Zaroxolyn. Serial chest x-rays at three
different points throughout her hospital course demonstrated
no evidence of congestive heart failure. The patient's lower
extremity edema improved after gentle diuresis.
Electrophysiology: The patient remained in an A-V paced
rhythm. Her Coumadin continued to be held secondary to
supertherapeutic levels. The patient was maintained on
amiodarone, Toprol XL, and a calcium-channel blocker.
Telemetry was monitored on a daily basis without any
abnormalities.
Diabetes mellitus: The patient was placed on Glipizide XL 5
mg p.o. q.d. and placed on an insulin-sliding scale. Her
glucose control remained adequate throughout her hospital
stay.
2. Upper extremity cellulitis: The patient was continued on
ciprofloxacin 500 mg p.o. b.i.d.
3. Hypokalemia: The patient was profoundly hypokalemic and
was as low as 2.5 mEq/L at various points in her hospital
stay despite aggressive p.o. potassium repletion. The
patient refused to take intravenous potassium chloride,
although on [**2127-7-25**], on the date of her septal ablation, she
did allow potassium chloride to be repleted through a
concentration of 40 mEq of potassium in a 500 cc 1/2 normal
saline bag at 50 cc/hour.
4. Electrolytes: The patient's renal function was monitored
throughout her hospital course, and remained stable.
5. Hypertrophic obstructive cardiomyopathy: The patient
underwent an alcohol septal ablation on [**2127-7-25**] without
complication with minimal right groin bleeding postprocedure
that quickly resolved.
Summary of alcohol septal ablation:
1. Coronary angiography of the right side dominant system
revealed no significant obstructive disease. The left main,
left anterior descending artery, left circumflex, right
coronary arteries, and mild luminal irregularities without
significant obstructive disease.
2. Resting hemodynamic measurements at baseline revealed a
left ventricular outflow gradient at 45 mm Hg. Right and
left sided filling pressures were severely elevated with a
right ventricular end diastolic pressure of 50 mm Hg. Left
ventricular end diastolic pressure of 20 mm Hg. Pulmonary
artery pressures were moderately elevated to 55/25. Cardiac
index was mildly reduced at 2.3 liters/minute/meters squared
calculated by the Fick equation using assumed oxygen
consumption. On pullback across the aortic valve, the
gradient was confirmed to be isolated to the left ventricular
outflow tract with no appreciate gradient across the aortic
valve. On dobutamine at 5 mcg/kg/min IV drip, hemodynamic
measurements revealed worsening of the left ventricular
outflow gradient to 100 mm Hg.
3. Septal ablation was successfully performed by injection of
ethanol into three septal perforators under fluoroscope and
echocardiographic guidance.
4. Post-procedure hemodynamic measurements revealed
resolution of the left ventricular outflow gradient. Final
hemodynamic measurements reveal a residual outflow gradient
of less than 10 mm Hg. An echocardiogram was performed on
[**2127-7-28**]. The results are still pending at the time of
dictation. By verbal report, the cardiac catheterization
findings were confirmed.
The patient's prior medications used to control her CHF and
cardiomyopathy were gradually weaned beginning with the
Lasix, which was weaned on [**2127-7-26**], and the verapamil which
was weaned on [**2127-7-28**].
6. Hematological: The patient's Coumadin was restarted on
[**2127-7-26**] with a target INR of 2.0 to 3.0. On the day of
discharge, the patient's INR was 1.6 on 5 mg of Coumadin p.o.
q.d.
CONDITION ON DISCHARGE: At the time of discharge, the
patient complained of some anterior and posterior lower
extremity pain at the joints, which was relieved with Motrin.
The patient denied shortness of breath, chest pressure,
palpitations, or lower extremity edema.
DISCHARGE STATUS: Good.
DISCHARGE DIAGNOSIS:
1. Cardiomyopathy, hypertrophic obstructive.
SECONDARY DIAGNOSES:
1. Left sided congestive heart failure with an ejection
fraction at 55%.
2. Dyspnea.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Coumadin 5 mg tablet one p.o. q.h.s. The patient will
have her INR checked in one week's time by her primary care
doctor.
3. Spironolactone 25 mg p.o. q.d.
4. Glipizide 5 mg tablet one p.o. q.d.
5. Brimonidine tartrate eyedrops at 0.2% one drop O.U. q.8h.
prn.
6. Metoprolol 25 mg p.o. b.i.d.
7. Docusate sodium 100 mg capsule one p.o. b.i.d.
8. Amiodarone 200 mg tablet one p.o. q.d.
FOLLOW-UP PLANS: The patient was evaluated by Physical
Therapy and Occupational Therapy, and both of whom felt that
she would benefit from evaluation for home safety. The
patient was discharged with a home safety evaluation and
skilled nursing VNA. The patient was advised to call 911, or
go to the nearest Emergency Room, or call her primary care
doctor with chest pressure, shortness of breath,
palpitations, swelling in the legs, or lightheadedness.
She was advised to call her primary medical doctor if she
gains more than 5 pounds. She was advised to eat less than 2
grams of sodium per day and limit her fluid intake to 1,000
cc as at the discretion of Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 2031**]. She was advised
to followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**] on [**2127-8-7**] at 9:45 a.m.,
[**Telephone/Fax (1) 2660**], [**Location (un) 8170**], [**Apartment Address(1) 93647**], [**Location (un) **], [**Numeric Identifier 94054**] and with Dr. [**First Name11 (Name Pattern1) 449**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2031**], M.D. at the [**Hospital Ward Name 23**] Center
Cardiac Services, [**Telephone/Fax (1) 11216**] on [**2127-8-11**] at 2
p.m. Patient will likely have a follow-up echocardiogram in
one month's time, and will gradually wean her beta blocker,
amiodarone, and spironolactone in the discretion of Dr.
[**First Name (STitle) 2031**].
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 11-691
Dictated By:[**Last Name (NamePattern1) 1811**]
MEDQUIST36
D: [**2127-7-29**] 19:56
T: [**2127-7-31**] 07:12
JOB#: [**Job Number 94055**]
ICD9 Codes: 4280, 4240, 2768, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8392
} | Medical Text: Admission Date: [**2106-6-25**] Discharge Date: [**2106-6-30**]
Date of Birth: [**2024-6-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
impacted food bolus
Major Surgical or Invasive Procedure:
Upper Endoscopy
R IJ placement
History of Present Illness:
History of Present Illness:
Mr. [**Known lastname 30226**] is a 81 year old gentleman with dementia and history
of aspiration, presenting from nursing home with food bolus
impaction, admitted to MICU for urgent upper endoscopy. Patient
was supposed to be on liquid diet at nursing home and ate a
hamburger. He originally presented to OSH, where he was given
glucagon and nitro with minimal effect, but was transfered to
[**Hospital1 18**] for further management.
.
Of note, he was hospitalized recently at OSH [**Date range (3) 90541**] for
RLL pneumonia, thought to be secondary to aspiration.
.
In the ED, initial vs were as follows: 97.4 123 138/76 91%
2L Nasal Cannula. Patient was noted to be drooling and spitting
up some pieces of meat. Airway was intact. Patient was awake
and responsive. CXR showed COPD with patchy opacities in
setting of bronchiectasis which could represent aspiration, and
no radiopaque foreign bodies appreciated. Vitals in ED prior to
transfer to ICU were as follows: 97 117/74 97% 3L NC.
.
On arrival to the ICU, patient appeared comfortable. He was
noted to have occasional dry cough. Denied fevers, shortness of
breath, chest pain, abdominal pain, sore throat.
Past Medical History:
- Dementia
- Dysphagia
- BPH
- Right inguinal scrotal hernia
- History of aspiration pneumonia
Social History:
Lives in Den [**Hospital **] Nursing Home, dependent on 24hr caregivers.
[**Name (NI) **] [**Name (NI) 1022**] [**Name (NI) 90542**] is HCP. DNR/[**Name2 (NI) 835**]. Per last discharge summary
from OSH, patient has no recent smoking or alcohol.
Family History:
Unable to obtain due to patient's dementia.
Physical Exam:
ON ADDMISSION
Vitals: T: 99.4 BP: 112/49 P: 117 R: 29 O2: 95% 2.5L NC
General: Alert, oriented to "hospital" and self, no acute
distress
HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: harsh crackles in LLL
CV: Regular rhythm, rate rapid, 2/6 systolic murmur loudest at
apex Abdomen: soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, no leg edema
ON DISCHARGE:
PE: t97.3, bp106/60, h63, r16, s94%RA
Gen: AAOx1, NAD, lying comfortably in his hospital bed.
Cardiac: RRR, +2/6 systolic murmur loudest at apex
Pulm: CTAB anteriorly, good air entry.
Abd: S/NT/ND, normoactive BS, no HSM, no rebound or guarding.
Ext: all 4 extremeities warmer to touch, no CCE.
GU: Has foley placed
Neuro: A+O x1, responds to greeting, unchanged, +masked facies.
Pertinent Results:
[**2106-6-25**] 08:40PM GLUCOSE-154* UREA N-17 CREAT-1.1 SODIUM-140
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-25 ANION GAP-17
[**2106-6-25**] 08:40PM WBC-11.2* RBC-4.96 HGB-15.7 HCT-45.0 MCV-91
MCH-31.7 MCHC-35.0 RDW-13.7
[**2106-6-25**] 08:40PM NEUTS-80.6* LYMPHS-15.1* MONOS-3.1 EOS-0.6
BASOS-0.7
[**2106-6-26**] 02:41 40.9* CORTISOL
MRSA SCREEN (Final [**2106-6-27**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
Upper Endoscopy [**6-25**]: Erythema in the whole Esophagus. No
impacted food noted in esophagus. Large hiatal hernia
Otherwise normal EGD to Stomach Antrum.
CXR [**6-25**]: IMPRESSION: COPD with patchy opacities in both lung
bases in the setting of bronchiectasis, which could represent
infection, inflammation or aspiration. Probable trace right
pleural effusion. Enlargement of the hila may reflect pulmonary
arterial hypertension. No radiopaque foreign bodies were
identified.
[**2106-6-30**] 07:15AM BLOOD WBC-5.2 RBC-3.74* Hgb-12.2* Hct-33.7*
MCV-90 MCH-32.6* MCHC-36.1* RDW-13.1 Plt Ct-148*
[**2106-6-30**] 07:15AM BLOOD Glucose-87 UreaN-13 Creat-1.2 Na-139
K-3.7 Cl-108 HCO3-27 AnGap-8
[**2106-6-30**] 07:15AM BLOOD Calcium-7.9* Phos-2.3* Mg-2.1
Brief Hospital Course:
81M with hx of dementia presenting with drooling and inability
to take POs, presumed to have food bolus impaction in esophagus,
admitted to MICU for urgent endoscopy.
.
# Impacted Food Bolus:
Patient was admitted to MICU for urgent endoscopy to remove
suspected impacted food bolus. GI preformed upper endoscopy and
did not observe any residual food in the esophagus, but did show
a large amount of erythema. It was recommended to follow-up
with endoscopist within 6 weeks, and to avoid chocolate,
peppermint, alcohol, caffeine, onions, aspirin. Elevate the
head of the bed 3 inches. He is to go to bed with an empty
stomach and take a PPI.
.
# Likely Aspiration Pneumonia vs Pneumonitis:
Patient had a history of dysphagia and aspiration pneumonia
presenting with mildly elevated WBC, low grade temperature and
hypoxia. Because patient was a nursing home resident with
history of aspiration pneumonia and low reserve, it was elected
to treat as pneumonia covered broadly with vanc/zosyn for an 7
day course, which completed and his symptoms resolved. He has
been afebrile over the last 4 days prior to discharge and has
been saturating well. He was evaluated by speech who did not
find any evidence of dysphagia, so he was put on a mechanical
soft diet with thin liquids. He was also kept on aspiration
precautions and the head of his bed was kept at 45 degress.
.
# Bradycardia/hypotension:
Patient was noted to have intermittent heart rates to the 40s
with systolics in the 80s. He never exhibited any symptoms
during these episodes, continuing to mentate at his baseline.
EKGs showed 1st degree AV block. Patient had a random cortisol
of 40.9 suggesting he was not adrenally insufficient. On the
floor, his SBP averaged 95-110 and his heart rate was around the
60s. He was not symptomatic at all during this time.
.
# BPH
His proscar and flomax were initially held, however once he was
cleared by speech and swallow they were restarted.
.
# Psych:
Unclear whether patient has psychiatric history but is on
depakote and abilify as an outpatient at nursing home. Pshyc
Meds delivered via NG tube while patient was NPO and then
transition ed to PO once he was able to tolerate taking pills.
___________________________________________
Pending:
-None
___________________________________________
Transition of care:
-pt has a follow up appointment with GI on [**2106-7-13**] 01:00p
GI,[**Date Range 2606**] [**Doctor Last Name 2607**]
RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
GI [**Hospital 14974**] CLINIC (SB)
Medications on Admission:
- Abilify 10mg po daily
- Depakote 125mg po TID
- Ativan 0.25mg po BID prn anxiety
- Trazodone 50mg po at bedtime
- Proscar 5mg po daily
- Flomax 0.4mg po daily
- PRN acetaminophen
- PRN milk of mag
- PRN fleets enema
- PRN dulcolax
- PRN immodium
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia. Tablet(s)
4. divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
6. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY PRN () as needed for constipation.
9. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
10. Ativan 0.5 mg Tablet Sig: 0.5 tablet Tablet PO twice a day
as needed for anxiety: PRN anxiety.
11. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day: take 30 minutes
before breakfast.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*5*
Discharge Disposition:
Extended Care
Facility:
[**Month (only) 53281**] Rehabilitation & Nursing Center - [**Location (un) 28318**]
Discharge Diagnosis:
Primary diagnosis:
Food impaction
[**Hospital **]
Hospital Acquired Pneumonia
Discharge Condition:
Awake and Oriented to person.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
It was a pleasure taking care of you during this
hospitalization. You were brought to the hospital because it
was thought that you had a piece of food stuck in you throat.
We looked down your throat with a scope and we did not see any
food. You were found to have inflammation of your esophagus. We
have you a medication called omeprazole to help with this
inflammation. We also thought that you had pneumonia. We gave
you antibiotics through your veins for 7 days and your symptoms
have improved. You do not need anymore antibiotics. We hope you
continue to feel better.
Medications Changes:
START: Omeprazole 40mg daily- this is a medication for the
inflammation in your throat.
Followup Instructions:
Please make sure to see your primary care doctor in the next 2
days.
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2106-7-13**] at 1 PM
With: [**Name6 (MD) 2606**] [**Name8 (MD) 2607**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
ICD9 Codes: 0389, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8393
} | Medical Text: Admission Date: [**2108-12-13**] Discharge Date: [**2108-12-18**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
Syncope, bradycardia, and hypotension
Major Surgical or Invasive Procedure:
Right central line placement and removal.
Arterial line placement and removal.
History of Present Illness:
Pt is a 87 yo male with h/o HTN, severe MR, who presents from
[**Hospital1 1501**] following syncopal episode w/ bradycardia and hypotension.
Per report, patient was was working with PT/OT when he slumped
in a chair with decreased MS (unable to follow commands,
somnolent, able to open eyes). His SBP was noted to be 74/37 and
HR was 46. FS was 114. EMS admistered atropine x 2 which raised
pt's HR to 60, and SBP to the 60s.
In the ED vital signs were : T 98.8, HR 60s-70s, bp 94/64, resp
24 100% NRB. He received ASA 325 X 1, Atropine 1 mg IV X 1, and
levofloxacin 500 mg IV X 1, 2L NS. Dopamine was initiated for
hypotension and titrated up to 7.5. EKG showed irregular HR and
0.[**Street Address(2) 1755**] depressions in V4-V6. A Head CT was obtained, which
showed showed subacute external capsule infarcts. In the MICU
Neurology was consulted who recommended an MRI which showed
nothing acute. Cardiology was consulted for bradycardia and
hypotension, however A line was placed and BPs were ~20 pts
higher than cuff, and thus unlikely pt was hypotensive. Pt was
easliy weaned off dopamine. He was then transferred to the
regular medicine floor.
Past Medical History:
1) HTN
2) Paget's disease
3) Severe MR [**Last Name (Titles) **] 67%
4) PUD
5) HAV
6) ERCP s/p sphincterotomy in [**2099**] for CBD stone
-- c/b choledochalduodenal fistula [**2103**]
7) s/p appy
8) Depression
9) H/o EtOH abuse
10) newly diagnosed dementia
11) Chronic LFT abnormalities.
Social History:
Pt lives at the [**Hospital3 4414**] Rehab Center for one month (previously
he lived alone). He has two sons and twelve grandchildren.
Retired worker at paper company. Quit smoking at 35. History of
EtOH [**3-5**] whiskeys x 4-5 days per week. No history of black outs.
No IVDU.
Family History:
Non-contributory
Physical Exam:
Upon transfer to the regular medicine floor
VS: T: 97.2 m; BP: 120/80 (112-124/60-80); P: 60-64; RR: 20; O2:
96 on 3L I/O 700 cc out 8 hours
Gen: Elderly male, nonsensicle in NAD
HEENT: [**Name (NI) **] pt does not follow direction to open
Neck: right central line in place. No JVD
CV: III/VI holosystolic murmur at apex and at LLSB. RRR S1S2.
Lungs: right basilar rales. Pt could not take in deep breaths on
direction
Abd: +BS. soft, nt, nd.
Ext: DP 1+. No edema.
Pertinent Results:
Labs on admission:
[**2108-12-12**] 01:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2108-12-12**] 01:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-7.0 LEUK-NEG
[**2108-12-12**] 01:42PM GLUCOSE-103 LACTATE-2.0 NA+-138 K+-4.2
CL--106 TCO2-28
[**2108-12-12**] 01:40PM UREA N-16 CREAT-0.9
[**2108-12-12**] 01:40PM CK(CPK)-29* AMYLASE-45
[**2108-12-12**] 01:40PM CK-MB-NotDone cTropnT-<0.01
[**2108-12-12**] 01:40PM CALCIUM-8.2* PHOSPHATE-3.7 MAGNESIUM-1.7
[**2108-12-12**] 01:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2108-12-12**] 01:40PM WBC-4.2 RBC-2.71* HGB-7.9* HCT-24.8* MCV-92
MCH-29.2 MCHC-31.9 RDW-14.4
[**2108-12-12**] 01:40PM PLT COUNT-207
[**2108-12-12**] 01:40PM PT-13.8* PTT-32.9 INR(PT)-1.2
[**2108-12-12**] 01:40PM FIBRINOGE-359
_____________________
Labs on discharge:
[**2108-12-18**] 06:22AM BLOOD WBC-5.3 RBC-3.96* Hgb-11.5* Hct-35.7*
MCV-90 MCH-29.1 MCHC-32.3 RDW-14.6 Plt Ct-246
[**2108-12-18**] 06:22AM BLOOD Glucose-95 UreaN-14 Creat-0.5 Na-142
K-4.4 Cl-109* HCO3-26 AnGap-11
[**2108-12-18**] 06:22AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.9
______________________
Other:
[**2108-12-17**] 06:48AM BLOOD Triglyc-73 HDL-55 CHOL/HD-2.2 LDLcalc-50
[**2108-12-13**] 03:20AM BLOOD TSH-0.99
[**2108-12-13**] 03:20AM BLOOD Cortsol-32.8*
[**2108-12-13**] 10:15AM BLOOD Cortsol-32.4*
[**2108-12-13**] 10:47AM BLOOD Cortsol-34.6*
_____________________
Cardiac enzymes:
[**2108-12-12**] 01:40PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2108-12-13**] 03:20AM BLOOD cTropnT-0.03*
[**2108-12-16**] 01:35AM BLOOD CK-MB-4 cTropnT-0.14*
[**2108-12-16**] 01:00PM BLOOD CK-MB-NotDone cTropnT-0.16*
[**2108-12-17**] 06:48AM BLOOD CK-MB-NotDone cTropnT-0.15*
[**2108-12-16**] 06:30AM BLOOD CK(CPK)-62
[**2108-12-16**] 01:00PM BLOOD CK(CPK)-59
[**2108-12-17**] 06:48AM BLOOD CK(CPK)-29*
_____________________
Radiology:
CT Head without contrast [**2108-12-12**]-IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Chronic external capsule infarcts.
3. Mottled appearance of the vertex of the skull, which may be
of no clinical significance. A bone scan can be performed to
evaluate for conditions such as Paget's disease.
_____________________
MRA Brain without contrast [**2108-12-14**]-FINDINGS: The major
tributaries of the circle of [**Location (un) 431**] are patent motion. Decreased
signal in the proximal basilar may be due to turbulent flow or
patient motion. No other areas of abnormality are identified.
There is no significant stenosis or aneurysmal dilatation.
Within the limits of coverage of this study, no sign of
arterial-venous malformation is apparent.
IMPRESSION:
1. No evidence of acute infarction.
2. Chronic microvascular infarcts in the periventricular white
matter.
3. Areas of susceptibility in the occipital lobes and right
parietal and temporal lobes may represent mineralization versus
chronic small vessel hemorrhage.
4. Patent circle of [**Location (un) 431**]. Slight irregularity of proximal
basilar artery may be secondary to turbulence or patient motion.
_____________________
Chest AP [**2108-12-15**]-Since the prior study, there has been removal
of the right subclavian line. There is no evidence of
pneumothorax. There has been worsening in the degree of diffuse
bilateral pulmonary infiltration associated with bilateral
pleural effusion. Cardiomegaly is unchanged.
IMPRESSION:
1) Interval removal of the right CVP line.
2) Worsening congestive heart failure.
Brief Hospital Course:
1. [**Name (NI) **]
Pt was maintained on pressors (dopamine) in the MICU for one
day. Differential diagnosis on admission included adrenal
insufficiency, hypothyroidism, sepsis (although no clear
source), myocardial ischemia (minor ST abnormalities noted), and
decreased volume status. Pt was likely volume deplete in the
setting of decreased PO intake and anemia.
Discussed by possible diagnosis:
a. Arrythmia/Bradycardia/[**Name (NI) **] Pt received atropine x 2 without
large response. Two sets of cardiac enzymes were normal and
initial EKG showed lateral ST depressions. Echocardiogram
revealed the presence of a preserved EF 70%, moderate AS, 2+ MR,
[**12-2**]+ TR. Electrophysiology consulted on pt and there was no
indication for a pacemaker. Pt was kept on telemetry without
incident in the MICU. CHF was not evident on initial physical
exam. Once an a-line was placed, BPs were 20 points higher than
on cuff pressure.
b. Hypothyroidism-TSH was normal
c. Adrenal insufficiency- Cortisol stimulation test was 32-->34.
Pt was initially started on dexamethasone in the MICU but this
was d/cd when pt came to the floor without incidence.
d. [**Name (NI) 15305**] Pt was afebrile throughout and cultures were
negative.
e. Volume depletion-Pt was hypovolemic in the setting of both
decreased PO intake and a chronic anemia. Pt was aggressively
fluid resuscitated in the MICU and also received 2 units of
pRBCs for volume increase. BPs came up to systolic 110s-130s on
the floor.
2. CHF/[**Name (NI) 12329**] Pt was volume resuscitated in the MICU and required
lasix as evidence of volume overload. Based on oxygen
requirement of 3 L NC(previously not on oxygen) and wheezing, as
well as CXR, pt was overloaded. He was slowly diuresed with
lasix ~10 mg IV per day. Additionally, ACE inhibitor was added
back slowly as pt had been hypotensive on admission. Upon
discharge, pt is satting in the mid-90s on room air and is
euvolemic. Goal should be to keep pt even at this point.
Pt had one acute episode of SOB where he required diureses, and
with EKG showing further lateral depressions and increased
troponins to .16. CKs were flat and this was in the setting of
CHF exacerbation and demand ischemia. EKG returned more to
baseline.
3. Anemia-
Reported baseline of pt's HCT is 27-29 and was 24.8 on
admission. He was guaiac (-) here with no obvious source of
bleeding. Pt with history of "slow GI bleed" with negative
colonoscopies in the past (per report). He was transfused 2
units pRBC on admission for volume resuscitation and Hct bumped
>5 points. Iron studies show iron deficiency anemia with low
iron and low ferritin and pt was continued on iron.
4. Endocrine- Cortisol was 32 and post-stimulation was 34. He
was started on dexamethasone in the MICU. Upon transfer to the
floor, steroids were d/cd.
5. Delirium- Upon transfer to the floor, per family, pt was not
at his baseline. He was speaking non-sensibly. Normally pt is
conversant and can recognize family which he was not able to do.
In the MICU, pt received valium for agitation. On the floor,
benzodiazepines were stopped, pt's foley was d/cd, and we tried
to orient pt to day/night. He was also started on Seroquel [**Hospital1 **].
On discharge, pt is again oriented to place, time (year and
season) and was conversant, making sense. While pt was
delirious, he required a 1:1 sitter as he pulled at lines.
6. Subacute infarcts- Head CT showed subacute capsular infarcts.
Pt was seen by neuro and had MRI which showed old infarcts and
thus nothing further was done.
7. History of EtOH abuse- There were no symptoms of withdrawal.
Pt was kept on thiamine and folate here.
8. F/E/[**Name (NI) **] Pt was seen by speech and swallow who recommended thin
liquids pureed solids. He was also seen by nutrition who added
boost supplements.
9. Prophylaxis- On Lovenox at [**Hospital1 1501**] and subcutaneous heparin here.
Continued PPI. Pt received Pneumovax vaccine prior to discharge.
10. [**Name (NI) 59529**] Pt with dementia, continued Aricept. Also with
depression continued lexapro here. We also added Seroquel
low-dose [**Hospital1 **].
11. [**Name (NI) 12010**] Pt with Right subclavian line put in MICU which was
d/cd on floor. Otherwise had peripheral IVs.
12. Code Status: Pt was DNR/DNI. This was discussed with son [**Name (NI) **]
[**Name (NI) **], HCP.
Medications on Admission:
Lisinopril 10 mg qday
ASA 81 mg qday
Folate 1 mg qday
Thiamine 100 mg qday
Lexapro 10 mg qday
Lovenox 30 mg qday
Aricept 5 mg qday
Protonix 20 mg qday
Iron 325 mg qday
Levoquin ([**Date range (1) 59530**])
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Donepezil Hydrochloride 5 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO once a day.
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
10. Lexapro 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Quetiapine Fumarate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
12. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
14. Furosemide 20 mg Tablet Sig: 0.5 (half) Tablet PO once a
day: 10 mg qday.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 59531**] REHAB
Discharge Diagnosis:
Primary Diagnosis:
Hypotension
Congestive Heart Failure
Delirium
Secondary Diagnosis:
Anemia
Depression
Dementia
Discharge Condition:
[**Name (NI) 23148**] Pt is normotensive and is oriented again. He has been
stabilized on his medications.
Discharge Instructions:
-Please call your doctor or go to the emergency room immediately
if you have problems breathing, shortness of breath, chest pain,
Seizure, feel dizzy or lightheaded, or any other health concern.
-You should weigh yourself daily. Call your doctor if your
weight increases or decreases by 3 pounds.
Followup Instructions:
-You should call your doctor (PCP) and set up an appointment
within 2 days of discharge.
-Pt needs to have his hearing aid reconfigured and hearing
retested.
-Per the nursing facility
ICD9 Codes: 2765, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8394
} | Medical Text: Admission Date: [**2120-5-14**] Discharge Date: [**2120-5-24**]
Service: MEDICINE
Allergies:
Tetanus Toxoid / Bee Pollens
Attending:[**First Name3 (LF) 5123**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85M with complete heart block s/p pacer, HTN, diastolic CHF,
IDDM, gout, COPD, PVD s/p LLE stents several weeks ago
transferred from [**Hospital3 **] ED from NH for hypoxia.
.
Today at his nursing home, he was found around 1:30pm to be more
lethargic, short of breath with BP 70/50 and difficult to assess
radial pulses. O2sat 86% on RA. Pt was BIBA to [**Hospital3 **]
ED, VS at EMS evaluation was P 50, BP 70/P, RR 20, unable to get
a pulse ox, FSBS 114. In the [**Name (NI) 46**] [**Name (NI) **], pt was alert but noted
to be cyanotic and pallid with mottled skin. Pt c/o diffuse
abdominal pain. VS were not recorded. Labs notable for WBC 21.1
(88.3N, no bands), CPK 48 but trop I 0.6 (ref 0-0.04) - ?0.47
when confirmed; pt remained CP free and EKG showed a paced
rhythm at 80 bpm. CXR was read as unremarkable with pacing
leads in place. Noncontrast CT chest showed "small patchy
interstitial infiltrates with focal bronchiectasis and
nodularity in the posterior left lung base" and emphysematous
changes. Noncontrast CT abdomen was unremarkable other than for
mild diverticulosis. Pt was given vanco/zosyn and 3L IV fluid
without improvement in his Started on peripheral levophed for
SBP 70/palpable and given hydrocortisone 100mg IV. He was
transferred to our ED for further management.
.
In the ED, initial VS were: T97.8 P80 SBP135 R18 100% on NRB.
Transferred on 13 mcg of peripheral levophed but pt was given
another 1L NS, and pressures remained stable after levophed
weaned off. CXR with increased infiltrate in LLL. WBC 17, Hct
25, guaiac negative. Lactate 2.1. EKG paced at 80. Pt given
combivent neb. Only complaint was foot pain. Has 2 PIV in. On
transfer, HR80, 100/61, 20, 96% on NRB CXR.
.
On arrival to the ICU, pt without any complaints other than L
toe pain. Earlier abdominal pain had resolved at some point in
the [**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **]; not c/w GERD. He does recall feeling more
dyspneic on exertion for several days. No CP, shoulder/jaw
pain, palpitations, N/V, LH. Per son, pt was recently admitted
to [**Hospital3 3583**] on [**5-3**] for dyspnea and L toe pain. Per his
son, there was concern for DVT and PE, but LENIs and d-dimer
were negative. He was treated with nitro, lasix, ASA, plavix,
lovenox, and bronchodilators initially and sx improved while in
the ED. Cardiology c/s attributde mildly elevated troponins
attributed to demand. Per his son, he underwent a nuclear stress
test that was unremarkable and was discharged. He was started on
prednisone for presumed gout with no improvement in his sx
since.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
(1) Syncope/presyncope
(2) complete AV block, status post [**Company 1543**] pacemaker [**2112-11-11**]
(3) Hypertension
(4) Diastolic CHF and possible restrictive cardiomyopathy
(5) AEA/VEA/CAD
(6) IDDM with albuminuria
(7) Gout on prednisone
(8) COPD
Social History:
- Tobacco: Quit 45 years ago
- Alcohol: Denies
- Illicits: Denies
Family History:
Non-contributary
Physical Exam:
Vitals: T 95.6, P 80, BP 123/78, RR 17, O2sat 97 on 4L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally with only minimal
wheezes at bases, rales, rhonchi
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: Extremities slightly mottled b/l, 2+ pulses, L toe tender
on plantar surface but not erythematous, warm, or swollen.
Neuro: AAOx3, nonfocal exam.
Pertinent Results:
[**2120-5-14**] 11:24PM GLUCOSE-136* UREA N-57* CREAT-1.9* SODIUM-138
POTASSIUM-5.7* CHLORIDE-108 TOTAL CO2-19* ANION GAP-17
[**2120-5-14**] 11:24PM ALT(SGPT)-3211* AST(SGOT)-3169* LD(LDH)-6280*
CK(CPK)-98 ALK PHOS-72 TOT BILI-0.7
[**2120-5-14**] 11:24PM CK-MB-NotDone cTropnT-0.15*
[**2120-5-14**] 11:24PM CALCIUM-8.1* PHOSPHATE-4.4 MAGNESIUM-2.1
IRON-172*
[**2120-5-14**] 11:24PM calTIBC-221 VIT B12-GREATER TH FOLATE-GREATER
TH HAPTOGLOB-209* FERRITIN-GREATER TH TRF-170*
[**2120-5-14**] 11:24PM WBC-21.9* RBC-3.55*# HGB-10.6*# HCT-34.3*#
MCV-97 MCH-30.0 MCHC-31.0 RDW-14.0
[**2120-5-14**] 11:24PM NEUTS-93.8* LYMPHS-3.0* MONOS-2.6 EOS-0.3
BASOS-0.2
[**2120-5-14**] 11:24PM PLT COUNT-304
[**2120-5-14**] 11:24PM PT-14.8* PTT-28.7 INR(PT)-1.3*
[**2120-5-14**] 11:24PM FIBRINOGE-339
[**2120-5-14**] 11:24PM RET AUT-1.1*
[**2120-5-14**] 07:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2120-5-14**] 07:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2120-5-14**] 07:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2120-5-14**] 07:00PM URINE AMORPH-FEW
[**2120-5-14**] 06:18PM COMMENTS-GREEN TOP
[**2120-5-14**] 06:18PM LACTATE-2.1*
[**2120-5-14**] 06:05PM GLUCOSE-92 UREA N-38* CREAT-1.1 SODIUM-144
POTASSIUM-3.4 CHLORIDE-123* TOTAL CO2-12* ANION GAP-12
[**2120-5-14**] 06:05PM estGFR-Using this
[**2120-5-14**] 06:05PM CK(CPK)-48
[**2120-5-14**] 06:05PM CK-MB-NotDone cTropnT-0.10*
[**2120-5-14**] 06:05PM CALCIUM-4.3* PHOSPHATE-3.1 MAGNESIUM-1.2*
[**2120-5-14**] 06:05PM WBC-17.3*# RBC-2.57*# HGB-7.6*# HCT-25.5*#
MCV-99* MCH-29.4 MCHC-29.7* RDW-13.9
[**2120-5-14**] 06:05PM NEUTS-95.4* LYMPHS-2.7* MONOS-1.6* EOS-0.2
BASOS-0.1
[**2120-5-14**] 06:05PM PLT COUNT-238
CXR (Portable) [**2120-5-14**]:
HISTORY: This is an 85-year-old male with elevated white blood
cell count,
hypotension and wheeze. Evaluate for acute process.
COMPARISON: Chest radiograph [**2114-7-3**].
SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: There is no change in
the
cardiomediastinal contour, with mild cardiomegaly, but no
evidence for CHF. A
left chest pacing device is in unchanged position in comparison
to [**2114**].
There is left lung base atelectasis, but developing infection
cannot be
completely excluded. The bony thorax appears unremarkable.
IMPRESSION: Left lung base atelectasis, but developing pneumonia
cannot be
excluded. PA and lateral may be helpful for further evaluation
if clinically
feasible.
Brief Hospital Course:
# Shock:
Patient with hypotension requiring pressors at OSH ED with a
lactate 2.1. At [**Hospital1 18**] patient was responsive to IVF and weaned
off levophed. Most likely septic given mild hypothermia, WBC
17.3 and neutrophilia, hypoxia, and CT chest finding c/w
pneumonia. While it is possible that the leukocytosis may be
secondary to prednisone, the prednisone may also be masking a
fever. Treated empirically with vanc, zosyn with rapid
improvment. There may have also been a component of hypovolemia
in setting of decreased oral intake at [**Hospital1 1501**] given response to
IVF. Pt has only been on short taper of prednisone so less
likely adrenal insufficiency although did receive hydrocortisone
at OSH. Pt with elevated troponin but less likely cardiogenic
shock - may more likely represent end organ damage from
hypoperfusion; no evidence of CHF and BP unlikely to reverse so
quickly. He was never again hypotensive on the floor and his
white count resolved with IV Abx. We were never 100% convinced
that this was from pneumonia and a foot CT was checked prior to
discharge to r/o osteomyelitis which showed no evidence of
osteomyelitis. All cultures were negative.
.
Plan going forward:
-Complete 14day course of broad spectrum abx (last day [**5-28**])
-Patient must have CXR in 1 month to f/u for complete resolution
of his PNA/r/o underlying malignancy.
.
# Hypoxia: Patient quickly weaned from NRB to NC to room air.
This was likely related to pneumonia, though volume overload
from resuscitation can not be excluded, or any contribution from
his underlying lung disease.
.
# CAD: Nl CK but elevated trop likely represents demand in
setting of ARF and hypoperfusion rather than an occlusive
lesion. The patient peaked and ruled out on labs in house. EKG
was paced and c/w prior. Per son, recent stress test
unremarkable.
.
# DM: Patient had issues with o/n low blood sugars, [**Last Name (un) **] was
consulted, we dialed back his PM humalog and lantus and his
blood sugar control optimized.
.
# Anemia: Hct here 25.5, was 32.3 at OSH. Pt is on ASA and
plavix but guaiac negative, no evidence of active bleeding.
Concern for DIC in setting of sepsis although pt currently
appears well. [**Month (only) 116**] have been hemoconcentrated at OSH and now
diluted in setting of 4L IVF. Patient drifted back up to 33
without intervention
.
# Toe pain: Recently s/p LLE stenting; embolic event possible,
but this was thought to be most likely Gout in house. Prior
noted mottling more likely d/t shock than embolus however as b/l
and appears to be improving w/ fluid resuscitation. No acute
inflammation concerning for gout although has been on
prednisone. Pain unchanged per pt. He underwent CT foot to r/o
osteomyelitis or osteonecrosis as a source, this instead showed
evidence of pseudogout and osteoarthritis.
.
Plan going forward:
Patient has follow-up scheduled with rheumatology
.
#DVT/?PE: Patient found to have RUE DVT on exam, later found to
have LLL consolidation with resolution of RUE swelling. Most
likley PE. Patient to continue lovenox.
.
Plan going forward:
Patient to continue [**Hospital1 **] lovenox for [**4-13**] mo, pending PCP f/u
.
Urinary Retention:
Patient developed new urinary retention while in house. This
was felt to be secondary to oxycodone which was stopped. A
foley was placed on the day prior to d/c and the patient was
started on flomax.
.
Plan going forward:
Foley to be d/c'd in 3 days, patient must void spontaneously
8-10 hours following the removal. If he does not void the floor
physician must be consulted.
Medications on Admission:
Medications: Per NH notes
Prednisone 40mg x 2 days, 30mg x 3 days (completed), then
prednisone 20mg x 3 days, 10mg x 3days
Vicodin 5/500 [**2-10**] tab q6h prn pain
Lantus 50 units SQ qhs (previously on 28 units)
Diovan 20mg daily
Verapamil 120mg daily
Pulmicort 200 mcg 2 puffs inh [**Hospital1 **] (4 puffs [**Hospital1 **] per pt)
[**Name (NI) 44405**] 50 mcg 2 puffs [**Hospital1 **]
Spiriva 18 mcg q puff inhaler daily
ASA 81mg daily
Plavix 75mg daily
Metoprolol 50mg [**Hospital1 **]
Erythromycin 500mg q8h x 7 days (unclear why)
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. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) Puffs
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days: last dose 4/20.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: 4.5 Grams Intravenous Q8H (every 8 hours) for 4 days: last
dose 4/20.
12. Vancomycin 500 mg Recon Soln Sig: 1000 (1000) mg Intravenous
Q 24H (Every 24 Hours) for 4 days: should finish [**5-28**].
.
13. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty Four (24)
units Subcutaneous at bedtime.
14. Pulmicort Flexhaler 180 mcg/Inhalation Aerosol Powdr Breath
Activated Sig: Two (2) puffs Inhalation twice a day.
15. Salmeterol 50 mcg/Dose Disk with Device Sig: Two (2) puffs
Inhalation twice a day.
16. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) puff Inhalation once a day.
17. Insulin Aspart 100 unit/mL Cartridge Sig: One (1) as
directed Subcutaneous qACHS: as per attached sliding scale.
18. Valsartan 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
19. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
20. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO at bedtime.
21. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) units
Subcutaneous Q12H (every 12 hours).
22. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
23. Chest XRAY
Patient must have f/u CXR 1 mo. following discharge from
hospital.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at Silver [**Doctor Last Name **] Commons
Discharge Diagnosis:
Septic Shock
Pneumonia
Gout Flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to [**Hospital1 **] after you were found
to be severly ill at your rehabilitation center. You were
briefly in the ICU where you were found to be hypotensive and
have a condition known as septic shock. This was thought to be
caused by pneumonia. You improved quickly with IV antibiotics.
You also developed a blood clot in the hospital for which you
are being treated with a blood thinner called lovenox. You were
monitored on the floor and aside from toe pain you had not other
major issues.
.
The following changes were made to your medication regimen:
Your antibiotics will be completed on [**2120-5-28**]
You completed your prednisone course
We believe that oxycodone was causing you to retain urine, we
stopped the oxycodone and started you on tylenol.
Your Bedtime lantus was reduced to 24mg.
Your metoprolol was reduced to 12.5mg twice per day
You were started on lovenox 90mg twice per day
Followup Instructions:
Department: RHEUMATOLOGY
When: WEDNESDAY [**2120-5-29**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Unit Name **] [**Location (un) 861**]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
.
Department: [**Last Name (un) **] Diabetes Center
When: [**2120-6-3**] 10:00am
With: NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7280**]
Location: [**Last Name (un) 3911**], [**Location (un) 86**] MA
Phone: [**Telephone/Fax (1) 2384**]
Completed by:[**2120-5-24**]
ICD9 Codes: 0389, 486, 5849, 4019, 4280, 496, 4439, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8395
} | Medical Text: Admission Date: [**2146-5-30**] Discharge Date: [**2146-6-4**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
EGD [**5-31**]
History of Present Illness:
[**Known firstname **] [**Known lastname 29298**] is an 85 yo with MDS and maltoma, and recent GI
Bleed who presented to [**Hospital1 **] [**Location (un) 620**] with shortness of breath and
found to have melanotic stools with drop in hematocrit. Of note
he had a recent admission from [**Date range (1) 10375**] for BRBPR requiring 7
units of PRBCs. During that admission, he underwent EGD which
showed an ulcerated, malignant-appearing mass in the antrum of
the stomach, with stigmata of recent bleeding. Biosies were
taken but the vessel was unable to be clipped due to difficult
location and access. Biopsies since returned showing B cell,
non-Hodgkin lymphoma, marginal zone type which is consistent
with his previous MALT lymphoma. During the last admission, he
underwent XRT to stomach for Maltoma; he was supposed to get
8th/10 dose of XRT today but tx held for evaluation. Patient
reports that he had some vague abdominal pain yesterday and felt
gassy. This morning he felt extremely fatigued and short of
breath. He had a loose bowel movement this morning. He reports
brown stool, but his wife thought it looked bloody.
.
In the ED, initial vs were: 92 111/49 22 100%. Patient was given
1 bag of platelets and one unit of blood and 500cc of NS. He
was given lasix for shorntess of breath. He received benadryl
and tylenol prior to platelet transfusion. In the ED, patient
has been hemodynamically stable with SBP 90-100s. GI was
consulted, and they plan to see patient in the ICU. VS prior to
transfer were 98 113/56 20 99% ra.
.
In the ICU, the patient feels weel. His fatigue and shortness
of breath resolved with the unit of PRBCs. He denies abdominal
pain, nausea or vomiting. NG lavage performed and was negative.
Past Medical History:
Oncologic History:
1. MDS on dacogen
- presented in [**2143-9-28**] with pancytopenia, complained of
dyspnea on exertion
- cytopenias progressed and he had a repeat bone marrow done in
[**1-4**] which showed a markedly hypercellular bone marrow with
significant dysplasia in the erythroid and megakaryocytic
lineages. There were >15% ringed sideroblasts. Flow cytometry
demonstrated CD-34-positive cells comprised 4-5% of total blast
gated events. Cytogenetics revealed [**11-16**] cells have abnormal
chromosome 12 and an abnormal chromosome 17 in a possible three
way translocation.
- refractory to Procrit, at escalating doses and then became red
blood cell transfusion dependent
- Decitabine therapy was initiated [**2145-9-13**] but had to be
discontinued due to a hematoma which developed at the site of a
wound. He resumed C1D1 Dacogen for MDS on [**2146-2-21**]. So far he has
tolerated therapy well but remains severely pancytopenic and
requires frequent blood product support.
.
2. MALT lymphoma of the stomach: no evidence of disease since
[**2142**]
- initially presented in [**2139**] with abdominal upset/indigestion.
CT scan demonstrated perigastric adenopathy and EGD had a
multilobulated mass with ulceration. Biopsy demonstrated
extranodal marginal zone lymphoma of mucosa associated lymphoid
tissue (MALT).
- Bone marrow biopsy demonstrated mildly hypercellular marrow
for age with megakaryocytic dysplasia and occasional ringed
sideroblasts (10%) without evidence of lymphoma. Evolving
myelodysplastic syndrome could not be excluded.
- treated for Stage IIB MALT lymphoma of the stomach with 6
cycles of CVP, completed in [**11-30**]
- recurred in [**2142**] and was treated with four weeks of Rituxan
therapy ([**Date range (1) 51244**])
- no evidence of disease since this time.
.
Other Past Medical History:
Open AAA repair-[**2130**]
Cataract surgery
HTN
Social History:
The patient is married with two children, three grandchildren
and four great grandchildren. He smoked a pack a day for 40
years and quit in [**2123**]. He previously drank heavily, currently
only 2 drinks/day. He is a retired electrician.
Family History:
Mother-died in her 70s of acute leukemia
Father-died of AAA
Sister-Hemochromatosis
[**Name (NI) 51245**]
Physical Exam:
General: well-nourished, well-appearing, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, no white
plaques,
Neck: supple, JVP flat, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, tender to deep palpation in epigastric
area, non-distended, bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ radial, DP & PT pulses, no
clubbing, cyanosis or edema.
Neuro: A&Ox3, CN grossly intact, strength 5/5 in UE and LE
bilat, sensation grossly intact.
Pertinent Results:
[**2146-5-30**] 07:29PM HCT-19.1*
[**2146-5-30**] 07:29PM PLT COUNT-32*#
[**2146-5-30**] 11:40AM WBC-0.2*# RBC-2.19*# HGB-6.6*# HCT-19.2*#
MCV-88 MCH-30.0 MCHC-34.2 RDW-15.4
[**2146-5-30**] 11:40AM NEUTS-84* BANDS-0 LYMPHS-8* MONOS-8 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-2*
[**2146-5-30**] 11:40AM PLT SMR-RARE PLT COUNT-10*#
.
[**5-31**] EGD:
Schatzki's ring
Erosions in the gastroesophageal junction compatible with
esophagitis
Mass in the lesser curvature (endoclip)
Erythema and petechiae in the duodenal bulb compatible with
duodenitis
There is no fresh red blood or coffee-ground liquid in his
stomach and duodenum.
Erythema in the antrum compatible with gastritis
Otherwise normal EGD to third part of the duodenum
CXR [**2146-6-2**]: In comparison with the study of [**5-31**], the left
hemidiaphragm is more sharply seen, consistent with some
improvement in the atelectatic change in the region. No evidence
of acute focal pneumonia. Tortuosity of the aorta is again seen.
Port-A-Cath remains in place.
Brief Hospital Course:
85 yo with MDS and maltoma, and recent GI Bleed who presented to
[**Hospital1 **] [**Location (un) 620**] with shortness of breath, found to have GI bleed.
.
#. Acute blood loss anemia: Likely secondary to an upper GI
bleed given his history of ulcerated maltoma in his GI tract,
melena on exam, and a visible vessel which was clipped on EGD.
The patient remained hemodynamically stable with BPs in the
90s-100s systolic which he says is at his baseline. He was
transfused a total of 7 units of pRBCs with a goal Hct of 30 and
3 units of platelets with a goal of maintaing platelets above
30. He is on a PPI [**Hospital1 **] and his diet was advanced slowly. He
continued to have episodes of diarrhea, but no further BRBPR.
C. diff was negative x2. His Hct remained stable throughout the
rest of the hospital course. He will be discharged on PPI [**Hospital1 **].
.
#. Dyspnea: Likely related to anemia. Improved with pRBC
transfusion. CXR at OSH was normal.
.
# Acute Kidney Injury: Creatinine was up to 1.2 from baseline
of 0.8 on admission. Likely pre-renal, given blood loss and
improvement with transfusions. Improved back to baseline Cr 0.8
prior to discharge.
.
# Maltoma: The patient completed XRT 2500 cGy to stomach on
[**2146-6-2**].
.
# Pancytopenia: Anemia most likely secondary to bleeding.
Patient is neutropenic, anemic, and thrombocytopenic. Neupogen
injections were administered while inpatient in an attempt to
improve neutropenia. The patient will follow-up with Dr. [**Last Name (STitle) 410**]
for further management upon discharge.
.
#. Myelodysplastic Syndrome on decitabine: He received C3 of
decitabine
from [**4-25**] - [**4-29**]. Continued on treatment guided per his primary
oncologist.
.
# Fevers: The patient with a febrile episode. CXR revealed
improving atelectasis, but no evidence of PNA. Cultures failed
to yield any organisms. The patient was started empirically on
Levaquin 750mg daily. Fevers have resolved prior to discharge.
Medications on Admission:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO three times
a day.
4. Compazine 10 mg Tablet Sig: One (1) Tablet PO q 6H PRN as
needed for nausea.
5. Magnesium 250 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Vitamin E Oral
7. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
3. 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*
4. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 14 days: Please take until instructed to stop by Dr.
[**Last Name (STitle) 410**].
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Myelodysplastic syndrome, mucosa-associated lymphoid
tissue lymphoma, acute upper gastrointestinal bleed
Secondary: Hypertension
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 because you noticed blood in
your stool. We found your red blood cell count to be very low
and gave you red blood cells and platelets. We performed an
endoscopy (also called esophagogastroduodenoscopy). It showed
that you had a recent bleed from an ulcer in your stomach caused
by your lymphoma in the stomach. A blood vessel in your stomach
was clipped to prevent further bleeding. Afterward, you had an
episode of fever and we started you on a course of antibiotics.
You had no further bleeding and your red blood cell counts
remain stable. You are now ready to go home.
We made the following changes to your medications:
We STARTED you on Pantoprazole 40mg twice a day
We STARTED you on Levaquin 750mg daily. Please continue to take
it until told by Dr. [**Last Name (STitle) 410**] to stop.
Please continue to take all your other medications as
prescribed.
Please follow up with Dr. [**Last Name (STitle) 410**] as shown below.
Please call [**Telephone/Fax (1) 8717**] and ask for [**Telephone/Fax (1) 3242**] fellow on call or come
to the hospital right away if your develop any of the following
symptoms: chest pain, shortness of breath, fevers, dizziness,
lightheadedness, bleeding from below, dark or tarry stools,
vomiting, nausea, worsening diarrhea, or any other concerning
symptoms.
Followup Instructions:
You need to follow up with your primary oncologist Dr. [**First Name4 (NamePattern1) 449**]
[**Last Name (NamePattern1) 410**] as follows:
[**Last Name (LF) 766**], [**2146-6-6**]. Please call the clinic first thing on
[**Year (4 digits) 766**] to schedule a same day appointment. You can schedule by
calling: [**Telephone/Fax (1) 3760**].
Thursday, [**2146-6-9**] at 09:30 am
Completed by:[**2146-7-19**]
ICD9 Codes: 5849, 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8396
} | Medical Text: Admission Date: [**2147-11-24**] Discharge Date: [**2148-1-20**]
Date of Birth: [**2071-9-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Bilateral parotid gland swelling; dehydration.
Major Surgical or Invasive Procedure:
Endotracheal intubation
Placement of plasmapheresis catheter
Tracheostomy
History of Present Illness:
76 yo male with below med hx presents with bilateral parotitis
suspectedly due to dehydration who are consulting for help with
management of fluid balance and question of when to restart
[**First Name3 (LF) 17339**]. Pt reports increasing parotid pain and swelling for 4
days associated with worsening dry mouth. He denies fever,
chills, cough or sick contacts but does produced very thick oral
secretions that he has to spit out and are white in color. Pain
on left face radiates up to his ear but no changes in hearing.
He reports not being able to tolerate PO's since his radiation
but has be taking 2 cans of G-tube feeds tid along with 2x 16oz
boluses of water [**Hospital1 **] consistently. He denies current diziness
but does report diziness with standing in the past around his
time of chemotherapy which is why he was taken off his lasix and
lopressor. His blood pressure had been in the low 100's systolic
and so they have not been reinitiated. He is very sedentary and
does report intermittent LE swelling worse on the left leg where
his SVG CABG graft was harvested from. He denies any CP, CT,
SOB, PND or orthopnea. He stopped his [**Hospital1 17339**] 2 months ago since
he had to start Diflucan to treat XRT associated thrush and has
not initiated it since. He lost >20 lb's over the past 3 months
and felt that his cholesterol can't be bad at this point.
Past Medical History:
1. Laryngeal SCC T4 dx [**5-15**] s/p chemo unknown type(still has
port in place followed by Dr. [**Last Name (STitle) 17315**] at [**Hospital1 4601**] ) and XRT
for 7 weeks 5 days/week ending [**2147-8-17**]
Esophageal stricture s/p dilation for stricture [**2147-11-16**]
s/p G tube placement
CHF preserved EF(records at [**Hospital1 756**])
CAD s/p 3v CABG [**10-14**]
HTN-off meds for unclear reason
hypercholesterolemia
BCC on nose and back
Social History:
Quit smoking 20 yrs ago after 1ppd x 30yrs
Pt admits to 3 shots of vodka a day
Family History:
Mother died at the age 65 from an MI/CAD
Physical Exam:
PE-T 98.7 HR 84 BP 100/50 RR 18 O2sats 96% [**Female First Name (un) **]
Gen-NAD
HEENT-PERRL, mild left mouth droop, severe parotid swelling
bilat,
no ant or post cerv LAD, erythema and warmth over parotids
bilat, neck supple, JVD to 7cm
Hrt-RRR nS1S2 [**2-13**] SM at RUSB
Lungs-poor air movement, no crackles or wheeze
Abd-soft, NT, mod distended, PEG in place with min surrounding
erythema and no drainage
Extrem-2+ pitting edema to mid shin on left and to ankle on rt
Neuro-CNII-XII intact except mouth droop as above, [**4-13**] UE and LE
strenth, distal sensation intact
Skin-multiple telangiectasias around neck and erythema
Pertinent Results:
Admission Labs:
134 97 19
------------<135
4.6 29 0.8
estGFR: >75 (click for details)
Ca: 8.7 Mg: 2.2 P: 3.0 D
Alb: 3.7
Cholesterol:145
.
Iron: 20
calTIBC: 222
Ferritn: 483
TRF: 171
Triglyc: 57
HDL: 52
CHOL/HD: 2.8
LDLcalc: 82
.
10.5
2.7>---<120
29.0
N:87.0 L:8.2 M:3.3 E:1.4 Bas:0.1
Macrocy: 3+
.
.
OTHER:
.
.
[**2147-12-3**] GBM AB: <3 U/ML
[**2147-12-3**] C-ANCA positive
Summary of results of proteinase 3 [**Doctor First Name **]:
Date Direct [**Doctor First Name **] [**Location (un) **] [**Doctor First Name **] (anti-proteinase 3
titer in units)
---- ------------ --------------
[**2147-12-3**] 301 >65,536
[**2147-12-14**] 147 3,225
[**2147-12-15**] 83 2.304
.
[**2147-12-16**] HEPARIN DEPENDENT ANTIBODIES: NEGATIVE
.
MICROBIOLOGY:
[**2147-11-28**] BRONCHOALVEOLAR LAVAGE:
GRAM STAIN (Final [**2147-11-28**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2147-11-30**]): NO GROWTH, <1000 CFU/ml.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final
[**2147-11-29**]):
PNEUMOCYSTIS CARINII NOT SEEN.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2147-11-29**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending)
[**2147-11-28**] Rapid Respiratory Viral Screen & Culture: No Virus
isolated so far.
STOOL [**2147-11-25**]: negative for c.diff.
[**2147-11-28**]: negative for c.diff, shigella, campylobacter
[**2147-11-29**]: negative for c.diff
.
.
IMAGING AND PATHOLOGY:
.
.
EKG: sinus rhythm, no change from prior
Bronchoscopy report [**11-27**]: Hemoptysis with likely source the
anterior segment of the left upper lobe
blood cultures: [**2147-11-26**] NGTDx2, [**2147-11-27**] NGTDx2, [**2147-11-29**]
NGTDx2
urine cx [**2147-11-25**] <10,000 organisms, [**2147-11-26**] NG, [**2147-11-30**]
pending
.
[**11-26**] CXR: Patchy opacities throughout the left lung are
concerning for pneumonia. Small bilateral pleural effusions.
.
[**11-27**] CXR: Compared with [**2147-11-27**], the moderately extensive left
lung
infiltrate shows marked interval consolidation, consistent with
progressive pneumonia and/or intra-alveolar blood or infarction.
Right lung remains grossly clear. No CHF.
.
[**11-27**] Echo
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and 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) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion. IMPRESSION: Normal global and regional
biventricular systolic function. Moderate pulmonary
hypertension.
.
CTA CHEST W&W/O C &RECONS [**2147-12-3**] 3:51 PM
1. Interval marked worsening of alveolar consolidations
including the entire lungs The findings appear consistent with
infection ehich might overlay aspiration, especially in the
setting of gradual worsening.
2. No evidence of pulmonary emboli.
3. Small associated bilateral pleural effusions.
4. Mild-to-moderate emphysema, unchanged.
5. Heterogeneous spleen enhancement with rounded hypodense
lesions might represent splenic infection.
.
[**12-2**]
Bronchial lavage: NEGATIVE FOR MALIGNANT CELLS.
Scant cellularity with bronchial epithelial cells,
pulmonary macrophages and blood.
.
CT NECK W/CONTRAST (EG:PAROTIDS) [**2147-12-4**] 10:17 AM
Limited study, without definite fluid collection. Fluid in
nasopharynx and upper trachea, with fluid density posterior to
left nasopharynx, probably a continuation of nasopharyngeal
cavity. No definite abscess. Mild diffuse increase of the
subcutaneous fat, especially at the level of the tongue base,
which can be due to edema, however, inflammation in this area
cannot be totally excluded given the clinical setting. Please
correlate with physical examination.
.
[**2147-12-18**]
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Limited study due to bony artifact from patient's arms in the
scanner. Bilateral pleural effusions, intra-abdominal fluid, and
anasarca are suggestive of fluid overload. No evidence of
retroperitoneal bleed or fluid collections within the abdomen.
.
Tracheal Wall Bx:
Fibrous connective tissue, cartilage and focal ossification.
No malignancy identified.
.
Skin Bx [**2147-12-12**]
Skin, left cheek, biopsy (A):
Leukocytoclastic vasculitis with adjacent granulomas, some
containing fragmented elastic fibers (see note).
.
.
BILAT LOWER EXT VEINS PORT [**2147-12-28**] 4:57 PM
No evidence of deep vein thrombosis in the bilateral lower
extremities.
.
CHEST (PORTABLE AP) [**2147-12-28**] 11:31 AM
1. Interval improvement in right mid lung and left upper lung
air space opacities, consistent with either resolving pneumonia
or resolving pulmonary hemorrhage given history of Wegener's
granulomatosis.
2. Increase in right perihilar opacity likely represents
worsening mild asymmetric pulmonary edema.
Brief Hospital Course:
Mr. [**Known lastname 27273**] is a 76 yo gentleman with newly diagnosed laryngeal ca
([**5-15**]) c/b esophageal stricture s/p dilation, who presented with
bilateral parotiditis, transferred to the medical ICU with
hypoxia and diffuse alveolar hemorrhage. Found to have Wegeners
by C-ANCA and skin biopsy. His hospital course is summarized
below and by problem subsequently.
.
Patient was admitted to the ENT service and started on clinda
and ceftriaxone. He was later transferred to the medicine
service for fevers x 2 d ([**11-25**]). On medicine team, patient was
complaining of worsening shortness of breath, and cough with
hemoptysis. CXR revealed patchy opacities and CTA revealed
multifocal PNA L>R. Patient was treated vanco (started
[**11-27**])/levo (started [**11-26**])/clinda (started [**11-23**]).
.
Patient also had loose stools x 2 d (c diff neg x 2). In
addition his Hct dropped from 28--> 24. Aspirin was held.
Patient was then transferred to the ICU after bronch and IR
procedure for concern of hemoptysis and hypoxia. He continued to
have hemoptysis, dried dark blood, small amounts. He continued
to be dyspneic but was improving with 40% humidified face mask.
He has been noted to be tachycardic in the ICU (sinus) and was
given 500cc IVF [**11-29**] with no improvement. He was also restarted
on metoprolol at 12.5 tid [**2147-11-28**] which was increased to 25mg
tid [**2147-11-29**]. Patient was transferred to the floor [**11-29**] as his
respiratory status improved and this RUL bleeding seemed to be
stable.
.
On the floor, patient remained on 40% fm until a.m. of [**11-30**]
when he was found to be tachypneic to the 20's. His hematocrit
was found to be 22 so he was given 1u prbc. During the
transfusion he became increasingly tachypneic, tachychardic and
had a fever of 101. He was given 40 IV lasix. ABG was done
7.5/32/67 on 60%. He was then changed to 100% FM and tranferred
back to the MICU.
.
MICU COURSE BY PROBLEM:
.
# WEGENER'S: Diagnosed [**12-7**] by positive C-ANCA, Anti-GBM
negative. Derm biopsy of neck rash demonstrated vasculitis.
Patient was transferred to the MICU and reintubated due to
increasing hemoptysis and bloody output from ETT. No focal
bleeding sites were found on Bronchoscopy [**12-2**]. Patient was
started on treatment with Cytoxan 150 mg [**Hospital1 **] for 10 days however
this was held on [**2147-12-22**] in the setting of dropping WBC and
pancytopenia. He was also treated with Dexamethasone. He also
received plasmapheresis starting [**12-7**] for four sessions. He was
treated with Vit K and FFP to maintain an INR <1.5. He remained
difficult to wean from the ventilator despite no further
bleeding. A tracheostopy was placed on [**2146-12-22**] by ENT.
Rheumatology was consulted and recommended Prednisone 60 mg
daily. Patient was placed on Neutropenic precautions when his
WBC reached a nadir of 1.1, although the ANC remained >1000. He
was started on Ceftriaxone for a fever on [**12-24**]. He was also
treated with GCSF. Cytoxan was restarted once his WBC recovered
on [**12-28**], GCSF discontinued. Mr. [**Known lastname 27273**] was eventually able to use
the trach collar duing the day with minimal rusty sputum
production. Patient spiked a low grade fever to 100.7 on [**12-29**]
and was started on Ceftrixone. Repeat sputum cultures have been
negative. Prednisone and Cytoxan were continued with close
monitoring of his counts. Eventually Rituxan was also added at
the request of the rheumatology service. Eventually, the family
decided to make the patient CMO due to failing clinical status.
At this time, his immunosuppressants (prednisone, cytoxan, and
rituxan) were all discontinued.
.
# RESPIROTORY FAILURE: Patient was intubated in the MICU for
diffuse alveolar hemorrhage subsequently diagnosed with
Wegener's. The patient was difficult to wean from the vent and
ultimately required trach placement by ENT on [**2147-12-22**].
Eventually, he required less support and was maintained on the
trach collar during the day with pressure support overnight. He
continued to have minimal rusty sputum production with cultures
showing sparse oropharyngeal flora. He was very weak secondary
to a prolonged hospitalization and possibly steroid myopathy. At
one point during his hospitalization, he successfully used a
Passy Muir valve; however, his speech was not fully recovered.
ENT changed his trach to a 7.0 on [**2147-12-30**]. Laryngoscopy at that
time showed laryngeal edema. In addition, Mr. [**Known lastname 27273**] had been
fluid overloaded due to IVF he received throughout his
admission. He was transiently on a lasix drip and subsequently
diruesed with prn lasix IV boluses. Eventually, he began to
have increase in bloody secretions. After discussion with the
family, he was made CMO and eventually expired secondary to
respiratory failure due to diffuse alveolar hemorrhage related
to his underlying Wegener's. He was made comfortable at the
time of his death with morphine, ativan, and scopolamine to
minimize secretions.
.
# PANCYTOPENIA: Thought to be multifactorial in etiology with
largest contributant from cytoxan therapy and possibly Bactrim.
Plts nadir at 41 on [**2147-12-19**], Hct nadir 20.7 [**2147-12-18**], WBC nadir 1.1
ANC 1010 on [**2147-12-24**]. Anemia exacerbated by ongoing slow ongoing
bleeding, phlebotomy, thrombocytopenia exacerbated by recent
plasmapheresis. As described above, patient was transiently on
Neutropenic precautions, never frankly neutropenic. He was
started on GCSF transiently. Cefepime was used transiently for
fever and neutropenia. Patient's lines (left port) and PIV's
were monitored closely for infection, blood cx remained
negative, sputum with sparse oropharyngeal flora. Patient had
loose stool however was negative for C.diff.
.
#) LARYNGEAL CANCER: Status post chemo and radiation. Recently
had esophageal stricture dilated [**11-15**]. Patient was maintained
NPO during his admission and given tube feeds.
.
#) ABDOMINAL PAIN: The patient complained of intermittent
abdominal pain, with decreased bs/increased residuals, likely
secondary to ileus. This resolved with reglan.
.
#) PAROTIDIS: This was thought to be secondary to radiation
scarring vs. infection. Resolved throughout his admission.
.
#) CAD s/p CABG: No evidence of active ischemia. He was
continued on high dose metoprolol; however, [**Month/Day (4) **] was held due to
alveolar hemorrhage. He was also continued on [**Month/Day (4) 17339**] and
captopril.
.
#) NSVT: Patient had recurrent NSVT. Bilateral LENIs ruled out
clot. EKG was unchanged. The patient's beta blocker was
uptitrated with good effect.
.
#) HTN: Continued metoprolol, captopril.
.
#) CODE STATUS: Patient was initially DNR, not DNI; patient was
later made CMO by family after clinical status continued to
decline and patient had further bloody secretions.
.
#) DISPO: Patient expired on [**2148-1-20**] secondary to respiratory
failure due to diffuse alveolar hemorrhage related to his
underlying Wegener's. He was made comfortable at the time of
his death with morphine, ativan, and scopolamine. Family was
present at the time of expiration and declined autopsy.
.
Medications on Admission:
Roxicet [**12-12**] tsp q4h prn
Lopressor 50mg [**Hospital1 **]
Lasix 40mg qd
[**Hospital1 **] 10mg qd
Discharge Disposition:
Expired
Discharge Diagnosis:
1) Wegener's
2) Diffuse Alveolar Hemorrhage
3) Respiratory Failure
4) Pancytopenia
5) Laryngeal Cancer
6) Acute Renal Failure
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 486, 2851, 5845, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8397
} | Medical Text: Admission Date: [**2150-1-26**] Discharge Date: [**2150-2-1**]
Date of Birth: [**2088-9-19**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 61-year-old male had no
prior history of coronary artery disease, but reported a 10-
year history of angina with progressive angina in the past
year. Electrocardiogram showed ST depressions in leads I, II
and V4 through V6 as well as ST elevations in V1. He was
admitted to the hospital on [**2150-1-26**], and cardiac
catheterization was performed which showed a 90 percent
distal left vein lesion, a 90 percent left anterior
descending lesion, 70 percent circumflex lesion and a totally
occluded RCA in the mid portion. His ejection fraction was
40-45 percent. Intra-aortic balloon pump was placed in the
Cardiac Cath Laboratory at the time of catheterization. It
also showed anterolateral and distal inferior hypokinesis.
PAST MEDICAL HISTORY: Angina.
Bell's palsy.
Hypertension.
Hypercholesterolemia.
PAST SURGICAL HISTORY: Repair of his left shoulder.
Tonsillectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS: He was on no medications daily.
SOCIAL HISTORY: The patient was a cab driver who said that
he never smoked and had no history of alcohol use.
FAMILY HISTORY: Unknown as the patient was adopted.
PHYSICAL EXAMINATION: He is 5 feet, 8 inches tall and 195
pounds. He is in sinus rhythm at 65. Blood pressure
175/95. Respiratory rate 21. Sating 100 percent on three
liters nasal cannula. He was
in bed in the Coronary Care Unit. He was in no apparent
distress. He was alert,
oriented and appropriate. He had a slight left facial droop
due to his Bell's palsy and no
carotid bruits. His lungs were clear to auscultation
anteriorly bilaterally. His heart was regular rate and
rhythm with S1 and S2 tones. His balloon pump was on 1:1.
His abdomen was soft, round, obese, nontender and
nondistended with positive bowel sounds. His extremities
were warm and well perfused with no edema or varicosities
noted. He had 2+ bilateral radial dorsalis pedis and
posterior tibial pulses.
PREOPERATIVE LABORATORY DATA: White count 7.6. Hematocrit
41.6. Platelet count 234,000. Sodium 136. Potassium 3.9.
Chloride 103. Bicarb 27. BUN 11. Creatinine 0.8 with a
blood sugar of 99. PT 12.7. PTT 33.8. INR 1.0. ALT 19.
AST 22. Alkaline phosphatase 49. Amylase 22. Total
bilirubin 0.5. Albumin 3.8.
Chest x-ray showed no acute cardiopulmonary disease. His
urinalysis was negative.
The patient was referred immediately in the Cath Laboratory
to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Additional history showed that the
patient in the morning of admission had walked to the [**Hospital Ward Name 8559**] and thinks he passed out or almost passed out. He was
brought in to the emergency room directly at that time. Dr.
[**Last Name (STitle) **] saw the patient emergently in the Cath Laboratory and
in consultation asked by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], the cathing
cardiologist, and the patient consented to have surgery the
following morning. That day in the evening in the Coronary
Care Unit the patient was started on captopril and metoprolol
as well as a nitroglycerin drip with good effect. He did not
have any complaints at that time. He was also given aspirin
and Lipitor and remained stable overnight. On the morning of
the 28th, he was taken to the operating room where he had a
coronary artery bypass grafting times three by Dr. [**Last Name (STitle) **]
with a left internal mammary artery to the left anterior
descending, a vein graft to the obtuse margin and a vein
graft to the distal RCA with a balloon pump in place. He was
transferred to the Cardiac Cath Intensive Care Unit in stable
condition on the Neo-Synephrine drip at 0.4 mcg/kg/minute and
a propofol drip at 20 mcg/kg/minute. He was extubated on the
evening of the 28th without incident sating 95 percent. The
balloon remained in place with good augmentation and systolic
and diastolic unloading. He did have some episodes of sinus
tachycardia to the 120s-130s. He awakened in pain, and he
was monitored without any intervention. His heart rate was
in the 90s at rest. His Neo-Synephrine was weaned off. His
nitroglycerin was started after extubation and weaned off
through the night. He was taking sips of water and also
remained on an insulin drip with plans to remove his balloon.
He was also seen by Case Management. In the CSRU, his
balloon was removed later that day, and he was transferred
out to the floor. The patient was also seen by Social Work
as the patient had few supports and there was concern about
his ability to care for himself and have rehabilitation. The
patient was living in a rooming house at [**Location (un) **] at the
time with three roommates. On postoperative day two, the
patient was in sinus rhythm at 100, a blood pressure of
112/67. Postoperative labs were as follows, white count
14.6, hematocrit 32.7, platelet count 167,000, potassium 5.0,
BUN 20, creatinine 1.0 and INR 1.1. He began his beta
blockade with Lopressor 25 b.i.d. He continued with Lasix
intravenous diuresis. Aspirin also had been restarted. His
chest tubes remained in place. His intravenous line was
removed. Pacing wires remained in place. Later that day,
his chest tubes were discontinued. The patient was
encouraged to get up with physical therapist and the nurse.
He was evaluated by the staff of physical therapy to work on
his ambulation. He was switched over to Percocet p.r.n. for
pain control. His pacing wires were discontinued on
postoperative day three. His blood pressure remained stable.
He was alert with a nonfocal examination. His heart was
regular in rate and rhythm. His lungs were clear
bilaterally. He had one episode of mild heart palpitations
while on the stairs which subsided immediately with rest. He
was steady on his feet though and quite independent, and
discharge planning continued. He had some trace ankle edema
bilaterally. The patient had a complaint of constipation on
[**1-31**]. He did have flatus. Milk of Magnesia was also
given as well as prune juice. Percocets were providing good
pain relief. He was also given a Dulcolax suppository.
Incisions were clean, dry and intact. The patient continued
on telemetry monitoring with encouragement to increase his
pulmonary toilet and continue to ambulate. The patient did
verbalize some fears and despondent thoughts secondary to his
home situation. Nursing staff continued to work with Social
Work and Case Manager to help plan postoperative services
with the [**Hospital6 407**] for counseling, etc.
On postoperative day four, the patient's examination was
unremarkable. He continued on diuresis, and his medications.
He continued with physical therapy and working with the
Social Work staff to plan for his discharge. Case Management
also agreed to help the patient fill out his health insurance
paperwork as he was slightly anxious about it. The patient
was discharged to his rooming house with [**Hospital6 1587**] services on [**2150-2-1**] with the following
discharge diagnoses:
Status post emergency coronary artery bypass grafting times
three.
Bell's palsy.
Hypertension.
DISCHARGE INSTRUCTIONS: The patient was instructed to follow
up with his primary care physician in approximately two weeks
and to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] his cardiac surgeon in
the office first postoperative surgical visit in
approximately one month.
DISCHARGE MEDICATIONS: Potassium chloride 20 mEq p.o. twice
a day for seven days.
Lasix 20 mg p.o. twice a day for seven days.
Zantac 150 mg p.o. twice a day.
Enteric coated aspirin 81 mg p.o. once a day.
Percocet 5/325 one tablet p.o. p.r.n. every four hours for
pain.
Lipitor 20 mg p.o. daily.
Metoprolol 50 mg p.o. twice a day.
The patient was discharged with care group home care services
on [**2150-2-1**] in stable condition.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2150-2-18**] 12:35:32
T: [**2150-2-18**] 14:17:45
Job#: [**Job Number 111184**]
ICD9 Codes: 4111, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8398
} | Medical Text: Admission Date: [**2194-2-10**] Discharge Date: [**2194-2-21**]
Date of Birth: [**2155-3-7**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 39 year old
male with the history of alcoholism whose last drink was on
[**2194-2-9**]. He presented to an outside emergency room after
having a tonic clonic seizure at alcohol detoxification. In
the emergency room at the outside hospital patient was found
to have a blood pressure of 70/40 which decreased to 60/40 on
standing. Patient was aggressively fluid resuscitated with
normal saline, however, had a near syncopal episode while
using the commode. Patient was transferred to [**Hospital1 18**] for
further treatment of his hypotension. In the E.D. patient
had a temperature of 97.2, blood pressure 80/53, pulse 88,
respiratory rate 22, sating 99% on 2 liters. Patient had an
arterial blood gas that was notable for pH of 7.7, PCO2 19,
PO2 79. Given the concern for hypotension, cardiology was
consulted for a bedside echo in the E.D. which revealed a
huge RV with decreased function, high pulmonary pressures,
but no evidence of tamponade physiology. Given patient's RV
dysfunction, patient received a CTA which showed no definite
evidence of pulmonary embolism. Patient was started on a
dopamine drip. Patient was also noted to be in acute renal
failure with creatinine of 1.6 and had a Foley placed with
minimal urine output.
PAST MEDICAL HISTORY: Notable for alcoholism as above with a
seizure.
MEDICATIONS ON ADMISSION: Librium, promazine 10 mg p.o.
q.day. Promazine is an alpha agonist.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Remarkable for tobacco use as well as
alcoholism. Patient is currently homeless.
PHYSICAL EXAMINATION: On admission temperature was 97.5,
blood pressure as noted above 80/53, pulse 82, respirations
12, sating 99% on 2 liters. Generally, patient was
lethargic, oriented to time and person, but not place, had
coherent speech. HEENT was notable for mildly icteric
sclerae, poor dentition, pupils were reactive. Patient was
noted to have diffuse expiratory wheeze. Heart had regular
rate, 3/6 systolic murmur at left lower sternal border.
Abdomen mild tenderness in the upper quadrants bilaterally
with normoactive bowel sounds, nondistended, no
hepatosplenomegaly. No lower extremity edema. Neurologic
exam was grossly nonfocal.
LABORATORY DATA: On admission white count was 14.2,
hematocrit 34.8, platelets 95. INR was elevated at 1.4, PTT
37.0, PT 14.8. Sodium was 135, potassium 5.7, chloride 106,
bicarb 19, BUN 14, creatinine 1.6, glucose 98. ALT was 23,
AST 53, alka phos 86, total bili 2.6, total protein 6.3,
albumin 3.0. Tox screen was negative. CK was 256, MB 2,
troponin 0.22. Chest x-ray showed mild cardiomegaly, no
evidence of congestive heart failure. EKG was normal sinus
rhythm at 85 with rightward axis, deep T inversions in leads
V1 through V6, left atrial enlargement, no ST segment
depressions, right bundle pattern. Right seated EKG showed
no evidence of infarct.
HOSPITAL COURSE: In short, this is a 39 year old male with
alcoholism who presented with hypotension, status post
seizure. He was noted to have a dilated right ventricle with
negative CTA and no evidence of acute ischemia as well as
acute renal failure and elevated total bilirubin. Patient's
MICU course was as follows. Patient was hydrated with normal
saline and was briefly on dopamine. With hydration patient's
acute renal failure resolved and creatinine was 0.8. Patient
had a right heart catheterization showing markedly elevated
PA pressure of 97/42 and increased pulmonary vascular
resistance of 832. Patient had no response to Adenosine
challenge. Patient was also found to have a small nodular
liver on right upper quadrant ultrasound with small ascites.
This was evaluated by the hepatology service for further
workup. Patient was also started on Levaquin for bilateral
basilar infiltrates that were seen on chest CT.
1. Pulmonary hypertension. The patient had no evidence of
pulmonary embolus on CTA and on CTA lung parenchyma appeared
grossly normal. As noted above patient's elevated pulmonary
artery pressure would suggest that this is not an acute
process. Indeed, on further questioning patient revealed
that he had symptoms of lightheadedness and dizziness with
exertion for months prior to admission. Additionally,
patient had been evaluated by an outside physician and
started on an alpha agonist due to questionable orthostatic
hypotension. As noted above, patient underwent formal right
heart catheterization in the cardiac cath lab as well as
Adenosine challenge. Since patient had no response to
Adenosine challenge, it was felt that calcium channel
blockers would be of little use in this patient. Patient's
inability to abstain from alcohol additionally made him a
poor candidate for this. In the absence of other causes that
could be located for patient's pulmonary hypertension, it was
thought likely that he had portal pulmonary hypertension due
to cirrhosis which will be discussed below.
2. As noted in HPI patient was found to have elevated
bilirubin upon admission. He underwent right upper quadrant
ultrasound which showed a small nodular liver consistent with
cirrhosis as well as small ascites. Patient was elevated by
the liver service. Patient's hepatitis serologies were
checked and were negative. Patient underwent EGD while
hospitalized to evaluate for evidence of varices. Patient
was noted to have grade 2 varices in the middle third of the
esophagus. There was no stigmata of bleeding. Patient was
vaccinated against hepatitis B. Because of varices, patient
was started on a low dose of nadolol.
3. Infectious disease. The patient was treated for 10 days
with levofloxacin for bilateral lower lobe pneumonia present
on chest CT.
4. Substance abuse. The patient was started on Librium
while in-house to prevent withdrawal. Patient had no further
seizures or evidence of withdrawal while hospitalized. He
was continued on a Librium taper.
At the time of this intern going off service on [**2194-2-16**], the
patient was still in-house on Librium taper, clinically
stable, awaiting placement. Given patient's substance abuse
issues and severe disability due to his pulmonary
hypertension, ongoing attempts to find appropriate placement
for him were underway. This discharge summary will require
an addendum. Further dictation will be performed by [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **].
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Name8 (MD) 8330**]
MEDQUIST36
D: [**2194-6-5**] 15:56
T: [**2194-6-11**] 10:17
JOB#: [**Job Number 47162**]
ICD9 Codes: 5849, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8399
} | Medical Text: Admission Date: [**2162-8-25**] Discharge Date: [**2162-9-1**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 16115**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
[**Age over 90 **]M w/ho gallstones presenting to the emergency department from
an [**Hospital1 1562**] for likely cholangitis. Patient reports having right
upper quadrant and epigastric abdominal pain for the last 24-36
hours. At the outside hospital his initial VS were 96.8, 116/65,
65 16, 100RA, and he spiked a temp to 102.2 and he had an
episode of NBNB emesis. His labs were notable for evated T. bili
to 1.6 as well as elevated alkaline phosphatase. He was given 3g
IV Unasyn, morphine, zofran and MD [**First Name (Titles) **] [**Last Name (Titles) 90357**] for likely
cholangitis transferred. The patient has had ERCP with
sphincterotomy approximately a year ago. Right upper quadrant
ultrasound did demonstrate sludging and stones but no evidence
of CBD dilatation or cholecystitis. Also received tylenol at the
OSH for his fever. Was initially stable here initial VS were:
99.5 65 130/53 18 98% ra. Had increased O2 requirement and
became hypotensive sbp 70s, got 1L at OSH, 1.5L here. Had RIJ
put in 92/33, Vpaced. RR 20 99%2L. Started on norepi in ED, also
vanc here. ERCP fellow contact[**Name (NI) **]. [**Name2 (NI) **] do it in the morning.
FFP will need to be given.
On arrival to the MICU, patient's VS were BP 77/53 (not on
pressors), HR 65 Vpaced, 20 97% 2L. He was mentating well with
complaints of a slightly upset stomach and feeling like his
speech was slurred from the pain medicaitons. He denied any
abdominal pain currently, chest pain, shortness of breath,
dizziness or lightheadedness. He reports recently trying a low
fat diet. Pt reports the pain comes on when he eats.
Review of systems:
(+) Per HPI
(-) denies fevers, chills, dysuria, nausea, vomiting currently.
Past Medical History:
atrial fibrillation on coumadin
HTN
CAD
Hypercholastrolemia
OSA on CPAP
AAA repair
Pacemaker
spinal surgery
Social History:
no ETOH or drug abuse.
Family History:
not relevant to the current hospitalization
Physical Exam:
Admission:
Vitals: 98.2 83/41 65 17 96% 2L NC
General: Alert, oriented, no acute distress, very
comfortable-appearing
HEENT: MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no JVD
CV: Normal rate, reg ryhthm, +systolic murmur
Lungs: Crackles at bases bilaterally
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAOx3, moves all extremities, gait deferred.
Discharge exam:
T 99.2 HR 60 BP 130/64 RR 18 98% RA
General: Alert, oriented, no acute distress, very
comfortable-appearing
HEENT: MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no JVD
CV: Normal rate, reg ryhthm, +systolic murmur
Lungs: Crackles at bases bilaterally
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pitting edema LE bilaterally, with
scrotal edema (improving)
Neuro: AAOx3, moves all extremities, gait deferred.
Pertinent Results:
Admission:
[**2162-8-25**] 09:45PM WBC-12.7* RBC-3.69* HGB-12.5* HCT-37.0*
MCV-100* MCH-34.0* MCHC-33.9 RDW-13.4
[**2162-8-25**] 09:45PM NEUTS-91.6* LYMPHS-4.6* MONOS-3.5 EOS-0.1
BASOS-0.2
[**2162-8-25**] 09:45PM ALT(SGPT)-207* AST(SGOT)-556* ALK PHOS-399*
TOT BILI-3.1*
[**2162-8-25**] 09:45PM LIPASE-18
[**2162-8-25**] 09:45PM GLUCOSE-119* UREA N-21* CREAT-1.1 SODIUM-140
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-25 ANION GAP-16
[**2162-8-25**] 09:53PM PT-28.3* PTT-37.5* INR(PT)-2.7*
ERCP [**2162-8-26**]
-Impression: Evidence of a previous sphincterotomy was noted in
the major papilla. Cannulation of the biliary duct was
successful and deep with a balloon catheter using a free-hand
technique. Contrast medium was injected resulting in partial
opacification. Thick sludge was seen exuding out of the ampulla
after cannulation. A mild diffuse dilation was seen at the main
duct with the CBD measuring 10 mm. Multiple stones ranging in
size from 6 mm to 10 mm that were causing partial obstruction
were seen at the main duct. Given cholangitis, only limited
contrast injection was made.
Given cholangitis and elevated INR, a 5cm by 10FR double pig
tail biliary stent was placed successfully in the main duct.
Otherwise normal ercp to third part of the duodenum
-Recommendations: Return to [**Hospital Unit Name 153**]. NPO overnight with aggressive
IV hydration as tolerated with LR at 100-150 cc/hr. Follow for
response and complications. If any abdominal pain, fever,
jaundice, gastrointestinal bleeding please call ERCP fellow on
call ([**Pager number 8437**]). Continue IV antibiotics. Will need antibiotics
for total of 2 weeks. Can be transitioned to oral antibiotics
prior to discharge. Repeat ERCP in 5 weeks for stent removal and
extraction of stones. Hold coumadinn for 5 days prior to ERCP.
[**2162-8-28**] URINE CULTURE-FINAL no growth
[**2162-8-26**] URINE CULTURE-FINAL no growth
Brief Hospital Course:
[**Age over 90 **] yo male with CAD, Afib, HTN p/w hypotension requiring
pressors in setting of likely cholangitis.
Active Issues:
#Sepsis: Pt was initially hypotensive despite fluid
resuscitation and required BP support with norepinephrine.
Though his U/S is unchanged from prior study, in the setting of
his fever, hypotension, and rising enzymes and bili, most likely
cause is cholangitis. ERCP on [**8-26**] showed stones and some
sludge. Pt had stent placed but did not have sphincterotomy
given elevated INR. Pt had 1 of 4 bottles at OSH growing pan
sensitive E coli. Pt was initially treated with IV vancomycin
and unasyn. Weaned off norepinephrine [**2162-8-28**] once his paced
rate was increased from 65 to 85 bpm. WBC and LFTs continued to
down trend and normalized by the time of discharge. UA [**2162-8-27**]
concerning for UTI so Pt was started ciprofloxacin po.
Vancomycin and unasyn were discontinued on [**8-29**] given results of
blood cultures and switched to PO cipro at 750mg [**Hospital1 **] per ERCP
and pharmacy recs. He tolerated a regular diet and had complete
resolution of his abdominal pain. Pt needs repeat ERCP in 5
weeks, and will need to hold warfarin 5 days prior to procedure.
He will need a total of 14 days of oral antibiotics to treat
the cholangitis.
#Hypotension: Presumed [**1-14**] sepsis in the setting of cholangitis.
Low cardiac output could also be contributing to the hypotension
since his BP responded to increasing his paced rate to 85 from
baseline 65. Pt needed norepinephrine to support BP despite
receiving fluids but was weaned off once his HR was increased.
TTE showed 45% LVEF, markedly dilated RA, moderately dilated LA.
Overall LV systolic function is mildly depressed (LVEF = 45 %)
secondary to pacemaker-induced dyssynchrony and to ventricular
interaction, with a pressure/volume overloaded right ventricle.
Pt also had moderate to severe [3+] tricuspid regurgitation,
moderate pulmonary artery systolic hypertension. These results
indicate that he is preload dependent and requires to be
hydrated optimally. On transfer to the floor, however, and on
day of discharge to the [**Hospital1 1501**], he was significantly volume
overloaded with extensive LE edema and scrotal edema. He was
given lasix 40 mg IV over last 3 days to assist in getting rid
of the extra fluid, and discharged on Lasix 40 mg PO daily.
Please continue to monitor his renal function and electrolytes
with diuresis.
# ? UTI. UA with pyuria. Pt asymptomatic but was started on
ciprofloxacin (see above). Urine cultures negative to date.
#Afib: Paced rhythm (See above). On warfarin with therapeutic
INR, Pt was given FFP x 2 to correct coagulopathy but INR was
2.1 at time of ERCP, so no sphincterotomy was performed. Pt's
rate was increased to 85 given hypotension by EP service and was
reverted back to 60 by EP on discharge. He tolerated this
reversion back to his baseline HR without any problems. The
coumadin was restarted initially at 2.5 mg QHS and then 2 mg QHS
on [**8-31**] once his INR became therapeutic.
#CAD: Continue statin. ASA was initially held given plan for
ERCP but restarted aftewards given absence of sphincterotomy.
Carvedilol, enalipril, furosemide were all held due to
hypotension. These medications can be resumed if his BP
continues to be elevated. Of note, the patient has not taken
his furosemide in approximately 2 years because he feels he does
not have swelling but his cardiologist is not aware.
# Urinary retention: due to significant scrotal and penile
edema, a foley was placed in the ICU. The foley needed to be
performed by the urology - reportedly due to phimosis (likely
from the extra swelling). Mr. [**Known lastname 7568**] also has a history of
urinary retention most consistent with BPH. He was placed on
flomax and should be continued.. Once the extra fluid and edema
is properly eliminated, the foley should be discontinued.
#OSA: Continue CPAP.
#HLD: Continue statin.
# Communication: Patient , wife [**Name (NI) 2048**] [**Name (NI) 7568**] [**Telephone/Fax (1) 90358**]
# Code: DNR/DNI
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Calcium Carbonate 1000 mg PO DAILY
2. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral daily
3. Enalapril Maleate 5 mg PO DAILY
hold for sbp<100 or hr<60
4. Warfarin Dose is Unknown PO DAILY16
5. Coreg CR *NF* (carvedilol phosphate) 30 mg Oral daily
6. Furosemide 40 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Aspirin 81 mg PO DAILY
9. Clonazepam 0.25 mg PO QHS:PRN insomnia
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Warfarin 2 mg PO DAILY16
3. Acetaminophen 650 mg PO Q4H:PRN pain
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing/sob
5. Ciprofloxacin HCl 500 mg PO Q12H
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Tamsulosin 0.4 mg PO HS
8. Enalapril Maleate 5 mg PO DAILY
hold for sbp<100 or hr<60
9. Clonazepam 0.25 mg PO QHS:PRN insomnia
10. Calcium Carbonate 1000 mg PO DAILY
11. Furosemide 40 mg PO DAILY
12. NexIUM *NF* (esomeprazole magnesium) 40 mg ORAL DAILY
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Male First Name (un) 4542**] Nursing Center - [**Hospital1 1562**]
Discharge Diagnosis:
- Cholangitis
- Hypotension (chronotropic insufficiency)
- Peripheral edema
- Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with an infected common bile duct
(cholangitis) and low blood pressure. The infected common bile
duct was attributed to stones obstructing the duct pathway. An
ERCP was performed to remove the stones and place a stent to
facilitate emptying of the bile. You were treated with
antibiotics and should continue on oral antibiotics for another
7 days. You will need to return on [**9-30**] to have the stent
removed.
You had low blood pressure - which warranted a stay in the
intensive care unit. You were given iv fluids and your
pacemaker was temporarily increased in rate. Your blood
pressure is now stable and thus the pacemaker was reverted to
its previous settings.
You have substantial extra fluid and will benefit from
continued lasix (diuretic).
Followup Instructions:
Department: ENDO SUITES
When: THURSDAY [**2162-9-30**] at 1 PM
Department: DIGESTIVE DISEASE CENTER
When: THURSDAY [**2162-9-30**] at 1 PM
With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], 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) 1951**]
Campus: EAST Best Parking: Main Garage
ICD9 Codes: 0389, 5849, 2875, 5990, 4280, 2768, 4168, 2724, 4019 |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.