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{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8400 }	Medical Text: Admission Date: [2123-4-22] Discharge Date: [2123-4-29] Date of Birth: [2052-2-14] Sex: F Service: MEDICINE Allergies: Penicillins / Tegretol / Insulin,Beef / Insulin,Pork / Zaroxolyn Attending:[First Name3 (LF) 4980] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: 71 yo female with severe diastolic dysfunction, afib on coumadin, CAD, severe PVD with chronic LE ulcer and infection with MRSA who was recent admitted to [Hospital1 18] ([2123-3-30] - [2123-4-6]) for diastolic CHF and COPD excerbation where she was diuresed with Lasix gtt, and also just completed 14 day course of Vanc/Levo/Flagyl for her LE infection who was admitted for hypotension. . Prior to this admission, she was eating dinner at [Hospital 100] Rehab and vomited at 6 pm. At that time, she was noted to be lethargic and somnolent without respiratory distress. She had received an extra dose of Lasix that morning since her weight was up 3 lbs over the past 3 days. She reports no SOB, CP, dysuria, cough, only states feeling sleepy and "tired". She reports increased in her bliteral LE over the past few days. In ED, she had a temp of 101.1, WBC 16, lactate 1.9, and hypotensive in 70's/40's. She got a stress dose hyrdocortisone 50 mg IV x1, Vancomycin 1 gm IV x1, Ceftazidime 2 gm IV x1, Flagyl 500 mg IV x1, and 3 L NS bolus with BP response from 70's/40's to 90-100/50's. MUST protocol was initiated and pt was transferred to [Hospital Unit Name 153] for sepsis treatment. In the [Hospital Unit Name 153], she got a right subclavian line, and was briefly on Dopamine gtt from [Date range (1) ], and her BP has been stable off Dopa since. She got about 2.5 L of IVF in the ICU. She was started on Vanco/Ceftaz/Flagyl for her presumed sepsis from LE cellulitis/questionable osteo. Past Medical History: 1. CHF diastolic dysfunction (EF 65% 1/05 MIBI normal) DRY WEIGHT 194 lbs 2. DM 2 on insulin 3. Atrial Fibrillation 4. Anemia 5. CAD s/p PTCA x 3 (RCA '[09], LCx '[10], RCA '[13]) 6. Pulmonary HTN 7. Hypercholesterolemia 8. COPD/[Year (2 digits) 105496] on home O2 (sometimes on home O2) 9. Thyroid CA s/p resection/now hypothryoid 10. Myoclonic tremors 11. H/O PE 12. OSA on CPAP (started last admission) 13. Depression/Anxiety 14. h/o MRSA/VRE. ICU admit x 2 for MRSA aortic valve endocarditis and pseudomonal sepsis (secondary to wound infection), status post intubation x 2. 15. S/p laproscopic cholecystectomy [34]. s/p right throcoscopy and decortication. Right lung bx. 17. s/p right hip ORIF 18. s/p right ankle ORIF Social History: Pt is divorced with three children. Former CPA. Quit smoking in [2104] after a history of 1 ppd x 15 years. No etoh. No drugs.Lives at [Hospital 100] Rehab Family History: F: Died at 47 of MI; M: Colon CA; brother with DM Physical Exam: On transfer to the floor [4-26]: VS: Tm/Tc 99.9/97.5 BP 122/51 HR 118 RR 14 O2sat 97-99% RA GEN: Awake, pleasant, NAD HEENT: NC/AT, PERRL, EOMI, MMM, neck supple, no cervical LAD COR: Irregular, S1, S2, no M/R/G LUNGS: Crackles at the bases R>L ABD: +BS, soft, NTND, no hepatosplenomegaly EXT: R foot ulcer on plantar medial heel with black eschar, necortic. L foot with erythema/scab at the hallux lateral nail border. Heel with black eschar. L heel ulcer with necrosis, not probable to bone by [Month/Year (2) ]. bilateral LE venous stasis change and weeping serosanguinous fluid from the shin. NEURO: Alert and oriented x 3, CN II-XII intact. Strengths grossly [6-10]. Sensation intact to light touch. Pertinent Results: Micro: BCx: ([4-23])-NGTD, ([4-22])-NGTD x2 Sputum Cx: ([4-23])-Staph Aureus coag + Swab ([4-23]): Heels, tibial wounds: MRSA L great toe: Proteus sp ([Last Name (un) 36] ceftriax, ceftaz, cefepime) Cath tip: ([4-23])-Coag negative Staph (oxacillin resistant) Urine Cx: ([4-23])-NGTD Radiology: -MRI Foot ([4-26]): 1. Right calcaneal intraosseous lesion, most consistent with a bone infarct. Chronic osteomyelitis is less likely, but continued followup is recommended. 2. Diffuse subcutaneous edema of both feet and visualized portions of both calves, a nonspecific finding, but possibly related to cellulitis -CXR ([4-25]): +PICC placement, L linear atelectasis, small right side pleural effusion -Left foot film ([4-23]): diffuse dimineralization; no new fracure, no local bony destruction, possible dislocation of the second metatarsophalangeal joint. -NIAS ([4-23]):significant SFA and tibial dz bilaterally Brief Hospital Course: 71 yo F with severe diastolic dysfuntion, a-fib on coumadin, CAD, pulmonary fibrosis, severe PVD with chronic LE ulcer who presented with septic shock likely from LE ulcers secondarily infected. . MICU course: subclavian line placed and briefly on Dopamine gtt from [Date range (1) ]. She was presumed to be in septic shock secondary to L shifted elevated WBC. Other etiology would be over-diuresis and hypovolemia (but elev WBC does not fit this etiology). The source of sepsis was unclear but felt to be LE ulcers, as blood cx, CXR and UA were not revealing. She received 2.5 L of IVF in the ICU. She was continued on Vanco/Ceftaz/Flagyl for her presumed sepsis from LE cellulitis/questionable osteomyeltis. No Blood Cx or Urine Cx grew an organism. . 1)Foot ulcer/infection: Pt likely had re-infection of the LE wound after completing a 14 day course of Vanc/Levo/Flagyl. Pt got a non-invasive art studies this hospitalization with sigfnificant SFA and tibial dz. [Date range (1) ] and [Date range (1) ] surgery followed in house. Recommendations were for local wound care, with systemic antibiotics, and outpatient follow-up for continued discussions of re-vascularization/angiogram. Swabs of L and R heel and L great toe and tibial wounds revealed MRSA and Proteus species (sensitive to 3rd/4th gen cephalosporins, but resistant to FQ, gent). [Date range (1) ] was unable to probe to bone on their exam. An x-ray of the L foot showed no evidence of osteomyelitis. An MRI was also obtained which showed possible intraosseus bone infarct of L calcaneus but no clear evidence for osteomyelitis. A follow-up xray should be obtained after patient finishes course of antibiotics. -- patient will finish 2 week course of Vanc/Ceftaz/Flagyl, PICC line placed. -- Vanc trough sl elevated (25), changed to 750 mg q24. -- all blood cx were NGTD. . 2)Hemodynamics: Pt was briefly (< 36hrs) on pressors (dopamine) for BP support in MICU. She remained basically euvolemic on the medical [Hospital1 ] requiring no pressors and just her maintenance diuresis. -- In the past, she required Lasix gtt for diuresis as she is very sensitive to lasix. . 3)Cardiovascular: Pump: Pt with severe diastolic dysfunction and very sensitve to lasix bolus. Goal was BP/HR control. -- Patient did not require IV lasix in and was restarted on her oupatient dose prior to discharge. She was euvolemic on physical exam. -- Her lisinopril 5 mg po daily was also restarted prior to discharge for optimum BP control. -- Metoprolol was titrated up throughout her stay for better HR control (see below) . Ischemia: -- She was continued on BB, ASA, simvastatin. . Rhythm: -- Afib throughout stay. -- Her dose of metoprolol was titrated up for better HR control, she was d/c'd on 37.5 mg tid with HR in 80's. -- For anti-coag the patient was placed on warfarin 5 mg po qhs (goal INR [3-11]), she should have INR checked in [3-11] days after discharge. -- amiodarone has been discontinued during the last admission for concern of pulmonary toxicity. . 5)Pulm: Pt h/o COPD/[Date Range 105496]/pulmonary fibrosis. Some wheezing noted in ICU but was treated successfully withn Albuterol and Ipratropium nebs PRN . 6)DM: The patient's glargine 14 units was stopped and she was switched to NPH 14 units in AM as she had low sugars in AM and high at night. She was maintained on HISS prior to meals and at bedtime. . 7)Pain: The patient had escalating pain on medical [Hospital1 ] and her doses of fentanyl patch was increased to 75mcg/q72hrs and her neurontin was also changed back to her dosing during her most recent hospital stay [Telephone/Fax (3) 105497]). She was receiving oxycodone 10mg every 4hrs prn for breakthrough pain and standing tylenol 1g tid. The patient was not somnolent or lethargic on this regimen. She should be monitored closely as she has had changes in her mental status before due to over-sedation with narcotics. . 8)Psych: Continue citalopram, methylphenadate, Topamax. . 9)Anemia: Anemia of chronic illness. Hct low but at baseline throughout stay (28-30). -- She was continued on iron supplements. . 10)Hypothyroid: -- Continued Levoxyl at outpatient dosing. TSH 1.1. Medications on Admission: tylenol amiodarone 200mg po q24h - d/c'd by pulmonary clinic [4-16]. ASA 325mg po q24h citalopram 60mg po q24h dulcolax 10mg po q24h colace 100mg po bid fentanyl 50mcg TP q72h FeSO4 325mg po q24h lasix 40mg po q24h lasix 40mg po q MWF am for wt > 200lbs neurontin 300mg po bid lansoprazole 30mg po q24h levoxyl 200mcg po q24h lisinopril 5mg po q24h methylphenidate 10mg po q24h metoprolol 25mg po tid multivit olanzapine 5mg po qhs oxycodone 10mg po q4h simvastatin 20mg po qhs topiramate 25mg po q24h warfarin miconazole glargine 18U qhs insulin SS 150-200 - 6U 200-250 8U 250-300 10U 300-350 12U 350-400 14U Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Citalopram Hydrobromide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Levothyroxine Sodium 200 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): please give 2 hrs before or after iron pill is taken. 7. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 12. Oxycodone HCl 5 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 13. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 15. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO twice a day. 16. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 17. Topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Methylphenidate HCl 10 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 19. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS (at bedtime) for 7 days. 20. Insulin NPH Human Recomb 100 unit/mL Syringe Sig: Fourteen (14) units Subcutaneous qAM. 21. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection four times a day. 23. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) patch Transdermal Q72H (every 72 hours). 24. Gabapentin 300 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime): please give 600mg [Hospital1 ] and 900mg at bedtime. 25. Ceftazidime 2 g Recon Soln Sig: Two (2) grams Intravenous twice a day for 10 days. 26. Vancomycin HCl 1,000 mg Recon Soln Sig: Seven [Age over 90 1230]y (750) mg Intravenous once a day for 10 days. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - Acute Rehab Discharge Diagnosis: Primary: -- presumed septic shock -- infected venous stasis ulcers Secondary: diastolic CHF Afib CAD DMII COPD vs [Hospital6 105496] vs pulm fibrosis h/o thyroid ca pulm HTN Discharge Condition: stable, tolerating room air, afebrile Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500ml --If you experience any chest pain, shortness of breath, fevers > 101.5, [Name6 (MD) 138] primary MD or go to ER. --please continue Antibiotics for 10 days. --please have INR checked in [3-11] days. Followup Instructions: --Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4582], M.D. Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 3512] Date/Time:[2123-5-6] 2:30 --Provider: [Name10 (NameIs) ] SCAN Where: [Hospital6 29] RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2123-7-1] 2:00 --Provider: [Name10 (NameIs) 1571] BREATHING TESTS Where: [Hospital6 29] PULMONARY FUNCTION LAB Phone:[Telephone/Fax (1) 612] Date/Time:[2123-7-16] 11:35 --Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SURGERY Where: [Last Name (NamePattern4) ] SURGERY Date/Time:[2123-5-13] 11:00 Completed by:[2123-4-28] ICD9 Codes: 0389, 4280, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8401 }	Medical Text: Admission Date: [2142-9-30] Discharge Date: [2142-10-15] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Presyncope Major Surgical or Invasive Procedure: [2142-10-2] Aortic Valve Replacement(27mm [Company 1543] Mosaic Porcine Valve). Replacement of Ascending Aorta and Hemiarch(30mm Gelweave Graft) with Reimplantation of Innominate Artery History of Present Illness: This is an 82 year old male with known aortic stenosis and increasing episodes of presyncope. Recent echocardiogram showed severe aortic stenosis with [First Name8 (NamePattern2) ] [Location (un) 109] of 0.8cm2, peak 87 and mean 53 mmHg. There was trace aortic insufficinecy and 2+ mitral regurgitation. His LVEF was estimated at 70%. Subsequent cardiac catheterization showed heavily calcified aorta and dilated ascending aorta, measuring 5.1 centimeters. Angiography revealed a left dominant system and an 80% lesion in the right coronary artery. Based upon the above, he was admitted for cardiac surgical intervention. Past Medical History: Congestive Heart Failure, Aortic Stenosis, Ascending Aortic Aneurysm, Coronary Artery Disease, Peripheral Vascular Disease with Claudication, History of Stroke, Atrial Fibrillation, Sick Sinus Syndrome, Type II Diabetes Mellitus, Hypertension, Obesity, History of Silent MI, Prostate Cancer - Lupron Injections, Gout, Macular Degeneration, Neuropathy, Osteoarthritis Social History: 30 pack year history of tobacco - quit 20 years ago. Denies ETOH. Married. Retired. Family History: No premature coronary artery disease Physical Exam: Vitals: BP 126/70, HR 82, RR 18, SAT 95 on room air General: obese, slow moving male in no acute distress HEENT: oropharynx benign, no peripheral vision in right eye Neck: supple, no JVD, hard to asses JVD due to squat neck Heart: irregular rate, normal s1s2, 2/6 systolic ejection murmur Lungs: clear bilaterally , diminished at bases Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, 2+ edema, rubor present Pulses: decreased distally Neuro: PERRL, EOM not intact, CN 2-12 grossly intact, nonfocal, slightly decreased strength on left side, moves all extremities Pertinent Results: [2142-9-30] 09:30PM BLOOD WBC-6.0 RBC-3.48* Hgb-11.0* Hct-33.6* MCV-97 MCH-31.8 MCHC-32.8 RDW-16.2* Plt Ct-191 [2142-9-30] 09:30PM BLOOD PT-13.0 PTT-37.5* INR(PT)-1.1 [2142-9-30] 09:30PM BLOOD Glucose-108* UreaN-21* Creat-0.9 Na-137 K-4.9 Cl-100 HCO3-27 AnGap-15 [2142-10-1] Carotid Ultrasound: No evidence of hemodynamically significant stenosis in the carotid arteries bilaterally. [2142-9-30] Chest x-ray: Cardiomegaly. Increased linear markings involving both lung bases. Findings represent atelectasis versus scarring. Pneumonia is not entirely excluded. COPD. No effusion detected. Brief Hospital Course: Mr. [Known lastname 68565] was admitted for heparinization and preoperative evaluation. Workup was unremarkable, and carotid ultrasound showed only minimal disease of the internal carotid arteries. He was subsequently cleared for surgery. On [10-2], Dr. [Last Name (STitle) 1290] performed an aortic valve replacement and replacement of his ascending aorta and hemiarch with reimplantation of his innominate artery. For additional surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CSRU for invasive monitoring. He initially required atrial pacing for junctional bradycardia. Within 24 hours, he awoke neurologically intact and was extubated on postoperative day one. Initially hypoxic, he required aggressive diuresis. Antihypertensives were titrated to maintain systolic blood pressures less than 120mmHg. Over several days, his heart rate improved as did his hypoxia. Pacing wires were removed on postoperative day three and he transferred to the SDU for further care and recovery. He remained in a rate controlled atrial fibrillation. Warfarin was resumed and dosed for a goal INR between 2.0 - 2.5. Warfarin was intermittently held for a subtherapeutic prothrombin time. He experienced urinary retention which required reinsertion of a foley catheter. Before discharge, foley catheter was removed and he was voiding without difficulty. He remained fluid overloaded with oxygen requirements. He continued to require aggressive diuresis and responded well to intravenous Lasix. He concomitantly had a productive cough. Serial chest x-rays were significant for improving bilateral pleural effusions with persistent lower lobe atelectasis. He was empirically started on antibiotics. Sputum cultures were obtained due to thick, green secretions. Microbiology showed gram negative rods and gram positive cocci, for which he was treated with levaquin. Over several days, he made significant clinical improvements with diuresis. Postop, he was also noted to have left upper extremity edema. Ultrasound was obtained which showed no evidence of left upper extremity deep venous thrombosis. Given his prior history of stroked with persistent left sided weakness, he worked with physical and occupational therapies to improve strength and mobility. Medical therapy was optimized and he was eventually cleared for discharge to rehab on postoperative day 13. Medications on Admission: Glipizide 5 qd, Avandia 2 qd, Warfarin, Colchicine 6 qd, Altace 5 qd, Levothyroxine 175 mcg qd, Lopid 600 [Hospital1 ], Allopurinol 300 qd, Prilosec 20 qd, Neurontin, Torsamide 100 qd, Lupron, Darvon prn Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 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. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Rosiglitazone 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:120 Capsule(s) Refills:0 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. 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 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 13. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Tablet(s) 14. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: Check INR [10-17]. 15. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day: x 1 week when reassess need for diuresis. Tablet(s) 16. Acetazolamide 250 mg Tablet Sig: One (1) Tablet PO twice a day for 2 days. Levaquin Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 1294] Discharge Diagnosis: Aortic Stenosis, Ascending Aortic Aneurysm - s/p Aortic Valve Replacement and Replacement of Ascending Aorta, Congestive Heart Failure, Coronary Artery Disease, History of Stroke, Peripheral Vascular Disease with Claudication, Atrial Fibrillation, Sick Sinus Syndrome, Type II Diabetes Mellitus, Hypertension, Obesity, History of Silent MI, Prostate Cancer, Gout, Macular Degeneration 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. Resume preoperative Warfarin management with Dr. *******. Followup Instructions: Dr. [Last Name (STitle) 1290] in [2-28] weeks, call for appt Dr. [Last Name (STitle) ] in [12-29] weeks, call for appt Dr. [First Name (STitle) ] in [12-29] weeks, call for appt Completed by:[2142-10-15**] ICD9 Codes: 9971, 486, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8402 }	Medical Text: Admission Date: [2120-11-8] Discharge Date: [2120-11-12] Date of Birth: [2036-9-12] Sex: F Service: MEDICINE Allergies: Lactose Intolerance Attending:[First Name3 (LF) 2009] Chief Complaint: UGIB Major Surgical or Invasive Procedure: nasogastric tube placement, foley catheter placement (both removed prior to discharge) History of Present Illness: Per MICU: "84 yo F w/ Hx of dementia, Hx of GIB, p/w UGIB at [Hospital1 1501]. NG lavaged in ED cleared after 750cc, GI does not want to scope given comorbidities. Also noted to have fever to 101.4 and U/A was positive so started on CTX in ED. Got CTA for mesenteric ischemia w/ and w/o contrast which was negative. Rectal exam guiac + but not grossly positive. Trop 0.04, EKG baseline: Sinus, small depressions V4-V6. Has been HD stable. Complains of abd pain. mental status is at baseline per son. In the ED, initial VS: 97.6 108 172/87 16 97. Pt got 3LIVF and hct dropped from 40->37. Started on IV pantoprazole and a foley and NGT placed and pt admitted to MICU for ? emergent EGD." . In MICU pt was seen by GI who felt pt was not a candidate for EGD given comorbidities unless she was to become hemodynamically unstable. Son is HCP and he agreed with no EGD. MICU team also discussed code status c son and he felt firmly that pt should be FC (though was dnr/dni several admissions ago in [12-15]). Pt did not have any further vomiting. Pt had one run of svt treated with 5 metop IV x1. Pt was continued on ceftriaxone for her UTI. Past Medical History: Alzheimers Diverticulosis (LGIB) IDDM, c/b diabetic nephropathy and neuropathy w/ some balance problems HTN [Name2 (NI) ] s/p TAH/BSO s/p cholecystectomy Lt humerus Fx [2117] shoulder tendonitis s/p breast cyst surgery osteoarthritis of knees L eye cataract repair SVT in micu, paroxysmal afib Social History: Patient currently living at [First Name4 (NamePattern1) 6107] [Last Name (NamePattern1) ], a [Location (un) 169] [Hospital1 1501], where she has been for over the past year. Her only living family is her son [Name (NI) ]. She is in the [Hospital1 1501] because of court ordered protective services. She currently is unable to walk, or carry out any ADL's. Smoking, drinking, and drug history unable to be elicited. Family History: Signficant for Alzheimer dementia : her father, sister. [Name (NI) ] mother died of bone cancer. Physical Exam: Vitals - 98.7 143/79 105 18 100%RA GENERAL: Mumbling incoherently, responds, but does not follow commands. HEENT: No elevated JVP. No scleral icterus. MM dry CARDIAC: RRR, No MRG LUNG: CTA anteriorly ABDOMEN: Soft, NT, ND, BS+ EXT: 2+ pitting edema in L leg, L leg contracted NEURO: Unable to perform neuro exam, pt. moving all extremities spontaneously. DERM: No rashes Pertinent Results: Admission labs: [2120-11-8] 09:25AM BLOOD WBC-8.6 RBC-4.52# Hgb-13.2# Hct-40.8# MCV-90 MCH-29.2 MCHC-32.4 RDW-15.4 Plt Ct-153 [2120-11-8] 09:25AM BLOOD Neuts-88.0* Lymphs-9.1* Monos-2.7 Eos-0.2 Baso-0.1 [2120-11-8] 09:25AM BLOOD PT-12.8 PTT-27.5 INR(PT)-1.1 [2120-11-8] 09:25AM BLOOD Glucose-314* UreaN-18 Creat-1.0 Na-138 K-8.2* Cl-104 HCO3-22 AnGap-20 [2120-11-8] 09:25AM BLOOD ALT-9 AST-54* LD(LDH)-1123(hemolyzed, wnl on repeat) CK(CPK)-206 AlkPhos-73 TotBili-0.4 [2120-11-8] 09:25AM BLOOD Lipase-26 [2120-11-8] 09:25AM BLOOD CK-MB-4 [2120-11-8] 09:25AM BLOOD cTropnT-0.04* [2120-11-8] 07:30PM BLOOD CK-MB-5 cTropnT-0.05* [2120-11-8] 11:57PM BLOOD CK-MB-6 cTropnT-0.05* [2120-11-8] 09:25AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.1 [2120-11-8] 09:39AM BLOOD Lactate-2.5* [2120-11-10] 03:32PM BLOOD Lactate-1.4 Discharge labs: [2120-11-12] 07:40AM BLOOD WBC-5.4 RBC-3.50* Hgb-10.3* Hct-31.3* MCV-89 MCH-29.4 MCHC-32.9 RDW-15.6* Plt Ct-131* [2120-11-12] 07:40AM BLOOD Plt Ct-131* [2120-11-12] 07:40AM BLOOD Glucose-146* UreaN-13 Creat-0.8 Na-144 K-4.1 Cl114* HCO3-26 AnGap-8 [2120-11-12] 07:40AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.9 Cholest-PND [2120-11-8] CTA abd/pelvis: IMPRESSION: 1. Mild wall thickening involving the rectosigmoid junction and rectum, compatible with mild proctocolitis, which is either inflammatory or infectious in etiology. Clinical correlation with endoscopy is recommended. 2. Patent mesenteric arteries with diffuse atherosclerotic disease within the celiac artery, SMA artery,and bilateral renal arteries without significant stenosis. 3. Bilateral renal cysts, stable in size and appearance when compared to prior study. 4. Two enhancing lesions in the liver, one seen on the arterial phase, and the other in the portal venous phase. These were not seen previously, and may represent perfusion anomalies. If clinically indicated, an MR can be obtained for further evaluation. [2120-11-9] LENI L leg: IMPRESSION: Limited study due to portable technique and decreased diameter of the left lower extremity veins as described above. However, no definite evidence of left lower extremity deep venous thrombosis. URINE CULTURE (Final [2120-11-10]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- 16 I CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: # UGIB: Appeared stable in ED and on the floor though she did initially have coffee grounds in the ED which cleared from NG lavage after 750cc. GI was consulted and recommended no EGD as pt hemodynamically stable. It was felt that risks outweighed the benefits. She was started on PPI [Hospital1 ] and her diet advanced back to her home diet (purees and nectar thick liquids). . #UTI: Lactate initially elevated but wnl after fluid repletion. Pt was treated with ceftriaxone while inpatient and transitioned to cefpodoxime to complete a 7 day course. . # Severe dementia: Remained near baseline per pt's son. She makes eye contact but does not respond to questions appropriately and does not know her name. She was continued on depakote and risperdal. . # tachycardia/lateral 1mm ST depressions on EKG (variable throughout admission) and small troponin bump: Trop felt to be most likely secondary to small amount of demand given tachycardia. Pt was ruled out for MI with 3 sets of cardiac enzymes which did not show a rising troponin. Pt was started on low dose metoprolol. A recent echo showed preserved EF so ace not started (pt not hypertensive). Aspirin was deferred as pt admitted for GIB. Sinus tachycardia resolved with fluid repletion. Pt was continued on simvastatin. . # ? paroxysmal atrial fibrillation: pt carries this diagnosis per paperwork from [Hospital1 ]. Did have one brief episode of SVT ~100bpm on telemetry which resolved spontaneously. Metoprolol 12.[4-9] help with rate control during these episodes. . # DMI: Pt's NPH decreased to 11U and humalog sliding scale started. She required minimal sliding scale. . # CONTACT/HCP: [Name (NI) ] [Name (NI) ] [Telephone/Fax (1) 25703]. Communication was maintained c son throughout admission, though he was unable to come in [1-8] recent rib injury. Medications on Admission: Purreed diet Colace 100mg [Hospital1 ] CaCO3 500mg [Hospital1 ] Vitamin D 50k unitsQW Risperdal 0.25mg [Hospital1 ] Depakote 250mg [Hospital1 ] Simvastatin 10mg QHS NPH 22U sc qam RISS [Hospital1 ]: 200-250 4U, 250-300 6U, 300-350 8U, 351-400 10U Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [Hospital1 ]: One (1) Injection three times a day: please continue if pt unable to ambulate. IF continued, NEED to check PTT and platelets to confirm no rise in PTT and no drop in platelets twice weekly. NEXT CHECK ON [2120-11-13]! If PTT rising or plts dropping MUST [Name8 (MD) ] MD as pt may require adjustment in dose or perhaps require a test for heparin induced thrombocytopenia. 2. Simvastatin 10 mg Tablet [Name8 (MD) ]: One (1) Tablet PO DAILY (Daily). 3. Risperidone 0.25 mg Tablet [Name8 (MD) ]: One (1) Tablet PO BID (2 times a day). 4. Calcium Carbonate 500 mg Tablet, Chewable [Name8 (MD) ]: One (1) Tablet, Chewable PO BID (2 times a day). 5. Divalproex 125 mg Capsule, Sprinkle [Name8 (MD) ]: Two (2) Capsule, Sprinkle PO BID (2 times a day). 6. Metoprolol Tartrate 25 mg Tablet [Name8 (MD) ]: 0.5 Tablet PO BID (2 times a day). 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 8. Cefpodoxime 100 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO twice a day for 6 doses. 9. Colace 100 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO twice a day. 10. Vitamin D 50,000 unit Capsule [Last Name (STitle) ]: One (1) Capsule PO once a week. 11. NPH Insulin Human Recomb 100 unit/mL Cartridge [Last Name (STitle) ]: Eleven (11) units Subcutaneous qam: titrate up as indicated. 12. Humalog 100 unit/mL Cartridge [Last Name (STitle) ]: One (1) Subcutaneous three times a day: per sliding scale. Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 6107] [Last Name (NamePattern1) ] Discharge Diagnosis: UTI, Upper GI Bleed Discharge Condition: able to speak and eat, not oriented to person, place or time. Discharge Instructions: Ms [Known lastname ] was admitted to the hospital for upper GI bleed noted at her nsg home. She was found to have coffee grounds by GI lavage in the ED that cleared in the ED. She was admitted to the MICU and had no further bleeding and was transferred to the floor. GI was consulted but felt that pt would be a poor EGD candidate. She was also found to have a UTI, for which she was treated with ceftriaxone and then transitioned to cefpodoxime to complete 7 day course. She was noted to have left>R lower extremity swelling, but no DVT was found on ultrasound. She was also noted to be very dehydrated and was treated with IV fluids on day 1 and 2 of hospitalization. On day 3 she was able to drink enough fluids (~1 liter). Her NPH was decreased from 22 qam to 11 qam as she had several low blood sugars. She was initially not eating, and recieved IVF, but on HD 3 began eating full pureed meals. She was also noted to have a small troponin leak but ruled out for MI and was started on low dose metoprolol [Hospital1 ]. Pt was observed overnight and was stable. Medication changes: 1. NPH decreased from 22U to 11U. This may need to be uptitrated as she continues to eat more. 2. pt was started on metoprolol 3. she was started on UTI treatment with ceftriaxone and should finish 7 day course with cefpodoxime at skilled nsg facility 4. added lansoprazole [Hospital1 ] Followup Instructions: -Please monitor her vital signs and call physician for HR <60 or >100, SBP >160 or <90, RR >20 or <12, oxygen saturation <93%. -Please monitor for signs of UTI by follow up UA in 1 week as pt is poor historian, as pt has had multiple prior UTIs. -Please continue her diet and aggressive PO fluids as pt appeared very dry on admission. Completed by:[2120-11-12] ICD9 Codes: 5789, 5990, 3572, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8403 }	Medical Text: Admission Date: [2178-2-20] Discharge Date: [2178-2-26] Date of Birth: [2132-2-26] Sex: M Service: Cardiac Surgery HISTORY OF PRESENT ILLNESS: This is a 45 year old gentleman who had new onset of angina six days ago, referred for a stress test which was positive for inferolateral ischemic changes, referred for cardiac catheterization. On cardiac catheterization he was found to have an ejection fraction of 60%, 70% left main lesion, 50% proximal left anterior descending lesion, 70% diagonal lesion and 95% circumflex lesion and 90% ramus. The patient was admitted to [Hospital6 1760] for cardiac surgery. PAST MEDICAL HISTORY: 1. Hypertension; 2. Peripheral vascular disease; 3. Status post bilateral femoral popliteal bypass; 4. Hypercholesterolemia; 5. History of hepatitis C. SOCIAL HISTORY: The patient was married with three children. He smoked cigarettes, one pack per day times 25 years. He denies alcohol. He works for the city of [Hospital1 ] Fire Department. PREOPERATIVE MEDICATIONS: 1. Diovan 160 mg p.o. b.i.d. 2. Lipitor 20 mg p.o. q. day 3. Alprazolam .25 mg p.o. b.i.d. prn 4. Ultram 50 mg p.o. q.i.d. prn 5. Aspirin 325 mg p.o. q. day ALLERGIES: No known drug allergies. HOSPITAL COURSE: The patient was admitted to [Hospital6 1760] on [2-20] and on [2-21], he was taken to the Operating Room with Dr. [Last Name (STitle) 70] for coronary artery bypass graft times four, left internal mammary artery to left anterior descending, right internal mammary artery to right coronary artery, saphenous vein graft to ramus and saphenous vein graft to obtuse marginal. Immediately postoperatively, upon reversal of anesthesia, the patient was noted to be extremely agitated and combative. There was some concern that the patient had a history of substance abuse. A Pain Service Consult was obtained, the patient was started on a prosthetic infusion and Valium and Clonidine for control of blood pressure. The patient was subsequently weaned and extubated from mechanical ventilation and initially required a moderate amount of pulmonary toilet with significant hypoxia which resolved. Over the course of postoperative day #2, the patient was weaned from his prosthetic infusion, had good pain control with Dilaudid. The patient continued to have moderate hypertension which was controlled with the addition of oral medications. The patient began ambulating in the Intensive Care Unit and on postoperative day #4 was transferred from the Intensive Care Unit to the regular part of the hospital. On postoperative day #4, the patient was seen and evaluated by physical therapy. At that time he was able to ambulate 500 feet and climb one flight of stairs without requiring oxygen and remaining hemodynamically stable, and on postoperative day #5, the patient was cleared for discharge to home. Temperature maximum 98.7, pulse 76 in sinus rhythm, blood pressure 146/67, respiratory rate 16, room air oxygen saturation 100%. Laboratory data revealed white blood cell count 11.2, hematocrit 25.4, platelet count 174. Sodium 141, potassium 4.3, chloride 103, bicarbonate 28, BUN 16, creatinine 0.8 and glucose 95. The patient is awake, alert and oriented times three and neurologically nonfocal. Heart: Regular rate and rhythm without rub or murmur. Breath sounds are clear bilaterally. Abdomen shows positive bowel sounds, soft, nontender, nondistended. Sternal incision is clean, dry and intact. Sternum is stable. Bilateral vein harvest site is clean and dry. There is no erythema or drainage. Distal extremities have 1 to 2+ pitting edema. DISCHARGE MEDICATIONS: 1. Lopressor 75 mg p.o. b.i.d. 2. Lasix 20 mg p.o. b.i.d. times seven days 3. Potassium chloride 20 mEq p.o. b.i.d. times seven days. 4. Zantac 150 mg p.o. b.i.d. 5. Enteric coated Aspirin 325 mg p.o. q. day 6. Imdur 60 mg p.o. q. day 7. Dilaudid 2 to 6 mg p.o. q. 4-6 hours prn 8. Folate 1 mg p.o. q. day 9. Thiamine 100 mg p.o. q. day 10. Clonidine 0.1 mg p.o. b.i.d. 11. Valsartan 160 mg p.o. b.i.d. 12. Lipitor 20 mg p.o. q. day 13. Nicotine patch 21 mcg transdermally q. day times one month. DISCHARGE DIAGNOSIS: 1. Coronary artery disease. 2. Status post coronary artery bypass graft. 3. Hypertension. CONDITION ON DISCHARGE: The patient is to be discharged to home in stable condition. FOLLOW UP: The patient is to follow up with his primary care physician, [Last Name (NamePattern4) ]. [First Name (STitle) ] in one to two weeks. The patient is to follow up with Dr. [Last Name (STitle) 2912] in one to two weeks. The patient is to see Dr. [Last Name (STitle) 70] in five to six weeks. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern1) 1541] MEDQUIST36 D: [2178-2-26] 12:53 T: [2178-2-26] 13:25 JOB#: [Job Number 95917] ICD9 Codes: 4111, 4439, 4019, 2720, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8404 }	Medical Text: Admission Date: [2107-3-21] Discharge Date: [2107-3-31] Date of Birth: [2062-3-10] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 12] Chief Complaint: Back pain Major Surgical or Invasive Procedure: [2107-3-22]: Spinal angiogram Dr. [Last Name (STitle) ] [2107-3-23]: Thoracic Laminectomy with Dr. [Last Name (STitle) ] History of Present Illness: This is a 44 year old man with metastatic RCC on sunitinib who presented with 1 week worsening band-like RUQ pain, He had associated nausea & one episode of vomiting which seemed to be due to pain. He also had diffuse LUE sharp pain. He denied parasthesias, numbness, saddle anesthesia, incontinence of bowel or bladder. He endorsed some LLE weakness which is chronic and has not worsened recently. He also has chronic left shoulder/neck pain. He had a CT in ED which ruled out GI/biliary pathology but revealed near obliteration of T8 canal due to metastatic lesion with anterolateral cord displacement. The patient was unable to tolerate MRI secondary to severe pain upon recumbency. At that point, it was decided that the patient would be intubated and sedated to allow for MRI. Neurosurgery was consulted for surgical decompression. Past Medical History: PAST ONCOLOGIC HISTORY: - presented to [Hospital1 1774] ED in [4-/2101] c/o abdominal pain and gross hematuria. CT scan performed and showed a 14-cm tumor on his left kidney. - [2101-4-22]: underwent a radical left nephrectomy which showed a 14 x 14 x 10 cm tumor that was of clear cell type, firm and nuclear grade [2-13]. There was evidence of tumor thrombus extending into a large muscular vein at the hilum of the kidney. His left adrenal gland was removed and was negative for tumor. 0/4 hilar lymph nodes, 0/20 paraaortic lymph nodes and a small bowel lymph node obtained was negative for malignancy. - [2104-11-17]: suffered a traumatic work-related fall (fell 25 feet off a ladder). Standard trauma x-rays and a nonenhanced CT, showed the presence of new pulmonary nodules. - [2105-1-13] CT TORSO: innumerable pulmonary metastases, bulky mediastinal lymphadenopathy. - [2105-1-30]: FNA right upper lobe lung nodules showed malignant cells consistent with metastatic clear cell carcinoma of the kidney [2105-6-16]: Started on IL-2; received 10 out of 14 doses, first week was complicated by encephalopathy and the second week was complicated by renal failure, transaminitis and Staph epidermitis bacteremia s/p Vancomycin - [2105-8-5] chest CT, no evidence of progression of metastatic disease - [2105-12-9] CT TORSO: progression of disease - [2106-5-5]: Started Avastin 10mg/kg q2 weeks; CT [2106-6-30] showed stable disease - [Date range (3) 85765]: Cyberknife to subcarinal mass; 2400 cGy in 3 fractions. - [8-26] C3D1 of Avastin after staging CT [8-26] showed disease progression . PAST MEDICAL HISTORY: GERD s/p appendectomy at age 23 [11-20] 25ft fall; suffered bilateral calcaneal fractures, bilateral tibial fractures, L2 fracture s/p IVC filter Depression Anxiety Social History: The patient lives with his wife and his two daughters in [Name (NI) 8242]. He does not work since his accident in 12/[2104]. He denies smoking, EtOH, or illegal drugs. He has VNA. Family History: Mother had breast cancer but died of alcohol abuse. His brother also has alcoholic liver disease. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals - GENERAL: Anxious, uncomfortable, crying due to pain SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, nontender supple neck, no LAD, no JVD CARDIAC: Regular tachycardia, S1/S2, no mrg 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: 4+ patellar RLE reflex, bilateral LE clonus R>L, strength [2-14] hip flexion b/l (raised off bed), gastrocs [4-16] b/l. Otherwise refused remainder of exam. DISCHARGE PHYSICAL EXAM: Vitals - 98.3 78P 20RR 100/62 96%RA Appearance: alert, NAD, drowsy but arousable Eyes: incomplete right abducens nerve palsy ENT: OP clear s lesions, mmm, no JVD, neck supple Cv: +s1, s2 -m/r/g, no peripheral edema, 2+ dp/pt bilaterally Pulm: clear bilaterally Abd: soft, nt, nd, +bs Msk: [4-16] lower extremity strength bilaterally, poor compliance with UE strength exam; back bandage c/d/i Neuro: cn 2-12 grossly intact, + 8-10 beats ankle clonus bilaterally (R>L), 3+ patellar reflexes bilaterally, refused remainder of exam Skin: no rashes Psych: appropriate, pleasant Heme: no cervical [Doctor First Name ] Pertinent Results: [2107-3-21] 05:47AM BLOOD WBC-2.9* RBC-3.11* Hgb-8.8* Hct-28.4* MCV-91 MCH-28.1 MCHC-30.8* RDW-23.2* Plt Ct-184 [2107-3-22] 05:06AM BLOOD WBC-3.3* RBC-2.79* Hgb-8.4* Hct-25.1* MCV-90 MCH-30.1 MCHC-33.4 RDW-22.9* Plt Ct-188 [2107-3-23] 01:06AM BLOOD WBC-2.8* RBC-2.67* Hgb-7.7* Hct-24.7* MCV-93 MCH-28.9 MCHC-31.1 RDW-23.7* Plt Ct-156 [2107-3-23] 12:09PM BLOOD Hct-28.8* [2107-3-23] 07:16PM BLOOD WBC-3.2* RBC-3.26* Hgb-9.6* Hct-28.1* MCV-86# MCH-29.4 MCHC-34.1 RDW-19.5* Plt Ct-134* [2107-3-24] 01:54AM BLOOD WBC-4.3 RBC-3.74* Hgb-10.6* Hct-33.2* MCV-89 MCH-28.4 MCHC-32.0 RDW-20.5* Plt Ct-141* [2107-3-25] 03:01AM BLOOD WBC-2.8* RBC-3.56* Hgb-10.3* Hct-31.9* MCV-90 MCH-28.9 MCHC-32.2 RDW-20.8* Plt Ct-125* [2107-3-26] 05:31AM BLOOD WBC-2.9* RBC-3.60* Hgb-10.7* Hct-31.3* MCV-87 MCH-29.8 MCHC-34.2 RDW-20.0* Plt Ct-124* [2107-3-27] 06:55AM BLOOD WBC-3.0* RBC-3.49* Hgb-10.2* Hct-30.5* MCV-88 MCH-29.4 MCHC-33.5 RDW-20.1* Plt Ct-136* [2107-3-28] 05:30AM BLOOD WBC-4.1 RBC-3.39* Hgb-9.9* Hct-30.2* MCV-89 MCH-29.2 MCHC-32.7 RDW-20.1* Plt Ct-139* [2107-3-29] 06:00AM BLOOD WBC-3.9* RBC-3.41* Hgb-9.9* Hct-30.6* MCV-90 MCH-29.0 MCHC-32.3 RDW-20.2* Plt Ct-152 [2107-3-30] 02:16AM BLOOD WBC-3.7* RBC-3.13* Hgb-9.2* Hct-28.1* MCV-90 MCH-29.3 MCHC-32.6 RDW-20.4* Plt Ct-130* [2107-3-30] 10:55PM BLOOD WBC-4.0 RBC-3.10* Hgb-9.1* Hct-28.0* MCV-90 MCH-29.4 MCHC-32.5 RDW-20.7* Plt Ct-143* [2107-3-21] 05:47AM BLOOD Glucose-98 UreaN-14 Creat-1.0 Na-135 K-4.0 Cl-97 HCO3-26 AnGap-16 [2107-3-30] 10:55PM BLOOD Glucose-101* UreaN-13 Creat-0.8 Na-139 K-4.2 Cl-104 HCO3-29 AnGap-10 [2107-3-21] 05:47AM BLOOD ALT-26 AST-60* AlkPhos-149* TotBili-0.8 [2107-3-22] 05:06AM BLOOD ALT-22 AST-53* LD(LDH)-288* AlkPhos-136* TotBili-0.7 CT Abdomen: IMPRESSION: 1. No evidence of bowel obstruction. 2. Interval increase in bony metastatic disease, especially notable for significant narrowing of the spinal canal at the T8 vertebral body level, and to a lesser degree the T1 vertebral body level. 3. Largely stable to slightly decreased size of multiple bilateral pulmonary nodules. MRI T spine: IMPRESSION: 1. Interval worsening of metastatic involvement of the thoracic and lumbar spine with severe spinal canal narrowing and cord compression at T8 level and mild mass effect on the spinal cord at T2 level. There are multiple metastatic lesions involving the ribs as described above. 2. Multiple lung nodules. Please correlate with CT chest study. 3. Right pleural effusion. 4. Multiple metastatic lesions involving the visualized sacrum and iliac bones. MRI Brain: MPRESSION: 1. Relatively stable osseous lesion identified on the right parietal/occipital bone with pattern of enhancement in the adjacent dura, the possibility of dural infiltration cannot be completely ruled out, close followup is recommended. No new lesions or other areas with abnormal enhancement are identified. Additionally there is a new mass lesion between the right petrous apex and the clivus, measuring approximately 14mm by 10mm in transverse dimensions, in close proximity with the right sixth cranial nerve and the right carotid canal(image #27, series #100a). Brief Hospital Course: 45M hx metastatic RCC who presents with acute thoracic bandlike lancing pain centered in the RUQ and RLE upper motor neuron signs, CT thorax with T8 lesion that is nearly obliterating the cord. . #T8 cord compression: Has upper motor neuron signs on exam with radicular bandlike abdominal pain in the T8 area. CT with concern for canal obliteration with anterolateral displacement of the cord. Also T1 lesion which has narrowed the canal. Started on dex for presumed cord compression prior to MRI. MRI T/L spine confirmed severe cord compression. The patient was extremely claustrophobic and so required intubation for MRI. He went for IR guided embolization of the T8 metastasis prior to neurosurgical intervention on [3-22], then underwent T6-T8 laminectomy on [3-23]. He did well after the procedure. His neurological exam was unchanged after laminectomy, with 8-10 beats of bilateral ankle clonus and lower extremity hyperreflexia. Unfortunately due to a chronic cervical radiculopathy in his left shoulder, he often would refuse the majority of the neurologic exam. He will undergo radiation to this T8 lesion 2 weeks post-op. His dex will be tapered by his radiation oncologist. He was discharged home with 24/7 care by his wife, who was trained by physical therapy to ensure adequate care for her husband at home. #Diplopia: the patient complained of diplopia that started 2 days prior to admission, however he refused the majority of the exam on admission. After transfer back from the neurosurgical service (after laminectomy), he still complained of diplopia; at this time, he was noted to have a partial right abducens nerve palsy with diplopia when looking to the right. The patient was reintubated for MRI of the brain, which showed a clivus bone metastatic lesion in the area of the right abducens nerve. Radiation oncology was consulted, and started lateral beam XRT to the clivus met prior to discharge. He will follow-up with rad/onc for further brain therapy for this metastatic lesion. #Metastatic Renal Cell carcinoma: on sunitinib with disease progression. Worsening metastatic disease (see above). Was discharged off of sutent with follow-up with his outpatient oncologist in the near future to determine other therapies. #Pain control: patient with high tolerance to opiates. The only addition upon discharge to his pain regimen was an increased dose of gabapentin, from 300/300/600 to 900 TID. This could be further uptitrated as an outpatient to 1200 TID if tolerated. This was increased particularly for his left shoulder radicular pain. Transitional Issues: - follow-up of neurologic issues - dexamethasone taper to be determined by radiation oncology - goals of care Medications on Admission: Gabapentin 300 mg nightly, hydromorphone 8-12 mg every two hours as needed, levothyroxine 150 mcg daily, lisinopril 5 mg daily, methadone 20 mg three times daily, pantoprazole 40 mg daily, Compazine 10 mg every six hours as needed for nausea, sertraline 75 mg once a day, sunitinib 37.5 mg daily, trazodone 150 mg at bedtime, docusate 200 mg twice daily, and senna 17.2 mg daily. Discharge Medications: 1. methadone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 6. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. Disp:30 Powder in Packet(s) Refills:0 7. trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) as needed for insomnia. 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Dilaudid 2 mg Tablet Sig: 4-6 Tablets PO q2hr as needed for pain. 10. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). Disp:270 Capsule(s) Refills:2 11. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home With Service Facility: VNA of [Location (un) 270]-East & Visiting Nurse Hospice Discharge Diagnosis: Renal cell metastatic tumor Spinal Cord compression Cranial nerve 6 compression/palsy Diplopia Transaminitis Anemia 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: It was a pleasure taking care of you at [Hospital1 18]. You were admitted with cord compression and neurologic issues from metastatic tumor in your spine and skull. You underwent a T6-T8 laminectomy for your spine, and radiation to your skull for your double vision. You will have radiation to your spine two weeks after the surgery. Please note the following medication changes: INCREASE gabapentin to 900mg by mouth three times per day START dexamethasone 4mg by mouth three times per day (your radiation oncologist will decrease this) START Miralax 17g packet by mouth once per day as needed for constipation Otherwise take all medications as previously prescribed. Please see below for your instructions from your neurosurgeon: ?????? Do not smoke. ?????? Keep your wound(s) clean and dry / No tub baths or pool swimming for two weeks from your date of surgery. ?????? If you have steri-strips in place, you must keep them dry for 72 hours. Do not pull them off. They will fall off on their own or be taken off in the office. You may trim the edges if they begin to curl. ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? Limit your use of stairs to 2-3 times per day. ?????? Have a friend or family member check your incision daily for signs of infection. ?????? If you are required to wear one, wear your cervical collar or back brace as instructed. ?????? You may shower briefly without the collar or back brace; unless you have been instructed otherwise. ?????? Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? Do not take any medications such as Aspirin unless directed by your doctor. ?????? Unless you had a fusion, you should take Advil/Ibuprofen 400mg three times daily ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine. ?????? Any weakness, numbness, tingling in your extremities. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, and drainage. ?????? Fever greater than or equal to 101?????? F. ?????? Any change in your bowel or bladder habits (such as loss of bowl or urine control). Followup Instructions: Follow Up Instructions/Appointments ?????? Please return to the office in [6-21] days (from date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [Telephone/Fax (1) 1669]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ?????? Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [Last Name (STitle) ] to be seen in 6 weeks. ?????? You will/will not need x-rays/CT-scan prior to your appointment. Department: Primary Care Name: Dr. [First Name8 (NamePattern2) 85766] [Name (STitle) 15264] When: Tuesday [2107-4-12] at 10:15 AM Location: [Hospital1 ] [Location (un) ] Address: [Apartment Address(1) 85767], [Location ],[Numeric Identifier 85768] Phone: [Telephone/Fax (1) 85769] Department: Hematology/ Oncology Name: Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) ] When: Dr. [Last Name (STitle) ] office is working on a follow up appointment for 16-30 days after your hospital discharge. You will be called by the office regarding your appointment date and time. If you have not heard from the office in 2 business days please call the office number listed below. Location: [Hospital1 18]-DIVISION OF HEMATOLOGY/ONCOLOGY Address: [Location (un) ], [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 67231] ICD9 Codes: 2768, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8405 }	Medical Text: Admission Date: [2123-7-11] Discharge Date: [2123-7-11] Date of Birth: [2057-2-15] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5608] Chief Complaint: hypoxemia, unresponsiveness Major Surgical or Invasive Procedure: Mechanical ventilation History of Present Illness: 66F with nasopharyngeal CA s/p radiation, cerbrovascular disease who presents after being found unresponsive this morning. Pt has had poor nutritional status and declining functional status over the past months living at home with care from her husband. She was having frequent falls over the past couple of days although was otherwise in her USOH until she fell last night and the husband helped her into bed. This morning he found her sleepy, poorly responsive, and with labored breathing. He called EMS In the ED, she was noted to be hypoxemic, hypotensive and had a dilated R pupil and she was emergency intubated and given Mannitol for concern for brain edema. Head CT however showed no evidence of hemorrhage or obvious mass lesion. CXR showed evidence of ARDS. Femoral central line was placed and the patient was started on levophed and neosynephrine. She received 1L NS. Ceftriaxone and flagyl were administered to treat a suspected aspiration PNA. Past Medical History: - Nasopharyngeal CA, diagnosed in [2093] and treated with radiation - R ICA occlusion, thought to be [3-20] radiation vasculopathy - L ICA stenosis, s/p L common carotid to L ICA bypass in [2115] at [Hospital3 ] - Vertebral Artery angioplasty (mentioned in [Hospital3 ] Op Note from [2115]) - ? TIA, episodes of leg weakness - hypothyroidism Social History: Taught computer science at [University/College ], lives with husband, no tobacco, very occ EtOH Family History: no FH of stroke Physical Exam: T: 100.8 BP 70/49 HR 92 RR 28 O2Sat: 83% Gen: intubated HEENT: JVP flat CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: bilateral rhonchi Abd: +BS soft, nontender ext: groin central line in place, c/d/i no edema Pertinent Results: Admission labs: [2123-7-11] 12:15PM WBC-5.1 RBC-3.53* HGB-9.3* HCT-30.0* MCV-85 MCH-26.4* MCHC-31.1 RDW-13.5 [2123-7-11] 12:15PM NEUTS-13* BANDS-20* LYMPHS-22 MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-34* MYELOS-8* NUC RBCS-1* [2123-7-11] 12:15PM PLT COUNT-369 [2123-7-11] 12:15PM PT-13.9* PTT-43.4* INR(PT)-1.2* [2123-7-11] 12:15PM GLUCOSE-140* UREA N-23* CREAT-1.2* SODIUM-127* POTASSIUM-4.0 CHLORIDE-92* TOTAL CO2-20* ANION GAP-19 [2123-7-11] 12:15PM ALBUMIN-2.4* CALCIUM-8.2* PHOSPHATE-4.9* MAGNESIUM-1.9 [2123-7-11] 12:15PM ALT(SGPT)-11 AST(SGOT)-17 CK(CPK)-64 ALK PHOS-59 TOT BILI-0.5 [2123-7-11] 01:12PM LACTATE-9.5* Brief Hospital Course: A/P: 66F with nasopharyngeal CA s/p radiation, cerbrovascular disease who presented after being found unresponsive morning on admission. . The patient presented to the ICU on norepinephrine and phenylephrine drips. She had remained severely hypoxemic in the ED with pO2 in the 40s for two hours despite mechanical ventilation with FiO2 100%. The husband had been updated by the medical team in the ED and understood that the prognosis was very poor. The son who is an anesthesiologist was updated on arrival of the patient to the ICU. The plan discussed with the son and husband was to preserve life if possible until the son and daughter to arrived to [Name (NI) 86] to be with the mother. After arrival to ICU, she required dopamine gtt and vasopressin gtt as well. She was administered 13L of IVF, including IVFs with bicarbonate to correct her acidemia. After the family arrived a meeting was held with the family and the attending physician. [Name10 (NameIs) ] patient was made CMO. Morphine gtt was started and pressors were discontinued. The pt passed away soon afterward. Medications on Admission: Propranolol Levoxyl Aspirin Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Anoxic brain injury Hypoxic respiratory failure Shock Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A ICD9 Codes: 0389, 5185, 2762, 5070, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8406 }	Medical Text: Admission Date: [2130-6-17] Discharge Date: [2130-6-21] Date of Birth: [2076-6-12] Sex: M Service: TRA HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old male gentleman who was transferred from an outside hospital status post motorcycle accident, which was described as patient T-boning a car at moderate speed. Helmet split. Positive loss of consciousness. GCS 14 on the scene, but was confused. Hemodynamically stable. No hypoxia. Right arm deformity and midface lacerations were noted. The patient was neurovascularly intact and hemodynamically stable in the Emergency Room. PAST MEDICAL HISTORY: Questionable COPD. Hypertension. PAST SURGICAL HISTORY: Not available. OUTPATIENT MEDICATIONS: 1. Captopril. 2. Hydrochlorothiazide. PHYSICAL EXAM: VITAL SIGNS: 101.6, 102, 138/70, 92 percent on nonrebreather, respiratory rate 18-20. HEENT EXAM: PERRLA, EOMI, positive lac on face extending into the upper lip. C-collar in place. CHEST: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rhythm and rate. GI: Soft, nontender, nondistended. FAST negative. EXTREMITIES AND BACK: Nontender. No step-offs. No deformities. NEUROLOGIC: Alert, oriented x 3. Moving all extremities well. LABORATORY: CBC: 13.4, 41.8, 222. Chem-7 unremarkable. Lactate 0.8, amylase 20. IMAGING: CT HEAD: Which revealed a subarachnoid hemorrhage appreciated in the sylvian fissure. Right nasal bone fracture. CT SPINE: Negative. TLS: Negative. CT ABDOMEN AND PELVIS: Negative. CT FACE: As above, revealed right nasal fracture. CHEST X-RAY: Negative. PELVIS X-RAY: Negative. RIGHT SHOULDER: Negative. RIGHT HUMERUS: Revealed a comminuted fracture of the distal humerus. RIGHT ELBOW: Negative. RIGHT FOREARM: Negative. RIGHT TIB/FIB: Revealed no acute fracture. HOSPITAL COURSE: The patient had largely unremarkable hospital course. The patient was originally admitted into the intensive care unit, but was discharged upon repeat CT which revealed the SAH to be stable. The patient had no neurological deficits on exam. However, the patient continued to have notable confusion and amnesia regarding event. The patient was transferred to the floor in stable condition. Behavioral neurology was consulted. Upon evaluation, it was noted that the patient did seem to have more confusion than what would be expected from the mechanism of the trauma. Therefore, the patient was to be discharged to rehab for supervision, as 24-hour supervision would not be available at home. However, medically the patient's humerus fracture was reduced by orthopedics and put in a cast. In an attempt to reduce patient agitation and clear-up mental status, efforts were made to rectify the reverse of patient's sleep-awake cycle. At the time of discharge to rehab, the patient was in stable condition with no new medical issues. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: To rehab. FOLLOW-UP: The patient will have follow-up at Trauma Clinic, as well as neurosurgery, and orthopedics. Please see discharge worksheet for further information. DISCHARGE MEDICATIONS: 1. Colace 100 [Hospital1 ]. 2. Phenytoin 100 mg po tid to be continued for a total of 5 days from day of incident pending no seizure activity. 3. Percocet 1-2 tablets po q 4-6 h prn pain. 4. The patient is to resume his outpatient high blood pressure regimen which was not available to this team during this admission. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5732], [MD Number(1) 5733] Dictated By:[Last Name (NamePattern1) 27758] MEDQUIST36 D: [2130-6-20] 14:38:56 T: [2130-6-20] 15:12:14 Job#: [Job Number 108575] ICD9 Codes: 496, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8407 }	Medical Text: Admission Date: [2133-12-30] Discharge Date: Date of Birth: [2133-12-30] Sex: F Service: Neonatology INTRODUCTION: [2134-1-18] HISTORY OF PRESENT ILLNESS: [Known lastname ] [Known lastname ] is the former 2.385 kilogram product of a 34-6/7 week gestation pregnancy born to a 26 year-old gravida II, par I, now II woman. Prenatal screenings: Blood type O positive, antibody negative, hepatitis B surface antigen negative, Rubella equivocal, RPR nonreactive, group Beta strep status unknown. The mother's medical history is notable for heroin and marijuana until 4 months' gestation during this pregnancy. She is also treated for mood disorder with Elavil, Klonopin and Celexa. Th e mother transferred her prenatal care from [Hospital3 ] Cente r to the [Hospital1 69] on [2133-12-22]. She had 1 prenatal visit. She presented on the day of delivery with spontaneous rupture of membranes in active labor. She had a fever of 101.6 degrees Fahrenheit. There was sustained fetal tachycardia and the moth er was taken to cesarean section. The infant emerged with good respiratory effort and tone. Apgars were 8 at one minute and 8 at five minutes. The mother has been maintained on methadone 95 mg a day through [Street Address(1) 69899] Clinic at [Hospital6 14430]. The infant was admitted to the neonatal Intensive Care Unit for treatment of prematurity. PHYSICAL EXAMINATION: Upon admission to the Neonatal Intensive Care Unit weight 2.385 kilograms, 75th percentile, length 48 cm, 75th to 90th percentile. Head circumference 32.5 cm, 75th percentile. General: Nondysmorphic preterm female, comfortable with nasal cannula O2. Head, eyes, ears, nose and throat: Anterior fontanel soft and flat. The palate intact. Positive red reflex bilaterally. Chest: Breath sounds clear. Minimal retractions. Cardiovascular: Regular rate and rhythm, no murmur, pulses +2. Abdomen soft, nontender, no hepatosplenomegaly. GU: Normal female genitalia. Musculoskeletal: No hip clicks. No sacral dimple. Neuro: Slightly hypotonic at rest but hypertonic and jittery on examination. Positive suck. Positive grasp. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: 1. Respiratory: [Known lastname ] weaned to room air within four hours after admission to the neonatal Intensive Care Unit. She has not had any episodes of apnea or bradycardia. 2. Cardiovascular: A soft systolic murmur has been audible at the left upper sternal border consistent with peripheral pulmonic stenosis. She has maintained normal heart rate and blood pressure. A CXR, hyperoxia, and 4 extremity blood pressures were normal. EKG suggested LVH. A cardiology assessment was done, and their impression was that the murmur was most likely peripheral pulmonic stenosis. Follow up is recommended in three months by Dr. [First Name4 (NamePattern1) 1439] [Last Name (NamePattern1) 4027]. 3. Fluids, electrolytes and nutrition: [Known lastname ] was initially n.p.o. and maintained on intravenous fluids until feeds were started on day of life 1 and gradually advanced to full volume. At the time of transfer she is all p.o. feeding, Similac 24 calories per ounce. Weight on the day of transfer is 2.535 kilograms. Patient continued good PO during Newborn Service stay; discharge weight 2850g. 4. Infectious disease: [Known lastname ] was evaluated for sepsis upon admission to the Neonatal Intensive Care Unit. Her initial white blood cell count was 3,500 with 6% polys, 8 band neutrophils. A blood culture was obtained prior to initiating intravenous ampicillin and Gentamicin. Repeat complete blood count on day of life 2 showed rising white count of 7,500 with a normal differential due to the maternal fever and clinical presentation there was presumed sepsis and [Known lastname ] received a 7 day course of Ampicillin and Gentamicin. The blood culture was no growth. A lumbar puncture was performed and had normal glucose and protein, 13 white blood cells and culture negative. HIV testing was performed on [2134-1-18] and PCR was negative. Pt was treated with po and topical Nystatin for oral thrush and candidal diaper rash. 5. Hematological: Hematocrit at birth was 42.5% with a follow - up crit of 33% on DOL #2. A repeat hematocrit and reticulocyte was sent on [2134-1-18] and crit was 30.7%, retic=1.3% at which time patient was started on Fe supplementation of 2 mg/kg/day. 6. Gastrointestinal: Peak bilirubin occurred on day of life 3, total of 7.2 mg per dl. 7. Neurology: The urine tox screen sent on the baby at the time of admission was positive for cocaine and barbiturates. Mother's tox screens were positive as well. The baby showed signs of substance withdrawal and required treatment with oral phenobarbital. Her dose was a maximum of 11.5 mg p.o. once daily. Her phenobarbital was weaned to 10.5 mg on [2134-1-16]. A phenobarbital level on [2134-1-18] was 28.7 down from a previous level of 29.8. Upon transfer to the Newborn Nursery, patient's NAS scores declined to less than 4 for 2 days, prompting a further wean of PB by 10% on [1-21] to 9.5 mg q day. The dose was subsequently weaned again to 8mg daily. A level on this dose was 10.2. The NAS scores have been [2-5] most recently, and so the dose has not been changed. 8. Sensory: Audiology - a hearing screen was performed on [2134-1-22], and the infant passed bilaterally. 9. Psychosocial. A 51A was filed by [Hospital1 69900]Office Department of Social Services. The social worker is [Name (NI) ] Pryjma and [Known lastname ] case ID# is [Numeric Identifier 69901]. The parents have visited regularly and have unrestricted visiting. On [1-20] temporary custody was court ordered to DSS; the baby will be placed in the care of her paternal aunt. The [Hospital1 69] social worker involved with this family is [Name (NI) 36130] [Doctor Last Name 36527] and she can be reached at [Telephone/Fax (1) 63016]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: To [Doctor Last Name ] care with paternal aunt (in DSS custody). FOLLOW UP: The baby's pediatrician is Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Hospital1 2177] ([Telephone/Fax (1) 63327]). Her first outpt appt is on [2134-1-29] at 2:20 pm with Dr. [First Name (STitle) ] (Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 13469], attending). She has an appointment with Dr. [First Name4 (NamePattern1) 1439] [Last Name (NamePattern1) 4027], Cardiology, on [2133-4-27] at 0940. CARE AND RECOMMENDATIONS: 1. Feeding ad lib p.o. Similac 24 calories per ounce. 2. Medications: Phenobarbital 9.5 mg p.o. once daily. Ferrous Sulfate 0.2 mg po qday. Nystatin ointment to diaper area. Nystatin 1 ml po tid. 3. Car seat position screening is recommended prior to discharge. 4. State newborn screening was sent on [2134-1-2] with no notification of abnormal results to date. 5. Hepatitis B vaccine was administered on [2134-1-21]. 6. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] who meet any of the following 3 criteria: First born at less than 32 weeks; second born between 32 and 35 weeks with 2 of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; or thirdly with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contact and out of home caregivers. DISCHARGE DIAGNOSES: 1. Prematurity at 34-6/7 weeks. 2. Transitional respiratory distress, resolved. 3. Suspicion for sepsis treated with antibiotics, now resolved. 4. In utero drug exposure and neonatal abstinence syndrome 5. Cardiac murmur- probable peripheral pulmonic stenosis 6. Anemia of prematurity [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. Dictated By:[Last Name (Titles) 69902] MEDQUIST36 D: [2134-1-18] 19:10:14 T: [2134-1-18] 20:00:52 Job#: [Job Number 69903] ICD9 Codes: V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8408 }	Medical Text: Admission Date: [2190-2-4] Discharge Date: [2190-2-22] Date of Birth: [2124-2-1] Sex: F Service: MEDICINE Allergies: Tetracyclines / Zinc Attending:[First Name3 (LF) 689] Chief Complaint: Sepsis and respiratory failure Major Surgical or Invasive Procedure: Endotracheal intubation Placement of arterial line History of Present Illness: 59 year old female with a h/o Castleman's disease s/p splenectomy, recurrent aspiration PNA necessitating recent PEG placement on [11-11] who presents from [Hospital1 599] after her HHA called EMS for lethargy and altered mental status. Home health aide notes that pt had large watery bowel movement on the day of admission. States that pt has been eating cheesecake and pudding, though she is aware and has been instructed by multiple MDs to remain NPO due to aspiration. On EMS arrival, she was febrile to 102F, and hypotensive to 80/50 with HR 70-80s. After 300mL NS in the field, BP increased to 90s. . In the ED she had a temp of 101.1F, HR 78, RR 16, and BP 100/65 initially and was found to have a RLL PNA on CXR, with lactate of 2.5, given 4L NS for concern of early sepsis, developed worsening respiratory distress, desaturation to 88% on 4L, and was intubated. A left subclavian CVL was placed, she was found to have copious secretions, with frequent suctioning. She was given vancomycin, ceftriaxone, and flagyl in the ED after BCx were drawn Past Medical History: -Castleman's disease since [2175], followed by Dr. [Last Name (STitle) 410]. Hx mediastinal LAD, but these were FDG negative on [2188] PET. Also with diffuse centrilobular and tree-in-[Male First Name (un) 239] opacities on last couple of chest CTs, unchanged. Last seen by Dr. [Last Name (STitle) 410] [3-7], who did not wish to pursue biopsy of these nodes at that time. -s/p splenectomy -Hx of anaplastic thyroid cancer as adolescent s/p thyroidectomy and subsequent hypothyroidism -Esophageal web and dysmotility s/p esophageal dilation -Recurrent aspiration pneumonia; last admission [Date range (1) 17594], 5/13-5-20; s/p course of Imipenem for most recent episode; [5-22] sputum culture grew [Month/Year (2) ] -Chronic R olecranon bursitis and MRSA osteomyelitis of R olecranon s/p multiple debridement (most recent one on [5-13]) -Hx of MRSA pneumonia -Bipolar disorder with hx of suicide attempt -PVD -HTN -GERD, hx perforated ulcer in past -Seizure disorder (reportedly had generalized seizure several years ago assoc. with hypoglycemia, none since, no meds) -s/p R hip fracture with failed ORIF and redo at [Hospital1 2025] -hx of Grave's dz with ophthalmopathy -Osteoporosis -Herpes Zoster -PFT ([2189-5-4]) w/ restrictive pattern: FVC 62% FEV1 65% FEV1/FVC 105% Social History: Living at home with HHA. No [Month/Day/Year ], no IVDU. Family History: NC Physical Exam: vitals on arrival to ICU: T 98.9 107/32 70 19 98% AC 450x16/1.0/10 PE: Gen: sedated, intubated HEENT: MM dry Neck: no JVD CV: RRR, nl S1/S2, no m/r/g Lungs: coarse breath sounds anteriorly Abd: soft, NT/ND, +BS, PEG in place with no surrounding erythema or drainage Extr: no edema, warm, bounding pulses Brief Hospital Course: # sepsis - Given history, this was thought to be most likely secondary to aspiration pneumonia, given thick white sputum suctioned on secretion, which grew strep pneumo, MRSA, and GNR which were ultimately speciated as klebsiella. Blood cultures were negative for growth on multiple occasions. Was on levophed for two days, which was then weaned off. Was also found to have an inadequate response to [Last Name (un) 104] stim test, and was given a seven day course of hydrocortisone and fludrocortisone. Completed 14-day course of vancomycin and zosyn. Initially treated with Levofloxacin as well for double-coverage of gram negative organisms, but was d/c'ed after consulting with infectious disease team. Was also initially empirically treated with flagyl for c. difficile colitis due to reported diarrhea prior to admission by her caretaker. Flagyl was d/c'ed after 3 days once stool samples were negative for c. diff x 3. Orthopedic surgery was also consulted after chest CT revealed a chronic sternoclavicular posterior dislocation with associated fluid collection. It was not thought that this was a source of infection, and ortho did not advise any intervention during this admission. Ms. [Known lastname 14] had significant improvement in her clinical status and, although Klebsiella sensitive only to carbapenems was ultimately speciated from her sputum approximately 10 days into her course,it was decided not to treat for this, since it did not appear to be clinically significant. Given pt's history of Castleman's disease, it was also recommended that Ms. [Known lastname 14] receive a pneumovax vaccination prior to d/c, given risk of sepsis with encapsulated organisms. . # hypoxic respiratory failure - Ms. [Known lastname 14] was initially intubated with hypoxic respiratory failure, thought to be due to aspiration pneumonia. Due to concerns that pleural effusions seen on chest Xrays and CT represented an empyema rather than transudative fluid secondary to aggressive fluid resuscitation, a R thoracentesis was done. Analysis of pleural fluid was consistent with a transudative etiology, and pleural fluid culture was negative for growth. After approximately a week of weaning and pressure support trials, Ms. [Known lastname 14] was extubated. Unfortunately, she quickly experienced hypoxia, dyspnea and stridor, and failed racemic epi and heliox. Pt initially indicated that she did not wish to be reintubated. After discussions with her and her power of attorney, however, it was ascertained that reintubation was acceptible to her, and this was quickly done. Given possible laryngeal edema as etiology, was placed on three days prednisone. She was also aggressively diuresed, as she was grossly overloaded for the course of stay due to aggressive volume resuscitation in response to sepsis, and failure to extubate was thought to be partly attributable to pulmonary edema. After three days, Ms. [Known lastname 14] was doing well on pressure support and several SBTs, and she was extubated. She did well following this, and was transferred to the floor satting well on 4L NC. . # Sedation: Ms. [Known lastname 14] was kept alert but comfortable with Versed and Fentanyl. This was weaned off once extubated. She experienced some mild signs and symptoms of narcotic withdrawal, and was placed back on a fentanyl drip transiently, and restarted on her home dose of fentanyl patch, which had been held during her early ICU course. Her fentanyl drip was then titrated to off. . # hypothyroidism - Ms. [Known lastname 14] was continued on her home dose of levothyroxine. . # Bipolar disorder - Was continued on her home doses of lamotrigine and venlafaxine . # FEN/GI - Ms. [Known lastname 14] received tube feeds through her PEG during the course of her stay. Nutrition service was consulted for assistance in monitoring her nutritional status. After extubation, she continued to be kept NPO secondary to aspiration risk. . # Access - An arterial line and L subclavian line were placed at admission. These were d/c'ed, and a PICC placed [2-9] for continued antibiotic delivery. Medications on Admission: 1. Levofloxacin 250 mg Tablet [Month/Year (2) ]: One (1) Tablet PO Q24H (every 24 hours). 2. Metronidazole 500 mg Tablet [Month/Year (2) ]: One (1) Tablet PO TID (3 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [Month/Year (2) ]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Metoclopramide 10 mg Tablet [Month/Year (2) ]: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 5. Senna 8.6 mg Tablet [Month/Year (2) ]: One (1) Tablet PO BID (2 times a day) as needed. 6. Acetaminophen 325 mg Tablet [Month/Year (2) ]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 7. Venlafaxine 37.5 mg Tablet [Month/Year (2) ]: One (1) Tablet PO BID (2 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet [Month/Year (2) ]: One (1) Tablet PO DAILY (Daily). 9. Levothyroxine Sodium 100 mcg Tablet [Month/Year (2) ]: One (1) Tablet PO DAILY (Daily). 10. Ipratropium Bromide 0.02 % Solution [Month/Year (2) ]: One (1) Inhalation Q6H (every 6 hours). 11. Albuterol Sulfate 0.083 % Solution [Month/Year (2) ]: One (1) Inhalation Q6H (every 6 hours). 12. Amlodipine 5 mg Tablet [Month/Year (2) ]: One (1) Tablet PO DAILY (Daily). 13. Atenolol 100 mg Tablet [Month/Year (2) ]: One (1) Tablet PO DAILY (Daily). 14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [Month/Year (2) ]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 15. Gabapentin 300 mg Capsule [Month/Year (2) ]: One (1) Capsule PO HS (at bedtime). 16. Guaifenesin 100 mg/5 mL Syrup [Month/Year (2) ]: 5-10 MLs PO Q6H (every 6 hours) as needed. 17. Enoxaparin 40 mg/0.4mL Syringe [Month/Year (2) ]: One (1) Subcutaneous DAILY (Daily). 18. Polysaccharide Iron Complex 150 mg Capsule [Month/Year (2) ]: One (1) Capsule PO DAILY (Daily). 19. Zolpidem 5 mg Tablet [Month/Year (2) ]: One (1) Tablet PO HS (at bedtime) as needed. 20. Fentanyl 75 mcg/hr Patch 72HR [Month/Year (2) ]: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 21. Docusate Sodium 100 mg Capsule [Month/Year (2) ]: One (1) Capsule PO BID (2 times a day) as needed. 22. Oxycodone 5 mg Tablet [Month/Year (2) ]: One (1) Tablet PO Q4H (every 4 hours) as needed. 23. Dolasetron 12.5 mg/0.625 mL Solution [Month/Year (2) ]: One (1) Intravenous Q8H (every 8 hours) as needed. Discharge Disposition: Home With Service Facility: Caritas VNA Discharge Diagnosis: Primary - aspiration pneumonia, sepsis, respiratory failure, CHF Secondary - macrocytic anemia, hypothroidism Discharge Condition: 96% on 2L Discharge Instructions: - continue with medications as prescribed - DO NOT EAT BY MOUTH AS YOU ARE AT A HIGH RISK FOR ASPIRATION - call your PCP if you have any fevers Followup Instructions: Provider: [Name10 (NameIs) ],[First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) ] & MINERAL-CC7 (SB) Date/Time:[2190-3-22] 11:30 Call your PCP to schedule an appointment. Completed by:[2190-2-23*] ICD9 Codes: 0389, 5070, 5849, 4280, 4271, 4439, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8409 }	Medical Text: Unit No: [Numeric Identifier 72560] Admission Date: [2101-3-8] Discharge Date: [2101-3-14] Date of Birth: [2101-3-8] Sex: F Service: NB HISTORY: This is a 35-5/7-weeks gestation girl born vaginally to a 38-year-old G1, P0 now 1 mother. Prenatal [Name2 (NI) ] were as follows: HBsAg negative, RPR nonreactive, GBS unknown, rubella immune, blood type O-positive, antibody negative. Maternal history is significant for diabetes treated with insulin. Labor was induced due to premature rupture of membranes on [2101-3-7]. Intrapartum penicillin was initiated 16 hours prior to delivery. Fetal tachycardia to the 170s was present prior to delivery. The baby emerged with a cry. Was brought to the warmer, dried, stimulated, and bulb suctioned. Blow-by oxygen was given with improvement in color. Apgars were 7 and 8 at 1 and 5 minutes respectively. The baby was transported to the NICU without incident for prematurity. PHYSICAL EXAM ON ADMISSION: Birth weight of 2940 grams which is 75th-90th percentile, length of 49 cm which is 75th-90th percentile, and head circumference of 33.5 cm which is 75th percentile. Showed a pink, comfortable, active infant. HEENT: Anterior fontanel open and flat. No cleft palate. Asymmetric cry with a downward deviation of the right side of the mouth, no neck mass appreciated, no crepitus, normal red reflex bilateral. CV: Normal rate and rhythm, no murmur. Strong femoral pulses. Respiratory: Breath sounds clear and equal with no retractions. Abdomen: Soft, nontender, nondistended, no masses and a 2-vessel [Year (4 digits) ]. Extremities: Moving all well. Hips: Stable. Back: Straight, no [Hospital1 ] or dimples. Skin: Acrocyanosis present. GU: Normal appearing external female genitalia. Anus appears patent, but anteriorly located at the posterior fourchette. Neuro is moves appropriate for age. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: 1. Respiratory: The infant has remained stable on room air since admission; although, she did have 1 brief episode of a desaturation with a pacifier on [2101-3-10], but has had no further episodes. 2. Cardiovascular: The infant presented briefly on day of life 1 with an audible murmur which resolved. A fetal echocardiogram was done in utero due to the gestational diabetes. Cardiology was consulted on [2101-3-9] at which time 4 extremity blood pressures were within normal limits. A chest x-ray was done with normal heart size, and cardiology did not feel an echocardiogram was necessary and no followup with cardiology will be necessary at this time. 3. Fluid, electrolytes, and nutrition: The infant was started on IV fluid on admission to the NICU due to transient hypoglycemia. The infant had initial D-stick of 35. Was given a single D10W bolus and IV fluid of D10W was started. The glucoses have since normalized. Enteral feedings were initiated on day of life 1. The infant has been ad-lib p.o. feeding and is presently feeding breast milk or Similac 24 calories per ounce, ad-lib p.o. and taking approximately 120-130 mL per kilogram per day. He is voiding and stooling normally. Most recent weight is 2835 grams. No electrolytes have been measured on this infant. 4. GI: The infant had hyperbilirubinemia with a peak bilirubin level of 12.3/0.3. The infant received a total of 2 days of phototherapy. The most recent bilirubin is 9.4 total/0.4 direct on [2101-3-14]. Surgery was consulted, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 17435], due to the anteriorly placed anus, and rectal dilatation was started while the infant was in the NICU due to concern for rectal obstructive issues related to the anteriorly placed anus. The infant, that the parents have been taught, rectal dilatation to be done after discharge twice a day, and the plan is for followup with Dr. [First Name (STitle) 17435] in the surgery clinic at [Hospital3 1810] with the plan for surgical repair needed at approximately 3-6 months of age. 5. Hematology: The infant's hematocrit was measured at birth and the hematocrit was 68. Due to the polycythemia, the infant had a repeat hematocrit done at 24 hours of life with the hematocrit at that time being 61.7. Platelet count at birth was 230,000 and at 24 hours of life, it was 196,000. No further hematocrits or platelets have been measured. The infant's blood type is O-positive, DAT negative. 6. Infectious disease: A CBC and blood culture were screened on admission due to the premature rupture of membranes. The CBC was within normal limits with no left shift. The infant received 48 hours of ampicillin and gentamicin which were subsequently discontinued when the blood culture remained negative at 48 hours of age. 7. Genetic: The infant presented with numerous physical abnormalities including a 2-vessel umbilical [Last Name (LF) ], [First Name3 (LF) ] anteriorly placed anus, wide-spaced nipples, diagonal position of the 4th toes on both feet, transverse palmar creases bilaterally, 13 ribs on x-ray, and a right-sided facial droop. Genetics was consulted. The geneticist of consult is [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 1557] from [Hospital3 1810], telephone number is ([Telephone/Fax (1) 62376]. On [2101-3-11], karyotype and a FISH for 22q11 was sent. Those results are pending. Renal ultrasound was done on [2101-3-9] to look for associated anomalies. The renal ultrasound was normal. Radial and ulnar x-rays were also normal. The spine film was normal on [2101-3-9]. The plan is for followup with [Hospital1 ] Genetics with Dr. [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) 57646] in [12-7] months from birth. 8. Neurology: The infant has maintained a normal neurologic exam. No neurologic studies have been done. 9. Sensory: Audiology: A hearing screen was performed with automated auditory brainstem responses, and the result is pass in both ears. 10. Psychosocial: [Hospital1 18] social worker has been involved with the family. At this time there are no issues, but the contact social worker can be reached at ([Telephone/Fax (1) 24237]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with the parents. Name of primary pediatrician is [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], telephone number ([Telephone/Fax (1) 56620]. CARE AND RECOMMENDATIONS: Ad-lib p.o. feedings by breast or supplement with Similac 24 calories per ounce ad-lib p.o. Rectal dilatation twice daily done by the parents at home. MEDICATIONS: None. IMMUNIZATIONS RECEIVED: Hepatitis B vaccine - [2101-3-11]. FOLLOW UP: [Hospital 2947] clinic on [3-30] at 11 AM with Dr. [First Name (STitle) 17435] after discharge with plans for anal repair at 3-6 months of age. Parents have been taught how to do anal dilations with dilators -sizes 10,11,12 twice daily. Please page Dr. [First Name (STitle) 17435] with any questions prior to first appointment. [Telephone/Fax (1) 38834]. Also follow up with Dr. [Last Name (STitle) 72561], [Location (un) 2274] Genetics at [Location (un) ] at 1-2 months after discharge. 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 gestation; 2) born between 32-35 weeks gestation with 2 of the following: Either daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings; or 3) with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the 1st 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. Follow-up appointment is scheduled with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [3-16]. VNA scheduled for [3-15]. Also follow up as mentioned above with genetics and surgery. DISCHARGE DIAGNOSES: Late preterm infant, rule out genetic anomaly, hyperbilirubinemia resolved, hypoglycemia resolved, anterior anus, sepsis ruled out. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 55750] Dictated By:[Name8 (MD) 69916] MEDQUIST36 D: [2101-3-13] 22:59:45 T: [2101-3-14] 08:48:58 Job#: [Job Number 72562] ICD9 Codes: V053, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8410 }	Medical Text: Admission Date: [2133-7-9] Discharge Date: [2133-7-19] Date of Birth: [2055-1-19] Sex: M Service: CARDIOTHORACIC Allergies: Cephalosporins Attending:[First Name3 (LF) 922] Chief Complaint: angina/ DOE Major Surgical or Invasive Procedure: [2133-7-9] CABG x 4 (LIMA to LAD, SVG to RCA, SVG to RAMUS, with proximal Y to SVG to DIAG) History of Present Illness: 78 yo M with PMH significant for hypertension, dyslipidemia, and known CAD s/p angioplasty and ?stenting in [2129] with increasing dyspnea on exertion and chest pain over the past few months. He underwent a stress test which was abnormal and presents today for cardiac catheterization which revealed 3vd. We are asked to evaluate for surgical revascularization. Past Medical History: Past Medical History: Hypertension Hyperlipidemia Diabetes Mellitus Coronary artery disease s/p RCA PTCA and ?stent at [Hospital1 336] in [2129] Arthritis ?Obstructive Sleep Apnea (CPAP)-has not been using x1 month d/t setting changes ?COPD Kidney stones Prostate CA s/p radical prostatectomy and hormone therapy Gout Past Surgical History: s/p LLE vein stripping s/p radical prostatectomy [2122] s/p hernia repair [2128] Social History: Lives with:wife, has 3 children from his 1st marriage Occupation:Retired Tobacco:quit in his 30s, up to 1ppd x 10 yrs ETOH:occasional beer Family History: Brother s/p CABG/double valve replacement Physical Exam: Physical Exam Pulse:79 Resp:16 O2 sat:95%RA B/P Right:143/77 Left:142/86 Height:5'[33]" Weight:230 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] L groin incision Extremities: Warm [x], well-perfused [x] Edema 0 Varicosities: BLE varicosities, multiple incisions on L thigh Neuro: Grossly intact Pulses: Femoral Right: +2 Left: +2 DP Right: +2 Left: +2 PT [Name (NI) 167]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: 0 Left: 0 Pertinent Results: Conclusions Prebypass No atrial septal defect is seen by 2D or color Doppler. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. Dr. [Last Name (STitle) 914] was notified in person of the results on [2133-7-9] at 900am. Post bypass Patient is in sinus rhythm and receiving an infusion of phenylephrine. Biventricular systolic function is unchanged. 2+ mitral regurgitation persists. Aorta is intact post decannulation. Very poor transgastric views throughout the case. 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) ] [2133-7-9] 16:12 Brief Hospital Course: Admitted on [7-9] and underwent surgery with Dr. [Last Name (STitle) 914].Transferred to the CVICU in stable condition on titrated phenylephrine and propofol drips. Postop right pneumothorax necessitated right chest tube placement in ICU. Extubated on morning of on POD #1. Left PICC placed for poor access on POD #1. Gently diuresed toward his preop weight. Beta blockade titrated. Transferred to the floor on POD #4 to begin increasing his activity level. Evaluated by clinical nutrition for diminished appetite which improved slowly over the course of his stay. Oral hypoglycemic agents were resumed with good glucose control. Oxygenation was an issue post-operatively and improved with aggressive diuresis with sats 89% on room air. He does have a history of obstructive sleep apnea on CPAP. A pulmonary consult was obtained and it was recommended that he follow up with his PCP to arrange [Name Initial (PRE) ] sleep study as an outpatient. His last sleep study was 2 years ago. He was noted to have a scant amount of serosanguinous drainage from the lower aspect of his sternal incision and was started on cipro (levaquin allergy) for 7 days. He will return for a wound check this thursday unless there is no drainage then he will return in the usual 2 week time period. All othe rappointments were advised. He was discharged to home on oxygen. He continued to make steady progress and was cleared for discharge to home on POD# 10 with VNA services by Dr. [Last Name (STitle) 914]. Medications on Admission: Allopurinol 300mg po daily Plavix 75mg po daily Diclofenac Sodium 75mg po BID Advair 1 puff [Hospital1 ] PRN Furosemide 20mg po daily Glyburide 5mg p [Hospital1 ] HCTZ 25mg po daily Imdur 30mg po daily Lisinopril 40mg po daily Metoprolol Tartrate 25mg po BID NTG 0.4mg tablets PRN CP Actos 15mg po daily Crestor 10mg po daily ASA 81mg po daily Niacin 500mg po daily Sodium Bicarb 650mg po BID Plavix - last dose:[2133-6-29] Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 4. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 6. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 8. oxygen 2 liters continuous pulse dose system for portability Diagnosis -COPD 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 10. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:1 Disk with Device(s) Refills:2 12. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:270 Tablet(s) Refills:2 13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 14. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 15. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:1 inhaler Refills:2 16. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H (every 12 hours) for 7 days: watch your blood sugar closely as you may be prone to low blood sugars. Disp:42 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: south eastern vna Discharge Diagnosis: CAD s/p CABG x 4 [2133-7-9] Hypertension Hyperlipidemia insulin dependent Diabetes Mellitus s/p RCA PTCA and ?stent at [Hospital1 336] in [2129] Arthritis ?Obstructive Sleep Apnea (CPAP)-has not been using x1 month d/t setting changes ?COPD Kidney stones Prostate CA s/p radical prostatectomy and hormone therapy Gout Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with percocet Incisions: Sternal - healing well, no erythema but scant serosanguinous drainage from distal aspect Leg Right - healing well, no erythema or drainage. Edema 1+ LE edema bilaterally- teds on 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 until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge 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:[First Name8 (NamePattern2) 177] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2133-8-11] 2:15 Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) 24862] in [1-24] weeks [Telephone/Fax (1) 64296] Cardiologist Dr. [Last Name (STitle) 7047] in [1-24] weeks Please have your primary care doctor arrange for a sleep study appointment. Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication Goal INR First draw Results to phone fax Provider: [First Name8 (NamePattern2) 177] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2133-8-11] 2:15 Completed by:[2133-7-19] ICD9 Codes: 496, 4019, 2749, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8411 }	Medical Text: Admission Date: [2158-12-31] Discharge Date: [2159-1-3] Date of Birth: [2089-4-18] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 19817] Chief Complaint: generalized tonic clonic seizure, status epilepticus Major Surgical or Invasive Procedure: intubation/extubation History of Present Illness: Per admitting resident: 69-year-old right-handed male with a past medical history significant for complicated forceps delivery at birth from presumed anoxic injury, mental retardation, and deep venous thrombosis with PE on Coumadin, who is followed for epilepsy at [Hospital1 18]. Briefly, the patient first developed seizures at age 14. He was found by his brother to have a generalized convulsion. He had a second seizure at age 16, two years after his first episode. He was maintained on Dilantin and phenobarbital. The patient went 50 years without another seizure. This past [Month (only) 404] he was admitted to the ICU at [Hospital1 18] for status epilepticus in the setting of fever of 105. Lumbar puncture was contraindicated due to cervical stenosis. He was empirically treated with 14-day course of antibiotics and antiviral medications for presumed meningitis. He was started on Keppra during that hospitalization. The patient had a recent admission to [Hospital1 18] in [Month (only) 116] for two generalized convulsions. He received 10 mg of Valium for his first convulsion, 80 mg for second convulsion. He was found to have a sub therapeutic Dilantin level in the outside hospital. He was started on Neurontin with a plan to wean Dilantin as an outpatient. He was seen in the neurology clinic on [2158-6-26]. At that time, he had no activity concerning for seizures. He was gradually requested to come off of Dilantin over a period of approximately one month, and his dilantin was stopped on [12-4]. Since his last appointment, the patient continues to be seizure-free till this am. I called his Group home after I saw him in ED, and obtained details of present history as follows- He was last seen yesterday night and was apparently at his baseline. This am, at 4.30 am the nurse went to see him, and give him his meds at 4.30, he was found to be seizing. his all 4 limbs were jerking and some movement was noted at the elbow, with some facial twitching and eye fluttering .This was described as non violent by RN. EMS was called in , who arrived at 4.36 am.Per EMS, " temp 98.5, BP 123/80, Glc 106, was given O2, and 10 mg valium with little response. valium repeated again in [6-4] mins (10 mg) with abortion of seizures in his limbs though facial twitching continues. was taken to [Hospital3 ], whre he was intubated following phosphenytoin 1000 mg, veucuronium 1 mg, succinylcholine 120 mg, veucuronium 9 mg in that order. His labs there- wbc 7, hct 36, plt 166, K 3.2, glu 147. he was transported to ED at [Hospital1 18]. after coming to ED , he was given midaz 5 mg, fentanyl 100 mcg times 2, and was put on propofol drip. When I saw him, he did not have any clinical seizure activity. (off propofol, he was moving his limbs and withdrawing) Past Medical History: Epilepsy as above, CHF, depression, anxiety, depression, left hip fracture status post ORIF seven years ago, DJD, GERD, and anemia. Social History: Lives at a nursing home. Family nearby, including brother also has sister in [Name (NI) 108]. At baseline as per NH ([First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]): he is alert, oriented to place and time (incomplete to date). Self propels a wheelchair. Needs 2 to hoist him out of bed, depended with feeding and self care. No alcohol, drugs or smoking per family Family History: NC Physical Exam: Physical Exam at time of transfer: T- 98.3 BP- 141/86 HR- 77 RR- 16 O2Sat 100% on CMV, 500/5/16/100 Gen: Lying in bed, intubated, NAD HEENT: NC/AT, moist oral mucosa Neck: supple CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: air entry equal , no crackles/rhonchi aBd: +BS soft, nontender ext: (+) non-pitting edema B/L. LLE had scaly lesions and bruises Neurologic examination: Mental status: Off sedation. Intubated. Non-responsive to verbal but withdraws to pain, active movements ain all 4 limbs if off sedation. Eyes closed and no spontaneous eye opening. Cranial Nerves: Pupils equally round and reactive to light, 2to 1 mm bilaterally (min reactive). Eyes set at midline without mvmt. No BTT B/L. no nystagmus. No gross facial asymmetries. (+) corneals B/L. (+) cough. Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor Moves all 4 limbs spontaneously and withdraws to pain Sensation: withdraws to noxious stim in all 4 ext. Reflexes: +1 and symmetric at biceps and patellae, 0 elsewhere. Toes mute on left but upgoing on right. Examination at time of discharge: Pertinent Results: LABS ON ADMISSION: [2158-12-31] 08:20AM BLOOD WBC-9.7 RBC-4.42# Hgb-12.7 Hct-39.6# MCV-90 MCH-28.8 MCHC-32.1 RDW-15.3 Plt Ct-175 [2158-12-31] 08:20AM BLOOD Neuts-91.2 Lymphs-6.0* Monos-2.6 Eos-0.1 Baso-0.1 [2158-12-31] 08:20AM BLOOD PT-33.0* PTT-36.2* INR(PT)-3.3* [2158-12-31] 08:20AM BLOOD Glucose-132* UreaN-16 Creat-1.0 Na-143 K-3.8 Cl-101 HCO3-30 AnGap-16 [2158-12-31] 08:20AM BLOOD Calcium-9.3 Phos-3.2 Mg-1.9 [2159-1-1] 02:13AM BLOOD TSH-1.0 [2158-12-31] 08:20AM BLOOD Phenyto-12.0 URINE STUDIES: [2158-12-31] 08:20AM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [2158-12-31] 08:20AM URINE RBC-0-2 WBC-0 Bacteri-NONE Yeast-NONE Epi-0 TOX SCREEN: [2158-12-31] 08:20AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [2158-12-31] 08:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG IMAGING: CT HEAD: IMPRESSION: No intracranial hemorrhage or edema. HIP XRAY - No definite evidence of acute fracture or malalignment. Brief Hospital Course: 69 year old man with history of MR, CHF, DVT/PE (on coumadin), depression, and seizure d/o (hospitalized in [2-3] for status epilepticus felt to be due to suspected meningitis), presented to OSH with facial twitching on the right and generalized shaking in at his NH which required 20 mg valium to cease seizure activity. Patient was sedated and intubated at the OSH, loaded with Dilantin and transferred to [Hospital1 18] for further care. He was admitted to NEURO ICU for further care and evaluation given intubation at time of presentation. Of note, per OMR he weas felt to have focal epilepsy with secondary generalization, likely due to anoxic brain injury at birth, and probably related to the atrophic changes seen on MRI, particularly in the left temporal lobe. NEURO. Patient did not have a clear source for lowering seizure threshold on evaluation of an infectious and toxic etiology (see pertinent results). HCT did not show an acute abnormality. He was provided with all of his medications at the nursing home and no new medications were started. He was recently, [2158-12-4] tapered off Dilantin, and it was felt that perhaps this medication was necessary to maintain him seizure free. His gabapentin was transiently increased to 1200 mg TID, however this was reduced to his home level of 900 mg TID by the time of discharge. His keppra dose was increased from 1500 mg [Hospital1 ] to 1750 mg [Hospital1 ]. The patient had no further events during the hospital course and was back at his baseline at the time of discharge. Full EEG reports are pending at the time of dictation. CV. Patient has a history of HF with b/l pitting edema 1+ which was noted on current examination. CXR revealed evidence of cardiomegaly but no acute infiltrate. He was continued on home regimen of lasix. PULM. By HD#1 patient was extubated without complications. HEME. Pt. is being treated for remote (> 3 years) DVT and PE. Coumadin was briefly held for supratherapeutic INR, however his INR was 1.9 on the day of discharge and his home dose was reinstated and should be routinely followed for goal INR [2-28]. Medications on Admission: Celexa 20 mg daily, furosemide 40 mg daily, gabapentin 900 mg t.i.d., Keppra 1500 mg b.i.d., metoprolol tartrate 12.5 mg b.i.d., potassium chloride 10 mEq daily, Risperdal 0.25 mg daily, simvastatin 40 mg daily, warfarin 10 mg daily,(confirmed with RN at group home) aspirin 81 mg daily, Colace 100 mg t.i.d., Pepcid-AC. Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO TID (3 times a day). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 6. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. Levetiracetam 500 mg Tablet Sig: 3.5 Tablets PO BID (2 times a day): 1750 mg [Hospital1 ]. 10. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H (every 8 hours). 11. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO DAYS ([Doctor First Name ],MO,TU,WE,TH,FR,SA). Adjust accordingly for goal INR [2-28]. Discharge Disposition: Extended Care Facility: [Location (un) 582] at Silver [Doctor Last Name ] Commons Discharge Diagnosis: Primary: Generalized tonic clonic seizure Secondary: Epiliepsy, Cerebral Palsy Discharge Condition: Hemodynamically stable. Patient is nonverbal but smiles and mimics. He moves all extremities equally and against resistance. Discharge Instructions: You were admitted to the hospital for an episode of generalized tonic/clonic seizure. You did not have further seizures while in the hospital. Your keppra was increased to 1750 mg [Hospital1 ] and your neurontin remained at your home dose of 900 mg tid. Should you experience any further seizures, please call your neurologist immediately. Should you experience any other concerning symptoms as listed below, please call your doctor or go to the emergency room. Followup Instructions: NEUROLOGY: Provider: [First Name11 (Name Pattern1) 12562] [Last Name (NamePattern4) 47259], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2159-3-26] 10:30 ICD9 Codes: 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8412 }	Medical Text: Admission Date: [2164-6-27] Discharge Date: [2164-7-2] Date of Birth: [2093-5-30] Sex: F Service: MEDICINE Allergies: Erythromycin Estolate / Iodine; Iodine Containing Attending:[First Name3 (LF) 8104] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: Ms [Known lastname 109298] is a 71 year old with history of hypertension, hyperlipidemia, presenting with acute bright red blood per rectum. Patient reports she was in her otherwise good state of health until 2 days PTA, when she noted a small amount of mucous that was blood tinged in her stool. Although she did not note anything else, she had an episode of large volume of bright red blood per rectum starting today at 3pm. Patient reports this tinged the toilet water red and contained clots. She has had ~10 bloody bowel movements up to now. She denies any preceeding nausea, vomiting, diarrhea, or any symptoms of chest pain, shortness of breath. She does report feeling lightheaded when she gets up quickly. She also reports some mild discomfort along her lower abdomen. No fevers or chills. In the ED, patient with temp of 98.1, HR 65, BP 155/91, RR 16, O2 sat 100% RA. two large bore IV's were placed and patient was give 2L NS and 2 units of PRBC. GI team was made aware and patient was admitted to MICU for close monitoring Past Medical History: Hypertension Hyperlipidemia Ankylosing spondylitis s/p c4/5 C6/7 fusion S/P CCK Patent foramen Ovale Social History: Patient is widowed, lives in >55 community. Denies any cigarrete use, occasional alcohol. Family History: Non contributory Physical Exam: Temp 97.7 HR: 94 BP: 122/72 RR: 15 O2 SAT: 95% RA GEN: Well appearing, in no distress HEENT: EOMI, pale conjunctiva, anicteric sclera NECK: No thyromegaly CV: Regular rate, no murmur, rubs or gallops. normal S1/S2 Lungs: CTA bilaterally ABD: Mild tenderness to deep palpation over lower abdomen. Hyperactive bowel sounds, no hepato/spleno megaly. EXT: no clubbing/cyanosis/edema Pertinent Results: [2164-6-27] 07:40PM BLOOD WBC-8.8 RBC-3.85* Hgb-11.2* Hct-32.9* MCV-86 MCH-29.2 MCHC-34.2 RDW-14.8 Plt Ct-337 [2164-6-27] 10:15PM BLOOD WBC-11.4* RBC-3.49* Hgb-10.1* Hct-29.8* MCV-85 MCH-28.9 MCHC-33.8 RDW-14.3 Plt Ct-310 [2164-6-28] 03:52AM BLOOD WBC-9.3 RBC-3.48* Hgb-10.4* Hct-30.1* MCV-87 MCH-29.9 MCHC-34.6 RDW-14.6 Plt Ct-272 [2164-6-28] 01:20PM BLOOD Hgb-9.1* Hct-25.1* [2164-6-28] 08:37PM BLOOD Hct-31.6# [2164-6-29] 03:52AM BLOOD WBC-7.9 RBC-3.74 Hgb-11.2* Hct-33.0* MCV-88 MCH-30.0 MCHC-34.0 RDW-14.7 Plt Ct-205 [2164-6-30] 09:15AM BLOOD WBC-7.6 RBC-3.58* Hgb-11.2* Hct-31.2* MCV-87 MCH-31.2 MCHC-35.8* RDW-14.4 Plt Ct-231 [2164-6-30] 07:00PM BLOOD Hct-31.4* [2164-7-1] 07:20AM BLOOD WBC-6.8 RBC-3.70* Hgb-11.4* Hct-33.0* MCV-89 MCH-30.7 MCHC-34.5 RDW-14.6 Plt Ct-266 [2164-7-1] 05:25PM BLOOD Hct-31.4* [2164-7-2] 06:25AM BLOOD WBC-6.6 RBC-3.87* Hgb-11.7* Hct-34.7* MCV-90 MCH-30.2 MCHC-33.7 RDW-14.4 Plt Ct-299 [2164-6-27] 07:40PM BLOOD Neuts-72.5* Lymphs-20.7 Monos-6.3 Eos-0.1 Baso-0.5 [2164-6-27] 07:40PM BLOOD PT-12.5 PTT-29.6 INR(PT)-1.1 [2164-6-28] 03:52AM BLOOD PT-13.7* PTT-29.8 INR(PT)-1.2* [2164-6-27] 07:40PM BLOOD Glucose-103 UreaN-14 Creat-0.5 Na-132* K-3.6 Cl-95* HCO3-26 AnGap-15 [2164-6-28] 03:52AM BLOOD Glucose-126* UreaN-10 Creat-0.4 Na-133 K-3.7 Cl-103 HCO3-24 AnGap-10 [2164-6-29] 03:52AM BLOOD Glucose-110* UreaN-4* Creat-0.4 Na-138 K-3.9 Cl-104 HCO3-28 AnGap-10 [2164-7-1] 07:20AM BLOOD Glucose-103 UreaN-4* Creat-0.4 Na-140 K-4.0 Cl-103 HCO3-29 AnGap-12 [2164-7-2] 06:25AM BLOOD Glucose-103 UreaN-6 Creat-0.4 Na-142 K-4.2 Cl-104 HCO3-28 AnGap-14 [2164-6-28] 03:52AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.6 [2164-6-27] 07:40PM BLOOD Calcium-9.6 Phos-3.9 Mg-1.9 [2164-6-27] 09:45PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.011 [2164-6-27] 09:45PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [2164-6-27] 09:45PM URINE RBC-21-50* WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 ---------------- . ECG: [2164-6-27]: Sinus rhythm Premature ventricular contractions No previous tracing available for comparison ECG [2164-6-28]: Sinus rhythm Premature ventricular contractions Since previous tracing of [2164-6-27], no significant change . CT Abd/Pelvis: IMPRESSION: 1. No definite diverticulitis. No other acute intra-abdominal process is identified. 2. Extensive diverticulosis. . Colonoscopy Biopsy Results (pending at discharge but available now) Colon, rectosigmoid, mucosal biopsy (A): 1. Patchy active colitis. 2. No dysplasia or granulomas noted. --- Colonoscopy Results: Impression: Diverticulosis of the whole colon, likely the source of her bleeding. Erythema in the rectum (biopsy) Otherwise normal colonoscopy to cecum Recommendations: Routine post-procedure orders Follow up on biopsy results Follow up with Dr. [Last Name (STitle) 3315] as an outpatient in [11-30] weeks. --- . Brief Hospital Course: Ms. [Known lastname 109298] 71 year old woman with history of hyperlipidemia, hypertension, presenting with acute lower GI bleed, in fair condition. 1)Diverticulosis: Patient presented with a several day history of blood in her stools. GI was consulted and followed her closely throughout her admission. Her Hct on admission was 32.9 and decreased to 25. She received a total of 5 units of pRBCs. After she was transferred to the MICU, she underwent a CT abd/pelvis which showed extensive diverticulosis and a question of diverticulitis. She was started on Cipro and Flagyl. She then underwent a colonoscopy which confirmed the diverticulosis. Based on the final CT read, there was no significant diverticulitis so the antibiotics were stopped. Her Hct remained stable the remainder of her stay. Colonoscopy could not identify a bleeding vessel. Patient's hematocrit and BP stabilized post-transfusion. She was monitored on the floor for 48-72 hours prior to discharge with stable vitals and hematocrit. Plan to follow-up as outpatient with Dr. [Last Name (STitle) 3315]. Dx: Diverticulosis w/ acute LGIB w/o diverticulitis. Plan: f/u with Dr. [Last Name (STitle) 3315] for results of biopsy, low residue diet, hold aspirin. . 2)Multiple risk factors for CAD but no known CAD: Patient was continued on statin but Aspirin was held given acute bleed. 3)Hypertension: Held antihypertensives in setting of acute blood loss. HCTZ safely restarted prior to discharge. 4)Hyperlipidemia: Continued statin. 5)Chronic back pain / Arthritis: Held sulfasalazine in the setting of a GIB 6)GERD: Continue PPI per outpatient regimen. Medications on Admission: Fish oil 1000mg Protonix 40mg Darvocet 100/650 PRN Aspirin 81mg Vitamin E HCTZ 12.5mg Sulfazine 1500mg [Hospital1 ] Zocor 40mg daily Folic acid 400mg Calcium Discharge Medications: 1. Simvastatin 40 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. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Diverticulosis w/o diverticulitis Hypovolemia Hypertension GERD Sleep Apnea Superficial Phlebitis Discharge Condition: good. Discharge Instructions: You were admitted to the hospital for treatment of bleeding from your colon. A CT scan and colonscopy demonstrated that your bleeding was likely from diverticulosis - small outpouchings of the colon that can bleed on occasion. Please return to the hospital or call your physician should you experience any dark black stools, bright red blood per rectum or severe abdominal pain. Please discuss with your doctor regarding your upcoming colonoscopy and whether this needs to be rescheduled to a later date. . It was also discovered that you have sleep apnea. A formal evaluation should be performed for this when you leave the hospital. Please follow-up as instructed below. Please exercise caution when using your automobile and do not drive while sleepy. . Please discontinue taking your low dose aspirin pill until you follow-up with your primary physician. Followup Instructions: 1. Please follow-up with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 29247] ([Telephone/Fax (1) 109299] in next [11-30] weeks for further evaluation. Please have a referral for a split night sleep study. 2. Please follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3315], please call for an office appointment in the next 1-2 weeks. 3. Provider: [First Name8 (NamePattern2) 20] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 463], Date/Time:[2164-7-25] 8:30 4. Provider: [Name10 (NameIs) ] [Apartment Address(1) ] (ST-3) GI ROOMS Date/Time:[2164-7-25] 8:30 5. Provider: [Name10 (NameIs) 1089] [Name11 (NameIs) 1090], MD Phone:[Telephone/Fax (1) 1652] Date/Time:[2164-8-2] 7:50 ICD9 Codes: 2851, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8413 }	Medical Text: Admission Date: [2139-5-8] Discharge Date: [2139-5-19] Date of Birth: [2139-5-8] Sex: M Service: ADMISSION DIAGNOSIS: 1. Newborn X 33 and [6-13] week male. 2. Respiratory distress. 3. Rule out sepsis. 1INDICATIONS: The patient is a now day of life #12 X 33 and [6-13] week male infant who was delivered on [2139-5-8], via cesarean section to a 29-year-old, gravida 1, para 0, now 1 mother, whose pregnancy was complicated by chronic appendicitis. The mother's appendicitis was first diagnosed at 26 weeks, and she was treated with inpatient parenteral antibiotics followed by a course of p.o. antibiotics. She was then readmitted and placed on intravenous Zosyn, and secondary to concerns regarding her chronic appendicitis, delivery was accomplished. Betamethasone was not given to the mother prior to the delivery secondary to concerns regarding the affect off betamethasone on her chronic appendicitis, as well as surgical concerns. Prenatal screens were unremarkable. The patient was delivered without complication, and Apgar scores were 8 and 9 in the Delivery Room. He was warmed, dried, suctioned and stimulated and given blow-by oxygen. He was brought to the Neonatal Intensive Care Unit at [Hospital6 1760] after a brief visit with his parents. He was in no distress. Upon admission into the Neonatal Intensive Care Unit, he developed mild grunting, flaring and retraction, and chest x-ray was obtained which was reflective of mild hilar membrane disease, as well as possible fetal lung fluid. PHYSICAL EXAMINATION: Upon admission weight was [2141] g, initial D-stick 52, admission heart rate 156, blood pressure 65/34 with a mean of 43, oxygen saturation on nasal CPAP at room air of 96%. General: Pink, active and nondysmorphic infant. HEENT: Normocephalic, atraumatic. Anterior fontanel open, flat and soft. Faces nondysmorphic. Ears normally set. No pits or tags. Nares patent bilaterally. Red reflux visible bilaterally. Palate intact. Chest: Mild inspiratory crackles bilaterally with good air exchange. Cardiovascular: Regular, rate and rhythm. Normal S1 and S2. Without murmurs, rubs, or gallops. Pulses: Palpable bilaterally, 2+ in femoral arteries. Abdomen: Soft, nontender, nondistended, with hypoactive bowel sounds. No organomegaly. Three-vessel cord. Genitourinary: Normal male genitalia with left testes in the canal and right testes distended. Anus patent. Extremities: Moves all extremities well. Five fingers and five toes present bilaterally. Normal bulk, tone and strength. Hips stable bilaterally. Neurological: Positive moro, positive grasp, suck not evaluated. Spine intact. Skin: Without lesions. HOSPITAL COURSE: 1. Cardiovascular: The patient remained cardiovascularly stable throughout his admission. He had no episodes of heart rate instability or hypotension or hypertension, and he is discharged to home without any concerns regarding his cardiovascular status. 2. Respiratory: The patient developed grunting, flaring and retracting with respiratory distress shortly subsequent to his admission to the Neonatal Intensive Care Unit at [Hospital6 1760]. He was placed on nasal CPAP at 21% oxygen shortly after his admission, and he remained on nasal CPAP for less than 24 hours, at which point he was transitioned to room air. The patient remained in room air for the remainder of his admission to the Neonatal Intensive Care Unit. The patient also had no episodes of apnea, bradycardia or desaturation during his admission to the Neonatal Intensive Care Unit. He is transferred to home without any concerns regarding his respiratory status and is comfortable in room air with oxygen saturations greater than 98%. 3. Fluids, electrolytes and nutrition: Upon admission, the patient was started on intravenous fluids and made NPO. His intravenous fluids were D10W, and his blood sugars was within normal limits. His intravenous fluids were increased, such that by day of life #6, he was on 140 cc/kg/day of total fluids, and he started feeding such that by day of life #4, he was at full feeds with Premature Enfamil 20 or maternal breast milk. The patient initially was fed both by mouth, as well as by gavage; however, by [2139-5-17], he had maintained himself on all p.o. feeds and remained on only oral feeding without the need for tube feeding for the remainder of his admission. He attained greater than 150 cc/kg/day of ad lib feeding by [2139-5-18], and on the day of discharge, [2139-5-19], he remained on all oral feeds with more than adequate volumes beyond 150 cc/kg/day. He is to be discharged to home feeding with Enfamil 24 cal/oz ad lib, and he is expected to do well. The patient had no difficulties with electrolyte abnormalities, as well as no difficulties with voiding or stooling, and as such he is discharged to home in stable status regarding his fluids, electrolytes and nutrition. 4. Hematologic and infectious disease: Secondary to his initial respiratory distress, the patient was started on an initial rule out sepsis work-up with a blood culture drawn, as well as CBC and antibiotics consisting of Ampicillin and Gentamicin. His initial CBC was benign without any indication of infection, and his blood culture remained no growth to date past 48 hours, and as such, his antibiotics were discontinued after 48 hours. He is discharged home without any concerns regarding infection. In terms of hematologic status, the patient had his total bilirubin measured on [2139-5-11], and it was found to be 12.6/0.3. He was started on one bank phototherapy and remained on phototherapy until [2139-5-14], at which point he was taken off of phototherapy. His highest rebound total bilirubin was 6.6, subsequent to the discontinuation of phototherapy, and he is transferred home without any concerns regarding continuing hyperbilirubinemia at this time. 5. Neurologic: The patient did not undergo head ultrasound scanning secondary to his weight, as well as his gestational age. 6. Sensory: The patient had a hearing screen performed prior to discharge, and he passed his hearing screen. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home. PRIMARY PEDIATRICIAN: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 37613], [Hospital ] Pediatrics. The recommendation will be for the patient to follow-up with his primary care pediatrician in [2-9] days.. DISCHARGE DIET: Ad lib Enfamil 24. If baby's weight gain is borderline, would consider switch to a transitional formula such as Neosure. DISCHARGE MEDICATIONS: Ferrous Sulfate 25 mg/cc 0.2 cc p.o. q.d. CAR SEAT POSITION SCREEN: Passed. STATE NEWBORN SCREENING: Normal. IMMUNIZATIONS RECEIVED: Hepatitis B #1. IMMUNIZATION RECOMMENDATION: Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] as he is an infant who was born between 32 and 35 weeks. If there are plans for daycare during the RSV season or if there is a smoker in the house, or if there are preschool siblings. DISCHARGE DIAGNOSIS: 1. Day of life #12 X 33 and 6/7 weeks infant. 2. Respiratory distress, now resolved. 3. Sepsis, ruled out. 4. Status post hyperbilirubinemia. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 37237], M.D. [MD Number(1) 37238] Dictated By:[Dictator Info ] MEDQUIST36 D: [2139-5-19] 14:46 T: [2139-5-19] 14:46 JOB#: [Job Number ] ICD9 Codes: 7742, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8414 }	Medical Text: Admission Date: [2191-4-29] Discharge Date: [2191-5-6] Date of Birth: [2114-12-19] Sex: F Service: MEDICINE Allergies: Erythromycin Base / Iodine-Iodine Containing / Demerol / Penicillins / Sulfa (Sulfonamide Antibiotics) / Cipro Cystitis / Iron Dextran Complex Attending:[First Name3 (LF) 20146] Chief Complaint: Weakness Major Surgical or Invasive Procedure: none History of Present Illness: 76 year old female with h/o laxative abuse and dehydration, personality disorder, nephrolithiasis with multiple UTI, Crohn's disease c/b rectovaginal fistula who presents with 3 days of weakness and poor po intake. . She has had multiple admissions in the setting of laxative use and "inability to have a bowel movement" over the last several weeks. She was admitted [3-31] with rectal pain and there was concern for laxative abuse. She had profuse diarrhea and a severe rectal ulcer and patient refused diverting ileostomy. She refused to give up laxative use as she was "afraid of vomiting up stool." She then went to [Hospital1 3278] [2191-4-3] and was treated for UTI (Ecoli resistent to cipro, otherwise sensitive). She left AMA. She then represented [4-4] with severe perianal rash and had abdominal CT with focal enteritis without obstruction, bilateral renal calculi with partial obstruction and ?pyelo. She was treated with CTX and then left AMA. She was then admitted [4-6] to [4-7] due to "inability to have a bowel movement" one morning. She has been previously fired by the GI service. The public health/city is also involved at home as reportedly she has stool all over her house (per the ED). . In the ED, initial VS were 98.0 95 109/49 18 98%. EKG normal. She had regular BMs in ED and was incontinent in the bed. Given 40 mEq PO potassium and given D5NS with 20 mEq K in 1L over 2 hours. . Currently, she requests colace, milk of magnesia, one glass of warm water, and coffee immediately to keep her bowel movements. She reports have 20-30BM/day in order to "keep from getting obstructed." During this conversation, she is sitting in a pile of liquid green stool. She also complains of abdominal pain that she thinks is due to the potassium she received in the ED. She states that without colace she will leave AMA. She reports she came to the hospital due to feeling weak. She was able to eat breakfast this morning, but just didn't have the appetite to eat lunch or dinner. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - Crohn's disease (s/p colon resection [2150] and rectal stricture dilitation) - Rectovaginal and intersphincteric fistula ([10-7]) - Diabetes Mellitus type 2 - Fibromyalgia - h/o nephrolithiasis - h/o rectal abscess - Personality Disorder Social History: (per OMR and patient) Patient lives alone with 24 hour private care. Tobacco: quit 20 years ago ETOH: none Power of attorney and friend: [Name (NI) ] [Name (NI) 104641] cell phone [Telephone/Fax (1) 104642] Family History: No family history with IBD. Dad died of pancreatic cancer. Physical Exam: GA: AOx3, thin and wasted in appearance HEENT: PERRLA. dry mucouse membranes, No JVD Cards: RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: CTAB no crackles or wheezes Abd: soft, NT, +BS. mild guarding, neg HSM. Extremities: wwp, no edema. DPs, PTs 2+. Skin: dry Rectum: area covered with brown liquid stool, peri-rectal area erythematous but without deep ulceration Neuro/Psych: delusional thought processes stating that without constant laxative use she will become painfully constipated in seconds, able to articulate that copious diarrhea is bad for her health, but still requesting laxatives and stating she will leave the hospital to use them if not given them here, also fixated upon diet and idea that multiple physicians have taken poor care of her in the past and that she is better able to care for her health than they are . On Discharge: 97.8, 126/76 (126-154/74-89), 82 (82-92), 18, 100%RA GENERAL: Cachectic female lying in bed, very concerned and worried about not being helped HEENT: EOMI, sclerae anicteric, MMM, OP clear. HEART: RRR, no MRG, nl S1-S2. LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored. Back: no CVA tenderness ABDOMEN: soft NT/ND, no HSM EXTREMITIES: WWP, Patient has edematous hands and feet bilaterally that are non-pitting, 2+ peripheral pulses. SKIN: See rectum exam below Rectum: did not allow me to examine this morning Neuro/Psych: A&Ox3, CN II-XII intact. Pertinent Results: LABS: CBC/DIF: [2191-4-29] 04:25PM BLOOD WBC-7.9# RBC-3.41* Hgb-9.0* Hct-27.9* MCV-82 MCH-26.2* MCHC-32.2 RDW-18.1* Plt Ct-501* [2191-5-1] 09:15PM BLOOD WBC-19.7* RBC-2.62* Hgb-7.0* Hct-22.2* MCV-85 MCH-26.7* MCHC-31.5 RDW-18.4* Plt Ct-395 [2191-5-6] 05:45AM BLOOD WBC-6.5 RBC-3.80* Hgb-10.6* Hct-33.6* MCV-88 MCH-27.7 MCHC-31.4 RDW-19.1* Plt Ct-434 [2191-5-1] 09:15PM BLOOD Neuts-67 Bands-20* Lymphs-5* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-2* . COAGS: [2191-4-30] 12:50PM BLOOD PT-12.7 PTT-24.7 INR(PT)-1.1 [2191-5-1] 09:15PM BLOOD PT-14.5* PTT-27.3 INR(PT)-1.3* . CMP [2191-4-29] 04:25PM BLOOD Glucose-121* UreaN-54* Creat-1.5* Na-134 K-3.2* Cl-93* HCO3-29 AnGap-15 [2191-5-6] 05:45AM BLOOD Glucose-70 UreaN-16 Creat-1.0 Na-143 K-3.9 Cl-117* HCO3-16* AnGap-14 [2191-4-30] 12:50PM BLOOD Albumin-2.4* Calcium-5.7* Phos-2.1# Mg-1.8 [2191-5-6] 05:45AM BLOOD Calcium-8.2 Phos-3.5 Mg-1.4* . MiSC: [2191-5-3] 05:40AM BLOOD calTIBC-159* Ferritn-266* TRF-122* [2191-5-1] 09:15PM BLOOD TSH-1.3 [2191-5-6] 05:45AM BLOOD CRP-25.5* # # # ################################################################ MICRO: URINE CULTURE (Final [2191-5-3]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . STOOL CULTURE: Negative MRSA SCREEN: NEGATIVE BLOOD CULTURE: NEGATIVE BLOOD CULTURE: PENDING ([2191-5-2]) ####################################################### IMAGING: ABD(upright and supine) [2191-4-30]: There is extensive amount of content noted in the left upper quadrant that might be in the stomach or potentially in the left colon. There is no evidence of bowel loop obstruction or free air. No pathologic air-fluid levels were noted. Staghorn calculus on the right and known left kidney calculus are redemonstrated. . CXR [2191-5-1]: Mild pulmonary vascular engorgement is new. Lung volumes are lower, compared to [4-6], but there is no focal consolidation to suggest pneumonia. Mild interstitial pulmonary edema is new. Pleural effusion is minimal if any. The heart is normal but increased since [4-6] . RENAL U/S: 1. Similar large right staghorn calculus, resulting in mild right hydronephrosis. 2. Multiple tiny non-obstructive left renal calculi. No left hydroureteronephrosis. Brief Hospital Course: A/P: 76 year old female with h/o laxative abuse and dehydration, personality disorder, nephrolithiasis with multiple UTI, Crohn's disease c/b rectovaginal fistula who presents with 3 days of weakness and poor po intake found to be in acute renal failure and hypokalemic . # Hypotension/Sepsis: Patient developed fever and hypotension and was transferred to the MICU. She was started empirically on Vanco/Cefepime given her history of recurrent UTIs, including enterococcus and enterobacter and E. Coli. She had a positive U/A and it was suspected that her known staghorn calculus was a nidus of infection. The patient's blood pressure improved with IVF boluses and antibiotics. She was stable to be transferred back to the floor the following day. Eventually, her urine grew out E. coli that was resistent to ciprofloxacin and renal U/S was performed which revealed mild right hydropephrosis, right staghorn calculus as well as small non-obstructing stones in the left kidney. She was initially placed on ceftriaxone, but later switched to cefpodoxime since patient refused IV antibiotics and did not want a PICC line to be placed. She received a 7 day course of Abx. . #. Diarrhea: Initially thought to be most likely related to heavy use of laxatives and many stools at home, however, it persisted after cessation of laxatives and concern for crohn's flare. Dehydration from this problem and K loss in stool likely causes of acute renal failure and hypokalemia. She was constantly stooling on the floor and was in the ED, yet still insisting to have laxatives. Pt found to have multiple bottles of laxatives in her belongings at bedside. No real abdominal pain to suggest flaring of her IBD. All laxatives were held and stools sent for culture and c diff toxin. Laxative screen ordered. Pt started on IVF to replace fluid loss and lytes were repleted. Pt was not allowed to leave AMA as wanted to pursue damaging behavior. Her diarrhea persisted and in spite of holding all laxatives and ruling out for infectious process her diarrhea persisted. She was on mesalamine during her hospital stay, but there was concern for crohn's flare. Dr. [Last Name (STitle) ] spoke with the patient about different treatment options, but patient refused any additional work-up give her history of Crohn's disease. Also, given issues with non-compliance would be hesitant about initiating treatment with immunosuppresants. We discussed this with her at length, but it was ultimately decided that she could be discharged with GI follow up in clinic. . # Psych: History of possible personality disorder. At this time pt with delusions regarding need to take laxatives and delusions leading her to self damaging behavior. Placement likely to be needed as pt unable to care for self properly at home but question if needs placement in a psych facility due to psych issues. She was seen by psychiatry who felt that she was acutely delirious, but as she improved they deemed her competent to make her own decisions. She spoke with her HCP often, but made decisions about her own care. She was started on zyprexa 2.5mg with PRN for increasing episodes of agitation. This seemed to work well with relation to her delirium. . #. Acute renal failure: Likely related to volume depletion in the setting of profound diarrhea. However, also had concerning history of pyelo in the past with inadequate treatment courses due to leaving hospital AMA. On admission had no CVA pain although reported dysuria. UA not overwhelming for infection. Urine culture showed E. Coli resistent to cipro. Urine lytes showed indeterminate etiology. Kept on IVF and Cr trended down re-inforcing diagnosis of pre-renal etiology. At the time of discharge her creatinine was 1.0. . #. Hypokalemia: Most likely related to ongoing diarrhea. Received KCL overnight. Laxatives held and pt monitored on tele overnight. Her potassium remained stable and required minimal repletion. . # Hypomagnesemia: Was 1.4 the day prior to and the day of admission. She was refusing repletion and so was discharged with a magnesium of 1.4. . #. H/o possible Pylonephritis: Has chronic staghorn calculi on recent CT and recent treated with course of cefpodoxime. Urine sent for culture and fever curve monitored. She had minimal hydronephrosis and was not interested in a perc nephrostomy tube even if she qualified for one. She was set up with an outpatient Urology appointment for further management. . #. Crohn's Disease: Has refused ileostomy in the past and doesn't take her mesalamine at home. Pt reports not taking home mesalamine but was given on prior admissions and given during this admission. [Month (only) 116] be having a crohns flare, but difficult to manage as described above. . #. Rectal Breakdown: Refused to let some personelle examine the site and had history of refusing treatment but agreed to wound care evaluation at her last hospitalization. Wound care consult was obtained and made recommendations, however, she would often refuse to let nurses clean the site nor would she allow phsyicians to monitor it daily. . #. Thrombocytosis: Likely reactive. Improved from previous baseline. . #. Non-anion gap acidosis: Patient with persistent non-anion gap acidosis. Likely secondary to ongoing diarrhea (as above). TRANSITIONAL ISSUES: Ongoing Diarrhea Medications on Admission: 1. [Last Name (un) ]-Max 500 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. mesalamine 250 mg Capsule, Extended Release Sig: Four (4) Capsule, Extended Release PO QID (4 times a day). 3. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 10 days. 4. temazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime) as needed for insomnia. 5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 7. Calcium 500 500 mg (1,250 mg) Tablet, Chewable Sig: One (1) tablet, Chewable PO twice a day. 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO twice a day. 9. multivitamin Tablet Sig: One (1) Tablet PO once a day. 10. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for pain. 11. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for anxiety, sleep. 12. Zinc-220 220 (50) mg Capsule Sig: One (1) Capsule PO once a day. 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day: HOLD FOR LOOSE STOOL. Discharge Medications: 1. mesalamine 800 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO three times a day. Disp:180 Tablet, Delayed Release (E.C.)(s) Refills:2 2. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 4 days. Disp:8 Tablet(s) Refills:0 3. temazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime) as needed for insomnia. 4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 10. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO DAILY (Daily). Disp:30 Tablet, Rapid Dissolve(s) Refills:2 11. clonazepam 1 mg Tablet Sig: 1-2 Tablets PO QHS (once a day (at bedtime)) as needed for anxiety. 12. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5-1 Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation. Disp:30 Tablet, Rapid Dissolve(s) Refills:0 13. Zinc-220 220 (50) mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary Diagnosis: Failure to thrive . Secondary Diagnosis: Crohn's disease (s/p colon resection [2150] and rectal stricture dilitation) Rectovaginal and intersphincteric fistula ([10-7]) Diabetes Mellitus type 2 H/o nephrolithiasis Personality Disorder Discharge Condition: Level of Consciousness: Alert and interactive. Mental Status: Confused - sometimes. Activity Status: Bedbound. Discharge Instructions: You are being discharged from [Hospital1 ]. You were admitted for weakness, poor food intake and diarrhea. We stopped your laxatives and you continued to have diarrhea. We think it is because of a crohn's flare. You were started on mesalamine and your diarrhea continued. We think that you should see a gastroenterologist for management of your diarrhea and crohns as they may have some recommendations for further treatment. we also found that you have a urinary tract infection and are treating you for 8 days. You received 4 days while here in the hospital and will receive 4 more days at home. . The following medication was STARTED: mesalamine 1600mg by mouth every 8 hours cefpodoxime 2gm by mouth for 4 more days (last dose [2191-5-10]) . PLEASE STOP TAKING ALL LAXATIVES. YOU ARE HAVING MANY BOWEL MOVEMENTS WITHOUT THEM AND IT IS NOT NECESSARY TO TAKE. Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) ] H. Location: [Hospital ] MEDICAL CENTER Address: [State 11413], [Location (un) ],[Numeric Identifier 8235] Phone: [Telephone/Fax (1) 12802] Appointment: Friday [2191-5-20] 11:45am Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [2191-5-18] at 4:00 PM With: [Name6 (MD) 21154] [Last Name (NamePattern4) 21155], 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, 5849, 2762, 2768
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8415 }	Medical Text: Admission Date: [2200-9-5] Discharge Date: [2200-9-12] Date of Birth: [2134-3-31] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 5790] Chief Complaint: Barrett's esophagus/heartburn Major Surgical or Invasive Procedure: [2200-9-5] Minimally invasive [First Name9 (NamePattern2) 12351] [Doctor Last Name ] esophagectomy, laparoscopic jejunostomy tube, and pericardial fat pad buttress. History of Present Illness: Mr [Known lastname ] is a 66M with a h/o Barrett's esophagus. Path from recent EGD revealed high grade dysplasia and adenocarcinoma in the background of Barretts at 37 cm. He was originally seen at [Hospital6 2561] 6 months ago for an EGD for reflux and heartburn. The first EGD showed [Last Name (un) 27191] esophagus. His repeat EGD showed the adenocarcinoma. He denies chest pain, SOB, DOE, or dysphagia. His medical history is significant for Hodgkin lymphoma 8 years ago. He recently [Last Name (un) 1834] an EGD with an unsuccessful attempt at EMR. He states he is feeling okay and his GERD symptoms are controlled with omeprazole. He did report nausea and vomiting after meals, however states this has improved since the EGD. He denies any fevers, chills, weight loss, chest pain or shortness of breath. Past Medical History: PMH: Morbid obesity, diabetes, hypertension, hypothyroidism, GERD, Barrett's esophagus, hyperlipidemia, Remote history of a Hodgkin lymphoma status post chemotherapy, hosp [4-3] with pericarditis, claustrophobia PSH: s/p knee [Doctor First Name ], s/p RCR Social History: 25 pack-year smoking history, quit 20 years ago. No alcohol use Family History: grandfather with throat cancer Physical Exam: BP: 130/77. Heart Rate: 83. Weight: 303.5. Height: 66.75. BMI: 47.9. Temperature: 97.5. Resp. Rate: 16. Pain Score: 0. O2 Saturation%: 95. PE: Gen - A&Ox3, NAD CV - RRR Pulm - CTAB Abd - S/NT/ND Ext - No edema Pertinent Results: CXR [2200-9-5] FINDINGS: In comparison with study of [9-2], there are lower lung volumes with evidence of esophagectomy and gastric pull-through. Nasogastric tube tip is at the level of the carina. There is some indistinctness of engorged pulmonary vessels. It is unclear whether this represents elevated pulmonary venous pressure or is merely a manifestation of low lung volumes. Right chest tube is in place without pneumothorax. Subcutaneous gas is seen along the chest wall on the lower and the upper abdomen. Bibasilar atelectatic changes are noted. CXR [2200-9-6] FINDINGS: In comparison with study of [9-5], there are continued low lung volumes. There is a small-to-moderate pneumothorax on the right. Nasogastric tube extends to just below the level of the carina. Opacification at the right base consistent with some combination of atelectasis and effusion, and there are atelectatic changes at the left base as well. Subcutaneous gas is seen along the lower right chest and upper right abdomen. IMPRESSION: Small-to-moderate right pneumothorax postoperatively. CXR [2200-9-7] FINDINGS: In comparison with the study of [9-6], there is no definite pneumothorax at this time. The nasogastric tube again extends to the level of the carina. Continued low lung volumes with little overall change in the appearance of the heart and lungs. Brief Hospital Course: Mr. [Known lastname ] [Last Name (Titles) 1834] a minimally invasive esophagectomy and J-tube placement on [2200-9-5]. He tolerated the procedure well and was transferred to the ICU in stable condition. He had a lot of pain immediately post-operatively, which improved after several epidural boluses. On POD #1, his epidural was split, his pain was well-controlled. His HSQ was started, and TFs were started at 20cc/hr. His chest tube was put on waterseal. On POD #2, he was doing well and transferred to the floor. His TFs were cycled with a goal rate of 105 cc/hr over 18 hours. He [Date Range 1834] teaching regarding administration of the feedings, flushing and general care of the J tube. He used his incentive spirometer effectively. He was more comfortable on post op day #4 following removal of his nasogastric tube. The Physical Therapy service evaluated him due to his size and decreased mobility and they recommended rehab following discharge. A barium swallow was done on [2200-9-11] which revealed no leak. He began a liquid diet in moderate amounts and did well without nausea. His chest tube and JP drain were removed on [2200-9-12]. His epidural catheter was removed and his PCA was stopped [9-11] and his foley catheter was removed. He continued to require 2L O2/min. Roxicet was effective for pain control. He was discharged to rehab on [2200-9-12]. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientPharmacy. 1. lisinopril-hydrochlorothiazide NF 10-12.5 mg Oral daily 2. Metoprolol Succinate XL 200 mg PO DAILY 3. MetFORMIN (Glucophage) 1000 mg PO BID 4. Simvastatin 40 mg PO DAILY 5. Omeprazole 20 mg PO BID 6. Aspirin 81 mg PO DAILY 7. Levothyroxine Sodium 100 mcg PO DAILY 8. Centrum Silver NF (multivitamin-minerals-lutein;<br>mv with min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250 mg-mcg-mcg Oral daily Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Centrum Silver NF (multivitamin-minerals-lutein;<br>mv with min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250 mg-mcg-mcg Oral daily 3. Levothyroxine Sodium 100 mcg PO DAILY 4. lisinopril-hydrochlorothiazide NF 10-12.5 mg ORAL DAILY 5. MetFORMIN (Glucophage) 1000 mg PO BID 6. Metoprolol Succinate XL 200 mg PO DAILY 7. Omeprazole 20 mg PO BID 8. Simvastatin 40 mg PO DAILY 9. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain hold for RR<12 RX hydromorphone [Dilaudid] 2 mg [12-30] tablet(s) by mouth Q4 hrs prn Disp #40 Tablet Refills:0 10. Lorazepam 0.5 mg PO HS:PRN insomnia RX lorazepam [Ativan] 0.5 mg 1 by mouth hs Disp #30 Tablet Refills:0 11. Acetaminophen 650 mg PO Q6H:PRN pain Discharge Disposition: Extended Care Facility: Aberjona Nursing Center - [Hospital1 2436] Discharge Diagnosis: Esophageal cancer. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[Name (NI) 2347] office [Telephone/Fax (1) 16996] if you experience: -Fevers greater than 101 or chills -Increased shortness of breath, cough or chest pain -Nausea, vomiting -Increased abdominal pain -Incision develops drainage -Remove chest tube and j-tube site bandages Saturday and replace with a bandaid, changing daily until healed. Pain -Roxicet via J-tube as needed for pain -Take stool softners with narcotics Activity -Shower daily. Wash incision with mild soap & water, rinse, pat dry -No tub bathing, swimming or hot tub until incision healed -No driving while taking narcotics -No lifting greater than 10 pounds until seen -Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30 minutes daily Diet: Tube feeds: Replete Full Strength @ 105 cc's x 18 hrs Flush J-tube with 10 cc's tap water every 8 hours before starting feeding, after ending feeding and every day ay noon. Full liquid diet, may increase to soft solids over the next few days as tolerated. Eat small frequent meals. Sit up in chair for all meals and remain sitting for 30-45 minutes after meals Daily weights: keep a log bring with you to your appointment NO CARBONATED DRINKS Danger signs Fevers > 101 or chills Increased shortness of breath, cough or chest pain Incision develops drainage Nausea, vomiting (take anti-nausea medication) Increased abdominal pain Call if J-tube falls out (save the tube and bring with you to the hospital to be re-placed) or suture breaks Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [2200-9-25] at 3:00 PM With: [Name6 (MD) 1532] [Name8 (MD) 1533], MD [0-0-] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Please report 30 minutes prior to your appointment to the Radiology Department on the [Location (un) ] of the [Hospital Ward Name 23] Clinical Center for a chest xray. Completed by:[2200-9-12] ICD9 Codes: 4019, 2449, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8416 }	Medical Text: Admission Date: [2200-5-7] Discharge Date: [2200-5-13] Date of Birth: [2169-5-3] Sex: F Service: PSU SERVICE: Plastic surgery HISTORY OF PRESENT ILLNESS: Ms. [Known lastname ] is a 31-year-old female with a history of right breast cancer. She is otherwise quite healthy. She presents for right mastectomy with [Last Name (un) 5884] flap reconstruction. PAST MEDICAL HISTORY: Right breast cancer. PAST SURGICAL HISTORY: 1. Cholecystectomy. 2. Excision of the a cyst in the right wrist. ALLERGIES: Penicillin. MEDICATIONS AT HOME: None. PHYSICAL EXAMINATION: Blood pressure 122/56, heart rate 93, oxygen saturation 100% on room air. The patient is alert, oriented, in no apparent distress. Heart is regular rate and rhythm with no murmurs, rubs or gallops. Lungs are clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended with no masses. The right breast is significant for a 2 cm mass in the upper lateral pole. HOSPITAL COURSE: The patient was admitted to the plastic surgery service on [2200-5-7]. She underwent a total mastectomy by the breast surgery service and a deep flap reconstruction by the plastic surgery service. For further information on these procedures, please see associated operative note. The patient tolerated the procedure well, and was observed overnight in the ICU. The pulses in her flaps were checked every half an hour to hour initially after surgery. Her flap maintained good blood flow, and was pink and warm. On postoperative day #1 she was able to be transferred to the floor. Her flap continued to be monitored carefully. There was a question of a small hematoma on postoperative day #3, but this was observed and did not increase in size. On postoperative days #4 and #5, the patient was feeling dizzy and had trouble ambulating. Her hematocrit was checked and was 26.1. On postoperative day #5, the decision was made to transfuse 1 unit of autologous red blood cells for symptomatic anemia. After the administration of the blood, the patient began to feel much better. Her lightheadedness went away and she was able to ambulate. She was then able to tolerate a regular diet, as well as oral pain medications. On postoperative day #6, the patient's symptoms had improved dramatically and she was doing quite well clinically. The decision was made to discharge her to home with [Hospital 269] nursing care to assist with her drains. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home with services. DISCHARGE DIAGNOSIS: Right breast cancer. DISCHARGE MEDICATIONS: 1. Percocet 5/325 mg tablet 1-2 tablets p.o. q.4-6h. p.r.n. for pain. 2. Clindamycin 300 mg p.o. t.i.d. time 7 days. 3. Colace 100 mg capsule 1 capsule p.o. b.i.d. while taking Percocet. 4. Aspirin 81 mg tablet 2 tablets p.o. daily. FOLLOW-UP PLANS: The patient will follow up with Dr. [First Name (STitle) ] this Friday. She will call the office for appointment. The patient will also follow-up with Dr. [Last Name (STitle) 364] on [2200-5-15] at 9:30. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD [MD Number(2) 39103] Dictated By:[Last Name (NamePattern1) 11988] MEDQUIST36 D: [2200-5-13] 09:41:50 T: [2200-5-14] 10:20:11 Job#: [Job Number 60482] ICD9 Codes: 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8417 }	Medical Text: Admission Date: [2111-10-14] Discharge Date: [2111-10-22] Service: MEDICINE Allergies: Epinephrine / Adhesive Tape Attending:[First Name3 (LF) 2840] Chief Complaint: unresponsiveness Major Surgical or Invasive Procedure: EEG History of Present Illness: Mr. [Known lastname ] is an 84 year old male with past medical history of CAD status-post CABG in [2103], systolic CHF, TIA and adenocarinoma of brain s/p resection, DVT and PE s/p IVC filter who had witnessed tonic-clonic seizure and subsequent unresponsiveness. Per EMS report he developed focal R sided sz that then generalized to tonic clonic sz. He was initially transported to [Hospital3 ] where he was dilantin loaded and then transferred to [Hospital1 18] for further care. In the [Hospital1 18] ED, initial vs were: T100.8 P77 BP97/62 R14 O2 sat99% on BIPAP. TMax in the ED was 102.8. Head CT from [Hospital1 ] was re-read as post-craniotomy with possible residual tumor. UA found to be suggestive of UTI. CXR showed L sided pleural effusion. He received Vancomycin, Levofloxacin and 2g ceftriaxone. In the ICU, patient on BIPAP. He moves both of his legs to light touch but is not moving his upper extremities. Past Medical History: 1. Dyslipidemia. 2. Hypertension. 3. CABG in [2103] 4. Pacemaker/ICD due to AV block and tachybrady syndrome 5. Cardiomyopathy with LVEF = 35% in [10-6]. 6. PAF 7. TIA in [2103]. 8. Macrocytic anemia, attributed to MDS with bone marrow biopsy in [State 531]. 9. Spinal stenosis. 10. Hypothyroidism. 11. H/o gastric ulcer; GERD. 12. OSA on nocturnal CPAP. 13. Prostate cancer s/p XRT. 14. Adenocarcinoma of unknown primary metastatic to the left occipitoparietal region s/p resection in [7-7] 15. DVT/PE s/p IVC filter on Lovenox [Hospital1 ] Social History: Per OMR: Substantial smoking history with 3 ppd until [2060]. No drinking. Family History: Per OMR: Father died of lung cancer at age 50. Mother had an MI and died at age 86. A brother also had lung cancer. He has two children that are healthy. Physical Exam: At Admission: General: Obtunded, BIPAP mask in place HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Reduced breath sounds at left base, no wheezes or crackles appreciated 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: 2+ LE edema Neuro: Unresponsive to verbal stimuli. Pupils minimally reactive. Moves lower extremities with light touch to feet, does not withdraw upper extremities to painful stim. Pertinent Results: [2111-10-14] 10:50PM URINE WBCCLUMP-FEW, AMORPH-FEW CA OXAL-RARE, GRANULAR-0-2, RBC-[4-2]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0, BLOOD-MOD NITRITE-POS PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-MOD, COLOR-Yellow APPEAR-Cloudy SP [Last Name (un) 155]-1.010 [2111-10-14] 10:50PM WBC-16.2* RBC-3.21* HGB-10.4* HCT-33.5* MCV-104# MCH-32.3 MCHC-31.0 RDW-18.1* PLT COUNT-473#, NEUTS-87.7 LYMPHS-6.1* MONOS-5.4 EOS-0.4 BASOS-0.4 [2111-10-14] 10:50PM PHENYTOIN-8.5* [2111-10-14] 10:50PM CK-MB-NotDone proBNP-4425* [2111-10-14] 10:50PM cTropnT-0.20* [2111-10-14] 10:50PM ALT(SGPT)-19 AST(SGOT)-37 LD(LDH)-346* CK(CPK)-38 ALK PHOS-186* TOT BILI-0.4 [2111-10-14] 10:50PM GLUCOSE-214* UREA N-20 CREAT-1.2 SODIUM-135 POTASSIUM-4.8 CHLORIDE-97 TOTAL CO2-28 ANION GAP-15 ALBUMIN-2.8* CALCIUM-8.4 PHOSPHATE-5.5# MAGNESIUM-1.9 GLUCOSE-212 LACTATE-2.6* [2111-10-14] 11:32PM TYPE-ART PO2-368* PCO2-68* PH-7.26* TOTAL CO2-32* BASE XS-1 INTUBATED-NOT INTUBA [2111-10-14] 10:50PM BLOOD WBC-16.2* RBC-3.21* Hgb-10.4* Hct-33.5* MCV-104# MCH-32.3 MCHC-31.0 RDW-18.1* Plt Ct-473# [2111-10-15] 03:50AM BLOOD WBC-15.3 RBC-3.00* Hgb-9.4* Hct-30.3* MCV-101* MCH-31.2 MCHC-30.8* RDW-18.1* Plt Ct-425 [2111-10-16] 01:54AM BLOOD WBC-11.2* RBC-3.05* Hgb-9.7* Hct-30.4* MCV-100* MCH-31.9 MCHC-32.0 RDW-18.0* Plt Ct-434 [2111-10-17] 07:00AM BLOOD WBC-10.4 RBC-3.53* Hgb-11.1* Hct-35.6* MCV-101* MCH-31.4 MCHC-31.1 RDW-18.0* Plt Ct-525* [2111-10-18] 07:45AM BLOOD WBC-9.0 RBC-3.73* Hgb-11.7* Hct-36.8* MCV-99* MCH-31.4 MCHC-31.8 RDW-18.1* Plt Ct-530* [2111-10-19] 07:05AM BLOOD WBC-9.1 RBC-3.73* Hgb-11.9* Hct-37.5* MCV-101* MCH-31.9 MCHC-31.7 RDW-18.3* Plt Ct-535* [2111-10-20] 05:22AM BLOOD WBC-8.5 RBC-3.51* Hgb-11.3* Hct-35.6* MCV-101* MCH-32.1* MCHC-31.7 RDW-18.5* Plt Ct-515* [2111-10-21] 09:51AM BLOOD WBC-9.4 RBC-3.28* Hgb-10.7* Hct-32.4* MCV-99* MCH-32.6* MCHC-32.9 RDW-18.4* Plt Ct-423 [2111-10-14] 10:50PM BLOOD Glucose-214* UreaN-20 Creat-1.2 Na-135 K-4.8 Cl-97 HCO3-28 AnGap-15 [2111-10-15] 03:50AM BLOOD Glucose-131* UreaN-21* Creat-1.2 Na-134 K-4.6 Cl-96 HCO3-31 AnGap-12 [2111-10-16] 01:54AM BLOOD Glucose-114* UreaN-17 Creat-0.8 Na-136 K-4.5 Cl-100 HCO3-28 AnGap-13 [2111-10-18] 07:45AM BLOOD Glucose-97 UreaN-16 Creat-0.7 Na-132* K-4.2 Cl-97 HCO3-26 AnGap-13 [2111-10-18] 07:45AM BLOOD Glucose-97 UreaN-16 Creat-0.7 Na-132* K-4.2 Cl-97 HCO3-26 AnGap-13 [2111-10-19] 07:05AM BLOOD Glucose-105 UreaN-15 Creat-0.7 Na-134 K-4.0 Cl-98 HCO3-29 AnGap-11 [2111-10-20] 05:22AM BLOOD Glucose-102 UreaN-13 Creat-0.7 Na-136 K-4.1 Cl-99 HCO3-28 AnGap-13 EEG Study Date of [2111-10-16] IMPRESSION: This telemetry captured no pushbutton activations. On seizure detection files, there were between 30 and 40 electrographic seizures consisting of generalized theta frequency spike and slow wave discharges intermixed with periods of faster monomorphic sharp waves with a beta frequency. The longest seizure lasted around 20 seconds with the majority of events occurring for 10-15 seconds. Only two of the seizures had clinical correlates which are mentioned above. Routine sampling showed a background that was slow and poorly organized with a theta Hz frequency. EEG Study Date of [2111-10-20] IMPRESSION: This telemetry captured no pushbutton activations. It captures many prolonged episodes of ongoing seizure activity seen in a generalized distribution with predominance of the posterior quadrants more on the left than on the right. The background activity was slow suggestive of a severe encephalopathy. CHEST (PA & LAT) Study Date of [2111-10-19] 2:36 PM FINDINGS: Prior sternotomy, joint chamber pacemaker, left pleural effusion and consolidation in the left lower lobe is again noted. These findings are without change from [10-16], [2111]. The previously noted PICC line appears to have been replaced by another, its tip lying at the junction of the SVC and right atrium. CONCLUSION: Left pleural effusion and left lower lobe consolidation without change from [2111-10-16]. CT HEAD W/O CONTRAST Study Date of [2111-10-14] 11:02 PM IMPRESSION: Status post left parietooccipital craniotomy with persistent small hyperdense focus at the margin of the resection bed, which may represent residual tumor as suggested previously. New oval area of hyperdensity adjacent to the parietooccipital craniotomy site, could be hemorrhage or residual tumor or post-surgical change. MRI is recommended to characterize this finding further, if there is no clinical contraindication for MRI. OUTSIDE FILMS READ ONLY Study Date of [2111-10-14] 11:02 PM IMPRESSION: Status post left parietooccipital craniotomy with persistent small hyperdense focus at the margin of the resection bed, which may represent residual tumor as suggested previously. New oval area of hyperdensity adjacent to the parietooccipital craniotomy site, could be hemorrhage or residual tumor or post-surgical change. MRI is recommended to characterize this finding further, if there is no clinical contraindication for MRI. Brief Hospital Course: Patient is a 84 yom with PMHx of CAD, CHF, adenocarcinoma of the brain s/p resection in [7-7] and DVT/PE admitted to the MICU with new onset tonic clonic seizure and initial persistent unresponsiveness. The patient was placed on BiPAP (DNR/DNI) and loaded on Dilantin at OSH. Per family, the patient is extremely sharp and functional at his baseline. # Obtundation: at the time of initial presentation, the patient was non-verbal and unresponsive. His physical exam was remarkable for clonus of his upper extremities and withdrawal of his bilateral lower extremities. In the setting of new onset seizure, initial differential included post-ictal state, metabolic process, CVA and underlying infection. Patient was initially febrile with leukocytosis. Initial head CT showed post-operative changes, hyperdensity which possibly could represent residual tumor, edema and possible mild midline shift. LP was therefore deferred for concern of increased ICP and empiric antibiotics (ceftriaxone and acyclovir) were started to cover for meningitis. The patient was initially placed on BiPAP for recorded O2 desaturations. Serial ABG's were initially performed showing improving respiratory status and BiPAP was discontinued within the first several hours of admission. Over the first few hours, patient's mental status substantially improved. He became more alert and engageable and neuro findings on physical exam normalized. The patient continued to have improving mental status over the first several days of his admission. Neurology was consulted and felt that post-ictal state and metabolic disturbance was most likely. EEG was performed on [10-16] which was concerning for underlying seizure activity and Neurology recommended continuing Dilantin and adding Keppra for improved seizure control. Subsequently, patient was transferred to the floor where continous EEG showed that there were seizure activities. However, given family wishes and patient's continous state of sedation, anti-seizure medications were peeled back. Neurotin was stopped and then the dilantin was stopped. Patient improved in his mentation and is no longer sedated. He was maintained on keppra till discharge. # Sepsis: Patient was initially hypotensive to high 80's systolic on arrival to ICU which responded to fluid boluses. Initial labs showed + UA thus raising the possibility of urosepsis. Patient also had numerous open skin sores and thus osteomyellitis and bactermia were also considered. Given respirator status, congested lung sounds on physical exam and serial CXR's pneumonia was also strongly considered. Patient was initially broadly covered with ceftriaxone, vancomycin and ciprofloxacin. The patient remained afebrile over the first several days of admission and leukocytosis trended down. On [10-17], antibiotics were tailored as suspicion for meningitis was very low considering his rapid clinical improvement and physical exam findings. Patient was started on Unasyn for possible pneumonia / aspiration and vancomycin for possible MRSA. After he stablized on the floor, a two view xray was done and showed findings of pneumonia. His antibiotics were broaden to zosyn and vancomycin. He remained afebrile and was maintained on these medications until discharge. He was discharged on vancomycin IV and augmentin PO for two additional days. # Seizure: New onset sz for this patient. Concerning that CT head shows new areas of hyperdensity as well as ?mild midline shift. Possible mass effect and edema could contribute to sz. Given infection must also consider this as an inciting factor. He is not on meds that are associated with lowering sz threshold. After peeling back neuroleptics, he was no longer sedated and did better with her mentation. Baseline answers questions, able to voice needs. # Respiratory Acidosis: patient initially presented with respiratory acidosis and reported desaturations on Bi-PAP. Serial ABG's showed improving respiratory status amd Bi-PAP was discontinued after several hours on the floor. Patient maintained good O2 sats on 3L NC, eventually was wean off supplemental O2. # PAF: amiodarone was held as rate was AV paced without any signs of atrial fibrillation and initial hypotension. # Cardiomyopathy: Carvedilol and furosemide was initially held for concern of sepsis. On [10-17] Lasix was restarted given his CXR, congested lung sounds and fluid overload. # h/o DVT/PE: Cont Lovenox 40mg [Hospital1 ] . # CAD s/p CABG: patient initially presented with TN of 0.2 with normal CK's and ECG not concerning for ischemia. This was attributed to sepsis / seizure activity. Cardiac enzymes were trended and gradually decreased. # FEN: IVF, replete electrolytes, NPO . # Prophylaxis: Lovenox . # Access: peripherals . # Code: DNR/DNI (confirmed with son Dr. [Known lastname ] . # Communication: Son, Dr. [Known lastname ] . # Disposition: ICU Medications on Admission: MEDICATIONS AT HOME: (taken from [Location (un) 5481] medication record) Lasix 30mg PO daily Levothyroxine 75mcg PO daily Protonix 40mg PO daily Amiodarone 200mg PO daily Coreg 12.5mg PO BID Neurontin 400mg PO QHS Lactobacillus 1 capsule [Hospital1 ] MVI Benefiber Miralax prn Percocet 1 tab Q4 hours PRN pain Robitussin 10cc PO Q6 hours PRN cough . Discharge Medications: 1. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for irritation. 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Furosemide 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 11. picc line maintenance Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 12. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous once a day for 2 days. Disp:2 solutions Refills:0 13. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 2 days. Disp:4 Tablet(s) Refills:0 14. Keppra 750 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Location (un) 5481] TCU Discharge Diagnosis: Primary: Aspiration pneumonia UTI Altered mental status Seizure Hyponatremia Secondary: Right wriste pain Paroxysmal atrial fibrillation CAD Hypothyroidism Discharge Condition: stable Discharge Instructions: You came to the hospital due to an episode of tonic-clonic seizure and unresponsiveness while you were in rehab. We were able to stablize you in the hospital. We found on testing that you had pneumonia and urinary tract infection which we treated with antibiotics. You were in stable condition and is mentating better at the time of discharge. Please follow up with the doctors listed below. Please note, we made the following changes to your medications. 1. vancomycin 1g IV once a day. 2. augmentin 875 PO twice a day. 3. Keppra 750 PO twice a day STOPPED: Neurontin 400mg PO QHS If you experience any fever, chest pain, nausea, vomiting, confusion, lethargy, shortness of breath, seizures, or any symptoms that is of concern to you, please go to the emergency room. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: Please follow up with your primary care physician and the physicians in your healthcare facility. ICD9 Codes: 0389, 5070, 5990, 5119, 2762, 2761, 4254, 4280, 2449, 2724, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8418 }	Medical Text: Admission Date: [2125-5-29] Discharge Date: [2125-6-6] Date of Birth: [2091-12-13] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1390] Chief Complaint: Unresponsiveness s/p assault. Major Surgical or Invasive Procedure: Intubated for altered mental status on admission, [2125-5-29]. History of Present Illness: This patient is a 33 year old female who presents to [Hospital1 18] via med flight s/p assault. She was found in her bathroom down, bleeding from her head and a nearby bathroom scale covered in blood. Questionable assault. She was unresponsive and her head was covered in blood. She was intubated on scene and transferred to [Hospital1 18] for evaluation by [Location (un) ]. Per EMS she is known to be in an abusive relationship. Past Medical History: PMHx: EtOH abuse, h/o seizures w/ DTs, bipolar disorder. PSHx: Unknown. Social History: History of alchoholism, abusive relationship. Physical Exam: On admission: Temp: afebrile HR: 106 BP: 170/72 Resp: 20 O(2)Sat: 100% vent Constitutional: intubated, sedated HEENT: + facial trauma, orbital edema ETT in place; c-collar in place Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nondistended Pelvic: No obvious GU trauma Extr/Back: No cyanosis, clubbing or edema Skin: No rash, Warm and dry Heme/[Last Name (un) ]/[Last Name (un) ]: No petechiae On discharge: VS Temp 97.8, BP 109/56, HR 80, RR 16, sat 96% on room air. Neuro: AAO x person, place, needed reorientation to date. EENT: Periorbital swelling and resolving ecchymosis. Pulm: Clear bilaterally in full lung fields. Abdomen: Soft, non-tender, non-distended. Hypoactive BS. Extremities: Warm, well-perfused. Pertinent Results: [2125-5-29] 05:15PM BLOOD ASA-NEG Ethanol-98* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2125-5-29] 05:15PM BLOOD WBC-16.0* RBC-3.90* Hgb-10.3* Hct-32.4* MCV-83 MCH-26.3* MCHC-31.7 RDW-18.1* Plt Ct-364 [2125-5-29] 05:15PM BLOOD PT-13.9* PTT-27.4 INR(PT)-1.3* [2125-5-29] 05:15PM BLOOD Plt Ct-364 [2125-5-29] 05:15PM BLOOD Fibrino-171* [2125-5-29] 05:15PM BLOOD UreaN-14 Creat-0.6 [2125-5-30] 12:23AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.7 [2125-5-30] 12:23AM BLOOD HBsAb-NEGATIVE [2125-5-29] 05:24PM BLOOD Glucose-107* Na-140 K-3.4 Cl-105 calHCO3-15* [2125-6-4] 06:06AM BLOOD WBC-6.3 RBC-3.49* Hgb-9.0* Hct-28.6* MCV-82 MCH-25.9* MCHC-31.5 RDW-19.5* Plt Ct-386 [2125-6-4] 06:06AM BLOOD Plt Ct-386 [2125-6-4] 06:06AM BLOOD Glucose-93 UreaN-13 Creat-0.5 Na-142 K-3.7 Cl-102 HCO3-27 AnGap-17 [2125-6-4] 06:06AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.9 [2125-5-29] CT of sinus/mandible/maxilla 1. Bilateral nasal bone, frontal processes of the maxilla and anterior nasal spine fractures. 2. Diffuse soft tissue swelling of the scalp and face. [2125-5-29] CT of head without contrast 1. Bilateral nasal bone and frontal process of the maxilla fractures. 2. Diffuse facial and scalp subcutaneous edema and subgaleal hematoma noted towards the left posterior vertex. Brief Hospital Course: 33F who presents to [Hospital1 18] s/p assault. She was found in her bathroom down, bleeding from her head. Questionable assault. She was unresponsive and her head was covered in blood. She was intubated on the scene and transferred to [Hospital1 18] for further management. She was pan-scanned in the ED (see results section above). FAST scan was negative and the patient was hemodynamically stable. Due to the question of sexual assault, [Name Initial (MD) ] SANE RN was contact[Name (NI) ]. She was evaluated by that individual and evidence was collected for processing. The patient was admitted to trauma SICU for continued care on [2125-5-29]. ICU course ([2125-5-29] - [2125-6-3]): Pt was admitted to TSICU intubated, sedated on [5-29]. CT spine shows acute fractures. CT maxillary sinus show bilateral nasal bone, frontal process of the maxilla and anterior nasal spine fractures. Diffuse facial and scalp subcutaneous edema. CT head show bilateral nasal bone fractures. And CT abd/pelvis shows no acute abnormality. On [5-30], the chin lac was repaired and T+L spine cleared. Pt was bolused 500 LR x1 for low UOP, and IVF increased to 125 with improvment. We were unable to extubate pt due to severe agitation and inability to follow commands. Pt also spiked temperature of 101, blood culture was sent. Home depakote was also restarted at this time. Pt was extubated with improvement in mental status on [5-31]. On [6-1], pt has altered mental status that requiring repeat doses of valium and haldol for agitation. On [6-2], we have to repeat multiple doses of valium and haldol throughout the day, we restarted psych meds in the afternoon, which resulted in great improvement in her mental status. On [6-3], pt's diet was advanced to regular, she was stable to transfer to regular floor. Her [Hospital ] hospital course per organs system are detailed below: Neurologic: -pain: oxycodone PO, dilaudid iv prn breakthrough, tylenol PO -hx heavy ETOH: decrease valium dosing to 20 q2, restart home depakote Cardiovascular: Tachycardia: Withdrawal vs. pain: continue ciwa and pain control Pulmonary: NAI Gastrointestinal: No acute issues Nutrition: advance as tolerates Renal: NAI Hematology: cont to monitor HCT, her anemia likely [12-21] ETOH use, and acute dilutional Endocrine: RISS Infectious Disease: augmentin MSK: facial fractures/lacerations: augmentin, sinus precautions, PRS f/u outpt, HOB elevation Ophthal: b/l orbital edema, ecchymosis, continue ointment. Optho f/u in 1 week Social: SANE nursing was involved for possible sexual assault - testing per protocol, privacy protection, check ID of all male visitors Psych: restarted home meds Consults: ACS, opthalomology, PRS, social work Prophylaxis: - DVT: boots, SQH Mrs. [Known lastname 111871] was transferred from trauma SICU to the surgical floor on [2125-6-3]. At that time, she was hemodynamically stable. Neurologically, the patient was agitated at times and uncooperative. A CIWA scale was initiated due to the patient's history of alcohol use. Unasyn was continued for facial fractures and later transitioned to PO augmentin. The total course of antibiotics was completed. The patient's foley was discontinued and she later voided without issue. Mrs. [Known lastname 111871] was being followed by the plastic surgery group for her nasal bone fractures, as well as physical and occupational therapy. The patient's mental status slowly returned and she required occupational therapy to assist with cognitive recovery. Physical therapy had assisted Mrs. [Known lastname 111871] with rehabilitation of her right arm, leg and ankle. It was their recommendation that she continue with outpatient OT and PT, as well as neuro-cognitive evaluation. The patient was discharged hemodynamically stable and afebrile. Social work has evaluated the patient during her stay. The patient felt that she was safe being discharged with her fiance. He will be taking time off to care for her full-time until her cognitive status improves. Discharge teaching was provided by myself and the bedside RN. Medications on Admission: Gabapentin 800''', trazodone 200 qhs, buspirone 10''', baclofen 20''' PRN, depakote 250 qAM, 500 qPM, hydroxyzine 25 q6h, celexa 40'. Discharge Medications: 1. Acetaminophen 650 mg PO Q6H pain 2. Senna 2 TAB PO HS 3. Docusate Sodium 100 mg PO BID 4. BusPIRone 10 mg PO TID PRN anxiety 5. Gabapentin 800 mg PO TID 6. Baclofen 20 mg PO TID 7. Divalproex (DELayed Release) 250 mg PO QAM 8. Divalproex (DELayed Release) 500 mg PO QPM 9. Citalopram 40 mg PO DAILY 10. HydrOXYzine 25 mg PO QID 11. Nicotine Patch 14 mg TD DAILY agitation 12. traZODONE 200 mg PO HS:PRN insomnia hold for sedation 13. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain RX oxycodone 5 mg [11-20] tablet(s) by mouth every four (4) hours Disp #40 Tablet Refills:0 14. Ibuprofen 600 mg PO Q8H:PRN pain RX ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:0 15. Artificial Tears Preserv. Free 1-2 DROP BOTH EYES PRN irritation 16. Outpatient Physical Therapy Outpatient PT to address R knee, R ankle, and R shoulder impairments/pain. 17. Outpatient Occupational Therapy OT evaluation to maximize safety secondary to cognitive deficits. Treatment Plan: cognition, ADLs, mobility, balance, patient and family education Frequency: 1-2x wk Duration: one week Discharge Disposition: Home Discharge Diagnosis: Bilateral nasal bone and frontal process of the maxilla fractures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [Hospital1 ] Hospital after you were assaulted. Your injuries include bilateral (both sides) nasal bone fractures, frontal process maxillary fracture and a subgaleal hematoma. You have also experienced pain to your right arm, knee and ankle. MEDICATIONS: o Resume all your home medications as you were prior to being admitted to the hospital. o In regards to your pain, you have been prescribed narcotic (oxycodone) and non-narcotic (ibuprofen) medications. They often work well when taken together. Follow the directions on the prescription bottles and take them when needed. o Do not drive or operate machinery when taking narcotics. The medicine can make you drowsy and impair your thinking. o Narcotics may cause constipation. You may take over the counter colace and senna if you experience this symptom. Drink plenty of water and get exercise, as tolerated, to reduce the risk of constipation. SINUS PRECAUTIONS: Regarding your nasal bone and sinus fractures: Certain precautions will assist healing and we ask that you faithfully follow these instructions: 1. Take the prescribed medications as directed. 2. Do not forcefully spit for several days. 3. Do not smoke for several days. 4. Do not use straws for several days. 5. Do not forcefully blow your nose for at least 2 weeks, even though your sinus may feel ??????stuffy?????? or there may be some nasal drainage. 6. Try not to sneeze; it will cause undesired sinus pressure. If you must sneeze, keep your mouth open. 7. Do not rinse vigorously for several days. GENTLE salt water swishes may be used. Slight bleeding from the nose is not uncommon for several days after the surgery. Please keep our office advised of any changes in your condition, especially if drainage or pain increases. It is important that you keep all future appointments until this condition has resolved. You will require 24 hour assistance at home while you recover from your injuries. Physical and occupational therapy have been ordered to assist you in regaining bothing cognitive and physical abilities as you were prior to your injuries. Also, follow-up appointments have been made for you as noted below. Followup Instructions: Department: DIV OF PLASTIC SURGERY When: FRIDAY [2125-6-15] at 1:30 PM With: [First Name11 (Name Pattern1) 2053] [Last Name (NamePattern1) 6751], MD [Telephone/Fax (1) 6742] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: COGNITIVE NEUROLOGY UNIT When: THURSDAY [2125-6-21] at 11:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6403], MD [Telephone/Fax (1) 1690] Building: Ks [Hospital Ward Name 860] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage Completed by:[2125-6-7] ICD9 Codes: 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8419 }	Medical Text: Admission Date: [2154-9-25] Discharge Date: [2154-10-5] Date of Birth: [2076-2-4] Sex: M Service: ORTHOPAEDICS Allergies: Latex Attending:[First Name3 (LF) 7303] Chief Complaint: L hip periprosthetic femur fracture with mechanical failure/breakage of femoral stem Major Surgical or Invasive Procedure: [2154-10-1]: Complex revision left total hip arthroplasty with reconstruction with proximal femoral endoprosthesis History of Present Illness: 78 yo male s/p fall transferring from powerchair to bed. Hx of b/l THA and TKA, revision L THA. New L femur fracture and fracture of femoral component. Past Medical History: Afib on Coumadin, Borderline DM2, HTN, Hypercholesterolemia, PVD Social History: Activity Level: usually stays at home Mobility Devices: uses his powerchair to get around most of the time, uses a walker to ambulate short distances Tobacco: denies EtOH: rarely Widowed. Family History: n/c Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * 5/5 strength * SILT, NVI distally * Toes warm Brief Hospital Course: The patient was admitted to the orthopaedic surgery service. Preoperatively the hip was aspirated to r/o infection. This was negative for growth. Pre operative CXR was notable for consolidation versus neoplasm. Neoplasm was ruled out with a CT scan. The patient was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: 1. MICU Course: -Patient was brought to ICU and extubated. Will need to continue CPAP (patient uses at home) throughout hospitalization. The patient's code status was discussed with family again and patient made DNR/DNI 24 hours after surgery. Patient was restarted on metoprolol and has been hemodynamically stable. PM Hct 27.8. 2. Post-anemia due to blood loss - POD Hct 23.1, asymptomatic. Transfused 2 units PRBCs due to comorbidities. At discharge, HCT was 27.1. INR 2.2. Goal is less than 2.5 but greater than 1.5. 3. Pneumonia - Patient was noted to be somewhat fluid overloaded and low O2 sats, Seen by medicine and started on IV ceftriaxone. This is switched to cefpodoxime 400 mg [Hospital1 ] x 5 more days upon discharge. O2 sats were in 90's on RA upon discharge. Oxygen discontinued. Internal medicine team felt patient was stable for dischage on oral antibiotics. Otherwise, pain was initially controlled with a PCA followed by a transition to oral pain medications on POD#1. The patient received lovenox for bridging DVT prophylaxis starting on the morning of POD#1 which was continued until the patient was therapeutic on coumadin which he was taking at baseline. The foley was removed on POD#2 and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity with posterior and trochanter-off precautions (no active abduction). Walker at all times for 6 weeks. Mr. [Known lastname ] is discharged to rehab in stable condition. 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. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. sertraline 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every 4-6 hours as needed for wheezing. 7. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 8. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily): D/C when INR > 2.0 x 48hrs. 11. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours). 12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 13. cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO twice a day for 5 days. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: Windgate of [Location (un) 8072] Discharge Diagnosis: Left hip periprosthetic femur fracture with broken femoral stem Post-op anemia due to blood loss 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: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please keep your wounds clean. You may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by the visiting nurse (VNA) or rehab facility two weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in four (4) weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue your wafarin DAILY to help prevent deep vein thrombosis (blood clots). [Male First Name (un) ] STOCKINGS x 6 WEEKS. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by the visiting nurse or rehab facility in two (2) weeks. 11. VNA (once at home): Home PT/OT, INR checks, dressing changes as instructed, wound checks, and staple removal at two weeks after surgery. 12. ACTIVITY: Weight bearing as tolerated with posterior and trochanter off precautions. Use walker or 2 crutches at all times x 6 weeks. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently. Physical Therapy: LLE WBAT Trochanter off and posterior hip precautions Walker or 2 crutches at all times x 6 weeks Mobilize frequently Treatments Frequency: Dry sterile dressing daily as needed for drainage Wound checks Ice as tolerated TEDs x 6 weeks INR/Coumadin - Goal INR 2.0 (not to exceed 2.5) - Check daily, then as directed by PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 37742] (Phone: [Telephone/Fax (1) 23083], Fax: [Telephone/Fax (1) 90602]) - For DVT prophylaxis and atrial fibrillation Followup Instructions: Provider: [First Name4 (NamePattern1) 6100] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2154-10-24] 10:45 Provider: [First Name4 (NamePattern1) 6100] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2154-10-24] 10:45 [First Name4 (NamePattern1) 6100] [Last Name (NamePattern1) ] MD [MD Number(2) 7305] Completed by:[2154-10-5] ICD9 Codes: 486, 2851, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8420 }	Medical Text: Admission Date: [2126-7-28] Discharge Date: [2126-8-6] Date of Birth: [2126-7-28] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: This is an intermittent coverage [2126-7-28] to [2126-8-6]. [Known lastname ] is a 2920-gram product of a 34 and [1-12] week gestation infant born to a 30- year-old gravida 3, para 0, mother. Prenatal laboratories with AB positive, antibody negative, rapid plasma reagin nonreactive, Rubella immune, hepatitis B surface antigen negative, and group B strep status unknown. This pregnancy was complicated by time of type 1 diabetes which was treated with an insulin pump, and then she developed unstoppable preterm labor. She was treated with antibiotics more than four hours prior to delivery and did not have prolonged rupture of membranes. The infant was born by spontaneous vaginal delivery with Apgar scores of 8 and 9 and was transferred to the Newborn Intensive Care Unit for further management. PHYSICAL EXAMINATION ON ADMISSION: The infant weighed 2920 grams (greater than the 90th percentile), length was 47.5 cm (70th percentile), and head circumference was 32 cm (75th percentile). He had a normal examination with clear lungs. A regular rate and rhythm with a soft systolic murmur and normal pulses. The abdomen was normal. He had no other concerns. SUMMARY OF HOSPITAL COURSE: The infant was admitted to the Newborn Intensive Care Unit with a stable respiratory status. 1. RESPIRATORY: The infant was admitted requiring a small amount of nasal cannula oxygen for the first four days of life and then weaned to room air. He subsequently needed small amounts of oxygen with feedings, but he now doing quite well without any oxygen at all. He has had no episodes of apnea or bradycardia. 1. CARDIOVASCULAR: The infant has done well. He has never had any murmur. He has had normal pulses and normal blood pressures. There have been no concerns. 1. FLUIDS, ELECTROLYTES AND NUTRITION: Initially, the infant was made nothing by mouth. He had an initial glucose of 47. He was given one small bolus D-10-W and a follow-up glucose was 87. Since then, he has had no concerns with his glucose. The infant was started on feedings on day of life two and advanced quickly. He has been on full feedings. He does not take oral intake very well, and is requiring partial gavages. This is improving slowly, but he continues to require some gavage feeding. His breast feedings very poorly and has had multiple lactation consultations. He was fortified to 24 calories and reduced to a minimum of 130 in the hopes that he would have better oral intake. His electrolytes have been quite stable. 1. HEMATOLOGY: The infant has had some problems with [Name2 (NI) 57800]a with a maximum bilirubin of 16. This has come down on its own, and most recently was 11.6 on [8-2]. He is slightly jaundiced, and the bilirubin should be followed. His hematocrit on admission was 54. 1. INFECTIOUS DISEASE: He was initially started on ampicillin and gentamicin. This was stopped after 48 hours of negative cultures, and he has done quite well without any concerns. 1. NEUROLOGY: The infant does not need a screening head ultrasound, and he has shown no concerning signs requiring one. INTERIM DIAGNOSES: 1. Prematurity. 2. Hyperbilirubinemia. 3. Transient oxygen need. 4. Poor oral feeding. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Last Name (NamePattern1) 57801] MEDQUIST36 D: [2126-8-6] 16:32:12 T: [2126-8-6] 19:08:30 Job#: [Job Number ] ICD9 Codes: 7742, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8421 }	Medical Text: Admission Date: [2168-7-18] Discharge Date: [2168-7-25] Date of Birth: [2168-7-18] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: [Known lastname 56581] [Known lastname 73083] is the former 2.03 kg product of a 34-week gestation pregnancy born to a 36- year-old G3, P0 woman. PRENATAL SCREENS: Blood type B+, antibody negative, rubella- immune, RPR nonreactive, hepatitis B surface antigen negative, group beta strep status unknown. The mother's medical history is notable for cerebral venous malformations and history of resection of a benign thyroid nodule. She was treated with thyroxine during her pregnancy. The pregnancy was complicated by frequent episodes of vaginal bleeding. An ultrasound on [2168-5-9] revealed an anterior subchorionic clot. The mother was beta complete as of [2168-5-8]. Due to the known cerebrovascular malformations the mother agreed to a planned cesarean section at 34-weeks gestation. The infant emerged vigorous, had Apgars of 8 at one minute and 9 at five minutes. She was admitted to the neonatal intensive care unit for treatment of prematurity. Anthropometric measurements at the time of admission: Weight 2.03 kg 50th percentile, length 43 cm 25th percentile, head circumference 31.25 cm 50th percentile. PHYSICAL EXAM AT DISCHARGE: General: Active, alert infant in open crib, room air. Skin: Warm and dry. Color: Pink, mildly jaundiced. Head, eyes, ears, nose and throat: Anterior fontanelle open and level, sutures opposed, eyes clear, palate intact. Chest: Breath sounds clear and equal, easy respirations. Cardiovascular: Regular rate and rhythm without murmur, normal S1, S2, femoral pulses +2. Abdomen: Soft, no masses, positive bowel sounds, cord remnant on and drying. GU: Normal female. Extremities: Moving all. Neurological: Alert, positive suck, positive grasp, symmetric tone. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: 1. Respiratory. [Known lastname 56581] has been on room air for her entire neonatal intensive care unit admission. She has had no episodes of spontaneous apnea. At the time of discharge she is breathing comfortably with a respiratory rate of 40-60 breaths per minute. 2. Cardiovascular. [Known lastname 56581] has maintained normal heart rates and blood pressures. A murmur was noted on day of life [3-12] and has not been heard since that time. Her baseline heart rate is 130-150 beats per minute with a recent blood pressure of 74/32 mmHg, mean arterial pressure of 42 mmHg. 3. Fluids, electrolytes, nutrition. [Known lastname 56581] has tolerated enteral feeds from the date of birth. At the time of discharge she is taking 130-140 mL per kg per day of Similac 24 calorie per ounce formula. 4. Infectious disease. There were no sepsis risk factors as this was an elective cesarean delivery. [Known lastname 56581] was not evaluated for sepsis. 5. Gastrointestinal. Peak serum bilirubin occurred on day of life 3, total 7.8 mg per dL. A repeat bilirubin on day of life 6 had a total of 6.9 mg per dL. 6. Neurological. [Known lastname 56581] has maintained a normal neurological exam during admission, there were no neurological concerns at the time of discharge. 7. Sensory. Audiology: Hearing screening was performed with automated auditory brainstem responses. [Known lastname 56581] passed in both ears on [2168-7-25]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with the parents. PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 42043], Pediatricians Incorporated, [Street Address(2) 52708], [Hospital1 2436], [Numeric Identifier 73084]. Phone number [Telephone/Fax (1) 42047]. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. Ad lib p.o. feeding Similac 24 calorie per ounce formula. 2. No medications. 3. Iron and vitamin D supplementation: 1. Iron supplementation is recommended for preterm and low birthweight infants until 12 months corrected age. 2. All infants fed predominantly breast milk should receive vitamin D supplementation at 200 International Units (may be provided as a multivitamin preparation) daily until 12 months corrected age. 4. Car seat position screening was performed. [Known lastname 56581] was observed in her car seat for 90 minutes without any episodes of oxygen desaturation or bradycardia. 5. State newborn screen was sent on [7-21] and [2168-7-25]. 6. Immunizations: Hepatitis B vaccine was administered on [2168-7-23]. 7. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following 4 criteria: A. Born at less than 32 weeks. B. Born between 32-35 weeks with 2 of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings. C. Chronic lung disease. D. Hemodynamically significant congenital heart disease. Influenza immunizations recommended annually in the fall for 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 care givers. This infant has not received rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks, but fewer than 12 weeks of age. FOLLOWUP APPOINTMENTS: Appointment with Dr. [Last Name (STitle) 42043] within 3 days of discharge. DISCHARGE DIAGNOSES: 1. Prematurity at 34-weeks gestation. Reviewed By: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 53043], [MD Number(1) 53044] Dictated By:[Last Name (Titles) ] MEDQUIST36 D: [2168-7-24] 18:26:57 T: [2168-7-24] 20:27:30 Job#: [Job Number 73085] ICD9 Codes: V053, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8422 }	Medical Text: Admission Date: [2141-4-29] Discharge Date: [2141-5-3] Date of Birth: [2092-4-1] Sex: M Service: SURGERY Allergies: Morphine / Nsaids / Dilantin Attending:[First Name3 (LF) 6346] Chief Complaint: BRBPR and abdominal pain Major Surgical or Invasive Procedure: [2141-4-27] ERCP with sphincterotomy and PD stent placement [2141-5-2] Repeat ERCP with lithotrypsy History of Present Illness: 49M s/p lap CCY in [10-26] originally presented and admitted to [Location (un) 620] for epigastric pain (no N/V or F/C). Imaging shows retained cystic duct stone. He underwent a ERCP and sphincterotomy here on [4-27]. A 1.5 cm retained cystic duct stone was seen but several attempts to extract it was unsuccessful. Given the multiple manipulations/prolonged procedure, a pancreatic duct stent was placed to minimize post ERCP pancreatitis. The patient presented to the ED on [4-28] with abdominal pain and BRBPR. In addition his lipase was elevated to 6970. He was admitted to the medical service/ICU for monitoring of his post-ERCP pancreatitis and LGIB secondary to an UGIB from his recent sphincterotomy. Past Medical History: PMH: cholecystitis, HTN, subdural hematoma (MVA [2110]) PSH: cholecystectomy, drainage of SDH as above [Last Name (un) 1724]: Amilodipine 10 mg PO qD Social History: Married with 3 children. Denies smoking, social drinker. Works at Department of Public Works. Family History: non-contributory Physical Exam: VS: Afebrile, VSS . Gen: In NAD. HEENT: PERRL, EOMI. No scleral icterus Neck: Supple, no LAD, no JVP elevation. Lungs: CTA bilaterally, no wheezes, rales, rhonchi. Normal respiratory effort. CV: RRR, no murmurs, rubs, gallops. Abdomen: soft, NT/ND Extremities: warm and well perfused, no cyanosis, clubbing, edema. Neurological: alert and oriented X 3 Skin: No rashes or ulcers. Psychiatric: Appropriate. . Pertinent Results: Admit WBC: 9.5 Discharge WBC: 6.0 Admit Hct: 41 --> 30.5 (admit to [Hospital Unit Name 153]) Discharge Hct: 32 Admit Lipase: 6790 Discharge Lipase: 136 . [4-27] ERCP: - A retained cyst duct stone was found. This was not removed. - Otherwise normal post-cholecystectomy cholangiogram. - A 5cm by 5FR Geenen pancreatic stent was placed to facilitate deep biliary cannulation. - A biliary sphincterotomy was performed. [4-28] CT Abd: 1. No evidence of perforation, or other post-ERCP related injuries. 2. Contrast in the CBD and cystic stump/gallbladder neck with a filling defect suggesting a residual stone in the cystic stump/gallbladder neck. No evidence of CBD or pancreatic ductal dilation. Stent noted in the pancreatic duct extending into the duodenum. 3. Multiple hypoattenuating left renal foci, largest in the superior pole could represent a simple cyst, others are too small to characterize. [4-30] ERCP: A plastic stent placed in the pancreatic duct was found in the major papilla. Evidence of a previous sphincterotomy was noted in the major papilla. Pancreatic duct stent was removed and sent for cytology Cholangioscopy with Electrohydrolithotripsy:SpyGlass System is introduced into the therapeutic duodenoscope. The bile duct is cannulated, and the SpyScope Catheter guided the SpyGlass?????? Direct Visualization Probe into the biliary tree over the guidewire. The SpyScope Catheter and SpyGlass Probe are maneuvered up to the cystic duct for direct visualization. 15 mm cystic duct stone was visuaized. A 3 Fr electrohydraulic lithotripsy probe is passed through the working channel of the SpyScope Catheter.Under direct visualization, the lithotripsy probe is advanced until it came in contact with the target stone. Water is infused through the dedicated irrigation channels to provide a fluid environment. Electrohydraulic lithotripsy is applied and the stone is broken into multiple fragments. A spiral retrieval basket or large stone extraction balloon is then passedthrough the working channel of the duodenoscope and into the bile duct and multiple sweeps of the duct are conducted to remove remaining stone fragments. We were successful to remove couple of fragments but there were still [6-25] stone fragments left in the cystic duct stump as the duct was quite tortous. Brief Hospital Course: After being admitted to the medical service/[Hospital Unit Name 153], the patient's repeat hct dropped from 41 to 30.5. He was still hemodynamically stable though. On [4-29]. the patient was transfused 1 unit of PRBC. His hct responded appropriately, increasing to 33, stabilizing at 30 with IVF running for his post-ercp pancreatitis. Given his hemodynamic stability and his progressively decreasing amylase/lipase, a repeat ERCP was done on [4-30] with attempts at lithotrypsy to remove the retained cystic duct stone. The bulk of the stone was removed with the basket, however approximately [6-25] pieces still remained. The pancreatic duct stent originally placed on [4-27] was taken out. The patient tolerated the procedure well. Repeat LFTs and amylase/lipase show resolving pancreatitis. His diet was advanced. Abdominal exam is benign. He is to follow up with Dr. [First Name (STitle) 2819] in one week. Per ERCP recs, the patient should undergo a MRCP in one month to reassess for stones. If the MRCP shows stones or is vague, a ERCP could be attempted again. Medications on Admission: Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 14 days. Disp:42 Tablet(s) Refills:0 2. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: 1) Retained cystic duct stone s/p ERCP, sphincterotomy and lithotrypsy 2) Post ERCP Pancreatitis Discharge Condition: Good Discharge Instructions: Please call or return to the ED if you experience any of the following signs/symptoms: - Fevers and chills - Dizziness - Chest pain/pressure - Difficulties breathing - Excessive nausea and vomitting - Difficulties keeping down liquids/dehydration - Abdominal pain - Coughing up blood/throwing up blood - Blood per rectum/in stools Followup Instructions: Follow up with Dr. [First Name (STitle) 2819] in one week. Please call his office at ([Telephone/Fax (1) 6347] to schedule an appointment. Completed by:[2141-5-3] ICD9 Codes: 2851, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8423 }	Medical Text: Admission Date: [2182-7-10] Discharge Date: [2182-7-19] Date of Birth: [2130-11-15] Sex: F Service: MEDICINE Allergies: Abacavir / Vancomycin / Haldol / Heparin Agents / Bactrim Ds / Actonel Attending:[First Name3 (LF) 943] Chief Complaint: Acute Renal Failure Major Surgical or Invasive Procedure: Right IJ central catheter placement Paracentesis x4 (3 bedside, 1 U/S guided) Arterial line placement History of Present Illness: 51yo F with h/o HIV, HCC s/p liver tx with recurrence of hep C presents from liver clinic for direct admission with concern for acute worsening of renal function. Her baseline creatinine, although fluctuates somewhat, tends to run 1.3-1.9; last 1.7 on [2182-5-30]. Upon routine lab work on [2182-7-8], however, her creatinine was 3.2 and potassium was noted to be 5.5. Thus, she is now being admitted for further evaluation of the acute bump. She reports she has overall been feeling well. She recently traveled to [State 108] and returned within the past week. Pt states she went several days without taking her medications as prescibed because she "didn't want to deal with them". It is not clear exactly what her regimen had been and what medications she was missing. Pt is clear that she missed several doses of Norvir because she left it in a hotel refrigerator. She states that she has been eating okay and reports she has been keeping up with her fluids and denies dry mouth and feeling dehydrated. She says her urine has been very light and denies dysuria, hematuria, and frothy urine. She has not been taking any NSAIDs nor other OTC/herbal meds or teas. She denies any significant med changes with the exception of spironolactone being added to her lasix dose approximately 6 weeks ago. She was on Chantix x 1month, but this was stopped approx. one month ago due to lack of insurance coverage for med. She has noted UE muscle "twitching" over the past month and some calf cramping (she describes as "restless legs" and says this has been ongoing x several months). She does report one dark, brown/black, tar-like stool on Monday but this has not reoccured. . Of note, RUL long nodule was recently noted on chest CT concerning for malignancy for which she is being followed by imaging. . ROS: As above. Additionally reports 70lb weight loss since transplant in [2179] and approximately 8lb weight loss over the past month. No changes in vision/headache. Occasional LH with fast movement. No chest pain/SOB. No palpitations. No N/V/diarrhea. Abdominal pain which is chronic and unchanged. No dysuria/hematuria. No joint pain/rashes. Past Medical History: # HIV, last CD 4 count 145 and VL <50 in [6-10] count pending. # HCV s/p liver transplant 2/[2179]. Transplant complicated by an anhepatic period x 24 hours due to edematous primary transplant necessitating second liver, Also complicated by PE with placement of IVC filter. Liver biopsy [11/2181] showed rurrent HCV (grade 2 inflammation and stage 3 fibrosis) - currently being monitored. Last VL [2181-10-8] 1,170,000 IU/mL -followed by Dr. [Last Name (STitle) 497] and Dr. [Last Name (STitle) 724]. - h/o encephalopathy and ascites post transplant per patient - s/p gastric variceal bleed [12-15] # Pancytopenia: w/u Wih Dr. [Last Name (STitle) 2148] [8-/2181] (see note), BM biopsy consistnet with HIV related anemia. # Anemia: baseline 28-30, BM bx thought c/w HIV related anemia # Heparin-induced thrombocytopenia # Chronic methadone use: recently stopped, now on oxycontin # Depression # Fibromyalgia/Chronic Pain # CRI (baseline creat 1.3-1.9) # H/[Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (NamePattern1) ] tear # H/O Internal hemorrhoidal bleed # RUL lung nodule # PE peri liver transplant # Abnormal pap; ASCUS, s/p colpo [10-15] (normal epithelium) and followed by OB/GYN Social History: Social hx: Divorced. Lives with boyfriend in [Name (NI) 1411]. Previously worked in family restaurant. Makes jewelry. -Former IV heroin, cocaine user; last smoked crack cocaine 8 months ago. -Tob: Still smoking 1ppd, no EtOH. Family History: Mother with [Name2 (NI) ], breast CA, AMI; Father with MI. Brother with IVDU, sister with asthma. Uncle with [Name2 (NI) 499] CA. Physical Exam: PE: T: 97.7 BP 95/55 HR 79 RR 18 O2sat 100% on RA. Gen: somnolent, intermittantly falling asleep, inappropriate responses to questioning. NAD HEENT: PERRL, sclera anicteric, mmm Neck: JVD 9cm, no lymphadenopathy CV: rrr, s1/s2, 3/6 systolic ejection murmur appreciated throughout Resp: CTAB Abd: + bowel sounds, soft, non-tender, non-distended, palpable liver edge. No fluid wave. Ext: 2+ distal pulses. 1+ edema bilateral lower extremities. Skin: slightly jaundiced, LEs with [Known lastname ], puritic, papules over the shin and dorsal surface of the feet. Neuro: oriented x3. Somnolent but directable. 1+ patellar reflexes, 5/5 strength throughout. Pertinent Results: [2182-7-10] 08:30PM BLOOD Glucose-103 UreaN-42* Creat-2.6* Na-140 K-5.3* Cl-111* HCO3-24 AnGap-10 [2182-7-18] 04:33AM BLOOD ALT-18 AST-20 AlkPhos-71 TotBili-3.3* [2182-7-19] 05:18AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.8 [2182-7-10] 08:30PM BLOOD Albumin-3.6 Calcium-8.5 Phos-4.6* Mg-2.5 [2182-7-11] 11:12AM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-POS amphetm-NEG mthdone-NEG [2182-7-14] 1:10 am BLOOD CULTURE Site: ARM Source: Venipuncture. FINAL REPORT [2182-7-16] Blood Culture, Routine (Final [2182-7-16]): KLEBSIELLA OXYTOCA. FINAL SENSITIVITIES. [2182-7-15] 04:48PM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-POS amphetm-NEG mthdone-NEG CT ABDOMEN W/O CONTRAST Study Date of [2182-7-16] 2:48 PM IMPRESSION: 1. No bowel pathology or biliary pathology to explain sepsis. 2. Faint ground-glass right middle lobe opacities which are nonspecific and may represent microatelectasis or infection/inflammatory etiologies. Bilateral pleural effusions greater on the right side. 3. Distal esophageal and fundal wall thickening. This may be within normal limits given under distention or likely related to underlying third spacing/edema. Additional etiologies including lymphoma or gastritis cannot be excluded but are felt less likely. 4. Large amount of abdominal/pelvic ascites and third spacing. 5. Interval increase in splenomegaly with adjacent mass effect on the left kidney. [2182-7-19] 05:18AM BLOOD WBC-3.6# RBC-2.52 Hgb-8.7* Hct-26.2* MCV-104* MCH-34.5* MCHC-33.3 RDW-20.8* Plt Ct-58* PT-16.1* PTT-38.4* INR(PT)-1.4* BLOOD Glucose-108* UreaN-41* Creat-2.0* Na-139 K-4.2 Cl-114* HCO3-19* Brief Hospital Course: 51yo F with h/o HIV, HCC s/p liver tx with recurrence of hep C admitted from liver clinic for evaluation of acute worsening of renal function. # ARF on CRI: Pt was admitted for evaluation of acutre renal failure (cre 2.6). Diuretics were held and the patient responded well to gentle IV hydration, clearing over back down to baseline of 1.9 by hospital day 2. Her creatinine remained in the 1.9-2.0 range over the remainder of her admission. # HIV: At the time of admission, the patient admitted to non-complaince with her ARV therapy. Per ID and discussion with the patient, she was discontinued from all anti-retroviral medications. # Bacteremia- On hospital day 3, the pt was noted to be febrile with nausea and vomiting over night. Blood cultures were postitive for GNRs determined to be Klebsiella. Pt was started on IV cefepime. All blood cultures subsequent to treatment were negative. The patient was transitioned to PO cipo on discharge and was instructed to complete the remainder of a 14 day course. # Hypotension/ICU course- On Sunday [7-14], pt was noted to be profoundly hypotensive. She intially responded to fluid boluses but then had intermittant steep declines requring nearly 8L of NS over 36 hour course in order to maintain adequate pressure. On the eveing of [7-15], she required admission to the ICU for administraion of IV pressors. She required <24 hours of pressor therapy and demonstrated ability to maintain BP. A paracentesis was suggestive of SBP and a CT showed no evidence of intraabdominal abcesses. After several hours, the patient was stable and she was returned to the medical floor. Her blood pressure remained stable throughout the remainder of her hospital stay. # Hep C cirrhosis: The patient had a known reinfection of Hep C and there was question of encephalopathy given her intermittant somnolence on exam. Her home dose of lactulose was increased and titrated for a goal of [4-14] bowel movements per day. During admission, the patient underwent 3 paracentesis for suspected SBP. Following the second paracentesis, the patient was noted to have a significant drop in her hematocrit (from 24 to 19) and she was transfused 2 units of blood with an appropriate response. Her hematocrit was low (24) but stable at the time of discharge. # Substance Abuse: Pt admitted to injecting drugs as recent as [7-8]. There was concern over the course of her admission that she continued to use illicit substances as an inpatient, as she had unexplained episodes of lethargy and confusion which corresponded both with visits from family members or unauthorized trips to smoke. The patient denied in hospital use of drugs. Toxicology screens were positve for opioids and cocaine both on day 2 and day 6 of hospitalization. # Goals of Care/Palliative Care: During the patient's admission to the ICU, a discussion was had regarding the goals of her medical care. At that time, the patient, in conjunction with several of her long-time physicians discussed quality of life and resonable expectations for recovery. The patient decided to become DNR/DNI. Further discussions over the remainder of her hospitalization lead to the development of an outpatient care plan that would provide her the most comfort and quality of life. The patient was discharged with Hospice care. # Fibromyalgia/chronic pain: On presentation it was noted that the patient was maintained on very high dose oxycontin as outpatient. Of note, at the time of her inital evaluation, she had recieved 40mg dose of oxycontin and was extremely somnolent. Pain control and somnolence were in gentle balance over the course of her admission. She was discharged on a plan of 50mcg Fentanyl patches every 72 hours and 5-10mg oxycodone for breakthrough pain. Further pain management was to be coordinated through hospice care. Medications on Admission: Albuterol 2 puffs q4h prn Atazanavir 300mg daily Azithromycin 600mg qThursday Citalopram 60mg daily Dapsone 100mg daily Marinol 10mg PO bid (she takes "prn") Truvada 200mg-300mg q48hours Epogen 40K units weekly prn? Neupogen 300mcg qweek Advair 100mcg-50mcg inhaled [Hospital1 ] Furosemide 60mg PO daily Boniva q3 months (has not had x5 months due to insurance issues) Lactulose 30ml daily (she takes prn for 1BM/day) Nadolol 20mg daily Oxycontin 40mg q12h (listed in OMR as q12, she reports taking q8) Oxycodone 5-10mg q4-6h prn breakthrough Ranitidine 150mg [Hospital1 ] Ritonavir 100mg daily Spironolactone 25mg [Hospital1 ] (has been taking once a day) Tacrolimas 0.5mg qMonday and Friday Trazodone 50-75mg hs prn Tums prn Ensure tid with meals Discharge Medications: 1. Azithromycin 600 mg Tablet Sig: One (1) Tablet PO 1X/WEEK (TH). 2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. 3. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 6. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 8. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO DAILY (Daily). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Dronabinol 2.5 mg Capsule Sig: Four (4) Capsule PO BID (2 times a day). 11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:30 Tablet(s) Refills:0 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 13. Ciprofloxacin 500 mg Tablet Sig: 1.5 Tablets PO Q24H (every 24 hours): Please complete this entire prescription. Last dose to be taken on [7-26]. . Disp:45 Tablet(s) Refills:2 14. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:5 Patch 72 hr(s) Refills:2 15. Ensure Liquid Sig: One (1) PO three times a day: Please take three times a day with meals. 16. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO as directed. Disp:30 Capsule(s) Refills:1 17. Trazodone 50 mg Tablet Sig: One (1) Tablet PO qHS:PRN as needed for insomnia: For sleep. 18. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 19. Outpatient Lab Work Please draw on Monday, [7-22]: Tacrolimus level. Please have results faxed to: Dr. [Last Name (STitle) 724], Fax# ([Telephone/Fax (1) 4409] Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Acute renal failure on chronic renal insufficiency Klebsiella bacteremia Spontaneous bacterial peritonitis HIV Substance abuse Discharge Condition: Stable, BP at baseline, afebrile. Discharge Instructions: You were admitted with acute renal failure. This improved mildly with IV fluids and holding of your diuretics. We have restarted you on a lower dose of diuretic (spironolactone) to help with fluid retention in your abdomen. While hospitalized, you developed an infection in your blood which was likely due to SBP (peritonitis). You were started on IV antibiotics and required a brief stay in the intensive care unit with medication to support your blood pressure. Your blood pressure has since improved and you have been transitioned to oral antibiotics. Please be sure to complete your antibiotics regimen as prescribed. In addition to a new antibiotic, there have been some changes to your home medications. You have indicated your wish to discontinue your anti-retroviral medications. In addition, we have transitioned your original oxycontin dose to fenanyl and this will be followed up with your new palliative care provider. You are being discharged on Tacrolimus for your liver. You will need to have this level followed. Please have blood drawn on Monday, [7-22]. Please call your doctor or return to the emergency room if you develop fever, chills, nausea or vomiting, abdominal pain, chest pain, shortness of breath, or any other concerning symptom. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4861], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2182-8-13] 11:00 Completed by:[2182-7-31] ICD9 Codes: 5849, 5859, 2767
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8424 }	Medical Text: Admission Date: [2173-3-24] Discharge Date: [2173-4-8] Date of Birth: [2115-8-1] Sex: M Service: MEDICINE Allergies: Sulfasalazine / Warfarin / Vancomycin Attending:[First Name3 (LF) 3561] Chief Complaint: Edema, dyspnea Major Surgical or Invasive Procedure: Right and left heart catherizations PICC placement [2173-4-7] History of Present Illness: 57 yo male with afib, venous insufficiency, significant UGIB, who presents to Dr.[Name (NI) 5452] office today with c/o worsening dyspnea and increasing weight gain and edema. He denies orthopnea or PND. He was told to have a sleep study, but he has not had that. He states he has alot of medical problems, but none of them are to the point where it concerns him. He denies any back or neck pain. He's had venous insufficiency and ulcers associated with that for a while, followed by Dr. [Last Name (STitle) ] of vascular for that. In Dr.[Name (NI) 5452] clinic, an echo was performed which showed e/o right heart strain and ? cor pulmonale. He was referred to our ED for further eval. In ED, initial vitals were 61, 112/85, mid 80s on RA, and then increased to 95% on 4L. He was noted to have bilateral crackles and anasarca on exam. A CTA was performed which was negative for PE. The patient was then admitted for volume overload. He was not given lasix in the ED in case a cath was to be performed in the AM. ECG was afib without any ischemic changes. cardiac enzymes were not very remarkable. On floor, patient was comfortable. he denied chest pain or SOB. he confirmed above. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint pains, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: 1. Atrial fibrillation not anticoagulated since significant GIB 2. History of alcohol abuse. 3. Hypertension. 4. Upper gastrointestinal bleed in [2167-7-7] secondary to prepyloric ulcer. 5. Psoriasis. 6. Mitral valve prolapse. 7. Gastric biopsy in [2163-2-7] showing esophagitis and gastritis, H-pylori negative. 8. The patient had repeat esophagogastroduodenoscopy in [2167-10-7] showing evidence of gastritis, however, a healed prepyloric ulcer. 9. Adrenal insuffiency diagnosed in [2172] and on hydrocortizone replacement therapy. Social History: The patient currently works part time as a spanish teacher at middle school. He has smoked a half a pack per day of tobacco times 30 years. He reports occasional alcohol use, but has a history of alcohol abuse in the past. He denies any other drug use. Family History: Noncontributory Physical Exam: VS:98 120/81 58 22 95% 4L GENERAL: obese male, NAD. had "ruddy" look. sleeping, but arousable and answers questions appropriately. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. ruddy appearance of face NECK: Supple with JVP of 12 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. irregularly irregular, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. decreased BS bilateral bases, few bibasilar crackles. no rhonci ABDOMEN: obses, soft tissue edema; large stretch marks throughout abdomen. reddish color. normal bowel sounds EXTREMITIES: dark feet, erythematous legs, bandaged. 3+ edema bilatearlly up through thighs SKIN: stasis dermaitits and ulcers present; bandage in place PULSES: Right: Carotid 2+ unable to appreciate femoral pulse [2-8] body habitus. 1+ DP pulse Left: Carotid 2+ unable to appreciate femoral pulse [2-8] body habitus. 1+ DP pulse Pertinent Results: Admission Labs: [2173-3-24] 05:30PM CK-MB-NotDone [2173-3-24] 05:30PM cTropnT-0.06* [2173-3-24] 05:30PM ALT(SGPT)-15 AST(SGOT)-35 LD(LDH)-382* CK(CPK)-45 ALK PHOS-188* TOT BILI-3.0* DIR BILI-1.6* INDIR BIL-1.4 [2173-3-24] 07:50PM PT-17.4* PTT-32.2 INR(PT)-1.6* . CTA [2173-3-24]: 1. No evidence of pulmonary embolus or aortic dissection. 2. Nodular shrunken hepatic contour, could reflect chronic passive congestion and/or liver disease. clinical correlation is advised. 3. Unchanged left hepatic lobe hypoattenuation, could reflect a simple cyst. 4. Bilateral pleural effusions, anasarca and ascites, in the setting of cor pulmonale is probably secondary to right heart failure. . Arterial Doppler [2173-3-25]: Doppler evaluation was performed of both lower extremity arterial systems at rest. On the right, Doppler tracings are triphasic at the femoral, popliteal and dorsalis pedis. They are absent at the posterior tibial. Ankle brachial index is 1.08. Pulse volume recordings are mildly decreased at the ankle and metatarsal. Left Doppler tracings are triphasic at the femoral, popliteal, and posterior tibial levels. They are monophasic at the dorsalis pedis. Ankle brachial index is 0.94. Pulse volume recordings show mild drop off at the ankle and metatarsal. IMPRESSION: Mild bilateral tibial artery occlusive disease. . Abdominal utlrasound [2173-3-25]: 1. Very heterogeneous liver with no solid liver mass identified. 2. Hyperdynamic pulsatile bidirectional flow seen in all of the portal veins. Large hepatic vein. These findings suggest tricuspid insufficiency. 3. Sludge in the gallbladder. 4. Small amount of ascites. . Cardiac echo [2173-3-26]: This study was compared to the prior study of [2170-10-9]. LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. The IVC is dilated (>2.5cm) LEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Dilated RV cavity. RV function depressed. Abnormal diastolic septal motion/position consistent with RV volume overload. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: Aortic valve not well seen. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild (1+) MR. TRICUSPID VALVE: Moderate [2+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. CONCLUSIONS: Suboptimal image quality. Images insufficient to exclude an ASD or PFO.The left atrium is moderately dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. The right ventricular cavity is dilated with depressed free wall contractility. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. The aortic valve is not well seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Suboptimal image quality. Agitated saline could not be seen in the right atrium after injection. [2173-3-30] PFTS: SPIROMETRY 8:00 AM Pre drug Post drug Actual Pred %Pred Actual %Pred %chg FVC 1.54 4.55 34 1.67 37 +9 FEV1 1.01 3.26 31 1.07 33 +6 MMF 0.47 3.19 15 0.44 14 -7 FEV1/FVC 66 72 92 64 90 -2 LUNG VOLUMES 8:00 AM Pre drug Post drug Actual Pred %Pred Actual %Pred TLC 2.99 6.81 44 FRC 1.81 3.82 47 RV 1.59 2.26 70 VC 1.41 4.55 31 IC 1.18 2.99 40 ERV 0.22 1.56 14 RV/TLC 53 33 160 He Mix Time 4.75 . DLCO 8:00 AM Actual Pred %Pred DSB 11.46 27.09 42 VA(sb) 2.21 6.81 32 HB 17.70 DSB(HB) 10.64 27.09 39 DL/VA 4.81 3.98 121 . CCath [2173-3-30]: cath - left clean, right elevated pressures, severe pHTN, did not respond to nitric oxide . Right Foot XRay: IMPRESSION: Degenerative changes primarly involving the great toe. No findings to suggest bone destruction . Discharge Labs: . 140 / 96 / 18 / 107 3.8 / 36 / 0.9 Ca: 9.0 Mg: 2.0 P: 2.6 WBC 6.6 Plt 247 Hct 48.6 PT: 16.1 PTT: 34.9 INR: 1.4 . ABG [2173-4-8]: pH 7.38 pCO2 62 pO2 78 HCO3 38 BaseXS 8 Brief Hospital Course: Mr. [Known lastname 21914] is a 57 yo M with afib, p/w severe R CHF and volume overload as well as c/b BLE venous stasis breakdown. R CHF [2-8] cor pulmonae from OSA and pulmonary edema and anasarca on lasix ggt and on BiPAP at night. . Since admission, aggressive diuresis has been pursued. [3-25] began diuresis with IV lasix. Abdominal u/s was obtained to evaluate for cirrhosis given distended abdomen and elevated INR and revealed a hetergenous liver. Wound care recs obtained. Pulmonary consult [3-26] thought exam / studies consistent with pulmonary HTN, obtained PFTs, [Location (un) ]/lung volumes/DLCO & obtain HIV, [Doctor First Name ], ds-DNA, anti-CSL, RF, ESR, CRP. Sleep evaluation recommended supplemental O2, avoid empiric CPAP (both CPAP and autotitrate BiPAP with desaturation). He was also being followed by PT. [3-27] Sprinolactone and K were added. Dermatology consult [3-29] for pruritic rash though c/w prurigo nodularis and recommended anti-histamines, clobetasol [Hospital1 ], d/c neosporin, bactroban [Hospital1 ] to open lesions, if persittent could consider cryothearpy or IL sterioids, f/up in 3 months. For his stasis recommneded compression of entire foot and knee if can tolerate, elevation, Unna boots. Trigger [3-30] for spreading rash and somnolence, given Fenofexadine, on supplemental O2. Trigger [3-31] for hypoxia and altered mental status, pt O2 to 70s on CPAP at 10L with patient difficult to arouse. Pulmonary [3-31] reccommended keeping upright, continue lasix and consider adding Diamoxx, nebs PRN, try auto-BiPAP. On [4-2] recommended d/c Spironolactone and continuing diuresis. Cardiology attending was recommending screening for rehab while continuing Lasix gtt. [4-3] patient triggered for difficulty with arousing, was cultured and ABG was sent revealing pH 7.38, pCO2 69, pO2 66, HCO3 42, lactate 1.1. Repeat ABG pH 7.37, pCO2 68, pO2 66, HCO3 41. Patient remained somnolent with some concern for hypotension and bradycardia. He was then transferred to the ICU for further evaluation of these complaints. . MICU Course: Patient stabilized clinically on BiPAP. Sleep recommended a special ASV machine. We continued aggressive diuresis with lasix 120mg PO BID with good effect. He grew [2-10] MSSA from his blood for which he was placed on nafcillin after a brief course of daptomycin (has vanco allergy). A PICC was placed [2173-4-7]. He will need a 2 week course of nafcillin through [2173-4-17]. Vascular changed his LE dressings. He will need follow up with vascular and dermatology. We restarted his metoprolol with good effect. . By Problem: . 57 yo M with afib, admitted with CHF exacerbation [2-8] cor [Hospital 21915] transferred to ICU for AMS likely multifactorial [2-8] pulmonary edema, OSA and GPC bacteremia [2-8] chronic RLE ulcer. . MSSA Bacteremia/RLE ULCER: Most likely source at this time was RLE ulcer, vascular was consulted. Foot xray without concern for infection. He was empirically on daptomycin then switched to nafcillin. PICC was placed [2173-4-7]. His surveillance cultures remained NGTD except for 1 culture with coag neg staph was thought to be contaminant. Echo was negative for vegetation. he will need 2 weeks of antibiotics through [2173-4-17]. . Obstructive Sleep Apnea: Patient was seen by pulmonary and vasculitis labs sent. During R heart cath, patient had severe pHTN and no improvement with nitric oxide. Sleep study not tolerated because patient could not tolerate CPAP mask. PFTs were reflective of restrictive physiology from obesity. He was put on ASV machine and tolerated well. He will need to wear this at night and follow up in sleep clinic. He will need a sleep study prior to that appointment. . Hypoxia/Hypercarbia: - Likely multifactorial including some pulmonary edema (as evidenced on CXR), pulmonary hypertension and cor pulmonale. no e/o PE on CTA from admission. He is mildly hypercarbic at baseline. He responded well to the above interventions and to lasix. . Right heart failure - Secondary to cor pulmonae from COPD/OSA. No significant evidence of alcoholic cardiomyopathy. Echo showed normal EF, not major LV dysfunction and showed significant pHTN and TR. No improvement with nitric oxide, thus did not start sildenafil or CCB. Patient s/p right and left heart cath. No evidence of ASD. Left heart cath negative for CAD. We resumed his lasix at 120mg PO BID with very good effect. We re-started his metoprolol with good effect. His lasix will need to be adjusted prn given his volume status, though he likely remains total body fluid overloaded on discharge. . Atrial Fibrillation: Currently not anticoagluated [2-8] massive GIB while on coumadin and Ciprofloxacin. Rate controlled with metoprolol. No ASA due to h/o GIB. . Prurigo nodularis: Dermatology saw patient who recommended applying creams and to follow up with dermatology in 3 months. Continue atarax QHS, clobetasol 0.05% ointment [Hospital1 ], capsaicin cream TID x 4 weeks, mupirocin Cream 2% 1 Appl TP [Hospital1 ] to open lesions/excoriations . Venous insuffiency/RLE Ulcer: Status post Apligraf placement on his right leg on [1-14]. Arterial flow studies, good flow until tibia. Chronic issue. Foot xray without evidence of infection. Continued dressings and will need follow up with vascular surgery. . Depression ?????? started on citalopram 10mg daily. Can uptitrate as needed . Access: PICC was placed successfully on [2173-4-7] Medications on Admission: Protonix 40 mg [Hospital1 ] Vitamin C 500 mg daily Lasix 100 mg daily Hydrocortisone 10 mg daily Digoxin 250 mcg daily Hydroxyzine 25 mg 1-2 tabs [Hospital1 ] Ferrous Sulfate 325 daily Folic acid 1 mg daily Metoprolol 100 mg daily Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 5. Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 14. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 15. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 16. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 17. Capsaicin 0.025 % Cream Sig: One (1) Appl Topical TID (3 times a day). 18. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 19. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 20. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 21. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day): adjusted prn based on fluid status. 22. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. 23. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 24. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1) injection Intravenous Q4H (every 4 hours): through [2173-4-17] for 14 day course after negative cultures. 25. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: Hypercarbic respiratory failure Obesity Hypoventilation Syndrome Obstructive Sleep Apnea Pulmonary Hypertension Congestive Heart Failure Bacteremia: Methicillin Sensitive Staph Aureus . Secondary Diagnoses: Atrial Fibrillation Venous insufficiency Hypertension Adrenal Insufficiency Discharge Condition: Good, mentating well, hemodynamically stable, oxygenating well Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 liters . The patient was admitted with multifactorial shortness of breath most likely caused by congestive heart failure and fluid overload, obstructive sleep apnea, and pulmonary hypertension. He was initially aggressively diuresed with a lasix drip on cardiology. However, he was transferred to the MICU due to persistent somnolence. While in the ICU his ASV was adjusted with the help of pulmonology with good effect. He was also diuresed aggressively. He will be discharged to continue his ASV mask and to follow up in sleep clinic. He will also need continued diuresis. . He was also followed by vascular surgery for his lower extremity venous insufficiency as well as rash. He will need to follow up with vascular surgery as well as dermatology to track his rash. . He was also diagnosed with MSSA bacteremia, for which he will need 2 weeks of IV Nafcillin and periodic liver and kidney monitoring . He should also follow up with his cardiologist and PCP as soon as possible. . Please continue all of his medications as prescribed and adjust his lasix based on his volume status. Please have patient return to the hospital if his shortness of breath worsens, he experiences chest pain, somnolence or any other concerning symptoms Followup Instructions: Vascular Surgery: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2173-4-14] 1:45 . Sleep Clinic/Pulmonology: Provider: [First Name11 (Name Pattern1) 3688] [Last Name (NamePattern4) 10476], MD Phone:[Telephone/Fax (1) 8645] Date/Time:[2173-4-22] 11:00 . Endocrinology: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2164], MD Phone:[Telephone/Fax (1) 1803] Date/Time:[2173-5-24] 1:30 . the patient will need an outpatient sleep study prior to his appointment with Dr. [Last Name (STitle) 4507]. . The patient should follow up with Dermatology in the next 3 months to re-evaluate his rash ICD9 Codes: 2762, 7907, 496, 5715, 4280, 4168, 3051, 4240, 4019, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8425 }	Medical Text: Admission Date: [2111-8-14] Discharge Date: [2111-9-7] Date of Birth: [2064-9-9] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 33596] Chief Complaint: change in mental status Major Surgical or Invasive Procedure: Endotracheal intubation Subclavian central venous line placement X 2 Radial arterial line placement Peripheral intravenous central catheter placement Sacral decubitus wound debridement History of Present Illness: 46 year old man with a hx of DM2, HTN, hypercholesterolemia, and schizophrenia presented from his group home with a change in mental status noted by staff at his group home on [8-14]. On admission, pt was alert and oriented x2 however is unable to provide a history of present illness. Information was obtained from the director of his group home. . Patient was in his USOH until evening of [2111-8-13] when he did not take his PM medications. Staff found him to be asleep in bed, difficult to arouse. He refused his medications. He was NOT noted to have a facial droop, loss of conciousness or witnessed seizure activity. EMS was called and foud patient sitting in chair, leaning to the left. He answered some questions but was "occasionally aphasic". He was able to ambulate to the ambulance independently. He was then transported to the [Hospital1 18] ED. . Initial vital signs in ED on [8-14]: 104.8 P 113 BP 135/86 R 28 97% on 3L. He had LP which was unrevealing. HE recieved 3.5 L NS and also vanco/ceftriaxone/ampicillin, acyclovir and multiple ativan. . Pt was admitted to the MICU for sepsis workup. Was intubated on the evening of admission due to worsening respiratory status. . Past Medical History: 1. DM2 2. Paranoid Schizophrenia w/ auditory hallucination- well controlled on Clozaril and history of violence 3. GERD 4. High Cholesterol 5. HTN Social History: Lives in a group home ([Location (un) ]) since [3-16]. Phone # of home: [Telephone/Fax (1) 96990]. Usually spends days in day program or pan handling at Downtown Crossing. Known to use marijuana, but no other drugs. [Month (only) 116] have a remote EtOH history. No close family. Family History: Unknown Physical Exam: Exam on Admission: T104.8 BP135/86 HR113 RR28 O2 Sat 93% Gen: A+O x2 HEENT: NC/AT, sclera anichteric, no conjunctival injection, dry oral mucosa, face appears flushed Neck: supple, no Kernig's or Brudzinski signs, no bruit CV: Tachy, Nl S1 and S2, Lung: +basilar crackles bilaterally, occasional expiratory wheeze Abd: +BS soft, non-distended Ext: no edema Neurologic examination: Mental status: Awake, lethargy, cranial nerve normal, minimally responsive to external stimuli and nearly non-verbal, His muscle tone is normal and reflexes are decreased throughout . Exam on Day of Transfer [2111-8-29]: T 98.6 144/80 76 18 94%RA Gen: Lying in bed, pill rolling tremor at baseline A+O x3 HEENT: PERRLA (3mm--> 2mm bilat), no conjunctival injection, dry oral mucosa, face appears flushed Neck: supple, no LAD, no bruit, thyroid smooth and not enlarged CV: Nl S1 and S2, [1-18] holosystolic murmur at LLSB no radiations Lung: decreased breath sounds at bases, otherwise CTA bialterally Abd: NABS soft,obese non-distended, NT Ext: no edema, no clubbing Neurologic examination: Mental status: pill rolling tremor; CN 3-12 indivisually tested and intact; strength 5/5 upper and lower extremities Pertinent Results: Labs on admission: [2111-8-13] 02:25PM BLOOD WBC-16.3* RBC-4.07* Hgb-12.8* Hct-36.1* MCV-89 MCH-31.4 MCHC-35.4* RDW-14.8 Plt Ct-150 [2111-8-13] 02:25PM BLOOD PT-12.8 PTT-30.7 INR(PT)-1.1 [2111-8-15] 12:05AM BLOOD Fibrino-1031* [2111-8-13] 02:25PM BLOOD Glucose-360* UreaN-34* Creat-1.7* Na-136 K-3.4 Cl-99 HCO3-19* AnGap-21* [2111-8-13] 02:25PM BLOOD ALT-9 AST-18 CK(CPK)-475* AlkPhos-61 Amylase-36 TotBili-0.5 [2111-8-14] 07:38AM BLOOD Lipase-34 [2111-8-13] 02:25PM BLOOD Albumin-4.1 Calcium-9.2 Phos-2.9 Mg-1.7 [2111-8-14] 07:41PM BLOOD Hapto-339* [2111-8-14] 07:38AM BLOOD Cortsol-44.4* [2111-8-14] 07:38AM BLOOD CRP->30 [2111-8-25] 03:58AM BLOOD Vanco-3.5* [2111-8-13] 02:25PM BLOOD Valproa-24* [2111-8-13] 02:32PM BLOOD Lactate-2.4* [2111-8-14] 01:53PM BLOOD O2 Sat-81 . [8-29] am labs (on transfer to floor): Valproate 51 . Na 137 K 3.5 Cl 101 HCo3 26 BUN 12 Cr 0.5 Glu 153 . WBC 5.6 hct 28.0 (up from 26.2 yesterday) Plt 612 MCV 91 . Vancomycin Trough 15.9 . Labs on discharge: ******* MICRO: [8-31] Blood Cx: negative [8-30] Blood Cx: negative [8-29] Blood Cx: NGTD [8-28] Blood Cx: negative [8-28] Right Subclavian Cath tip: 3 species staph, including MRSA [8-27] Blood Cx: [12-16] bottle: Coag Neg Staph (Anaerobic) - contaminant [8-26] Blood cx: negative [8-25] Blood cx: [12-16] bottle: Coag Neg Staph (Aerobic) - contaminant [8-25] C DIFF AG: NEG [8-23] sputum: <10PMNs, <10 epi: 3+ MRSA [8-24] Blood cx: [2-13] bottle MRSA [8-22] Ucx: NEG [8-22] Myco/Lytic Blood Cx: NGTD [8-22] Blood Cx: [12-15] coynebacterium diptheroids (aerobic) [8-20] Blood cx: NGTD x 2 [8-15] Sputum: Legionella Pneumophilia [8-14] CSF cx: NEGATIVE [8-13] Blood cx x 2: NEGATIVE . Imaging: [9-3] ECHO: 1. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 2. The aortic root is moderately dilated. The ascending aorta is mildly dilated. 3. No evidence of endocarditis seen. 4. Compared with the findings of the prior study of [2111-8-14], there has been no significant change. . [8-28] RUE U/S: No DVT . [8-28] CXR: RLL Pneumonia improving, small right sided pleural effusion (new or newly seen), left lung clear. . [8-20] Abdominal U/S: Nl liver, gallbladder, splenomegaly at 15.7 cm . [8-13] CT HEAD: No bleed, tiny calcification within posterior right eye, retention cyst within right maxillary sinus and possible acute sinusitis Brief Hospital Course: 1. Pneumonia - Legionella: Patient presented initially with high fevers (>104F) requiring cooling maneuvers and was initially broadly covered for pneumonia with levofloxacin, vancomycin, and metronidazole. Urine legionella was noted to be positive with sputum culture presumptive legionella positive on hospital day 3. Course was complicated by ARDS (see below). Antibiotics were tapered to levofloxacin 750mg single [Doctor Last Name 360] with good effect targeted against legionella as cultures were identified with assistance by infectious disease consultants. By hospital day 9, patient began to defervesce, and levofloxacin was discontinued after completing a 14 day course. . 2. ARDS: Patient had severe hypoxia and oxygen requirements despite high PEEP and FIO2 as well as paralysis with cisatracurium. Esophageal balloon measurements were used to guide PEEP levels with target >0 transpulmonary pressures to prevent atelectrauma to max level of 28 (FIO2 70%). Nonetheless, patient required ventilation at Tv 570 (ARDSNET 6cm = 507) in order to maintain oxygenation. Ultimately, however, compliance improved from 21 on hospital day 3 to 40s on hospital day 10, and PEEP was successfully downtitrated. . By hospital day 13, patient was weaned to minimal vent settings with RSBI <100, and patient was extubated on hospital day 14 and transferred to floor on hospital day 16. . 3. Pneumonia - MRSA: However, course was further complicated by development of new fevers. Sputum culture and gram stain revealed gram positive infection which ultimately speciated MRSA along with 3/4 bottles of blood cultures positive for MRSA on [2111-8-24] [SEE below]. Patient was reinitiated on vancomycin, however, increasing doses were required to achieve effective trough level (1650mg q8h for target level of 15-20). Patient completely defervesced by day 6 of vancomycin, and completed a 14 day course of Vancomycin. . 4. MRSA bacteremia: Blood cxs on [2111-8-24] 3/4 bottles MRSA +, source = MRSA VAP. On Vancomycin titrated to appropriate troughs. With initial + blood cultures, central line was removed, which demonstrated 3 staph species, including MRSA. Surveillance cultures drawn after initial positive blood culture demonstrated no growth x 8 blood cultures (2 cultures demonstrate 1/4 bottles coag negative staph - 1 in aerobic bottle, 1 in anaerobic bottle - determined to be contaminant, and remainder of surveillance blood cultures were negative). Trans-thoracic ECHO was obtained on day #11 of Vancomycin therapy that demonstrated no evidence of endocarditis. Patient remained afebrile since day 6 of Vancomycin throughout remainder of hospital course and completed a 14 day course of Vancomycin. . 5. Sacral Decubitus Ulcer: Cooling blanket was placed under patient in emergency department at 37F due to the fact that patient was >104F core temperature. Patient was transferred to MICU on this. As patient became unstable secondary to respiratory status, it became impossible to move blanket. Blanket temp was adjusted to 70s, however, patient ultimately developed an ulcer on sacral area thought to be secondary to frostbite from a total time on blanket of 5 hours. As patient's respiratory status stabilized, plastic surgery was consulted, and patient was debrided at bedside. Plastic surgery and wound care nursing followed patient throughout hospital course, and patient remained on [Hospital1 ] wet-to-dry dressing changes at time of discharge. Was discharged to acute rehab where wound care would continue with plans to follow up with plastic surgery in clinic for further management of the ulcer. . 5. DM2: Given severe legionella PNA, patient was started on [Location (un) 24402] protocol insulin infusion. Following extubation, patient was initiated on NPH and sliding scale regular insulin. As his medical issues stabilized, patient was re-started on his outpatient hypoglycemics (Avandia 4mg qam and glucophage 1000mg [Hospital1 ] and ASA 81mg qam) with good blood sugar control throughout remainder of hospitalization. . 6. Schizophrenia: Patient with history of severe schizophrenia controlled as an outpt with Clozaril 400mg [Hospital1 ], Depakote 750mg qam and 1000mg qhs, Seroquel, Ativan 1mg [Hospital1 ] and 0.5mg PRN, Zoloft 25mg Qam. Since admission, Clozaril discontinued (as initially patient was intubated in ICU, and as he approached extubation, did not want to cloud clinical picture, as clozaril can cause fevers), other psych meds listed above also discontinued except kept on Depakote. As approached extubation, patient was started on standing Haldol dose complicated by akithesia which was treated with Propanolol (Benztropine was not used secondary to ?encephalopathy from underlying medical conditions). As patient was transferred from the MICU to the floor and his medical issues stabilized, patient was started on low dose Clozaril, initially 25mg [Hospital1 ] (also remained on Depakote 750mg qam and 1000mg qpm). This was slowly titrated up by 25mg/day per psychiatry recommendations, and orthostatics and WBC were followed, with improvement of mental status/responsiveness as Clozaril was titrated up. Patient remained on Haldol with plans to discontinue once patient reached outpatient dose of Clozaril (400mg [Hospital1 ]). Patient was discharged to rehab with instructions to continue titrating up Clozaril until reached outpatient dose of 400mg [Hospital1 ], at which time, both Haldol and propanolol (patient on this for akithesia side effects of propanolol) could be discontinued. Pychiatry monitored patient throughout hospital course. . 7. HTN: On Lisinopril 5mg qhs as an outpatient. Held on admission due to sepsis. Patient's blood pressure remained stable (averaging around 130/70) during hospitalization. As sepsis resolved, patient's schizophrenia was treated as described above, including being placed on Propanolol to address the akithesia side effects of Haldol. As was on propanolol, lisinopril was held. Due to patient's DM, lisinopril is the ideal anti-hypertensive for this patient. Therefore, patient was discharged with instruction to: When Haldol is discontinued (upon titration of Clozaril to reach goal of outpatient dose of 400mg [Hospital1 ]), then may also discontinue propanolo and restart patient on outpatient dose of Lisinopril of 5mg. . 8. Anemia: Pt with Hct of 36 on admission (likely hemoconcentrated). Has ranged between 30-36 since admission. MCV = 91. Guiac of stool was negative. Iron studies demonstrated consistent with anemia of chronic disease. HCT remained stable throughout hospital course. . 9. Hypercholesterolemia: Patient on Gemfibrozil as an outpatient. This was initially held during MICU course, but was subsequently restarted along with his oral hypoglycemics upon transfer to the floor and stabilization of his medical conditions. . 10. GERD: On protonix 40mg qd as an outpt. Continued during hospital course. . 11. FEN: Upon extubation, patient maintained on Cardiac and diabetic diet. . 12. PPX: Patient kept on Protonix, Bowel regimen, SC heparin. . 13. Code Status: Full . 14. Dispo: Back to group home facility after rehabilitation at acute rehab. . 15. Contact: father [Name (NI) 382] [Telephone/Fax (1) 96991] Medications on Admission: Clozaril 400mg [Hospital1 ] Depakote 750mg qam and 1000mg qpm Protonix 40mg QD Seroquel Ativan 1mg QD and 0.5mg PRN Zoloft 25mg QD ASA 81mg QD Lisinopril 5mg QD Avandia 4mg qam Gemfibrozil 600mg [Hospital1 ] glucophage 1000mg [Hospital1 ] Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer Inhalation every six (6) hours as needed for shortness of breath or wheezing. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day): Continue while bed-bound. Once becomes more active, can discontinue. 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [12-14] Puffs Inhalation Q4H (every 4 hours) as needed. 6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 8. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 9. Valproic Acid 250 mg Capsule Sig: Four (4) Capsule PO QPM (once a day (in the evening)). 10. Valproic Acid 250 mg Capsule Sig: Three (3) Capsule PO QAM (once a day (in the morning)). 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 14. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) for 14 days: Through [9-12]. 16. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 17. Propranolol 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for restlessness: [Month (only) 116] discontinue once reach 400mg [Hospital1 ] of Clozaril. Then may START Lisinopril 5mg PO QD. 18. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 19. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 20. Rosiglitazone 4 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 21. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 22. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 23. Haloperidol 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): [Month (only) 116] discontine once reach 400mg PO BID of Clozaril. 24. Papain-Urea 830,000-10 unit-% Spray, Non-Aerosol Sig: One (1) Appl Topical DAILY (Daily). 25. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 26. Clozapine 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day): Please titrate up Clozaril dose: Currently taking 75mg Clozaril PO BID ([9-6]). Titrate up by 25mg daily: [9-7] 75mg qam, 100mg qpm [9-8] 100mg [Hospital1 ] [9-9] 100mg qam, 125mg qpm [9-10] 125mg [Hospital1 ] [9-11] 125mg qam, 150mg qpm [9-12] 150mg [Hospital1 ] etc. until reach 400mg [Hospital1 ] ONCE have reached 400mg [Hospital1 ], may discontinue Haldol and Propanolol and restart Lisinopril 5mg PO QD . 27. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection Injection TID (3 times a day) as needed. 28. PICC LIne care PICC line care per protocol 29. Vancomycin 500 mg Recon Soln Sig: Three (3) Recon Soln Intravenous Q 8H (Every 8 Hours): until [9-7] (last dose 9/26 pm). Discharge Disposition: Extended Care Facility: [Hospital3 672] Hospital Discharge Diagnosis: 1.) Legionella pneumonia -> ARDS 2.) Ventilator associated pneumonia with MRSA 3.) MRSA bacteremia 4.) Sacral ulcer Discharge Condition: Stable. Patient status-post treatment of legionella pneumonia (including intubation and successful extubation) and on current treatment for MRSA pneumonia/MRSA bacteremia. Oxygenating well off of supplemental oxygen. Discharge Instructions: 1.) Please notify physician if fever > 100.4, worsening cough, Shortness of breath, chest pain/pressure, any other questions/concerns 2.) Please take medications as directed 3.) Please follow up with appointments as directed INSTRUCTIONS FOR REHAB: 1.) Please complete 14 day course of vancomycin antibiotics - through [9-7] 2.) Please titrate up Clozaril dose: -Currently taking 75mg Clozaril PO BID -Titrate up by 25mg daily: [9-7] 75mg qam, 100mg qpm [9-8] 100mg [Hospital1 ] [9-9] 100mg qam, 125mg qpm [9-10] 125mg [Hospital1 ] [9-11] 125mg qam, 150mg qpm [9-12] 150mg [Hospital1 ] etc. until reach 400mg [Hospital1 ] ONCE have reached 400mg [Hospital1 ], may discontinue Haldol and Propanolol and restart Lisinopril 5mg PO QD Followup Instructions: 1.) Follow up with physician at rehab 2.) Follow up with Plastic Surgery for sacral ulcer managment - Provider: [Name10 (NameIs) ] SURGERY CLINIC Where: LM [Hospital Unit Name 96992] SURGERY Phone:[Telephone/Fax (1) 4652] Date/Time:[2111-9-11**] 2:30 ICD9 Codes: 0389, 5849, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8426 }	Medical Text: Admission Date: [2185-5-25] Discharge Date: [2185-5-31] Date of Birth: [2128-11-11] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: Recurrent angina Major Surgical or Invasive Procedure: left heart catheterization, coronary angiography [2185-5-25] coronary artery bypass grafts x 1 (SVG-dRCA) [2185-5-27] History of Present Illness: Mr. [Known lastname 1968] is a 56 year old male with known coronary disease, suffering a non ST myocardial infarction in [2182]. Angioplasty with a bare metal stent was accomplished then. He has anomolous origin of the right coronary from the left cusp and recently developed recurrent pain. A stress test was positive for pain without perfusion defects. He was admitted for catheterization which revealed in stent stenosis which was not ammenable to percutaneous intervention. Past Medical History: Coronary artery disease/Myocardial Infarction s/p RCA stent Degenerative joint disease Noninsulin dependent diabetes mellitus Anxiety disorder Hyperlipidemia Hypertension s/p Bilateral total knee replacements s/p Appendectomy in his teens Social History: Tobacco history: None ETOH: None Illicit drugs: None Lives by himself, unemployed secondary to disability Family History: There is no family history of premature coronary artery disease. Physical Exam: Admission: VS: T 98.3 105/60 85 19 97% RA FS 102 . GENERAL: Well appearing man in no distress. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP not elevated 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: [2185-5-25] Cath: 1. Selective coronary angiography of this right-dominant ystem revealed single vessel coronary artery disease. The LMCA had no ignificant stenoses. The LAD had a 30% ostial stenosis. The LCX had a 30%ostial stenosis. The RCA arose from the left coronary cusp and had 60-70%instent restenosis; the vessel was best cannulated with an AL3 catheter. 2. Limited resting hemodynamics demonstrated elevated left ventricular filling pressures with an LVEDP of 28 mmHg. No gradient was seen across the aortic valve. [2185-5-27] Echo: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal for the patient's body size. Overall left ventricular systolic function is low normal (LVEF 50-55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Transmitral Doppler velocity is consistent with impaired ventricular relaxation. The right ventricular cavity is mildly dilated with borderline normal free wall function. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. 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 regurgitation. The prosthetic mitral valve leaflets are thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Pulmonary Artery Catheter is seen in PA. POST CPB: Good Biventricular Function. No changes in valve function. Aortic contours intact. Remaining exam unchanged. All findings discussed with surgeons at the time of the exam. [2185-5-24] 11:25PM BLOOD WBC-6.2 RBC-3.92* Hgb-11.4* Hct-35.0* MCV-89 MCH-29.2 MCHC-32.7 RDW-13.8 Plt Ct-306 [2185-5-31] 05:15AM BLOOD WBC-5.4 RBC-3.23* Hgb-9.6* Hct-29.2* MCV-90 MCH-29.8 MCHC-33.0 RDW-13.7 Plt Ct-288 [2185-5-25] 05:45AM BLOOD PT-12.3 PTT-29.4 INR(PT)-1.0 [2185-5-27] 11:40AM BLOOD PT-13.9* PTT-32.5 INR(PT)-1.2* [2185-5-24] 11:25PM BLOOD Glucose-96 UreaN-24* Creat-1.0 Na-140 K-4.7 Cl-105 HCO3-26 AnGap-14 [2185-5-31] 05:15AM BLOOD Glucose-121* UreaN-16 Creat-0.7 Na-137 K-4.5 Cl-103 HCO3-26 AnGap-13 [2185-5-26] 04:45AM BLOOD ALT-17 AST-18 LD(LDH)-171 AlkPhos-75 TotBili-0.3 [2185-5-27] 05:15AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.0 [2185-5-25] 05:45AM BLOOD %HbA1c-6.5* Brief Hospital Course: Following cardiac catheterization he was admitted receiving medical management and remained chest pain free. Catheterization revealed in-stent disease and intervention in the lab was not feasible due to anatomy. He was referred for surgical intervention. He underwent usual pre-operative work-up and on [5-27] he was taken to the operating room where a single vein graft was placed to the right coronary artery. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later on op day he was weaned from sedation, awoke neurologically intact and extubated. His chest tubes and epicardial pacing wires were removed according to protocols. He was transferred to the floor on post-op day one. Beta blockers and diuretics were initiated and he was titrated towards pre-op weight. Physical therapy worked with the patient for mobility and strengthening. On post-op day two he had several bouts of atrial fibrillation which was converted back to sinus rhythm with Amiodarone and Lopressor. The rest of his post-op course was uneventful and he was discharged to rehab for additional PT with the appropriate medications and follow-up appointments. Medications on Admission: Byetta 5mcg [Hospital1 ], Actos 45mg, Morphine SR 100 [Hospital1 ], IR 15mg PRN, Aspirin 81mg qd, Lipitor 80mg, Metoprolol 25mg [Hospital1 ], Lisinopril 40mg, Colace, Ibuprofen 800mg PRN, Metformin 850 mg daily Discharge Medications: 1. Byetta 5 mcg/0.02 mL Pen Injector Sig: One (1) Subcutaneous twice a day. 2. Actos 45 mg Tablet Sig: One (1) Tablet PO once a day. 3. Morphine 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 8. Ibuprofen 800 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [Hospital1 ] x 5 days. Then, 200mg [Hospital1 ] x 7 days. Then 200mg QD until stopped by Cardiologist. 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. 14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 5 days. 15. Metformin 850 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: TBA Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass graft x 1 Degenerative joint disease Noninsulin dependent diabetes mellitus Anxiety disorder Hyperlipidemia Hypertension s/p Bilateral total knee replacements s/p Appendectomy in his teens Discharge Condition: good Discharge Instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any redness of, or drainage from incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed Followup Instructions: Dr. [Last Name (STitle) 914] in 4 weeks ([Telephone/Fax (1) 170]) [Hospital Ward Name 121] 6 wound clinic in 2 weeks Dr. [First Name11 (Name Pattern1) 2270] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] in [12-10] weeks ([Telephone/Fax (1) 3581]) Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in 2 weeks please call for appointments Completed by:[2185-5-31] ICD9 Codes: 4019, 2724, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8427 }	Medical Text: Admission Date: [2112-2-27] Discharge Date: [2112-3-1] Date of Birth: [2027-4-7] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1646] Chief Complaint: Shortness of breath/fevers/HA Major Surgical or Invasive Procedure: IP service thoracentesis History of Present Illness: PCP: [Name Initial (NameIs) 7274]: [Last Name (LF) ],[First Name3 (LF) 1730] O. Location: [Hospital3 ] INTERNAL MEDICINE ASSOCIATES Address: [Street Address(2) 4472], [Apartment Address(1) 4473], [Hospital1 ],[Numeric Identifier 9331] Phone: [Telephone/Fax (1) 4475] Fax: [Telephone/Fax (1) 29683] . Date/Time: [2112-2-27]: 4:00 am . History obtained with the assistance of a [Name6 (MD) 8003] speaking RN 84M with h/o recurrent pleural effusions s/p pigtail catheter placement, VATS with talc pleurodesis. His thoracoscopy was complicated by a right pneumothorax requiring a chest tube. He also has CKD, DM, AS and presents with a HA x 24 hours but resolved on presentation to the ED. He also here with SOBOE and fever to 101.2 on presentation. He felt febrile so she took his temperature which was 99.3. He then took 1 gm of tylenol. Even though per the ED he presented with worsening SOB per pt he did not have difficulties breathing, solely a headache. No visual changes. No slurred speech. On 3L NC. CXR c/w PNA. S/p L US guided thoracentesis 4 days PTP which produced clear serosanguinous fluid. He felt very weak and tired after his thoracentesis and there was no change in his breathing. Not on oxygen at home. His breathing improved dramatically after his recent surgery such that he was able to climb stairs without difficulty. He is not very active at home but he is able to walk from one room to another. 101.2 83 207/89-> BP improved without intervention 18 94 Meds Given: azithromycin and ceftriaxone, Fluids given: Radiology Studies:, consults called. [x] IVF (dry on exam, increased creatinine) [x] Cx and abx (ceftx, azithro) - admit medicine + 10 pt crit drop- guiac negative in ED. Rsided PNA and L pleural effusion. IVF, cultures before abx. 99F 70 162/68 17 99% 2L 02 . ROS: -Constitutional: []WNL [+]Weight gain 8 lb []Fatigue/Malaise [+]Fever []Chills/Rigors []Nightweats [-]Anorexia -Eyes: [X]WNL []Blurry Vision []Diplopia []Loss of Vision []Photophobia -ENT: []WNL []Dry Mouth []Oral ulcers []Bleeding gums/nose []Tinnitus []Sinus pain []Sore throat -Cardiac: []WNL [-]Chest pain []Palpitations []LE edema []Orthopnea/PND []DOE -Respiratory: []WNL [+]SOB [-]Pleuritic pain []Hemoptysis [-]Cough -Gastrointestinal: []WNL [-]Nausea [-]Vomiting [-]Abdominal pain []Abdominal Swelling [-]Diarrhea- [-]Constipation []Hematemesis []Hematochezia []Melena -Heme/Lymph: [X]WNL []Bleeding []Bruising []Lymphadenopathy -GU: []WNL [-]Incontinence/Retention [-]Dysuria []Hematuria []Discharge []Menorrhagia [+]dribbling with urination -Skin: [X]WNL []Rash []Pruritus -Endocrine: [X]WNL []Change in skin/hair []Loss of energy []Heat/Cold intolerance -Musculoskeletal: [X]WNL []Myalgias []Arthralgias []Back pain -Neurological: [X]WNL []Numbness of extremities []Weakness of extremities []Parasthesias []Dizziness/Lightheaded []Vertigo []Confusion []Headache -Psychiatric: [X]WNL []Depression []Suicidal Ideation -Allergy/Immunological: [] WNL []Seasonal Allergies All other ROS negative. . Past Medical History: HTN DM2 CRI, baseline creatinine 2.5-3.0 hypothyroidism GERD antral ulceration with GI bleeding diverticulosis proctitis pancreatitis BPH colon polyps dperession AS chronic anemia . PSH: right VATS, talc pleurodesis, and pleural biopsise on [2112-1-1]. s/p colectomy Social History: Lives with wife and 1 of his daughters. From [Country ] republic, worked on farm there, last visit [5-29]. denies tobacco, alcohol, drug use. - No visual aides - no dentures - independent of ADLS - continues to drive, no memory problems, no falls, walks without cane or walker. grandaughter Daughter [Name (NI) 8314] is HCP Family History: sister and mother had stomach cancer. Daughter has CAD s/p PCIx3. Physical Exam: 97.8, 181/83L , 181/81, 64, 20, 88-89% RA, 96% 2L GENERAL: Thin, chronically ill appearing male in NAD. Nourishment: At risk Grooming: OK Mentation: Alert, speaks in full setences Eyes:NC/AT, EOMI without nystagmus, no scleral icterus noted Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Respiratory: Lungs CTA bilaterally without R/R/W Cardiovascular: RRR, nl. S1S2, no M/R/G noted Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Genitourinary: Skin: no rashes or lesions noted. No pressure ulcer Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Lymphatics/Heme/Immun: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. -sensory: No deficits to light touch throughout. -cerebellar: No nystagmus, dysarthria, intention or action tremor, dysdiadochokinesia noted. FNF and HKS WNL bilaterally. -DTRs: 2+ biceps, triceps, brachioradialis, patellar and 1+ ankle jerks bilaterally. Plantar response was flexor bilaterally. No foley catheter/tracheostomy/PEG/ventilator support/chest tube/colostomy * Physical exam on discharge: Patient now has good breath sounds on the left, but still has rhoncherous breath sounds on the right. No LE edema. JVP 6. Pertinent Results: [2112-2-27] 01:22AM LACTATE-0.7 [2112-2-26] 11:20PM GLUCOSE-179* UREA N-55* CREAT-2.9* SODIUM-136 POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-23 ANION GAP-12 [2112-2-26] 11:20PM estGFR-Using this [2112-2-26] 11:20PM WBC-10.8 RBC-3.31# HGB-8.5# HCT-25.8# MCV-78 MCH-25.6* MCHC-32.9 RDW-17.4* [2112-2-26] 11:20PM NEUTS-82.4* LYMPHS-13.1* MONOS-4.2 EOS-0.2 BASOS-0.1 [2112-2-26] 11:20PM PLT COUNT-223 [2112-2-26] 11:20PM PT-13.2 PTT-30.8 INR(PT)-1.1 . Procedure date Tissue received Report Date Diagnosed by [2112-1-1] [2112-1-1] [2112-1-5] DR. [Last Name (STitle) ] [Last Name (NamePattern4) ],DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/stu Previous biopsies: [-9/4084] PLEURAL FLUID (1 VIAL) [-9/4043] Slides referred for consultation. [-5/2031] EGD DIAGNOSIS: Pleural biopsies (A): Granulation tissue with acute and chronic inflammation; organizing fibrinous exudate. Some degree of atypicality is seen, probably reactive. Polarizable material present. No malignancy identified. . PLEURAL PLEURAL ANALYSIS WBC RBC Polys Lymphs Monos Eos Meso Macro Other [2112-2-23] 09:39AM 275* 185* 6* 53* 27* 9* 1* 41 [2111-12-25] 09:34AM 505 30* 34* 16* 0 17* 31* 22 [2111-11-4] 10:30AM 50 3* 4* 56* 0 1* 6* 30* 33 ATYPICAL CELLS, REFER TO CYTOLOGY REVIEWED BY [Last Name (NamePattern4) 39834], MD [2112-2-24] MESOTHELIAL CELLS,FAVOR REACTIVE REFER TO CYTOLOGY REVIEWED BY [Initials (NamePattern4) ] [Last Name (NamePattern4) ] ON [2111-12-28] ATYPICAL CELLS,REFER TO CYTOLOGY REVIEWED BY [Initials (NamePattern4) ] [Last Name (NamePattern4) 3157],MD ON [2111-11-6] PLEURAL CHEMISTRY TotProt Glucose Creat LD(LDH) [2112-2-23] 09:39AM 3.0 156 108 [2111-12-25] 09:34AM 4.1 116 2.3 151 [2111-11-4] 10:30AM 1.8 92 74 OTHER BODY FLUID OTHER BODY FLUID pH [2112-2-23] 10:06AM 7.451 [2111-12-25] 09:48AM 7.421 PLEURAL FLUID Brief Hospital Course: The patient is an 84 year old male with HTN, DM, recurrent pleural effusions who presented with new hypoxemia(not on home O2) Primary Diagnosis: 482.9 PNEUMONIA, BACTERIAL NOS Secondary Diagnosis: 786.05 SHORTNESS OF BREATH Secondary Diagnosis: 780.60 FEVER, UNSPECIFIED Secondary Diagnosis: 799.02 HYPOXEMIA Secondary Diagnosis: 428.32 HEART FAILURE, (B3) CHRONIC DIASTOLIC The patient was found on admission to have fever and new infiltrate on the right. this was in addition to the recurrent pleural effusion that had formed on the left, even after being drained just a few days before. With both problems he had significant resp comprimise and went to the ICU. There he was given broad spectrum antibiotics after having a rising WBC's and recurrant fever with CAP therapy. His fever improved and the fluid was drained. he is now down to 2L by NC. he will need to complete 10 days of broad abx therapy(until [3-6]). His vancomycin b/c of his renal function was dosed once, with vanc levels checked daily and given again for level <20(first dose lasted >72hrs). He will also need close monitoring of his i/o's to make sure he stays even and gets IV lasix if needed. he was previously on 40 mg of lasix prior to admission and the effusion returned. We are not entirely sure that this effusion is from CHF, so even if his volume status is maintained it may return. If his O2 worsens he should get CXR's to monitor that left lung. he will need f/u with the interventional pulmonary clinic 2 weeks after discharge. they will be scheduleing him an appt the day after discharge. He will also need pulm rehab as he lives up 2 flights of stairs. . Secondary Diagnosis: 585.4 CHRONIC KIDNEY DISEASE, STAGE IV (15-29) ACUTE RENAL FAILURE- b/l 2.4 now increased to 2.9. will need monitoring frequently. pls avoid nephrotoxins and dose vancomycin by level. . Secondary Diagnosis: 424.1 AORTIC STENOSIS-INSUFFICIENCY moderate aortic valve stenosis (valve area 1.0-1.2cm2). the patient may be preload dependent so euvolemia is difficult but important to maintain. . Secondary Diagnosis: 401.1 HYPERTENSION, BENIGN When ill, the patient had all his hypertension meds held. We recommend restarting his BB the night of discharge and the nifedipine if needed. . Secondary Diagnosis: 249.40 SECONDARY DIABETES MELLITUS WITH RENAL MANIFESTATIONS, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED -stopped o/p DM meds and using only insulin. had to add NPH for better control . Secondary Diagnosis: 600.90 HYPERPLASIA OF PROSTATE, UNSPECIFIED, WITHOUT URINARY OBSTRUCTION AND OTHER LOWER URINARY SYMPTOMS (LUTS) -continued flomax. . Secondary Diagnosis: 530.11 GASTROESOPHAGEAL REFLUX DISEASE (GERD) Continue o/p PPI . Code Status: FULL CODE, discussed with patient/family on admission. . HCP is [Name (NI) ] [Name (NI) 28942] (dtr) [Telephone/Fax (1) 39835] Medications on Admission: 1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s)* Refills:0 8. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) scoop PO once a day. Disp:1 can Refills:2 9. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). recently discontinued. 10. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 11. Enalapril Maleate 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Lasix 20 mg PO BID 13. Rosiglitazone 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose Injection TID (3 times a day): to stop when ambulating. 2. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. NPH Insulin Human Recomb 100 unit/mL Cartridge Sig: Five (5) UNITS Subcutaneous twice a day. 6. Insulin Aspart 100 unit/mL Cartridge Sig: sliding scale Subcutaneous AC&HS. 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for SOB or wheezing. 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOb or wheezing. 9. Nifediac CC 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 10. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 5 days: until [3-6]. 11. Vancomycin 1,000 mg Recon Soln Sig: One (1) dose Intravenous level <20. 12. Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection qdaily to [Hospital1 ] if i/o are positive or weight +>3lbs. 13. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: 518.81 RESPIRATORY FAILURE, ACUTE Secondary Diagnosis: 424.1 AORTIC STENOSIS-INSUFFICIENCY Secondary Diagnosis: 401.1 HYPERTENSION, BENIGN Secondary Diagnosis: 585.4 CHRONIC KIDNEY DISEASE, STAGE IV (15-29) Secondary Diagnosis: 530.11 GASTROESOPHAGEAL REFLUX DISEASE (GERD) Secondary Diagnosis: 428.32 HEART FAILURE, (B3) CHRONIC DIASTOLIC Secondary Diagnosis: 250.82 DIABETES TYPE II, UNCONTROLLED W/ COMPLICATIONS Secondary Diagnosis: 482.9 PNEUMONIA, BACTERIAL NOS Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Patient being transferred to facility Followup Instructions: with [Hospital ] clinic in 2 weeks(appt to be made 1 day after discharge) also need f/u with PCP upon discharge(he has been updated on the hospital course). ICD9 Codes: 5849, 5119, 2762, 4280, 5859, 4241, 311, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8428 }	Medical Text: Admission Date: [2181-10-12] Discharge Date: [2181-11-9] Date of Birth: [2110-1-3] Sex: F Service: HEPATOBILIARY SURGERY SERVICE ADMISSION DIAGNOSES: 1. Status post cholecystectomy. 2. Status post endoscopic retrograde cholangiopancreatography with duodenal perforation. 3. Status post exploratory laparotomy an outside hospital. 4. Status post pacemaker. 5. Status post hysterectomy and bilateral salpingo-oophorectomy. 6. Second-degree atrioventricular block. 7. Atrial fibrillation. 8. Hypertension. CHIEF COMPLAINT: Transfer for complications after endoscopic retrograde cholangiopancreatography. HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old female who was transferred from an outside hospital in [Location (un) 5450], [Location (un) 3844]. The patient had undergone an endoscopic retrograde cholangiopancreatography due to abdominal pain and back pain which were felt to be secondary to common bile duct stones. She had a prior admission for flank and abdominal pain and increased liver function tests. An ultrasound had shown an 11-mm common bile duct. On endoscopic retrograde cholangiopancreatography, there were no stones. There was only sludge found. A sphincterotomy was performed which was complicated by bleeding. This was controlled with a balloon and epinephrine. A large clot was occluding the common bile duct, so it was recannulized. Attempts were made to extract the clot with the balloon. The patient developed the sudden onset of chest pain and dyspnea and was noted to have subcutaneous emphysema. Therefore, the endoscopic retrograde cholangiopancreatography was terminated. A computed tomography scan showed that the patient had free intraperitoneal air and a right tension pneumothorax. A right chest tube was placed, and the patient was taken emergently to the operating room where a duodenal tear in the second part of the duodenum was closed transversely. A single [Location (un) 1661]-[Location (un) 1662] drain was placed. The patient was then extubated, and the chest tube was placed to water suction. The chest tube was then discontinued on [10-12]. Laboratories revealed that the patient had an increased white blood cell count with 20% bands. The patient began having frank drainage of bile from the [Location (un) 1661]-[Location (un) 1662] drain. The patient was then transferred to [Hospital1 346] for further evaluation and workup of a presumed bile leak. PERTINENT LABORATORY VALUES ON PRESENTATION: At our facility, the patient's laboratory values revealed her white blood cell count was 16.6 (which was consistent with the outside hospital white blood cell count of 17.4), her hematocrit was 39, and her platelets were 132. Chemistries revealed the patient's sodium was 139, potassium was 3.6, chloride was 109, bicarbonate was 20, blood urea nitrogen was 22, creatinine was 0.9, and blood glucose was 342. The patient's liver function tests revealed an albumin of 2.6, her total bilirubin was 0.6, her amylase was 268, and her lactate dehydrogenase was 349, her AST was 39, her ALT was 66, and her alkaline phosphatase was 65. The patient's coagulations revealed her prothrombin time was 15.5, her partial thromboplastin time was 34.9, and her INR was 1.6. PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's vital signs revealed she had a temperature of 101 degrees Fahrenheit, her heart rate was 98 (in atrial fibrillation) her blood pressure was 96/45, her respiratory rate was 22, and her oxygen saturation was 94% oxygen saturation on 4 liters of oxygen by nasal cannula. The patient was on a diltiazem drip at 20 mg per hour. On general physical examination, the patient was oriented to person only with mild agitation, with [Initials (NamePattern4) ] [Last Name (NamePattern4) 2611] Coma Scale of 15. Her sclerae were anicteric. The mucous membranes were moist. Her neck examination revealed no jugular venous distention. She had a central line catheter in place. The patient's cardiovascular examination revealed irregularly irregular but there were no murmurs, rubs, or gallops heard. The patient's lungs were clear to auscultation bilaterally with some subcutaneous air noted on examination. The patient's abdomen was soft and slightly distended with a midline wound. The right lower quadrant [Location (un) 1661]-[Location (un) 1662] drain was draining bilious drainage. The abdomen was diffusely tender to percussion with rebound tenderness and guarding. The patient's extremities were warm with no edema. ASSESSMENT AND PLAN: The patient with a bile leak status post perforation from endoscopic retrograde cholangiopancreatography and laparotomy for closure of duodenal tear, and a tension pneumothorax which had been resolved, atrial fibrillation, and leukocytosis, and delirium. The patient was admitted to the Intensive Care Unit for workup and treatment of a possible bile leak. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was started on total parenteral nutrition. Her cardiovascular atrial fibrillation was treated with a diltiazem drip with a Cardiology consultation. She was scheduled for a computed tomography scan and was started on broad spectrum antibiotics; including Zosyn and vancomycin pending cultures. The patient's plan was discussed with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. During her Intensive Care Unit stay, the patient continued to be febrile and continued to be in rapid atrial fibrillation. A computed tomography scan obtained on hospital day one showed the patient had free air in her abdomen. No fluid collections, thickening of the duodenum, and subcutaneous air, with no pneumothorax on a chest x-ray. On computed tomography scan it should also be noted that no further leak was noted, but the patient was noted to have a duodenal fistula. The plan continued to remain to keep the patient nothing by mouth with bowel rest as long as the [Location (un) 1661]-[Location (un) 1662] was draining allowing the fistula to heal, to keep the patient monitored with intravenous antibiotics, and support of blood pressures if needed. For the remainder of the patient's Intensive Care Unit course, her blood pressure was monitored. With each temperature spike, blood cultures were taken. The patient was started on appropriate antibiotics. The patient was consulted by the Infectious Disease Service and was started on antifungal medications and appropriate antibiotics to treat her sepsis. The patient was also seen by the Cardiology Service for treatment of her atrial fibrillation. Cardioversion attempts were made, and the patient was maintained on rate control for episodes of tachycardia. For details of the patient's Intensive Care Unit admission, please see the Intensive Care Unit notes. On hospital day twenty two, the patient was transferred from the Intensive Care Unit to the floor. The patient had been tolerating total parenteral nutrition well and was rate controlled with her atrial fibrillation. Her vital signs were stable. She had not been afebrile and was overall in stable condition. The patient did have an episode of atrial fibrillation upon transfer. Cardiac enzymes were sent and were negative. The patient continued to be rate controlled with intravenous beta blockers. The patient was started on clears and was continued on her total parenteral nutrition. The patient's laboratory values continued to reflect that her white blood cell count had responded well to antibiotics. She was continued on intravenous antibiotics and intravenous antifungal medications. On hospital day twenty four, the patient continued to have moments in which she would have regular tachycardia which was felt to be more of the patient's atrial fibrillation, and the Cardiology Service was consulted for recommendations on treatment. The patient was to be monitored and given by mouth and intravenous Lopressor as needed to maintain a controlled heart rate. The patient was continued on total parenteral nutrition and bowel rest. The patient was seen and evaluated by Physical Therapy and Occupational Therapy who worked with the patient. The Cardiology Service was again consulted on the patient for questions of atrial fibrillation, and discussion was made surrounding whether or not to attempt cardioversion. Cardiology recommended increasing the patient's amiodarone dose from 200 mg to 400 mg three times per day. The patient subsequently, after changing her medications and increasing he Lopressor dose and amiodarone dose, continued to be in a sinus rhythm, and no cardioversion was needed. At this time, the patient was evaluated for rehabilitation screening, and it was felt that due to the patient's caloric intake that she would most benefit from continued total parenteral nutrition throughout rehabilitation and to work on her nutritional status. On hospital day twenty six, the patient had an episode of sinus tachycardia which was controlled well with intravenous Lopressor. Her intravenous Lopressor was increased to 15 mg twice per day. At this time, the patient was tolerating a regular diet as well as receiving total parenteral nutrition. The patient was working with Physical Therapy on endurance and ambulation. On hospital day twenty seven, the patient continued to do well. The patient's oral intake was poor, with only 200 calories; however, this was being supplemented with total parenteral nutrition. The patient was up and ambulating with Physical Therapy and Occupational Therapy. The [Initials (NamePattern4) 228] [Last Name (NamePattern4) 1661]-[Location (un) 1662] drain continued to put out minimal drainage which was serous in nature and nonbilious. This was monitored. The patient's urine output was good. Her physical examination revealed no abnormalities. The patient's disposition was discussed with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. It was felt the patient would most benefit from an acute rehabilitation setting in which total parenteral nutrition and physical therapy would be able to be administered. Discussion was also made with the family, and plans were made to transfer the patient to an acute rehabilitation center closer to the patient's home. DISCHARGE DISPOSITION: The patient was to be transferred to acute rehabilitation. CONDITION AT DISCHARGE: The patient's condition on discharge was stable. MEDICATIONS ON DISCHARGE: (The patient's discharge medications included) 1. Lasix 40 mg by mouth once per day. 2. Protonix 40 mg by mouth once per day. 3. Amitriptyline 10 mg by mouth at hour of sleep. 4. Metoprolol 50 mg by mouth twice per day. 5. Lorazepam 0.5 mg to 1 mg by mouth q.4-6h. as needed. 6. Insulin sliding-scale. 7. Albuterol/ipratropium nebulizers one nebulizer q.6h. as needed. 8. Nystatin swish-and-swallow 5 mL by mouth four times per day. 9. Sucralfate 1 g by mouth once per day. 10. Miconazole powder 2% one application to affected area four times per day as needed. 11. Sarna lotion one application to affected area as needed. 12. Acetaminophen 325 mg to 650 mg by mouth q.4-6h. as needed. DISCHARGE PLAN/INSTRUCTIONS/FOLLOWUP: 1. The patient was to be discharged to an extended care facility for physical therapy and nutrition rehabilitation. 2. The patient was instructed to continue on total parenteral nutrition for a goal caloric intake to be approximately 1800 to [2178] calories per day. 3. The patient was instructed to be on a regular diet supplemented by total parenteral nutrition. 4. The patient was instructed to follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in his office in one to two weeks after discharge. The patient was to call for an appointment. DISCHARGE DIAGNOSES: 1. Status post complications from endoscopic retrograde cholangiopancreatography. 2. Duodenal fistula. 3. Sepsis. 4. Coronary artery disease. 5. Paroxysmal atrial fibrillation. 6. Hypertension. 7. Hypercholesterolemia. 8. Status post cholecystectomy. 9. Status post pacemaker. 10. Status post exploratory laparotomy. 11. Status post right pneumothorax. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], M.D.,Ph.D. 02-366 Dictated By:[Last Name (NamePattern1) 50710] MEDQUIST36 D: [2181-11-9] 11:45 T: [2181-11-9] 11:49 JOB#: [Job Number 50711] ICD9 Codes: 5185
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8429 }	Medical Text: Admission Date: [2171-9-26] Discharge Date: [2171-10-1] Date of Birth: [2095-11-14] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 12] Chief Complaint: sdfsda Major Surgical or Invasive Procedure: None History of Present Illness: [Known lastname 4048] is a 75 y.o. female with pertinent history of MDS x 2 years, chronic anemia requiring blood transfusions (last transfusion 1 wk prior to admission), and recent admission for melanotic stools w/ neg GI workup. Pt was recently discharged [9-16] from [Hospital1 ] following admission for GIB, and subsequent stabilization w/o intervention. Following discharge reports that she was feeling tired and weak, with decreased appetite. +for black, tarry stools (states she has had this intermittently x 6-8 weeks). Denies BRBPR. No abdominal pain. Went to Heme/onc clnic on day of admission and was found to have a HCT of 10. Sent to ED where she was af, hr 120, bp 122/56, received 2U PRBC (with appropriate Hct rise [9-8]), and 2L NS. She had been on Cipro for treatment of asymptomatic UTI x 1day which was changed on hospital day 2 to Cefepime since she was considered to be functionally neutropenic with an ANC of 320 and declining. She was seen in the unit by GI who performed a push enteroscopy on [9-27] despite recent negative EGD and found no source of bleeding to mid jejunum. She continued to have melenic stools but vitals remained stable. Despite having no previous cardiac history, she also developed a mild troponin leak that peaked at 1.04 and CK's of 160's with 17MB. She was never symptomatic and was treated medically with aspirin and B-blocker. In total she was transfused another 4 units PRBC's with appropriate increase in Hct from 17.4-29.3, which has been stable for the last 12 hours Past Medical History: 1) MDS-evaluated [1-22] for anemia leukopenia and fatigue seen by DR. [First Name (STitle) ] with bone bx=nondiagnostic. Cont to be followed and started on procrit for anemia. In [5-25] repeat biopsy revealed similar patttern to previous but for unclear reason was diagnosed with MDS. Pt had moderate response to procrit. in [2-24] pt developed more profound anemia and at that point developed guaiac positive stools and has required occasional transfusion. 2) Melena/guaiac positive stools, s/p workup positive only for ileal diverticulosis. [6-18] Colonoscopy- Diverticulosis of the entire colon Otherwise normal Colonoscopy to cecum [6-18] EGD- Normal EGD to second part of the duodenum [6-28] SBFT Ileodiverticulosis without evidence of diverticulitis. No source of bleeding identified within the small bowel. [7-18] Colonoscopy- Polyps in the proximal ascending colon, mid-ascending colon and transverse colon (polypectomy) Diverticulosis of the sigmoid colon Otherwise normal Colonoscopy to cecum Capsule Enteroscopy 1. Erythema and pethiciae in the duodenum 2. Small non bleeding ileal diverticulum 3. No site of GI bleding 3) Osteoarthritis 4) diphtheria in [2115] treated with penicillin 5) repeatedly positive PPD due to work-related TB exposures and negative CXR (per pt's report) 6) a CVA in [2159] that led to right-sided hemiparesis (minimal residual) and increased distractibility 7) a fall in [2168-11-2] that caused a right wrist fracture 8) hypothyroidism 9) history of cystitis 10) cataracts 11) HTN 12) hypercholesterolemia 13) back pain 14) hip fx, s/p surgery [9-25] Social History: Pt lives alone in senior living facility. She has someone who helps her with her grocery shopping, laundry, and her son [Name (NI) 4049] helps her out also when needed. Used to work as a PN. Her Niece is her proxy, as she lives the closest - pt. has two sons, but they are further away. She lives alone in a 1 bedroom at a senior living facility. She smoked [11-23] PPD x 60 years, and used to drink 4-5 drinks/night, but her last drink was months ago, as she "lost her taste for it." She denies any IVDU. Family History: non-contributory: She had 7 brothers and sisters. 1 brother died of colon CA, and one sister also died of colon CA. Her mother died in her late 60s from CAD and obesity. Her father had a cerebral hemorrhage. Physical Exam: t 98.7, hr 86, bp 120/48, r18 100% 2L NC PERRLA. Pale sclera. Diffuse white lesions of tongue. 7cm JVP. No cervical/sm/sc LA Regular s1,s2. no m/r/g LCA b/l +bs. soft. nt. nd. Liver margin palpable at lower costochondral border. No le edema. 2+ dp pulses b/l. Pale palms. Pertinent Results: CBC: [2171-9-26] 09:36PM WBC-1.7* RBC-2.04# HGB-5.9# HCT-17.4# MCV-85 MCH-28.8 MCHC-33.9 RDW-16.9 [2171-9-26] 05:20PM PLT SMR-LOW PLT COUNT-100* LPLT-2+ [2171-9-26] 05:20PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL Chemistries: [2171-9-26] 11:00AM GLUCOSE-114* UREA N-54* CREAT-1.6* SODIUM-138 POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-20* ANION GAP-14 [2171-9-26] 11:00AM LD(LDH)-242 CK(CPK)-62 TOT BILI-0.5 [2171-9-26] 11:00AM CK-MB-NotDone cTropnT-0.21* Coags: [2171-9-26] 11:00AM PT-13.8* PTT-25.0 INR(PT)-1.2 UA: [2171-9-26] 07:10PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD [2171-9-26] 07:10PM URINE RBC-0-2 WBC-21-50* BACTERIA-MANY YEAST-NONE EPI-0-2 [2171-9-26] 07:10PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.014 CXR: No acute cardiopulmonary process ECG: 100 bpm, nl axis, nl intervals, sinus, STd in II,F,V3-V6, new compared to ecg of [9-16] Brief Hospital Course: 1. [Name (NI) 4056] Pt has undergone extensive endoscopic workup which has all been negative, although she continued to have melenic stools now with no BM x 5d. Difficult to assess what proportion of anemia is due to GIB versus progressoin of her MDS. History of four known RBC antigens to match versus. She received "weakly incompatible" blood, although hemolysis labs neg. Four units cross typed and matched in blood bank waiting but Hct remained stable >72 hours but no BM so couldn't assess for melena. She was discontinued aminocaproic acid and GI recommended tagged RBC scan if pt rebleeds. 2. Elevated troponin- Pt small troponin leak with ST depressions on ECG consistent with demand ischemia in the setting of anemia. ECG changes now resolved and planned to transfuse as above and medically manage with B-Blocker but hold on ASA due to bleeding risk. 3. UTI- although asymptomatic and afebrile, pt is neutropenic and was being treated more aggressively as neutropenic fever with Cefepime 2g IV q8h day discontinued [9-30] since UA clear. No need for further antibiotic treatment was advised. 4. MDS-Pt cont declining ANC with otherwise stable cell lines. Decline coincides with starting Cefepime and metoprolol although leukopenia is no a major SE of these meds. Plan was to start pt on thalidomide after discharge today and will need weekly procrit and CBC checks by VNA. 5. Hypothyroidism-cont on outpatient dose levothyroxine 6. Oral thrush-appears to have resolved after using Nystatin S and S. 7. LBP-likely due to MDS. Well controlled on percocet elixir although pt not requiring greater than every 24 hours while in hospital. Medications on Admission: 1. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY 4. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Ciprofloxacin 500mg po qday Discharge Medications: 1. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 2-5 MLs PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:300 ML(s) Refills:0 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 8. Aminocaproic Acid 500 mg Tablet Sig: Four (4) Tablet PO Q6H (every 6 hours). Disp:480 Tablet(s) Refills:2 9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:2700 ML(s) Refills:2 10. Procrit 40,000 unit/mL Solution Sig: One (1) 40,000u dose Injection once a week. Disp:12 syringes Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Anemia Urinary tract infection Discharge Condition: Hematocrit and Vitals stable Discharge Instructions: If you experience any fever, chills, nausea, vomiting, bloody or black stool, or increasing diziness you should call your doctor and if he/she is not available you should go to the emergency room. You will also start on your Thalidomide therapy today after leaving the hospital which you should take as prescribed by Dr. [Last Name (STitle) ]. Followup Instructions: Please schedule an appointment with Dr. [Last Name (STitle) 1266] or Dr. [Last Name (STitle) ] in the next 1-2 weeks for post hospitalization follow-up. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 647], MD Where: [Hospital6 29] HEMATOLOGY/ONCOLOGY Phone:[Telephone/Fax (1) 22] Date/Time:[2171-11-26] 2:00 ICD9 Codes: 5990, 5849, 2449, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8430 }	Medical Text: Admission Date: [2103-8-18] Discharge Date: [2103-8-21] Date of Birth: [2079-10-17] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1943] Chief Complaint: Agitation/hallucinations in the setting of EtOH withdrawal. Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname ] is a 23 yo M with history of alcohol dependence since [07] years of age, hx alcohol withdrawal complicated by seizures who presents from [Hospital3 8063] because of agitation and hallucinations. Last drink was [8-16], the same day he was admitted to [Hospital1 ] for alcohol withdrawal. He received (per records) ~ 8 mg lorazepam [Date range (1) ] and 50 mg of chlordiazepoxide. On [8-18] he was found to be increasingly confused, hallucinating and agitated, and was transferred for further management. In the ED, initial VS were: Temp 99.1 HR 90 BP 145/98 RR 18 Pox 98% RA. On inital presentation the patient was found to be in withdrawal but stable and was given 10 mg diazepam. He later became acutely confused, began pacing around the ED, was aggitated and thought one of the security guards was his father. [Name (NI) ] was given 8 mg lorazepam and put on 4x leather restraints. He was transferred to the [Hospital Unit Name 153] [8-18]. In the [Hospital Unit Name 153], initial VS were: 96.5, 90, 106/67, 95% RA. After admission to the [Hospital Unit Name 153] he was somnolent, mildly arousable but unable to answer any questions. His confusion improved and he was no longer apparently hallucinating. His home seroquel, gabapentin, zoloft restarted. Klonopin was held. On [8-19] he was changed from IV ativan to PO valium, underwent RUQ U/S, received banana bag (1L), 1L IVFs (lyte repletion), and nicotine patch. On the floor, HD stable but still tremulous and occasionally feeling hot, chills. Past Medical History: Alcohol dependence Substance-induced mood disorder Social History: - Tobacco: 1PPD x 7 years. - Alcohol: Since age 15, currently [12-31] pints vodka per day. Multiple detox admissions. Longest sobriety period 2 months. Last drink [8-16]. - Illicits: None, specifically denies hx IVDU - Current legal issues stemming from domestic violence (not vs. woman) - Stressors: Mom died [2101-11-17] Breast Ca; dad struggling with EtOH, girlfriend broke up with him 9 months ago. Family History: Father: Alcohol dependence. Physical Exam: Vitals: T: 96.2 BP: 118/72 HR: 85 R: 14 O2: 98% RA General: Alert, oriented, no acute distress, AOx3 HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, liver edge palpable Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Tremulous with outstretched hands, no asterixis, EOMI without nystagmus, PERRL (4->2); A+Ox3 upon discharge Pertinent Results: LABS: [2103-8-20] 05:53AM BLOOD WBC-4.3 RBC-4.40* Hgb-14.5 Hct-40.2 MCV-91 MCH-33.0* MCHC-36.1* RDW-12.6 Plt Ct-98* [2103-8-18] 10:55PM BLOOD PT-12.0 PTT-25.0 INR(PT)-1.0 [2103-8-20] 05:53AM BLOOD Glucose-106* UreaN-7 Creat-0.8 Na-138 K-3.8 Cl-101 HCO3-32 AnGap-9 [2103-8-20] 05:53AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.4 TOX: [2103-8-18] 10:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [2103-8-18] 10:40PM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG MICRO: MRSA SCREEN (Final [2103-8-21]): No MRSA isolated. [2103-8-19] 05:47AM BLOOD HBsAb-POSITIVE [2103-8-20] 05:53AM BLOOD HIV Ab-NEGATIVE [2103-8-19] 05:47AM BLOOD HCV Ab-NEGATIVE IMAGING: RUQ U/S (PRELIM): Neck liver consistent with fatty infiltration. However, other forms of liver disease including advanced liver disease and/or cirrhosis cannot be completely excluded based on this study. There is no intrahepatic biliary dilatation. Brief Hospital Course: This is a 23 year old man with history of alcohol dependence and history of alcohol withdrawal complicated by seizures who presents from detox facility out of concern for early DTs due to confusion, hallucinations and agitation, requiring large amounts of benzodiazepines. He is alert and oriented (AOx3), and medically stable for discharge. # Alcohol withdrawal. Patient's last drink was on [8-16] prior to his admission to detox at [Hospital3 8063]. He became confused, agitated and began having hallucinations on [8-17]. Given the time frame both delirium tremens (48-96 hrs after last drink) and alcoholic hallucinosis (12-48 hrs after last drink) were considered. He remained hemodyamically stable throughout without signs of autonomic instability. His symptoms were thought unlikely due to other ingestions as patient was in a monitored setting and urine/serum tox were negative (except for benzodiazepines, which he takes at home). He was transferred from the ED to the ICU due to degree of mental status change in ED and impressive benzodiazepine requirements. He was begun on a CIWA scale in the ICU with lorazepam 2-4 mg IV Q1H PRN for CIWA >10. His symptoms improved and by time of transfer he was on diazepam 10mg PO Q3H CIWA > 10. On arrival to general medicine he was alert and oriented (AOx3). There were no seizures throughout. He was given daily thiamine, folic acid and multivitamin. His presenting transaminitis trended down daily. # Leuko/thrombocytopenia: Patient found to have WBC of 3.5 and platelets of 105 on admission. This was felt to be likely alcohol induced. An HIV was sent, which was negative. His counts were trending up at discharge. # Substance-induced mood disorder: Patient is on several psychiatric medications as an outpatient. He endorses a history of depression, but denied suicidal ideations. His home seroquel, gabapentin, and sertraline were restarted in the ICU upon resolution of his symptoms resolved. We did not restart his home TCA or PRN clonidine. # Hypertension: The patient was hypertensive in the ICU, likely secondary hypertension in the setting of alcohol withdrawal. The patient denies any history of hypertension. He is on clonidine at home but for anxiety PRN. He was normotensive on transfer to the general medicine service. # Nicotene dependence: Patient is an approximate pack per day smoker for 6-7 years. He was given nicotene patch 14mg/d and encourage to quit smoking. # DVT prophylaxis: Heparin subQ # Full Code Medications on Admission: Zoloft 150 mg daily (depression) Clonidine 0.1 mg prn anxiety Seroquel 50 mg TID and 300 mg qHS (stopped ~1 mo ago) Doxepin 300 mg qHS (depression/sleep) Gabapentin 300 mg daily Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 5. Quetiapine 300 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 6. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO once a day. 9. Diazepam 10 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for CIWA > 10. Discharge Disposition: Extended Care Facility: [Hospital3 8063] - [Location (un) ] Discharge Diagnosis: Primary: Alcohol withdrawal Secondary: Substance induced mood disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted from [Hospital1 ] with increasing confusion, hallucination, and agitation in the context of alcohol detoxification. Due to your confusion, continued hallucinations, and agitation in the [Hospital1 18] ED, you were transferred to the ICU. Despite these symptoms, your blood pressure and heart rate remained stable throughout. You spent three days in the ICU, where your symptoms improved. You were given benzodiazepines, ativan and diazepam, as needed to control symptoms. By the time you were transferred to the general medicine service, you were alert and oriented and medically stable. Given your improvement, we transferred you back to [Hospital1 ] to complete your detoxification. The following changes have been made to your home medications: - You should stop your home doxepin and clonidine until you follow-up with your outpatient providers. - Please continue to take thiamine, multivitamin, and folate. - Otherwise, please continue all of your home medications. Followup Instructions: Please follow up with your PCP after your stay at [Hospital1 ]. ICD9 Codes: 2875, 3051, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8431 }	Medical Text: Admission Date: [2138-6-28] Discharge Date: [2138-7-21] Date of Birth: [2055-9-7] Sex: F Service: NEUROLOGY Allergies: Penicillins Attending:[First Name3 (LF) 2569] Chief Complaint: Severe Thunderclap Headache found on imaging to be intraparenchymal hemorrhage Major Surgical or Invasive Procedure: Tracheostomy placement PEG Tube placement History of Present Illness: Ms. [Known lastname 83553] is an 82 year old right handed woman with a past medical history significant for Multiple Sclerosis, Diabetes, Hypertension, previous stroke, and legal blindness who presents to [Hospital1 18] after having been found to have sudden onset of worst headache of her life, which on subsequent imaging was found to be a large right parietal intraparenchymal hemorrhage with subarachnoid hemorrhage at OSH. She had been in her usual state of health until the day prior to admission. On [2138-6-27], the patient began to complain about a severe headache which is frontal and radiates towards the top of her head. Initially she attempted to sleep for amelioration, but at 0400hrs on [2138-6-28], the headache recurred, waking her from sleep. Per her husband she [Name2 (NI) 63582]'t herself, and had urinary incontinence. She took an oxycodone which ameliorated the pain later that morning, but it returned later in the afternoon. Upon arrival of her daughter later that evening, she was found with altered mental status still complaining of severe headache. Given this, EMS was activated and the patient was transported to [Hospital3 ] for evaluation. Upon arrival, vitals were significant for BP of 210/79, HR: 97, RR: 18, T: 98.4 95% on RA. There, a NCHCT was performed revealing a right parietal intraparenchymal hemorrhage with a small subarachnoid hemorrhage. She was then transferred to [Hospital1 18] for urgent evaluation. Neurosurgery saw her in the ED, recommending platelets and Nicardipine for hypertension, but recommended no immediate surgical intervention and further management per the neurology service. Past Medical History: - Multiple Sclerosis -- diagnosed at age 45 managed by PCP. [Name10 (NameIs) ] apparently been on betaseron in the past (per unsure daughter). Has baseline right sided weakness and a b/l LE neuropathy, but is otherwise ambulatory with a walker and has no urinary incontinence at baseline. - Hypertension - Type 2 Diabetes Mellitus on oral hypoglycemics - Previous stroke unknown location, with no residual deficits - Legally blind - s/p bilateral laser surgery - Obstructive Sleep Apnea Social History: Lives at home with husband. Previously worked in a shoe department repairing shoes. History of tobacco use, but quit over 40 years ago. No Alcohol or Illicit Substances. Family History: Mother died [2-6] brain tumor many years ago. Otherwise, non-contributory. Physical Exam: Physical Examination on Admission: Initial VS: 98.6 68 182/54 14 97% General: Awake, alert, NAD HEENT: Sclerae anicteric, no conjunctival injection, oropharynx clear Cardiac: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops Chest: CTA bilaterally, no wheezes, rhonchi, rales Abdominal: NABS, soft, NTND abdomen Extremities: No lower extremity edema bilaterally Neurologic examination: Mental status: Awake, but with waxing and [Doctor Last Name 688] alertness. Cooperative with exam, though needs directions repeated to her multiple times. Oriented to person, "[Hospital3 ]", and "[Month (only) ] [2138]". Inattentive, unable to say [Doctor Last Name 1841] backwards, but starts to say them forwards after a different question was asked. +dysarthric, but fluent speech. Unable to assess naming [2-6] poor visual acuity. No right-left confusion. +perseveration on exam. Cranial Nerves: +surgical pupil on left that's non-reactive (~2mm) and irregular. +normal pupil on right, but reactive (~1mm). Unable to assess visual fields. Visual acuity to only to shapes and colors (though she complimented this examiner's beauty which may verify her poor visual acuity). Extraocular movements intact bilaterally without nystagmus. Sensation intact V1-V3. Facial movement symmetric. Palate elevation symmetric. Sternocleidomastoid and trapezius full strength bilaterally. Tongue midline, movements intact. Motor: Normal bulk and tone bilaterally. No observed myoclonus, asterixis, or tremor. No pronator drift. Apparent full strength throughout, but unable to fully cooperate for strength testing, particularly in the LE. Sensation: Intact to light touch throughout, but unable to test any other modalities. Reflexes: 2+ and symmetric in b/l UE and UTO in b/l LE. Toes mute bilaterally. Coordination: finger-nose-finger normal. Gait: deferred ************* Physical Exam on Discharge: Physical Examination on Admission: Initial VS: Temp = 99F, HR = 92, BP = 122/59, 96% on 10 pressure support, 10 PEEP, 50% FiO2 General: Awake, alert but unable to respond to command HEENT: Sclerae anicteric, no conjunctival injection, oropharynx clear, tracheostomy in place with some dried blood in the proximal aspect of tube Cardiac: Irregular Rate & Rhythm, no murmurs, rubs, or gallops Chest: CTA bilaterally, no wheezes, rhonchi, rales Abdominal: Soft, non-tender, non-distended, with positive bowel sounds. PEG tube in place c/d/i Extremities: No lower extremity edema bilaterally Neurologic examination: Mental Status: Awake, with spontaneously opening eyes, no response to commands. Cranial Nerves: CN I: Deferred CN II: Right reactive to light 3-2mm briskly, Left post-surgical pupil non-reactive, fixed at 3mm. No blink to confrontation. Unable to assess visual fields / acuity CN III, IV, VI: Extraocular movements intact bilaterally without nystagmus. CN V: Sensation intact to pain V1-V3. CN VII: Facial movement symmetric. Palate elevation symmetric. CN VIII: Alerts to voice in either ear. CN [Doctor First Name 81]: Sternocleidomastoid and trapezius full strength bilaterally. CN XII: Tongue midline, movements intact. Motor: Normal bulk and tone bilaterally. No observed myoclonus, asterixis, or tremor. Unable to cooperate for strength testing, moves right upper and lower extremities greater than left but withdraws to pain in all extremities. Sensation: Intact to painful stimuli throughout, but unable to test any other modalities. Reflexes: 2+ and symmetric in b/l UE and UTO in b/l LE. Plantar reflexes are equivocal bilaterally. Coordination and Gait were not able to be assessed. Pertinent Results: [2138-6-28*] 09:00PM GLUCOSE-125 UREA N-29* CREAT-1.2* SODIUM-137 POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-29 ANION GAP-14 [2138-6-28] 09:00PM estGFR-Using this [2138-6-28] 09:00PM WBC-12.5* RBC-4.69 HGB-13.4 HCT-41.0 MCV-87 MCH-28.6 MCHC-32.7 RDW-16.1* [2138-6-28] 09:00PM NEUTS-84.4* LYMPHS-11.8* MONOS-3.3 EOS-0.2 BASOS-0.4 [2138-6-28] 09:00PM PLT COUNT-159 [2138-6-28] 09:00PM PT-11.9 PTT-28.1 INR(PT)-1.1 EKG [6-28]: Sinus rhythm with borderline first degree A-V conduction delay. Poor R wave progression. MRI/A [6-29]: IMPRESSION: 1. Limited examination due to patient motion. Unchanged right parieto-occipital intraparenchymal hematoma with associated vasogenic edema. Long-term followup is recommended to identify underlying lesions within the hematoma. 2. Areas of small vessel disease are noted in the subcortical white matter. 3. MRA of the head is limited, however, the major vascular branches are patent. Segmental narrowing is noted in the vessels of the circle of [Location (un) 431], suggesting atherosclerotic disease. 4. No diffusion abnormalities are detected to suggest acute or subacute territorial infarction. CXR [6-29]: FINDINGS: The NG tube is coiled in the stomach. There is obscuration of the left hemidiaphragm laterally likely due to a combination of effusion and volume loss. An underlying infiltrate cannot be excluded. There are no old films available for comparison. There is mild pulmonary vascular redistribution and mild cardiomegaly. CT head [6-30]: IMPRESSION: 1. New trace intraventricular hemorrhage layering in the bilateral occipital horns of the lateral ventricles. 2. No significant change in the amount of intraparenchymal and subarachnoid hemorrhage. 3. Stable surrounding edema and mild mass effect. CXR [6-30]: IMPRESSION: Moderate-to-severe pulmonary edema and trace left effusion. CXR [7-1]: IMPRESSION: Unchanged pulmonary edema. CXR [7-2]: IMPRESSION: Increased moderate asymmetric right greater than left pulmonary edema and moderate bilateral pleural effusions. MRI head [7-2]: IMPRESSION: 1. Unchanged appearance of the right parieto-occipital parenchymal hemorrhage and its associated mass effect with compression of the occipital [Doctor Last Name 534] of the right lateral venticle. No evidence of transtentorial or tonsillar herniation. 2. Stable small subarachnoid and intraventricular blood, with no evidence of developing hydrocephalus. 3. Internal blood-fluid layer, and scattered punctate chronic "microbleeds" with susceptibility artifact are strongly suggestive of underlying cerebral amyloid angiopathy. 4. New bilateral frontal and right posterior parietal foci of slow diffusion; given the ditribution, these are concerning for acute embolic infarction. 5. Stable periventricular FLAIR-signal abnormalities are consistent with known multiple sclerosis, with possible component of small vessel ischemic disease. ************ TTE [7-1]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular global systolic function is normal. Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The right ventricular free wall is hypertrophied. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is at least borderline pulmonary artery systolic hypertension. There is a small pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. ************* Labs selected from days immediately prior to discharge [2138-7-21*] 03:48AM BLOOD WBC-8.4 RBC-2.52 Hgb-7.2* Hct-22.4* MCV-89 MCH-28.8 MCHC-32.3 RDW-17.6* Plt Ct-243 [2138-7-21] 03:48AM BLOOD Glucose-156* UreaN-64* Creat-1.3* Na-142 K-4.5 Cl-106 HCO3-25 AnGap-16 [2138-7-21] 03:48AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.4 [2138-7-18] 9:16 pm URINE Source: Catheter. FINAL REPORT [2138-7-19] URINE CULTURE (Final [2138-7-19]): YEAST. >100,000 ORGANISMS/ML.. Brief Hospital Course: Neuro: 82yo RH woman presented with severe headache and was found to have a right occipital intraparenchymal hemorrhage with subarachnoid component. She was hypertensive to 210 systolic upon arrival and was started on a nicardipine IV for BP control. She was admitted to the Neurology ICU for close monitoring with telemetry and further management. She was maintained on Q2hour neurochecks and close BP monitoring with a goal SBP < 160. Nicardipine gtt was titrated off and she was started on labetalol PRN. MRI/A was performed initially on [6-29] and showed no obvious underlying lesion or vascular abnormality to explain her hemorrhage. However this study was limited by motion artifact and no GRE sequence was able to be completed. A repeat head CT was performed on [6-30] which was essentially unchanged, except for trace intraventricular hemorrhage layering in the bilateral occipital horns of the lateral ventricles. Her exam initially remained stable and essentially nonfocal, other than some dysarthria and her baseline visual impairment. She developed intermittent agitation and disorientation and received a few doses of haldol and ativan IV. Routine EEG showed slow encephalopathic 5.5 Hz background, no epileptic discharges or seizures. On [7-2] she was noted to be moving her left side somewhat less at times. A repeat MRI showed stable R occipital hemorrhage but new acute infarcts in bilateral frontal and right posterior parietal regions. There were also scattered punctate lesions of susceptibility artifact suggestive of amyloid angiopathy. Over the course of the next two weeks, the patient became more active and interactive with staff and family. She remains globally aphasic, and poorly responds to any commands. The patient also experiences occasional epochs of agitation which are relieved with pain control or Seroquel for agitation. Cardiopulmonary: She had a brief respiratory decompensation in the afternoon on [6-30] for which Lasix 20mg IV x 1 was administered with some initial improvement. However, renal function subsequently worsened with decreased UOP and an increase in Cr to 1.7. She received albumin x 2 followed by additional Lasix. On [7-1], the patient was noted to have difficulty breathing, non-invasive positive pressure ventilation was attempted and ABGs were obtained which showed poor O2 saturation and worsening hypercapnea. CXR obtained was concerning for pulmonary edema. Pt became bradycardic and sustained a brief cardiopulmonary arrest for which resuscitation was accomplished with one round of epi and chest compressions. The patient was intubated and placed on ventilation for respiratory failure. EKG showed no ischemic changes, troponin initially rose to 0.34 but then downtrended. Between [7-5] and [7-10], the patient had episodes of hypertension which were associated with agitation requiring increased anti-hypertensive management. The patient at times was sedated on propofol for agitation which occurred with any attempts to wean from sedation. Blood pressures which ranged in the systolic range of 140-160 would escalate to the 180s with sedation weaning attempts. Her neurologic exam during this period was remarkable for increasing motion and strength in her extremities with left remaining greater than right, however thorough evaluation was not possible [2-6] sedation. Initially Nicardipine gtt was used, but was able to be discontinued in favor of increased dosages of the patient's home anti-hypertensive regiment. Between [7-12] and [7-15], the patient experienced several episodes of hypotension requiring a course of fluid boluses and pressors to maintain adequate perfusion, first with phenylephrine, and then later with norepinephrine for better pulse management. Of note following, [7-16] the patient did not require further pressor use with the exception of a period of hypotension to the 80/60s with some bradycardia to the 50s on [7-18]. Since this time, her cardiovascular function has been allowed to autoregulate with only her anti-hypertensive medications continued. The patient upon discharge does still have hypertensive swings into the 160-170 systolic blood pressure range which are relieved with medication or adequate sedation/pain relief. Renal: Over the next few days, renal failure persisted with Cr levels in the 1.7-2.0 range. Urine/Blood Osmolality and Lytes were obtained which were consistent with a pre-renal etiology for the worsening function. Additional free water flushes were added to the patients regimen (initially hypotonic lactated ringers were added as well, but were subsequently discontinued with worsening hypernatremia). With this intervention Creatinine improved over the next week to 1.2. GI: On [7-8], the decision to perform a tracheostomy and PEG tube was made which was accomplished on [7-10]. Prophylaxis: Over her ICU course, the patient was maintained on pneumoboots for DVT prophylaxis. SC heparin was held in the setting of her bleed but subsequently restarted on [7-1]. She was maintained on a bowel regimen for GI prophylaxis. 1. Dysphagia screening before any PO intake? (x) Yes - () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented? (x) Yes (LDL = 77) - () No 5. Intensive statin therapy administered? (for LDL > 100) () Yes - (x) No (if LDL >100, Reason Not Given: ) 6. Smoking cessation counseling given? () Yes - (x) No (Reason (x) non-smoker - (x) unable to participate) 7. Stroke education given? (x) Yes - () No 8. Assessment for rehabilitation? (x) Yes - () No 9. Discharged on statin therapy? () Yes - (x) No (if LDL >100, Reason Not Given: ) 10. Discharged on antithrombotic therapy? () Yes (Type: () Antiplatelet - () Anticoagulation) - (x) No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? (x) Yes - () No - () N/A -- Aspirin (as concern for bleeding given admission suggested against warfarin management) Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver. 1. Sertraline 12.5 mg PO DAILY 2. Gabapentin 600 mg PO DAILY AM dose 3. Gabapentin 900 mg PO HS 4. CloniDINE 0.1 mg PO BID 5. Metoprolol Tartrate 25 mg PO BID 6. Docusate Sodium 100 mg PO DAILY qAM 7. Lorazepam 0.5 mg PO HS 8. Aspirin 81 mg PO DAILY 9. GlyBURIDE 2.5 mg PO DAILY 10. Levothyroxine Sodium 125 mcg PO DAILY 11. Calcium 500 + D NF (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit Oral daily 12. Acetaminophen 650 mg PO Q6H home is PRN, keep standing here. Discharge Medications: 1. Sertraline 12.5 mg PO DAILY 2. Gabapentin 600 mg PO/NG DAILY 3. Gabapentin 900 mg PO/NG HS 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [Hospital1 ] 5. OxycoDONE Liquid 5 mg PO/NG Q6H:PRN pain 6. Senna 1 TAB PO/NG [Hospital1 ]:PRN constipation 7. Docusate Sodium 100 mg PO/NG [Hospital1 ] 8. Acetaminophen 650 mg PO Q6H:PRN Fever 9. Levothyroxine Sodium 125 mcg PO/NG DAILY 10. Famotidine 20 mg PO/NG DAILY 11. Aspirin 81 mg PO/NG DAILY 12. Captopril 50 mg PO/NG TID Hold for SBP < 110 13. CloniDINE 0.1 mg PO/NG [Hospital1 ] 14. Fluconazole 200 mg PO/NG Q24H (PLEASE CONTINUE THIS MEDICATION FOR 12 DAYS FROM DISCHARGE) 15. Quetiapine Fumarate 25 mg PO/NG [Hospital1 ] 16. Calcium 500 + D 400 Units (calcium carbonate-vitamin D3) 17. GlyBURIDE 2.5 mg PO DAILY 18. NUTRITION - Tubefeeding: "Replete with fiber" Full strength; Starting rate: 20 ml/hr; Advance rate by 10 ml q4h Goal rate: 50 ml/hr Residual Check: q4h Hold feeding for residual >= : 200 ml Flush w/ 100 ml water q6h Discharge Disposition: Extended Care Facility: [Hospital 5503] [Hospital ] Hospital Discharge Diagnosis: 1. Right Intraparenchymal Hemorrhage with small subarachnoid hemorrhage with radiologic findings strongly suggestive of underlying cerebral amyloid angiopathy 2. Small bilateral frontal and right posterior parietal foci of ischemia 3. Cardiac Arrest status post resuscitation 4. Ventilator Dependant Respiratory Failure status post tracheostomy and PEG placement 5. Urinary Tract Infection status post treatment (on two week course of fluconazole) Discharge Condition: Ventilator-dependant respiratory failure, but stable. Discharge Instructions: * Please note the patient has paroxysms of hypertension associated with agitation. This patient has responded very well to either morphine sulfate or oxycodone. Please attempt these interventions if the patient becomes acutely agitated, with elevated blood pressures. * The patient has passed spontaneous breathing trials while inpatient and was able to use trach collar oxygen for a number of hours at times. Please attempt to wean ventilator support as possible. * The patient has regained movement of her arms bilaterally and legs bilaterally but remains globally aphasic with poor response to command. It is unclear whether this is a permanent deficit, or will improve with time. Followup Instructions: * Please continue follow-up appointments with your primary care physician, [Name10 (NameIs) 2085], and other existing physicians. * An appointment is being scheduled for you to follow up with [First Name8 (NamePattern2) 2530] [Name8 (MD) ], MD with our Neurology Stroke Service. [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575] Completed by:[2138-7-21] ICD9 Codes: 431, 4275, 2760, 5849, 5990, 4019, 2449, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8432 }	Medical Text: Admission Date: [2128-7-19] Discharge Date: [2128-7-26] Service: NEUROLOGY HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 6993] is an 81-year-old right-handed male with bilateral total knee replacement, hip fractures, diabetes mellitus, atrial fibrillation on Coumadin, congestive heart failure. His family brought patient in for mental status changes of three or four day- duration, mainly "he was slow when speaking, answering their questions". They brought him to an outside hospital where a CT scan revealed bilateral subdural collections, subfalcial herniation, and a parasagittal hemangioma. Patient also had high INR. Coumadin was discontinued and he was given 6 units of fresh-frozen plasma to reverse INR. He was sent here for Neurosurgical evaluation, but they felt these collections were old and did not require intervention. Therefore, Neurology was consulted. The patient had an episode of desreased LOC on the floor. The patient was then admitted to Intensive Care Unit, and given mannitol x1 to decrease edema. He had a repeat CT which showed no significant change. Neurosurgery discussed options with family, and he was deemed not to be a surgical candidate. On examination when seen on the general floor, the patient had a blood pressure of 140/60, heart rate of 60, temperature of 100.8, and respiratory rate of 18. On physical exam, pertinent positives: The patient had an irregular rhythm with a positive S1, S2. There are no carotid bruits. Lungs were clear to auscultation bilaterally. Patient had no clubbing, cyanosis, or edema with 2+ dorsalis pedis. On neurologic examination, the patient had an appropriate affect. Was oriented to name, but did not know the hospital. Thought the date was [6-22]. Was unable to identify year and he was mildly inattentive. The patient did have slow fluent speech. Repetition and naming were intact. The patient was able to read and write. Memory was [3-8] registration, 0/3 consolidation. The patient had no apraxia, neglect to frontal signs. On cranial nerve examination, visual fields were intact to confrontation. Pupils are round from 2 mm to 1.5 mm bilaterally. Extraocular movements are intact without nystagmus. Patient had normal facial sensation and musculature. Hearing intact to finger rub. Patient had normal tone and bulk. Patient had 4+ iliopsoas and quadriceps, otherwise 5+. Patient had 2+ reflexes aside from triceps 1. On sensory examination, the patient had a negative Romberg with decreased proprioception, vibration, and temperature below shins bilaterally, otherwise intact sensation. The patient had no dysmetria on finger-to-nose. LABORATORIES AND TESTS: The patient had white blood cells [11-19] over the past five days with 75% neutrophils. Patient's INR was controlled. Patient had a BUN and creatinine of 37/2.1, which was rechecked daily. Patient also had a repeat head CT and MRI which showed redemonstration of bilateral subdural hematoma with left frontal parasagittal meningioma. He also had an EEG, which did not show seizure activity. CONCISE SUMMARY OF HOSPITAL STAY: Coumadin was discontinued with only aspirin for atrial fibrillation and beta blocker for hypertension with digoxin. Beta blockers were later discontinued because of asymptomatic bradycardia (~ 30s). Patient also had positive MRSA in heel which was treated during admission. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Stable. DISCHARGE DIAGNOSIS: 1- Subdural hematomas 2- Left frontal meningioma. DISCHARGE MEDICATIONS: 1. Glipizide 10 mg q am/5 mg q hs. 2. Aspirin 325 mg q day. 3. Digoxin 0.25 mg po q day. The patient will be discharged with Occupational Therapy and Physical [Hospital ] rehab home. DR.[Last Name (STitle) ],[First Name3 (LF) 4267] 13-282 Dictated By:[Name8 (MD) 15274] MEDQUIST36 D: [2128-7-26] 11:03 T: [2128-7-26] 11:20 JOB#: [Job Number 51359] ICD9 Codes: 4280, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8433 }	Medical Text: Admission Date: [2145-8-17] Discharge Date: [2145-8-21] Date of Birth: [2070-1-19] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 613] Chief Complaint: abd pain, hypotension Major Surgical or Invasive Procedure: Central line placement, R subclavian History of Present Illness: 75 y/o M w/ ILD, AVR who presented to the ED [2145-8-17] c/o abd pain. He was in his USOH until he was driving home from his Cardiology appointment and developed BLQ abd pain. He reported eating raw clams earlier in the day. He became nauseous and vomited 3 times (non-bloody) and had one episode of diarrhea. Also noted SOB but denied any cough or chest pain. Also had chills, no fevers. . In ED, he was initially tachycardic at 131, temp 99.5, bp 105/59, RR 20, 97% 2L. He spiked to 101.2 and was given levoflox 500 mg IV. His BP drifted down to 85/41, 78/palp-->66 at which point he was confused. Lactate level was 2.8. CXR revealed a LLL infiltrate. At this point a code sepsis was initiated and he was begun on levophed. He was given vancomycin 1g and 6L NS. R SC CVL was placed. Initial CVP 8-10, mixed venous 71. He was admitted to the MICU on the sepsis protocol. . MICU Course: Patient was off pressors since arrival to the MICU. He remained hemodynamically stable and afebrile on levofloxacin. He has been auto diuresing. . Patient was transferred to medicine service on [8-20] and was feeling well. He complained of abdominal pain with palpation. He is tolerating PO diet and has not had episodes of emesis or diarrhea since admission. He is guiaic positive with Hct 32 but stable. Cardiac enzymes were noted for slightly elevated tropI 0.03 on [8-19], normal CK-MB. He was afebrile with normal WBC count. He had mild SOB while laying flat. Denied fevers, chills, chest pain, weakness, headache, dysuria, hematuria. Past Medical History: Interstitial lung disase Glaucoma GERD CHF Cataracts GI Bleed Fistula repair surgery Social History: Retired. Lives with wife in [Location (un) 538], MA. Quit smoking 30 years ago after a 35 pack year hsitory. Drinks a [1-18] glass of wine daily. Denies any past or current recreational drug use. Family History: Noncontributory Physical Exam: T: Tm 98.4 (oral) Tc 98.4 (ax) P 93 BP 122.62 R 20 O2 98 on 2L Gen: alert and oriented pleasant male in NAD HEENT: anicteric, OP clear Neck: supple, no LAD, no JVD Lungs: dry crackles throughout, L>R at bases CV: RRR, II/VI SEM at LSB Abd: soft, mildly distended, tender over BLQ, no rebound no guarding Rectal - prior rectal fistula, GUIAC + per NF Ext: no edema, warm/dry Pertinent Results: [2145-8-20] 12:50PM BLOOD Hct-35.0* [2145-8-20] 06:15AM BLOOD WBC-5.0 RBC-3.08* Hgb-10.4* Hct-30.9* MCV-101* MCH-33.9* MCHC-33.7 RDW-15.2 Plt Ct-144* [2145-8-18] 04:16AM BLOOD Neuts-76.6* Bands-0 Lymphs-17.6* Monos-4.0 Eos-1.0 Baso-0.7 [2145-8-17] 05:30PM BLOOD Neuts-84* Bands-1 Lymphs-6* Monos-9 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2145-8-18] 04:16AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL [2145-8-20] 06:15AM BLOOD Plt Ct-144* [2145-8-17] 05:30PM BLOOD PT-12.2 PTT-18.1* INR(PT)-1.0 [2145-8-20] 06:15AM BLOOD Glucose-94 UreaN-8 Creat-0.7 Na-142 K-3.9 Cl-107 HCO3-31 AnGap-8 [2145-8-19] 03:34AM BLOOD Glucose-121* UreaN-7 Creat-0.8 Na-142 K-3.3 Cl-104 HCO3-29 AnGap-12 [2145-8-20] 06:15AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2145-8-19] 10:12AM BLOOD CK-MB-3 cTropnT-0.03* [2145-8-17] 05:30PM BLOOD cTropnT-<0.01 [2145-8-18] 04:16AM BLOOD Calcium-7.0* Phos-3.0 Mg-1.6 [2145-8-17] 07:10PM BLOOD Comment-GREEN TOP [2145-8-18] 01:00AM BLOOD Lactate-1.3 [2145-8-17] 11:32PM BLOOD Lactate-1.5 [2145-8-17] 07:10PM BLOOD Lactate-2.8* [2145-8-17] 10:15PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.014 [2145-8-17] 10:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2145-8-17] 10:15PM URINE RBC-0 WBC-0 Bacteri-RARE Yeast-NONE Epi-0 CHEST PORT. LINE PLACEMENT [2145-8-17] IMPRESSION: Properly positioned new right CV line. Bilateral loculated pleural effusions that are stable. Bilateral atelectasis and worsening pulmonary edema. CHEST (PORTABLE AP) [2145-8-17] 5:57 PM IMPRESSION: 1) Interval improvement in pulmonary edema compared to [2144-2-27] with persistent bilateral interstitial opacities. These are present on the preoperative study performed on [2144-2-19], suggesting that they represent chronic changes. 2) There is loss of the definition of the left hemidiaphragm suggestive of a left lower lobe process. 3) Density at the left lateral hemithorax with a sharp linear border is unchanged compared to the preoperative studies dated [2144-2-19]. Possibly representing loculated pleural fluid or pleural thickening. EKG [2145-8-17] Sinus tachycardia. Compared to the previous tracing of [2144-2-24] the rate is now faster. CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST [2145-8-20] CT OF THE ABDOMEN WITH IV CONTRAST: There are diffuse interstitial opacities in both lower lobes with a peripheral predominance with areas of subpleural honeycombing. Calcified pleural plaques are seen in the right lung base posteriorly. Extensive pleural fat deposition is present. There are no pleural or pericardial effusions. There is a vague area of decreased density within the left medial lobe of the liver inferiorly (segment IVB), which is located anteriorly just to the right of the gallbladder which measures 15 x 18 mm, and is incompletely assessed. Several tiny calcifications are seen in the periphery of the spleen. The gallbladder, adrenal glands, pancreas, stomach, and small bowel loops are unremarkable. There is no ascites or pathological mesenteric or retroperitoneal lymph node enlargement. Both kidneys enhance symmetrically and homogeneously without evidence of focal mass or obstruction. No intra-abdominal collection is identified. CT OF THE PELVIS WITH IV CONTRAST: There is diffuse diverticulosis but no evidence of acute diverticulitis. Distal ureters and bladder are unremarkable. There is no free fluid in the pelvis or pathological inguinal or pelvic lymph node enlargement. Note is made of bilateral fat containing inguinal hernias, left greater than right. There is diffuse demineralization and degenerative changes in the spine. No suspicious lytic or sclerotic osseous lesions are identified. IMPRESSION: 1. Vague round low density lesion in segment IVB of liver, incompletely assessed. Further evaluation with ultrasound is reccommended. 2. No other evidence of intraabdominal infection. 3. Multiple hepatic granulomas. 4. Diffuse interstitial lung disease in both lung bases with calcified pleural plaques and extensive fat deposition in the subpleural space. Differential diagnosis includes pulmonary fibrosis and asbestosis. 5. Diverticulosis without evidence of acute diverticulitis. . CHEST (PA & LAT) [2145-8-20] 5:20 PM PA AND LATERAL CHEST X-RAY: Patient is status post median sternotomy with the prosthetic aortic valve in stable position. The cardiac silhouette, mediastinal, and hilar contours are stable. There is decreased pulmonary edema compared with prior exam. Stable interstitial opacities are seen diffusely and bilaterally. There is circumferential pleural thickening bilaterally, with nodularity at the right lung apex. Increased opacity in the left lower lung is likely related is to the surrounding pleural thickening. The surrounding soft tissue and osseous structures are stable. . There has been interval removal of a right subclavian central venous catheter. No pneumothorax is seen. . IMPRESSION: Interval decrease in pulmonary edema. Brief Hospital Course: 75 y/o M w/interstitial lung disease on chronic steroids who presents with fever, hypotension, and tachycardia. . # SIRS w/sepsis: Patient's clinical status improved quickly with antibiotics and fluids. It is possible that the patient may have had a viral/bacterial gastroenteritis resulting in sepsis. This can happen in immunosuppressed patients. Patient's WBC count was normal since he is on azothioprine preventing from mounting an immune response to infection. Lung exam noted for bibasilar crackles [2-18] to interstitial lung disease. CXR in ICU was negative for pneumonia which may not have been intially detected given low volume status. However, a pneumonia could have also resulted in patient's sepsis. A repeat CXR on [8-20] to eval pneumonia/infiltrate showed interval decrease in pulmonary edema. Patient was on levofloxacin and flagyl for enteric and anaerobic bacterial coverage. He remained afebrile and hemodynamically stable after transfer from ICU to floor. . #Abdominal pain: Differential includes infectious causes resulting in sepsis either bacterial or viral gastroenteritis; diverticulosis or diverticulitis also likely given guiaic + stool; low probability of ischemic bowel due to improved abdominal exam and lack of board-like rigidity. CT abdomen with/without contrast revealed diffuse diverticulosis, multiple granulomas in liver, and vague round low density lesion in segment IVB of liver, incompletely assessed. Hematocrit had increased and initial drop was most likely dilutional effect from aggressive IVF resucitation. He was advised include fiber in his diet and stay well hydrated. . #. Demand Ischemia: Patient is diabetic and presented SOB. He had a mild increase in cardiac tropT due to strain on pump in setting of sudden hypotension and lack of oxygen being delivered to myocardium. However, his last set of enzymes were within normal and initial ST depressions in V4-V6 had resolved on repeat EKG. . #. HTN Patient's BP was stable in ICU and on medicine floor. His metoprolo was restarted prior to discharge, however patient may benefit from ACE more given diabetes. . #. ILD: On home O2 (2L NC), currently sats great on stable O2 requirement. He was resumed on prednisone, azathioprine; His oxygen requirement was at his home O2 of 2L. . #. Type 2 DM: FS QID, insulin sliding scale. Blood sugars remained stable while inpatient. . #. Dispo: Patient will be discharged with followup by outpatient cardiologist for caridiac stress test and echocardiogram for further evaluation. PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 58938] updated on inpatient status and progress. Medications on Admission: Metoprolol 25 mg [Hospital1 ] Protonix 40 mg daily Lasix 20 mg daily Aspirin 81 mg daily Prednisone 5 mg [Hospital1 ] Colace 1 drop Timolol left eye daily Azathioprine 50 mg daily Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). Disp:1 Refills:2 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:6 Tablet(s) Refills:0 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 days. Disp:18 Tablet(s) Refills:0 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Sepsis [2-18] viral gastroenteritis Possible pneumonia Secondary diagnoses: Interstitial lung disease with moderate restrictive PFTs [1-21] Porcine AVR for severe AS [2-21] DM type II HTN GERD Glaucoma Discharge Condition: Stable Discharge Instructions: Please take all medications. Avoid eating raw clams. Continue antibiotic course of levofloxacin and flagyl for 5 days. Followup Instructions: Please see PCP at [Hospital6 2910] for further management. Recommend cardiac stress test and echocardiogram outpatient given slightly elevated cardiac enzymes during hospital course. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] ICD9 Codes: 0389, 486, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8434 }	Medical Text: Admission Date: [2103-11-8] Discharge Date: [2103-11-11] Date of Birth: [2060-6-11] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Haldol Attending:[First Name3 (LF) 2297] Chief Complaint: polypharmacy overdose Major Surgical or Invasive Procedure: Intubated [2103-11-8] History of Present Illness: This is a 43 yo female with a PMH of Hep C, migraine headaches, h/o drug overdose, h/o seizures, asthma, who presents s/p polypharmacy overdose this morning. Apparently the pt told her [Last Name (un) 8317] that she had overdosed on ativan, seroquel, wellbutrin, marijuana, and ETOH at 8:30 AM. The pts [Last Name (un) 8317] called EMS who found the pt lethargic and minimally arousable. . In the ED, the pts vitals were: T 97.8 HR 107 BP 123/61, RR 14, sat 99% RA. She told ED nurses she took 8 tabs of ativan, 5 tabs of seroquel, 2 bottles of wine, and had +SI. The pt was lethargic in the ED and tox screen was found to be positive for cocaine. ETOH level was 167. Decision was made to protect the pts airway, so she was given Etomidate 20 mg IV and Succ 120 mg IV prior to intubation. The pt was noted to aspirate during intubation and vomited 3 times. She was started on propfol gtt and received Vecuronium 10 mg IVx 1 and then 5 mg IV x1. She received 3 L IVF. NGT was placed and pt was given charcoal down the NG tube. ABG on AC 550x14, PEEP 5, 40% FiO2 was 7.28/48/323. The pt was seen by toxicology who recommended seizure precautions, fluids for hypotension, serial EKGs to follow QTc level, and trileptal levels. . At this time, the pt is sedated and unable to answer questions. Past Medical History: h/o Hep C Migraine headaches h/o OD per daughter before [Holiday ], did not go to hospital h/o seizure d/o in setting of drugs h/o TB exposure, not compliant with INH Asthma Anxiety Depression ETOH abuse Social History: (per daughter)--has h/o ETOH abuse with binge drinking once a week, relapsed with use cocaine abuse 1 month ago, smokes many cigarrettes for many years. Lives with a male friend for 3 years as a friend Family History: mother with [Name2 (NI) 44858], sister with AIDS dementia, sister with SLE Physical Exam: Vitals: T 99.2 BP 137/89 P 102 Sat 100% AC 55x18, PEEP 5, 40% FiO2, Tv 500s Gen: obese, lying in bed intubated HEENT: MMM, PERRL Neck: obese CV: tachycardic, no m/r/g Lungs: CTAB Ab: protuberant, decreased bowel sounds Extrem: no c/c/e Neuro: sedated Pertinent Results: [2103-11-8] 12:10PM WBC-9.9 RBC-4.43 HGB-13.5 HCT-38.5 MCV-87 MCH-30.4 MCHC-35.0 RDW-14.2 [2103-11-8] 12:10PM NEUTS-51.7 LYMPHS-44.0* MONOS-4.0 EOS-0 BASOS-0.2 [2103-11-8] 12:10PM PLT COUNT-249 [2103-11-8] 12:10PM ASA-NEG ETHANOL-167* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2103-11-8] 12:10PM ALBUMIN-4.5 [2103-11-8] 12:10PM CK-MB-4 [2103-11-8] 12:10PM LIPASE-22 [2103-11-8] 12:10PM ALT(SGPT)-26 AST(SGOT)-37 CK(CPK)-310* ALK PHOS-77 AMYLASE-31 [2103-11-8] 12:10PM estGFR-Using this [2103-11-8] 12:10PM GLUCOSE-97 UREA N-10 CREAT-0.6 SODIUM-141 POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-21* ANION GAP-18 [2103-11-8] 01:00PM URINE RBC-[1-28]* WBC-0-2 BACTERIA-0 YEAST-NONE EPI-0 [2103-11-8] 01:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2103-11-8] 01:00PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.009 [2103-11-8] 01:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG . EKG: sinus tach at 110, nl axis, QTc 427 ms . Initial CXR: IMPRESSION: 1. Tip of the nasogastric tube within the superior portion of the esophagus. Re-evaluation recommended. 2. Collapse of right upper lobe with mediastinal shift and elevation of right hemidiaphragm. These findings could suggest either acute mucous plugging or in this clinical setting, significant aspiration. A repeat chest x-ray should be performed following suction of tracheal contents and repositioning of nasogastric tube. . Repeat CXR: Portable supine frontal radiograph compared to study done two hours earlier demonstrates partial re-expansion of the right upper lobe. There has been interval development of increased perihilar haziness and peribronchial cuffing suggestive of increasing interstitial edema. An NG tube has been advanced with its tip now in the proximal stomach, but the proximal side port remains above the GE junction. IMPRESSION: Worsening pulmonary edema. NG tube which is too high and should be advanced. Partial re-expansion of the right upper lobe. Brief Hospital Course: +A/P: 43 yo female with a PMH of Hep C, migraine headaches, h/o drug overdose, h/o seizures, asthma, who presents s/p polypharmacy overdose and now intubated for airway protection. . #Polypharmacy overdose: Pt overdosed on seroquel which, per toxicology note, can cause hypotension, tachycardia, elevated LFTs, seizures, QTc prolongation, hyperglycemia, and elevated CK levels. Wellbutrin overdose can lead to dose-related seizures, especially in those with prior h/o seizure, and cause hypertension/tachycardia. Cocaine would lead to hypertension and tachycardia. The pt reportedly overdosed on ativan, but urine and blood tox screen was negative for benzos. EKG showed normal QTc interval. She has no evidence of tylenol or ASA overdose. Patient was monitored in the ICU and did not have any signs of intoxicaiton. She was seen by psych who recommended inpatient psych once she was medically cleared. She was transferred to the general medicine floor [2103-11-10] and monitored overnight, repeat ECG showed stable QTc and she was deemed stable medically for inpatient psychiatric treatment. . #Airway Protection: Pt on CMV overnight for airway protection. She was extubated [2103-11-9] without any complications. She has a history of smoking and ashthma and was given scheduled nebs for post extubation wheezing. . #ETOH abuse: Given thiamine folate, B12 supplments and started on CIWA scale post extubation, although did not require in the MICU or on the general medicine floor through 72 hours after admission. . #Fever: Pt spiked temp of 101.9 on arrival to the MICU. DDX included aspiration pneumonitis vs. overdose on seroquel/wellbutrin. She was given clindamycin for aspiration PNA, however she defervasced quickly and did not have any obvious remaining infitrate thus abx were stopped (after 12 hours). No further fevers noted. . #H/o Seizure: Pt is on trileptal and topamax at home (trileptal for h/o seizure and topamax for migraines). Psych recommended d/c trileptal and topamx and will reassess her medications on the inpatient psych floor. . #Depression: Has had problems with suicide attempts in the past, seen by psych and will need inpatient psych. Maintained on suicide precautions with 1:1 sitter on the medical floor. Medications on Admission: Medications: (per OMR) Seroquel 100 mg qhs Prozac 40 mg a day Trileptal 600 mg twice a day Advair as needed Topamax 100 mg qhs Zomig 5 mg prn Meclizine 12.5 mg tid Flexeril 5 mg tid Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 5. Fluticasone 110 mcg/Actuation Aerosol Sig: Three (3) Puff Inhalation [Hospital1 ] (2 times a day). 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Discharge Diagnosis: Suicide attempt with polypharmacy overdose. Discharge Condition: Stable. Discharge Instructions: Please take all medications as prescribed, please keep all follow-up appointments. Followup Instructions: You are being transferred to inpatient psychiatric treatment. After this you should follow-up with your primary care doctor within 1-2 weeks. You have an appointment with Dr. [First Name8 (NamePattern2) 2894] [Last Name (NamePattern1) ] on [2103-12-3] at 2:00 pm, please call ([Telephone/Fax (1) 6301] with questions. You have an appointment scheduled with [Doctor First Name ] [Doctor Last Name 4253] [2102-11-30], please call ([Telephone/Fax (1) 2528] wiht questions. ICD9 Codes: 5070
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8435 }	Medical Text: Admission Date: [2119-5-27] Discharge Date: Date of Birth: [2119-5-27] Sex: F Service: NEONATOLOGY This is an interim summary covering the period from [2119-5-27] to [2119-6-2]. PRIMARY DIAGNOSIS: Prematurity. SECONDARY DIAGNOSIS: Feeding immaturity, hyperbilirubinemia, respiratory distress, resolved, apnea of prematurity. HISTORY OF PRESENT ILLNESS: The patient is a 26 [3-11] week gestational age infant admitted with respiratory distress. Maternal history: 37 year old gravida 1 female with past medical history notable for seizures in childhood, anxiety disorder, treated with Celexa prior to pregnancy. Prenatal screens: A positive, antibody negative, hepatitis surface antigen negative, RPR nonreactive, Rubella immune Group B Streptococcus unknown. Pregnancy history: Estimated date of delivery [8-31], for 26 2/7 weeks by last menstrual period, confirmatory first trimester ultrasound. Normal amniocentesis and fetal survey. Pregnancy complicated by hypertension at onset of 24 weeks, treated with bedrest, Nifedipine and magnesium. Betamethasone administered at 24 weeks. Today worsening, hypertension and transaminitis leading to cesarean section under spinal anesthesia. Rupture of membranes at delivery, yielding clear amniotic fluids. Breech extraction, no interpartum fever or other clinical evidence of chorioamnionitis, no intrapartum antibiotic therapy. Neonatal course: Infant initially hypotonic and apneic with heart rate approximately 60 beats/minute, orally and nasally bulb suctioned, dried and inspiratory pressures required for chest excursions of 30 to 40 cm of water. Orally intubated at 1 to 2 minutes with poor respiratory effort and bradycardia with rapid resolution of bradycardia, onset is spontaneous respirations and decrease in inspiratory pressure requirement to approximately 25 cm. Apgars 2 at one minute and 7 at five minutes, transferred eventually to Neonatal Intensive Care Unit. PHYSICAL EXAMINATION ON TRANSFER: Ventilated on SIMV, settings of positive inspiratory pressure of 25, positive end-expiratory pressure 5 at a rate of 25, sating 98% on room air. Birthweight was 625 gm. Anterior fontanelle soft and flat, nondysmorphic, palate intact. Neck normal. Chest with moderate retractions and spontaneous breaths. Good excursion with IMV. Good breath sounds bilaterally, scattered coarse crackles, well perfused, regular rhythm with normal rate. Femoral pulses normal S1 and S2, normal. No murmur. Abdomen is soft, nondistended, no organomegaly, no masses. Bowel sounds active. Anus is patent. Genitourinary, normal female genitalia, active and responsive to stimuli. Axial appendicular tone decreased in symmetric distributions, consistent with gestational age, moving all limbs symmetrically, gag intact, grasp symmetric. Moderate bruising on head, trunk and right arm otherwise unremarkable. HOSPITAL COURSE: (By systems) Respiratory - The patient remained intubated, quickly weaned on ventilator setting and was able to extubate by day of life #3. She was started on caffeine on day of life #2 and remains on caffeine at 5 mg/kg/day. Caffeine was bolused and increased on day of life #5 for increased spells. She is now averaging approximately six spells a day on a CPAP of 6 cm. Cardiovascular - [Location (un) 44133] has remained hemodynamically stable without any need for blood pressure support. She has had no murmur. Fluids, electrolytes and nutrition - Fluids were started on day of life #1 at 100 cc/kg/day with 10% dextrose solution and was started on parenteral nutrition by day of life #2. She is currently receiving 30 cc/kg/day of formula or breastmilk, and tolerating well. Dextrose sticks have always remained stable. Electrolytes have been within normal limits. Heme - Phototherapy was initiated on day of life #1. Peak bilirubin was on day of life #3 with a total of 2.9 and direct of .3. At the time of dictation she remains on one phototherapy bank. Hematocrit at birth was 41. On day of life #5, hematocrit was 35 and she was transfused 5 cc/kg mostly to replace blood taken. Platelets were 213 at birth. Infectious disease - She was started on Ampicillin and Gentamicin at birth and continued for 48 hours until cultures remained negative. Neurology - Head ultrasound on day of life #6 was normal. Reviewed By: [Doctor Last Name ] [Last Name (NamePattern5) 36094], M.D. [MD Number(1) 36250] Dictated By:[Name8 (MD) 55629] MEDQUIST36 D: [2119-6-2] 15:45 T: [2119-6-3] 08:50 JOB#: [Job Number 55630] ICD9 Codes: 769, 7742
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8436 }	Medical Text: Admission Date: [2156-11-18] Discharge Date: [2156-11-24] Date of Birth: [2090-3-31] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 5790] Chief Complaint: Stage IV lung cancer, malignant pleural effusion and shortness of breath Major Surgical or Invasive Procedure: Pleurex catheter placement, open thoracotomy, evacuation of pleural effusion, placement of Pleurex catheter. History of Present Illness: Mrs. [Known lastname 44696] is a 66 year old female with Stage IV, NSCLC and history of recurrent malignant pleural effusion who was transfered for [Hospital1 18] for plamcent of a pleurex catheter. She was last tapped on [2156-11-14]. At that time 800cc of fluid were removed. Three days later she returned to [Hospital 1562] Hospital with continued dyspnea nd was found to have a recurrent right pleural effusion. She was transferred to [Hospital1 18]. On arrival she was tachypnic, hypoxic with increased work of breathing and was found to have non-occlusive segment and sub-segmental left lower lobe pulmonary emboli and near complete collapse of the righ lung by a large pleural effusion. Past Medical History: Stage IV non-small cell lung CA Mitral valve prolapse. Social History: non-contributory Family History: non-contributory Pertinent Results: [2156-11-18] 04:52PM PT-14.6* PTT-80.7* INR(PT)-1.3* [2156-11-18] 01:18AM TYPE-ART PO2-67* PCO2-41 PH-7.43 TOTAL CO2-28 BASE XS-2 [2156-11-18] 12:52AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [2156-11-18] 12:52AM PLT SMR-NORMAL PLT COUNT-440 [2156-11-18] 12:52AM PT-12.5 PTT-27.4 INR(PT)-1.1 [2156-11-24] 01:56AM BLOOD WBC-9.4 RBC-2.85* Hgb-9.2* Hct-27.6* MCV-97 MCH-32.2* MCHC-33.2 RDW-16.8* Plt Ct-459* [2156-11-18] 12:52AM BLOOD Neuts-78* Bands-0 Lymphs-13* Monos-8 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [2156-11-24] 01:56AM BLOOD Plt Ct-459* [2156-11-18] 12:52AM BLOOD PT-12.5 PTT-27.4 INR(PT)-1.1 [2156-11-24] 01:56AM BLOOD Glucose-118* UreaN-19 Creat-0.9 Na-140 K-3.8 Cl-109* HCO3-26 AnGap-9 [2156-11-19] 12:39AM BLOOD Glucose-156* UreaN-11 Creat-0.6 Na-127* K-4.8 Cl-93* HCO3-24 AnGap-15 [2156-11-24] 01:56AM BLOOD Calcium-7.7* Phos-2.6* Mg-1.9 [2156-11-24] 02:12AM BLOOD Type-ART Temp-37.1 Rates-/26 Tidal V-383 PEEP-5 pO2-138* pCO2-36 pH-7.48* calTCO2-28 Base XS-4 Intubat-INTUBATED [2156-11-18] 01:18AM BLOOD Type-ART pO2-67* pCO2-41 pH-7.43 calTCO2-28 Base XS-2RADIOLOGY Final Report CTA CHEST W&W/O C&RECONS, NON-CORONARY [2156-11-18] 3:03 AM CTA CHEST W&W/O C&RECONS, NON- Reason: r/o pulmonary embolism; image lung for endobronchial disease Field of view: 36 Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 66 year old woman with stage IV NSCLC with progressive skeletal and pulmonary metastatic disease and continuing malignant effusions txferred from OSH for acute on chronic desaturation s/p thoracentesis on [11-14] with 800cc removed. REASON FOR THIS EXAMINATION: r/o pulmonary embolism; image lung for endobronchial disease CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 66-year-old woman with non-small-cell lung cancer and progressive metastatic disease with malignant effusion and acute desaturation status post thoracentesis; evaluate for pulmonary embolism. COMPARISONS: None. TECHNIQUE: MDCT images of the chest were obtained both without and with 90 cc of non-ionic intravenous Optiray contrast. Multiplanar reformations were essential to interpretation. The study was optimized for evaluation of the pulmonary arteries rather than the mediastinal structures. CHEST: There are non-occlusive filling defects within left lower lobe segmental and subsegmental pulmonary arterial branches (3, 43). The central pulmonary arteries are patent. Thoracic aorta has a normal caliber, without evidence of intramural hematoma or dissection. There is a fat attenuation focus in the left thyroid lobe. The right lung is almost entirely collapsed by a very large simple right pleural effusion causing mediastinal shift. The compressed lung parenchyma demonstrates areas of relative [Name (NI) 20534]. There is a focus of simple fluid in the left upper lobe, which appears fissural. There are numerous pulmonary nodules within the left lung, measuring up to 25 x 19 mm (3, 77). A small simple appearing left pleural effusion is also noted. Pathologically enlarged right axillary lymph nodes measure up to 20 x 11 mm. A left hilar node measures 18 x 15 mm. The right hilum is suboptimally evaluated but increased soft tissue in this region is suspicious for lymphadenopathy. A lower pretracheal lymph node measures 17 x 16 mm. A subcarinal node measures 28 x 18 mm. There is no pericardial effusion. OSSEOUS STRUCTURES: There are sclerotic metastases at multiple sites, without associated pathologic fracture. The approximate T10 body is completely sclerotic, as is the left T7 pedicle and transverse process and the majority of the sternum and the right scapular tip. Multiple additional smaller sclerotic foci are noted. IMPRESSION: 1. Non-occlusive segmental and sub-segmental left lower lobe pulmonary emboli. 2. Near complete collapse of the right lung by a large pleural effusion. [Name (NI) ] of portions of the compressed lung may be secondary to pneumonia. 3. Pulmonary nodules, thoracic adenopathy and numerous osseous lesions are compatible with diffuse metastatic disease. Bone scan correlation may be considered. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) 7805] [Name (STitle) ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Approved: [Doctor First Name ] [2156-11-18] 8:27 PM RADIOLOGY Final Report BILAT UP EXT VEINS US [2156-11-18] 2:33 PM BILAT UP EXT VEINS US Reason: source of PE [Hospital 93] MEDICAL CONDITION: 66 year old woman with stage 4 nsclc REASON FOR THIS EXAMINATION: source of PE INDICATION: 66-year-old woman with a stage IV non-small cell lung cancer, please evaluate for the source of pulmonary embolism. TECHNIQUE AND FINDINGS: Grayscale, color flow, and Doppler images of both upper extremities were obtained. Both jugular veins, subclavian veins, axillary veins, brachial veins, and basilic and cephalic veins demonstrates normal compressibility, respiratory variation in venous flow and venous augmentation. IMPRESSION: No evidence of DVT in both upper extremities. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) ] [Name (STitle) ] DR. [First Name11 (Name Pattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Approved: [Doctor First Name ] [2156-11-18] 5:18 PM Brief Hospital Course: Patient was transferred to the [Hospital1 18] for further management. CT scan of the chest revealed non-occlusive segmental and sub-segmental left lower lobe pulmonary emboli, near complete collapse of the right lung by a large pleural effusion, [Hospital1 20534] of portions of the compressed lung may be secondary to pneumonia, pulmonary nodules, thoracic adenopathy and numerous osseous lesions are compatible with diffuse metastatic disease. Interventional pulmonary service was consulted for placement of Pleurex catheter. She tolerated the procedure well but subsequently to placement, catheter became occluded. She was started on heparin gtt for her PEs. Overnight she developed relative oliguria and hypotension. She was taken to the operating room on [11-18] and underwent VATS with evacuation of 2.6 liters of effusion fluid and placement of Pleurex catheter. She was transferred back to ICU.Over the next several days she did well and was extubated. However, she experienced several episodes of respiratory distress followed by bradycardia and brief asistoly that was reversed with mask ventilation. On [11-22] she once again became bradycardic and required intubation. Extensive discussions were held with the family about the patients poor prognosis. The family made the decision to extubate the patient and make her comfortable and not initiate any other heroic measures aimed at prolonging her life. She was extubated on [11-24] and passed away shortly after. Medications on Admission: colace, digoxin, protonix, zofran, Discharge Medications: NONE Discharge Disposition: Expired Discharge Diagnosis: Stage IV lung CA Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None Completed by:[2156-11-25] ICD9 Codes: 5180, 5185, 2762, 4240, 4275
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8437 }	Medical Text: Admission Date: [2156-1-11] Discharge Date: [2156-1-30] Date of Birth: [2097-4-1] Sex: M Service: MEDICINE Allergies: Vancomycin Attending:[First Name3 (LF) 458] Chief Complaint: v tach arrest Major Surgical or Invasive Procedure: cardiac cath, stent placement EP study central line placement intubation extubation intubation History of Present Illness: 58 yo with PMH morbid obesity ?CMP w/ EF 40-45%, afib/flutter on amio at home, COPD, OSA, IDDM, tonsillar CA s/p chemo/XRT [12-22] with PEG. He was feeling generally well in his USOH and was witnessed falling to his bathroom floor in AM [1-9]. His son performed CPR until EMS arrived and found him in VF arrest (down-time <5 min). He was intubated in the field was converted out of VF with 1 shock, then transported to [Hospital6 ] where he was given lidocaine 100mg x 1 in the ED and started on amiodarone drip. . His cardiac enzymes were negative and his electrolytes were not derranged; His other labs were simply notable for a low hct of 27.1. . [1-10] midnight he was found to be in Vtach and was defibrillated x 3 "with transient response;" he was kept on amiodarone drip. He again went into pulseless VT and CPR was performed; he received lidocaine 100mg x 1 with good response; he was then started on lido drip at 2mg. He then had another VT event which was resolved by repeat lidocaine bolus and increasing drip to 3mg. The lidocaine drip was stopped today as per EP recommendations. . As per verbal report (not seen in notes) He has gone into sustained monomorphic VT 6 times with 2 episodes converting to VF; he was successfully defibrillated out of VF x 2. He was cardioverted out of VT x 4. He is transferred here for further management. Past Medical History: #HTN # dilated CMP with EF 40-45% in setting of AFib; last EF 60% # atrial fibrillation s/p cardioversion in [2151] and [2153] # 1st degree AV block; symptomatic bradycardia on atenolol # tonsillar CA s/p 3x cisplatin and XRT (finished [12-22]) # peripheral neuropathy # diabetes type 2 non-insulin-dependent; c/b peripheral neuropathy and toe amputations; chronic venous insufficiency with chronic LE cellulitis # recent tonsillar CA ?currently undergoing chemo/XRT? # COPD/asthma (FEV1 72% pred), # obstructive sleep apnea on BiPAP, # gastroesophageal reflux and peptic ulcer disease causing GIB # dyslipidemia, # history of colonic polyps, # iron deficiency anemia; ?AoCDz? # CRI baseline Cr 1.2 # BPH # OA with chronic back pain # sacral gluteal erosion; h/o MRSA cellulitis # laminectomy L5-S1, # anterior cervical discectomy with fusion C3 through 4 and C5 through 6, compression laminectomy C3 through 7, arthroscopy of the knee, toe abscess x2. Social History: lives in [Location ] with wife Family History: non-contributory Physical Exam: T BP 120/66 HR 81 (sinus) RR 14, 98% Gen: Intubated, sedated, morbidly obese. Opens eyes to command CV: RRR no m/r/g; decreased heart sounds Pulm: clear anteriorly Abd: obese, s/nd/nt + BS, PEG in place (non-functional Ext: B chronic venous changes, trace edema B Pertinent Results: EP study showed scar and many foci were ablated with some success, but residual foci. . cardiac cath had LAD stenosis and bare metal stent was placed. Brief Hospital Course: A/P 58 yo with PMH significant for morbid obesity, atrial fibrillation, tonsillar CA s/p chemo/XRT, found down with ventricular fibrillation with several episodes of recurrent VT s/p VT ablation. . # Cardiac 1. Rhythm: Pt with VF and recurrent monomorphic VT (RBBB superior morphology). Changed to an altered morphology and some polymorphic variation s/p 1x ablation. EP study on [1-14]- Several different morphologies of VT were noted, generally not well-tolerated hemodynamically which limited the ability to map the arrhythmia. A substrate based ablation was performed which modified but did not completely eliminate the VT. Post-ablation, the pt was treated with metoprolol, amiodarone, and mexilitine. Post-ablation, the pt continued to have occasional episodes of VT including poorly tolerated spells. Many of these were associated with increased catecholamine states such as reducing the amount of sedatives he was receiving but they did not well respond to increased beta blockade. BEcause of the concern re: ischemia contributing to the episodes of arrhythmia, the pt underwent cardiac catheterization (see below). Following stent placement, there was a marked reduction in the amount of arrhythmia the pt was having. On [2156-1-30] the pt suffered a Vtach arrest/PEA. Agressive resuscitative measures were performed but the pt had persistent and recurrent arrhythmia that was not hemodynamically tolerated and did not respond to repeated attempts at defibrillation. ECG during brief sinus rhythm during code did not demonstrate ST elevation or any evidence of acute stent thrombosis. Code was called after 30 minutes. Pronounced dead. . 2. CAD: Reduced EF, and findings at EP study consistent with CAD (regional scar), although cardiac enzymes persistantly negative. Medically treated with ASA, BB, plavix, statin, ACEI. Had cath and bare metal stent to prox LAD which markedly reduced the amount of arrhythmia he was having. . 3. Pump: LVEF now 30% with 1-2+MR and mild PAH. Treated with furosemide for diuresis. . # Altered mental status: likely was ICU/sedation induced delirium. Head CT without bleed or infarct. Remained confused but improved by time of death. . # Infection: Patient had E. coli UTI which was treated with 7day ceftriaxone. MRSA PNA being treated with vancomycin treated with 15 days. Treated with ceftaz for moraxilla and pseudomonas PNA. . # Diarrhea: Likely secondary to antibiotics. decreased with immodium. c.diff neg x 4 . # Respiratory failure: Intubated and extubated during hospitalization. Monitored for hypoxia (h/o pulmonary edema, pna, OSA). Thick secretions still ([1-13] parotid after surgery); improved on humidified oxygen. saline nebs. CPAP at night . # Diabetes: Treated with SSI and NPH [Hospital1 ]. . # Tonsillar Cancer: tonsillar CA s/p 3x cisplatin ([2155-11-3], [2155-11-24], [2155-12-15]) and XRT (finished [12-22]). Had good prognosis according to Oncologist:Dr. [Last Name (STitle) 19101] [Telephone/Fax (1) 19102]. . # Pressure ulcers: 2 small spots on back and under pannus which do not look infected. Treated with air bed, Zinc, vit c, wound care. . # FEN/GI: Tube feeds. Medications on Admission: Procrit on monthly injections allopurinol 300mg dialy amiodarone 200 mg daily, baclofen 20 mg t.i.d., Centrum Silver once daily, Detrol 4 mg once daily, Flomax 4 mg once daily, glyburide 5 mg in the morning 3.75 in the evening, Lasix 40mg tid, Lipitor 40 mg daily., metformin 500 mg b.i.d. Neurontin 600 mg t.i.d., protonix 40mg daily potassium 30 once daily, Proscar 40 Toprol-XL 50 once daily, Wellbutrin SR 150 t.i.d. Vicodin 500 mg t.i.d. vit b12 Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Primary V. Tach arrest Coronary artery disease Diabetes OSA CHF EF of 40% 1st degree AV block COPD/asthma CKD Secondary GERD/PUD Stage 4 tonsillar cancer treated with chemo and radiation Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired ICD9 Codes: 4271, 4254, 5859, 496, 5990, 4280, 4275, 3572, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8438 }	Medical Text: Admission Date: [2161-7-15] Discharge Date: [2161-7-30] Date of Birth: [2096-5-9] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2474] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Intubation Re-intubation History of Present Illness: 65 YO M with severe COPD, schizophrenia, pulmonary hypertension who presented to [Hospital1 18] with worsening cough, dyspnea, and hypoxia over the last 3 days. VNA found pt to be hypoxic and with sats in 70's. EMS was called and noted him to be cyanotic. His O2 improved to 80's with oxygen. . Upon presentation the the ED, his VS were: 97.6 72 131/79 18 98% on NRB. He was taken off the NRB and placed on 4L NC due to some agitation/discomfort. While on 4L NC, he became somnolent and was placed on BiPap at which time an ABG was 7.23/93/113. He was therefore intubated with succ and etomidate with a 7.5 ETT tube, 25 at the lip. He was sedated with propofol and given solumedrol, nebs, and levofloxacin 750mg IV. An EKG showed TWI in V3-V5 with first troponin of 0.01. CXR showed a possible RML PNA. He is being admitted to the MICU for further treatment of his hypercarbic respiratory failure. Just prior to transfer his BP was noted to be 93/64 despite 2L NS bolus. Given his hypotension, his propofol was changed to versed and fentanyl. . Of note, he has been admitted to the ICU multiple times for COPD exacerbations over the past year. During his most recent hospitalization, a CXR showed right basilar infiltrate and possible retro-cardiac infiltrate. . Upon arrival to the floor, he is intubated and sedated. He is unable to provide any additional history or ROS. Past Medical History: 1) COPD: FEV1 23% predicted, home 1.5-2L O2 at night only 2) Secondary Pulmonary Hypertension (51-66 mm Hg on ECHO [2159-9-18]) 3) Schizophrenia 4) Hx GI bleeding 5) Mental Retardation 6) Pulmonary Hypertension 7) s/p tonsillectomy Social History: Lives in [Location ] with brother and brother-in-law. On disability since [2149] for mental health issues. Has home nurse visit every morning and evening. Reports ~50 pack-year smoking and has now cut down to 3 cigs/day. Denies any ETOH/drug use. Family History: Patient unable to provide. Physical Exam: Vitals: T:97.2 BP:120/74 P:69 R:22 SaO2:100% on 2L General: Caucasian Male laying down in bed in NARD. [Year (4 digits) 4459]: EOMI, MMM, sclera anicteric Pulmonary: Diminished BS noted diffusely Cardiac: RR, distant S1 S2, no murmurs, rubs or gallops appreciated Abdomen: Appears distended (baseline per pt), soft, NT, normoactive bowel sounds Extremities: No edema Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. Normal bulk, strength and tone throughout. Pertinent Results: ================== ADMISSION LABS ================== [2161-7-15] 08:36AM BLOOD WBC-8.8 RBC-4.80 Hgb-15.0 Hct-45.3 MCV-94 MCH-31.2 MCHC-33.1 RDW-14.0 Plt Ct-253 [2161-7-15] 08:36AM BLOOD Neuts-72.0* Lymphs-22.4 Monos-3.4 Eos-1.9 Baso-0.3 [2161-7-15] 08:36AM BLOOD Glucose-123* UreaN-25* Creat-0.9 Na-145 K-4.6 Cl-104 HCO3-36* AnGap-10 [2161-7-15] 02:50PM BLOOD CK(CPK)-43* [2161-7-15] 02:50PM BLOOD CK-MB-2 cTropnT-<0.01 [2161-7-15] 08:36AM BLOOD Calcium-8.8 Phos-4.0 Mg-1.8 [2161-7-15] 08:36AM BLOOD Lactate-0.7 ================== DISCHARGE LABS ================== [2161-7-29] 07:30AM BLOOD WBC-14.0* RBC-4.34* Hgb-13.3* Hct-40.3 MCV-93 MCH-30.5 MCHC-32.9 RDW-13.4 Plt Ct-330 [2161-7-29] 07:30AM BLOOD Neuts-76.2* Lymphs-19.0 Monos-2.9 Eos-1.4 Baso-0.4 [2161-7-29] 07:30AM BLOOD Glucose-73 UreaN-30* Creat-1.1 Na-134 K-4.2 Cl-97 HCO3-29 AnGap-12 [2161-7-29] 07:30AM BLOOD ALT-48* AST-24 AlkPhos-53 TotBili-0.3 [2161-7-29] 07:30AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.9 ============ IMAGING ============ CTA CHEST ([2161-7-15] 4:15 PM) IMPRESSION: 1. No acute pulmonary embolism or thoracic aortic pathology detected. 2. Unchanged severe emphysema. 3. Linear subpleural consolidation in the right upper lobe and linear opacity in the left upper lobe, likely represent atelectasis. However, superimposed infection cannot be ruled out. 4. Multiple mediastinal lymph nodes, with cystic right hilar lymph nodes, have not enlarged since prior study. 5. Multiple pulmonary nodules in both lungs. The left lower lobe pulmonary nodules are slightly more conspicuous since the prior study of [2160-11-6]. A followup chest CT in three months is recommended for further evaluation of the same. 6. Right heart strain, likely secondary to the lung disease. CHEST X-RAY [7-27] FINDINGS: Hyperinflated lung, in keeping with known history of COPD. There is interval removal of feeding tube, and endotracheal tube. Interval improvement in aeration at the lung bases, with minimal atelectasis at the right lung base. Hilar, mediastinal, and cardiac silhouette stable. IMPRESSION: 1. No focal lung consolidation. 2. COPD. 3. No pleural effusion or pneumothorax. RENAL ULTRASOUND [7-28] FINDINGS: The right kidney measures 10.0 cm and the left kidney measures 10.5 cm. A tiny simple cyst is seen in the interpolar region of the right kidney measuring 1.0 x 0.7 x 0.9 cm. A simple cyst is seen at the medial portion of the lower pole of the left kidney measuring 5.2 x 4.5 x 4.0 cm. There is no hydronephrosis and no stone or solid mass is seen in either kidney. The pre-void bladder is moderately distended and unremarkable. The prostate is enlarged with a volume of 72 cc. IMPRESSION: 1. No hydronephrosis. 2. Simple bilateral renal cysts. 3. Enlarged prostate. Brief Hospital Course: 65 year old man with h/o COPD, pulm HTN, schizophrenia admitted with COPD exacerbation and respiratory failure, in improved condition. . # COPD Exacerbation: Pt presented to the ED after his VNA noted he was hypoxic to the 70s on his baseline O2 requirement of 2L NC at nightime. Work-up showed no PE but did show RUL conslidation. Patient was intubated on admission and had a prolonged and very complicated course, with difficulty in weaning off ventilator. Pt underwent a bronchoscopy given his difficulty weaning with cultures showing stenotrophomonas. After thorough discussions, patient was extubated and bridged with BIPAP as needed, however required re-intubation for hypercarbia and hypoxia. He was treated for HAP with Vanc/Cipro/Zosyn 8 day course. After multiple attempts at weaning sedation and poor progonsis, decision made to extubate on [7-23] and not to pursue re-intubation. Patient was able to maintain adequate ventilation and was transitioned to the medical floor. Patient was initially treated with high dose steroids, transitioned to oral prednisone with plan for slow taper by PCP upon outpatient [Name9 (PRE) ]. Patient placed on his home regimen of scheduled nebulizer treatments and pulmonary toilet. At time of discharge, O2 sats > 92% on 2L NC. . # Acute kidney injury: After diarrheal episode, Creatinine increased to 1.5 on [7-27], from 1.1 on [7-26] and baseline 0.7-0.8. After fluid resuscitation, creatinine improved to 1.1 on [2161-7-28]. Renal ultrasound [2161-7-28] shows simple cysts but no hydronephrosis. At time of discharge, renal function was at baseline. . # Tachycardia: Multifactorial in setting of critial illness, frequent b-agonists, volume depletion and alternating periods of sinus tachycardia and multifocal tachycardia. At time of discharge, patient with HR in 90's and in sinus rhythm. . # Positive blood culture: Pt has positive cultures from [7-19] which showed coag neg staph. Blood cultures have subsequently been negative suggesting contaminated sample. Although patient remained on linezolid, this was chosen for treatment of urinary infection and not bacteremia. . # VRE Urine: In setting of hypotension and positive urinalysis, found to have Vancomycin Resistant Enterococcus in urine culture from [7-19]. Pt completed 7 day course of Linezolid and is asymptomatic at time of discharge. . # GOALS OF CARE: Family meetings held throughout critical illness, and again once clinically improved. Primary care physician and health care proxy present during discussion, where patient re-iterated desire to remain full code. Also willing to undergo tracheotomy if necessary, although unclear of his long term wishes. Defer ongoing discussion to his primary care team. . # Schizophrenia: Stable, continued olanzapine. . # FEN/Lytes: Regular diet, replete lytes prn . # Prophylaxis: Heparin SC 5000 tid . # Code status: FULL CODE confirmed . # Dispo: Pending above . Medications on Admission: - Albuterol inhaler 2 puffs [Hospital1 ] and q4h PRN - Advair 250/50 2 puffs [Hospital1 ] - Home O2 1-2 L NC - Zyprexa 7.5mg daily - Spiriva 18 mcg daily - Tylenol PRN - Aspirin 81 mg daily - Docusate 100mg daily - Multivitain - Nicotine patch Discharge Medications: 1. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: Two (2) Tablet PO twice a day for 6 weeks. Disp:168 Tablet(s) Refills:0 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) for 7 days. Disp:qs qs Refills:0 6. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 1.5 Tablet, Rapid Dissolves PO DAILY (Daily). 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:2 8. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 9. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) inh Inhalation once a day. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [2-7] puff Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 12. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) patch Transdermal once a day. Discharge Disposition: Home With Service Facility: [Hospital ] Health Systems Discharge Diagnosis: Primary diagnoses: 1. COPD exacerbation 2. Community acquired pneumonia - stenotrophomonas 3. Respiratory failure 4. Bacteremia - gram positive cocci 5. Urinary tract infection - vancomycin resistant enterococcus 6. Pulmonary hyptertension . Secondary diagnoses 6. Schizophrenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 79627], You were admitted to the hospital for cough, trouble breathing and low oxygen levels due to a flare of your COPD and pneumonia. You were intubated twice for respiratory failure and given antibiotics, steroids and nebulizers. We have started you on two courses of antibiotics to treat bacteria we found in your lungs, urine and blood. Additionally, due to the injury to your lungs you will need to go to pulmonary rehab to improve your breathing. We are also very pleased to hear that you have cut back on your smoking and are confident that with the use of a nicotine patch you will be able to quit completely. Quitting smoking is one of the best measures you can take to prevent further decline in your lung function. . We have made the following changes to your medication list: 1. Please START Bactrim 2 tabs twice per day until [9-10]. 2. Please START Prednisone 40mg, Dr [First Name (STitle) 1022] will adjust the dose in the future. . 3. Please START nicotine patch Followup Instructions: Please be aware of your following appointments at [Hospital1 18]: . Department: [Hospital3 249] When: THURSDAY [2161-8-6] at 12:20 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2477], M.D. [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Provider: [Known firstname ] [Last Name (NamePattern1) 722], DPM Phone:[Telephone/Fax (1) 543] Date/Time: [2161-10-6] 1:15 . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2477], M.D. Phone:[Telephone/Fax (1) 250] Date/Time: [2161-10-7] 1:00 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2477] MD, [MD Number(3) 2478] ICD9 Codes: 2762, 4168, 3051, 5849, 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8439 }	Medical Text: Admission Date: [2162-1-28] Discharge Date: [2162-2-2] Date of Birth: [2095-12-3] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 398] Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a poor historian and thus most of the history is obtained from past records obtained from [Hospital3 2783].The patient is a 66 y.o female with a recent diagnosis of alcoholic hepatitis who presented to [Hospital3 2783] with diarrhea x 1 week. She describes the stool as black without blood. Not filling the toilet bowl, bits and piecses of black stool. No sick contacts. Eats out often but does not recall any strange foods. No recent foreign travel. Went to [Country 4754] in [Month (only) 216] and [State 15946]. She was recently hospitalized from 02/22-02-24-07 in [Month (only) 956] when she was presented with n/v/d and painless jaudince x 10 days. At this time her plt count was 252 K, cr = 0.6 and Na = 131. Her tbili = 33.6- diurect . She underwent a RUQ US which demonstrates sludge. GB wall mildly thickened measuring 4 mm and a small amt of perhicholecystic fluid. The hepatic echotexture was non-specifically coarse. She had a HIDA scan which demonsrated no excretion of radiotracer into the biliary system which was non-specific and might be secondary to biliary obstruction or intrahepatic cholestatis. MRCP performed which demonstrated a normal extrahepatic bile dut measuring 4 mm. No intrahepatic bile duct dilatation appreciated. No stones. Small am ascites. No pnacreatic mass lesions. demonstrated which was negative for a mass at the head of the pancreas. Multiple tests including CMV PR, hep [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Ag, Hep B surface AB, hep B IgM core ab, EBV IgM Ab, EBV nuclear Ag, EBV early Ag, endomysial ab, [Doctor First Name ] (<7.15 IU/mL), AMA, smooth musc ab, gliadin Ig A and IgGab, transglut IgA, Reticulin IgA Ab, translugt IgA. Reticulin IgA Ab, and hep C RNA by PCR were megative. Iron studies were significant for an elevated transferrin saturation of 78% and ferritin of 1128. At this time she had only been abstinent from alcohol for 2 weeks and thus was not considered to be a condidate for transplant. she did not have a biopsy or testing for hemochromatosis given her acute illness. There was she treated with pentoxyfilline and reported and derease in her nausea and vomiting but her diarrhea remained the same. She returned to [Hospital3 2783] today because her diarrhea persited. She does not report in any previous history of liver disease. On presentation to the ED she was afebrile per report, BP = 111/52, P = 100, RR = 20m O2 sat = 96% on RA. <I> ROS Reports small amts blood tinged mucous from R nostril x 2 weeks. She reports shortness of breath when walking up the stairs. No orthopnea. No PND. No increase in abdominal distension. On review of systems, the pt. denied recent fever or chills. No night sweats or recent weight loss or gain. Denied headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting. No dysuria. Denied arthralgias or myalgias. Decreased appetite and she has decreased her fluid intake since it promotes diarrhea. Past Medical History: Alcholic hepatitis Unliateral Herpes on L side of face s/p antibiotics x 10 days. ?? [9-4] but d/c summary documents R facial cellulitis and impetigo. Macrocytic Anemia UTI Social History: Drinks 3 large glasses per day to help sleep x 20 years. Per husband she drinks 1.75 K if gin qod and has drunk for 25 years. Her last drink was two weeks ago. Worked until last [Month (only) 116] when she fell and broke her wrist. She was an accountant. Now works part time. Married with six children. No ciggarette. No illicits. All of her children are in good health. Family History: Mother died of blood clot. Father smoked and drank and died of lung disease. No family h/o liver disease. Daughter with thyroid disease. Physical Exam: VS T = 97.5, BP = 119/64 P = 58-78 RR = 22-23 O2Sat = 96T on RA GENERAL: Deeply jaundice, no obvious tremor. HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, 2/6 SEM @ LUSB w/o radiation to the carotids. Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. + shifting dullness, Liver at costal edge. ?splenomegaly Extremities: Trace edema, bilaterally, 2+ radial, DP and PT pulses b/l. Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. Skin: no rashes or lesions noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history Pertinent Results: <BR> Labs below. <BR> [Age over 90 ]\|96\|47 /134 3.7\|15\|6.3\ . AST = 105 ALP = 179 ALT = 27 Tbili = 37.6 D bili = 25.8, TP = 6.7, Albmin = 1.8, Amylase = 23 . WBC = 20.7 - 92N, 4M, 2B, HCT = 36 PLT = 79 MCV = 103 . Urine sodium = 28, U creat = 221.6 glucose = 134, BUN = 47, Cr = 6.3, Na = 124, K = 3.7, Cl = 96, CO2 = 15 Brief Hospital Course: Hospital Course: 66 y.o. F with recent diagnosis of alcoholic hepatitis who presented with decompensated alcoholic cirrhosis and ARF. . # Decompensated cirrhosis- On admission the patient was assessed as having Child [Doctor Last Name 14477] class B cirrhosis with [Last Name (un) 71746] discriminant function defined by the patient's prothrombin time minus the control prothrombin time multiplied by 4.6, being equal to 54. As this was higher than 32, it was felt the patient would benefit from pentoxyfilline. Her MELD score was 43 but she is not a transplant candidate since she was drinking recently. Her cirrhosis was most considered most likely secondary to alcohol but she was also found to have an elevated iron saturation and ferritin at [Hospital ] hospital. The liver service followed the patient while she was in-house. A diagnostic paracentesis showed no evidence of SBP. Ultrasound with dopplers showed patent hepatic and portal veins. Pentoxyfilline was started, as above, but was discontinued secondary to thrombocytopenia. She developed signs of worsening encephalopathy. A family meeting held with husband and several children of the patient on [2162-1-30]. Given her poor prognosis and lack of treatment options for her end-stage liver disease, the family decided to make patient DNR/DNI. They subsequently decided she would not want to be committed to CVVH. Ultimately, on further discussion with the family, the patient was made comfort measures only on [2162-2-1]. The patient died on [2162-2-2] at 4:20 pm. The intensivist attending, Dr. [Last Name (STitle) ], and her PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ], were notified. The patient's family was at the bedside. The chaplain service and on call Catholic priest were [Name (NI) 653] at their request. * # Renal Failure: Her presentation in the setting of decompensated cirrhosis was concerning for HRS. She also became oliguric. Her urine electrolytes suggested HRS was not the only etiology, and it was felt that ATN was contributing. Nephrology consulted and placed a right femoral HD catheter in anticipation of starting dialysis. Due to low blood pressures, the patient was felt unlikely to tolerate HD. Plans were therefore made for CVVH. But after a family meeting, as above, the family decided not to proceed with CVVH given limited prospect for renal recovery. . # Thrombocytopenia: This was a new finding in the 2 weeks prior to admission. Possible etiologies included ITP, medications, or worsening liver disease. She had no signs of bleeding. Pentoxfylline held. . # Alcohol abuse: Her EtOH level was negative on admission and she reported her last drink was 2 weeks ago. She was maintained on a CIWA scale with prn lorazepam for prophylaxis against withdrawal. . # Prophylaxis: Until she was made CMO, the patient was maintained on a PPI, and sc heparin. Medications on Admission: Discharge meds on [2162-1-23]: Pentoxyfilline 200 mg tid Folic acid 1 mg po qd Thiamine 100 mg po qd Vitamin C Discharge Medications: The patient expired in the hospital. Discharge Disposition: Expired Discharge Diagnosis: The patient expired in the hospital. Discharge Condition: The patient expired in the hospital. Discharge Instructions: The patient expired in the hospital. Followup Instructions: The patient expired in the hospital. ICD9 Codes: 5849, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8440 }	Medical Text: Admission Date: [2150-4-26] Discharge Date: [2150-5-1] Date of Birth: [2088-1-14] Sex: M Service: MEDICINE Allergies: Carbamazepine Derivatives Attending:[First Name3 (LF) 613] Chief Complaint: hyperglycemia Major Surgical or Invasive Procedure: Foley insertion [2150-4-26] Foley removal [2150-4-29] Foley re-insertion [2150-4-30] History of Present Illness: Mr. [Known lastname 1007] is a 62yo M with history of lung cancer s/p resection, DM and CAD who presents after not taking his medications for the past 3 weeks and being found at home incontinent of urine. He was brought in by EMS (and police escort he says) after his roommate called after finding him incontinent. . In the ED, initial vs were: T 98.6 P 50 BP 114/98 R 20 O2 sat 100% RA. He was found to have hyperglycemia, hyperkalemia without peaked T waves and in acute renal failure with creatinine of 8.8 from 1.6 in [10-26]. His urinalysis was significant for glucosuria without ketones. He had an anion gap of 24 and was started on an insulin drip at 10cc/hr. A foley was placed and 2.5L of urine returned. Patient was given 2 liters of IVF and admitted to the ICU for further management. Vitals on transfer were 93, 141/86, 22, 100% RA. . In the ICU, he reports three-four weeks of not taking his medications as it was too confusing. His roommate typically cooks for him but has been on an alchol binge recently, and he reports decreased PO intake for the past couple weeks. On admission to the ICU, he complained of some diffuse abdominal cramping but was otherwise asymptomatic. He endorsed some increased urinary frequency from diuretics in the past but none recently. Patient has been wearing diapers for the past two months as he has been intermittently incontinent. He has not noted any hematuria. In the ICU he was monitored and his Cr improved, his anion gap closed, his hyperglycemia improved and he was taken off his insulin drip, and his toe film returned not osteolyelitis. Therefore, he was sent to the floor. . Upon transfer to the floor, he was somewhat confused and continually asked where he was. He denied any pain anywhere and was eager to "just understand all of this." . . Review of systems: (+) Per HPI, bilateral hand and foot numbness x 10 years, intermittent fevers and chills for unknown period of time (-) Denies night sweats, recent weight loss or gain. Denies headache, congestion, cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Past Medical History: 1. HTN 2. CAD 3. DM 4. Hyperlipidemia 5. Strokes 6. Panic/anxiety disorder Social History: The patient started smoking cigarettes at age 16 and smoked up to 2-4 packs per day. He quit smoking at age 58. The patient is currently retired. He denies alcohol intake. He worked previously in labor and is a retired janitor. He lives with a roommate who typically helps cook meals for him. He does allude to that roomate being his "incarcerator" and when asked what that meant he said "well she made me come here", but when asked specifically if she abused him, he replied "people just don't understand" Family History: NC Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 95.6 BP: 131/71 P: 94 R: 18 O2: 98% RA General: Alert, oriented to person and year, not date or month, no acute distress HEENT: Sclera anicteric, MM dry, EOMI, oropharynx clear Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, initial wheezing which cleared with cough, No rales or 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, no CVA tenderness Ext: Left large toe with erythema surrounding nail and severe onycholysis, warm, well perfused, 2+ DP pulses, no clubbing, cyanosis or edema, strength 5/5 in all extremities DISCHARGE PHYSICAL EXAM: Tc+Tm 98.3, BP 116/63 (116-131/63-89), 53 (53-89), 18 (18-22), 98%RA (98-100%RA) FS: 284, 338, 376, 324 GENERAL - elderly-appearing man in NAD, comfortable, sleeping HEENT - EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no JVD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/ND, NT, no masses or HSM, EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs),dressing on L big toe. NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [5-21] throughout, sensation grossly intact throughout Pertinent Results: ADMISSION LABS: [2150-4-26] 05:55PM SED RATE-95* [2150-4-26] 05:55PM PT-12.4 PTT-21.9* INR(PT)-1.0 [2150-4-26] 05:55PM PLT COUNT-203 [2150-4-26] 05:55PM WBC-10.9 RBC-5.16 HGB-15.0 HCT-43.9 MCV-85 MCH-29.0 MCHC-34.1 RDW-13.0 [2150-4-26] 11:08PM GLUCOSE-424* UREA N-128* CREAT-7.6# SODIUM-139 POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-22 ANION GAP-22 [2150-4-26] 11:15PM URINE HOURS-RANDOM CREAT-35 SODIUM-18 POTASSIUM-29 CHLORIDE-17 [2150-4-26] 08:43PM GLUCOSE-445* LACTATE-1.2 NA+-132* K+-5.3 CL--88* TCO2-20* DISCHARGE LABS: [2150-5-1] 05:35AM BLOOD WBC-6.4 RBC-3.87* Hgb-11.4* Hct-33.0* MCV-85 MCH-29.3 MCHC-34.4 RDW-13.0 Plt Ct-172 [2150-5-1] 05:35AM BLOOD Glucose-194* UreaN-35* Creat-2.6* Na-145 K-3.9 Cl-113* HCO3-24 AnGap-12 [2150-5-1] 05:35AM BLOOD Calcium-7.4* Phos-3.3 Mg-1.8 IMAGING: CXR [2150-4-26]: IMPRESSION: Bilateral low lung volumes with crowding of bronchovascular markings. No definite sign of pneumonia. RENAL U/S [2150-4-27]: FINDINGS: The right kidney measures 12.8 cm. The left kidney measures 12.8cm. No stones or masses are identified in either kidney. There is mild pelvocaliectasis, most marked in the lower poles, bilaterally, without evidence of frank hydronephrosis. The urinary bladder is contracted. IMPRESSION: Mild bilateral pelvocaliectasis, without evidence of frank hydronephrosis. No renal stones or masses identified. L FOOT XRAY [2150-4-27]:FINDINGS: Three views show no definite destructive change or gas within softtissues. Calcification in soft tissues is consistent with diabetes. CT CHEST [2150-4-30]: IMPRESSION: No evidence of new or recurrent intrathoracic malignancy following right upper lobectomy. Atherosclerotic coronary calcifications. HEAD CT: 4/15/11:1. No acute intracranial abnormality. 2. Slightly enlarged ventricles for the patient's age and relative to the sulci. No evidence of transependymal CSF flow. 3. Chronic small vessel ischemic change and old lacunes as previously Brief Hospital Course: Mr. [Known lastname 1007] is a 62yo M with history of lung cancer s/p resection, type 2 DM and CAD who presents with medication noncompliance and was found to be in acute renal failure with hyperglycemia consistent with HONK . # Acute renal failure: His creatinine on admission was elevated to 8.8 from recent value of 1.6 in [10-26]. His large amount of urine return after Foley placement in the ER is suggestive of possible post-obstructive etiology with possible overflow incontinence at home. This may be related to underlying BPH. Pre-renal cause is also likely given he appears dry on exam and patient's renal ultrasound did not show hydronephrosis. In addition, his Cr improved dramatically with fluids. Therefore this was likely pre-renal ARF with a component of BPH. We gave the patient IVF and tamsulosin with good effect. However on [4-30] patient became obstructed again and Cr bumped to 3.0, which improved to 2.6 with foley placement. Foley drained almost 2L of fluid when it was placed. Patient may therefore need a chronic indwelling foley catheter, and has a urology f/u appt to be evaluated for this. On dispo, patient taking in 2L per day of PO fluids, and therefore did not need further IVF to help with pre-renal component of ARF. # Hyperglycemia: He is a known diabetic and had not taken his medications for the past 3 weeks PTA which likely lead to his significant hyperglycemia. His elevated glucose in the setting of elevated anion gap was concerning for DKA but his lack of urinary ketones suggested this was more likely HONK. He was started on an insulin drip in the ER and transitioned to insulin sc [4-27]. Aggressive IVF repletion with NS/D5/0.45NS with K per protocol. His HgBA1C returned at 16.8. He will need insulin teaching at rehab as he is clearly not controlled on oral medications. We sent him to rehab on an insulin sliding scale and glargine at 16units QHS. This regimen was keeping his sugars in the high 200's and will likely need to be further titrated at rehab. We were hesitant as pt's renal failure was likely causing slower absorption of the glargine and we were concerned about the possibility of hypoglycemia. . # Toe wound: Concerning for underlying osteomyelitis in diabetic patient with peripheral neuropathy and poor hygiene and given elevated CRP and ESR was treated initially with unasyn and vancomycin for cellulitis. No evidence of osteo on xray. Vancomycin was stopped [4-27], and unasyn [4-28], after podiatry saw the patient and determined the wound was from trauma. We soaked the patient's foot in Domeboro soaks QD per podiatry recs. He has an outpatient podiatry appt for follow-up. # Altered mental status: His roomate and friend came to visit on [4-28] and felt he was more disoriented than at baseline. Apparently pt always has word finding difficulties (per them s/p "a few strokes"), but is usually AAOx3. Patient's MS improved with his renal failure and hyperglycemia until he was AAOx3 at dispo. Psychiatry saw the pt and felt that he did not show s/sx of a mental illness, but that his "oddness" was likely early dementia. We did a head CT to r/o NPH, which did show slightly englarge ventricles for pt's age, but no transepndymal CSF flow, and ventricle size essentially unchanged from CT head in [2148] but AMS and urinary incontinence were new sx. We did not believe that this therefore correlated with NPH, but were unable to rule it out completely. Therefore, pt will need outpatient neuro f/u as well as likely neuropsych testing and possible outpatient LP if neurology feels that this could be NPH. He will see neurology this month for further workup. In addition, we also ordered tests for reversible causes of dementia including vitamin B12, folate, TSH and RPR. We will follow these up and transmit this information to [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] if any of them are positive. . # CAD: He has a history of CAD reportedly s/p MI. He was restarted on home medications after contacting his pharmacy. PENDING RESULTS: BCX [2150-4-26]: Pending BCX [2150-4-27]: Pending RPR [2150-5-1]: Pending Vitamin B12 [2150-5-1]: Pending Folate [2150-5-1]: Pending TSH [2150-5-1]: Pending TRANSITIONAL CARE ISSUES: Patient will need his insulin dose adjusted at rehab and will need diabetes teaching and insulin teaching when discharged home. PATIENT EXPECTED TO BE AT REHAB LESS THAN 30 DAYS. Medications on Admission: Lipitor 40mg daily Plavix 75mg daily Lorazepam 0.5mg qHS PRN Diazepam 5mg TID Prilosec 20mg daily Imdur 30mg daily SL Nitro PRN Metformin 1g [Hospital1 ] Toprol XL 25mg daily Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 3. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold for loose stools. 5. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 6. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 10. aluminum-calcium Packet Sig: One (1) Packet Topical QDaily as needed for fungal infection on toe: Do a soak of L big toe once a day. 11. Zyprexa 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime: Hold for sedation. 12. insulin glargine 100 unit/mL Solution Sig: Sixteen (16) units Subcutaneous QHS. 13. insulin lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous QAHS. Discharge Disposition: Extended Care Facility: Rosscommon Discharge Diagnosis: Primary: Acute renal failure, BPH with obstruction, Hyperglycemia Secondary: Type II Diabetes Mellitus Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr [Known lastname 1007], You were seen in the hospital for acute renal failure and hyperglycemia. You were treated with a Foley catheter and intravenous fluids for your renal failure and with insulin for your hyperglycemia. While you were here, we did a test that checks your longterm blood glucose levels called a hemoglobin A1C, and this was elevated to 16.8, indicating your average blood sugars are in the 400s. This means that you will need insulin when you go home. You should be taught how to use this as at rehab. In addition, you may need to have a chronic foley catheter placed in the future. We made the following changes to your medications: 1) We STARTED you on a MULTIVITAMIN once a day by mouth. 2) We STARTED you on SENNA twice a day as needed for constipation. 3) We STARTED you on TYLENOL 325mg every 6 hours as needed for pain. 4) We STARTED you on DOCUSATE 100mg twice a day. 5) We STARTED you on TAMSULOSIN 0.4mg once a day. 6) We STARTED you on DOMEBORO soaks once a day to your L big toe. 7) We STARTED you on ZYPREXA 2.5mg at bedtime. 8) We STOPPED your DIAZEPAM. If you start to feel withdrawal symptoms please inform your doctor at your rehab facility. 9) We STOPPED your LORAZEPAM. 10) We STOPPED your GLIPIZIDE. 11) We STOPPED your METFORMIN. Please continue to take your other medications as prescribed. DO NOT DRIVE AGAIN UNTIL YOU HAVE COMPLETED A FORMAL DRIVING EVALUATION. Driving with your current medical illnesses could put your life and others lives at risk. If you experience any of the below listed Danger Signs, please call your doctor or go to the nearest Emergency Room. It was a pleasure taking care of you on this hospital admission. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [2150-5-7] at 11:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3000], MD [0-0-] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: Podiatry Location: [Location (un) 830] [Location (un) 86], [Numeric Identifier 718] Phone: [Telephone/Fax (1) 543] We are working on a follow up appointment with Podiatry within 1-2 weeks. You will be called at home with the appointment. If you have not heard from the office within 2 days or have any questions, please call the number above. Department: NEUROLOGY When: TUESDAY [2150-5-12] at 2:30 PM With: [First Name11 (Name Pattern1) 4092] [Last Name (NamePattern1) 4093], MD [Telephone/Fax (1) 2574] Building: Ks [Hospital Ward Name 860] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 1951] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Please contact your Primary Care Physician for [Name Initial (PRE) ] referral for this visit Department: SURGICAL SPECIALTIES When: WEDNESDAY [2150-5-13] at 8:00 AM With: UROLOGY UNIT [Telephone/Fax (1) 164] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Please contact your Primary Care Physician for [Name Initial (PRE) ] referral for this visit. They can fax it to [Telephone/Fax (1) 68166], attention [Doctor First Name ] PLEASE NOTE: On [2150-5-1] at 1:30pm Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] from [Hospital1 18] called pt's PCP referral [Name9 (PRE) 68167] service and requested a referral for the above neurology and urology appts. Please ensure that these referrals have been completed prior to sending pt to these appts. The PCP [Name9 (PRE) 68167] service stated that it takes 5 days for the referrals to go through. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] ICD9 Codes: 5849, 2762, 2930, 3572, 412, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8441 }	Medical Text: Admission Date: [2168-6-20] Discharge Date: [2168-6-29] Date of Birth: [2117-6-19] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Erythromycin Base Attending:[First Name3 (LF) 1491] Chief Complaint: transferred from OSH for evaluation of upper GI bleeding and possible esophageal rupture Major Surgical or Invasive Procedure: esophagogastroduodenoscopy; endotracheal intubation History of Present Illness: 51yoW with history of EtOH cirrhosis, transferred from [Hospital 1562] Hospital with UGIB and concern for esophageal perforation. Patient initially presented to OSH [2168-6-18] with hematemesis, Hct 23, pltl 26, and SBP 70. There she was intubated for airway protection and rescucitated with blood products (1unit cryoprecipitate, 4units FFP, 3units pltl, vitamin K, and 8units PRBC). A right IJ and right femoral cordis were placed. EGD showed [Doctor First Name ]-[Doctor Last Name ] tear and the endoscopist was concerned for possible esophageal perforation. She was treated with iv Protonix, octreotide gtt, intubated and placed on Levophed, and then transferred to [Hospital1 18] Thoracic Surgery service for management of esophageal perforation. At [Hospital1 18] patient underwent chest CT with contrast per NGT which showed no esophageal perforation, but did show small bilateral pulmonary effusions. Lab studies concerning for elevated transaminases (ALT 104, AST 259), Tbili 5.9, creatinine 1.4, WBC 12 12.7, and INR 1.5. She was continued on the octreotide gtt, placed on vancomycin and Zosyn. She is being transferred now to the MICU service for further management. On transfer T 98.9 HR 63 BP 112/62 RR 16 100% on AC 450 x 16 PEEP 10.0 FiO2 40% with last ABG 7.42/32/114. . She was admitted to the MICU once esophageal perforation was ruled out and treated with proton pump inhibitors and, once she could be weaned from the ventilator, transfered to the hepatorenal service until her alcoholic hepatitis stabilized. Past Medical History: Alcoholic cirrhosis c/b portal HTN, varices, and thrombocytopenia EtOH abuse with h/o DTs h/o cervical cancer h/o uterine cancer s/p TAH/BSO Ulcerative colitis Social History: married with 2 children h/o EtOH abuse - about 1/2pint vodka/day no tob use, no illicits works as CNA Family History: noncontributory Physical Exam: PE: T 97.3 HR 65 BP 115/73 RR 20 Sat 96% on ra GEN: NAD, comfortable HEENT: slight icterus, NG tube in place, clamped; OP clear NECK: no JVD, no bruits, no LAD CV: RRR, nml s1s2, no mrg RESP: diffuse rhonchi and expiratory wheezes ABD: +BS, distended, NT, no fluid wave, no organomegaly felt EXT: 2+ pitting edema bilaterally, 2+ PT pulses NEURO: A&Ox3 Foley and rectal tube in place when transferred from MICU, subsequently removed Pertinent Results: [2168-6-21] 02:32AM BLOOD WBC-9.5 RBC-3.41* Hgb-10.3* Hct-29.0* MCV-85 MCH-30.3 MCHC-35.7* RDW-17.6* Plt Ct-35* [2168-6-20] 04:00PM BLOOD PT-16.7* PTT-28.9 INR(PT)-1.5* [2168-6-20] 04:00PM BLOOD Glucose-113* UreaN-27* Creat-1.4* Na-145 K-4.2 Cl-114* HCO3-21* AnGap-14 [2168-6-20] 04:00PM BLOOD ALT-104* AST-259* AlkPhos-131* Amylase-45 TotBili-5.9* DirBili-4.2* IndBili-1.7 [2168-6-20] 04:00PM BLOOD Albumin-3.3* Calcium-8.2* Phos-2.3* Mg-2.0 [2168-6-20] 04:42PM BLOOD Type-ART pO2-40* pCO2-48* pH-7.29* calTCO2-24 Base XS--3 -ASSIST/CON Intubat-INTUBATED [2168-6-20] 04:42PM BLOOD Lactate-1.9 [2168-6-20] 07:16PM BLOOD Glucose-138* K-3.7 [2168-6-28] 06:00AM BLOOD WBC-10.1 RBC-3.62* Hgb-10.8* Hct-32.6* MCV-90 MCH-29.9 MCHC-33.3 RDW-20.9* Plt Ct-101* [2168-6-22] 03:25AM BLOOD Type-ART pO2-85 pCO2-37 pH-7.38 calTCO2-23 Base XS--2 [2168-6-28] 06:00AM BLOOD Plt Ct-101* [2168-6-28] 06:00AM BLOOD PT-21.3* PTT-33.1 INR(PT)-2.1* [2168-6-28] 06:00AM BLOOD Glucose-105 UreaN-27* Creat-1.2* Na-139 K-4.1 Cl-107 HCO3-21* AnGap-15 [2168-6-28] 06:00AM BLOOD ALT-26 AST-53* AlkPhos-131* TotBili-5.7* [2168-6-28] 06:00AM BLOOD Albumin-2.7* Calcium-7.6* Phos-2.0* Mg-1.2* Radiology studies: [6-25] RUQ U/s:There is mild gallbladder wall thickening; however, this could be related to the patient's cirrhosis and ascites. The gallbladder is not distended, and there is no evidence of stone. The liver is small and coarsened in echotexture consistent with cirrhosis. No definite focal lesions are identified. No biliary ductal dilatation is identified. There is a large amount of ascites. IMPRESSION: 1. Cirrhotic liver with associated large amount of ascites. 2. No biliary ductal dilatation identified. . [6-24] LENI: IMPRESSION: No evidence of right lower extremity DVT. .. [6-24] CXR: AP chest compared to [6-20]-27: NG tube passes into the stomach and out of view. Right PIC catheter ends in the lower third of the SVC. Mild enlargement of the cardiac silhouette is stable. Small bilateral pleural effusions have decreased since [6-23], obscuring the lower lungs, and probable mild-to-moderate bibasilar atelectasis. Upper lungs clear. No pneumothorax. .. CT Chest: no esophageal perforation; bilateral small effusions, cirrhotic liver Brief Hospital Course: 51yoW with h/o EtOH cirrhosis c/b varices and prior UGIB, admitted with UGIB, alcoholic hepatitis, RLL pneumonia originally to thoracic surgery service, then MICU on [6-20] now transferred to the floor on [6-26] evening. . # UGIB: Etiology of bleed felt likely [Doctor First Name 329]-[Doctor Last Name ] tear although pt has h/o varices as well. Patient has no evidence of variceal bleed or ulcer on EGD at OSH. There was a question of esophageal tear at OSH but this was not seen on CT here. Pt. came from OSH on octreotide which was stopped after no further bleeding for 48 hours. Pt is continued on PPI IV bid given h/o bleeding. Hematocrit stable and there has been no further evidence of bleeding. EGD was repeated at [Hospital1 18] to evaluate varices before discharge and revealed 4 cords of grade II varices without stigmata of bleeding as well as esophagitis and evidence of [Initials (NamePattern4) ] [Last Name (NamePattern4) ]-[Doctor Last Name ] tear. She will need to continue taking protonix 40mg [Hospital1 ] as well as nadolol, currently at 20mg daily but recommend to increase to 40mg daily if BP will tolerate, and will be seen in one week for EGD with possible banding of varices once the [Doctor First Name ]-[Doctor Last Name ] tear has had some time to heal. . # Resp: Patient was intubated for airway protection at OSH. Chest CT showed RLL consolidation with air bronchograms and small bilateral pleural effusions, concerning for PNA vs aspiration PNA. Patient was started on vanco/levo/flagyl for likely asp PNA and concern for MRSA on [6-20]. Patient was weaned off vent and extubated without complications on [6-21]. She was weaned slowly off face tent and currently o2 sats in the high 90's on RA. Sputum cx from [6-21] neg. for organisms, however with likely asp event, we treated empirically with 7-day course of antibiotics. Speech and swallow eval [6-27] found no aspiration risks after mental status improved. . She does have some component of COPD/asthma, which was maintained on her home albuterol inhaler prn. . # Hepatitis: transaminitis with AST>ALT consistent with alcoholic hepatitis. LFTs trended down over course of MICU stay and now resolving. Patient counselled that alcohol abuse was the direct cause of this illness and hospitalization and that continued alcohol use will lead to worsening of the disease. She verbalized understanding, but per social work investigation, she has participated in multiple alcohol abuse programs near her home without successful cessation of alcohol use. # Cirrhosis: patient with elevated bilirubin and INR c/w liver failure. Once patient was extubated and NGT placed, lactulose and rifaximin was started with good improvement in her encephalopathy. Nadolol and diuretics added during micu stay. Nadolol to prevent variceal bleeding. lasix 40mg daily and spirinolactone 50mg [Hospital1 ]; recommend to increase the lasix as needed to control LE edema. Dx tap on [6-26] did not show SBP. Continue rifaximin/lactulose to decrease symptoms of hepatic encephalopathy. Her prognosis is poor given her bilirubinemia, coagulopathy, and refusal to stop further alcohol intake. On the day of discharge, a therapeutic pericentesis was performed for tense ascites and three liters of straw colored fluid drained from the peritoneum without complication; given her slight leukocytosis, a 10 day course of levafloxacin 500mg daily (through [2168-7-9]) was begun empirically. . # Encephalopathy: in setting of sedatives for intubation, pneumonia and cirrhosis--now improved after transfer out of ICU, no longer sedated, and on regimen of rifaximin and lactulose. . # Anemia: as above, stable, likely baseline anemia secondary to liver dysfunction, alcohol. . # Coagulopathy: likely due to hepatic synthetic dysfunction. . # Thrombocytopenia: likely due to liver disease/alcohol abuse. Pt was transfused to keep plt >50,000 in setting of GI bleed. Pt received 3 units of platelets on admission and thrombocytopenia began to improve subsequently without further need for tranfusion. . # ARF: baseline creatinine unknown; may be ARF in setting of GI bleed and relative hypotension causing prerenal and/or intrarenal ATN. BUN/Cr remained stable and urine output adequate throughout stay. Will need judicious use of diuretics to reduce ascites and edema while balancing renal function. Cr stable at 1.2-1.4 at time of discharge. . # EtOH abuse: h/o withdrawals, DTs, patient was weaned off sedation post extubation and began to exhibit signs of withdrawal with HTN, tachycardia, tremors. Pt. was on ativan with CIWA scale to control withdrawl symptoms over the weekend. Patient stabilized and has not required ativan since [6-24] with no further signs of withdrawl. As MS improved patient became somewhat agitated and was given haldol prn with good effect. Pt seen by psych/addiction liaison and states that she will not drink after the events of this hospitalization, which she understands are due to alcohol use. However, as above, social worker has contact[Name (NI) ] several alcohol cessation programs patient has participated in in the past, and patient has relapsed or simply quit going and returned to drinking after each attempt at sobriety. Medications on Admission: Lasix prn Aldactone 24 flagyl levoquin vancomycin being dosed by level rifamixin lactulose nadolol 20 thiamine folate mvi Discharge Medications: 1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): for hepatic encephalopathy. 2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): to prevent variceal bleeding. 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): for swelling. 4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): titrate to [1-30] bowel movements per day. 5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4-6H (every 4 to 6 hours) as needed for wheezing. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): to prevent bleeding. 7. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): for swelling. 8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Discharge Disposition: Extended Care Facility: [Location (un) 69872] Healthcare Discharge Diagnosis: alcoholic hepatitis Discharge Condition: At the time of discharge, patient is tolerating po diet and meds, afebrile, breathing room air, and ambulatory with assistance. Discharge Instructions: Continue taking your medications as prescribed. . Abstain from alcohol. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 8507], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2168-7-7] 9:00 (Liver doctor) . Call your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 69873] [Name (STitle) 69874] ([Telephone/Fax (1) 69875]) for a follow-up appoinment approx 2 weeks after D/C from rehab. ICD9 Codes: 5070, 2875, 5849
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8442 }	Medical Text: Admission Date: [2152-9-13] Discharge Date: [2152-9-25] Date of Birth: [2083-9-6] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 15397] Chief Complaint: Left knee pain Major Surgical or Invasive Procedure: Revision of left knee replacement History of Present Illness: Mr. [Known lastname 60992] is a 69-year-old gentleman with a past medical history significant for OSA, HTN, sinus bradycardia, chronic renal failure, bipolar disorder, BPH who was admitted for a total left knee replacement, subsequently transferred to the MICU for fever and hypotension, now transferred to the general medicine floor upon resolution of his symptoms. Patient presented on [9-13] for left TKA, and did well post-op with mild hypotension on [9-13] to systolic 80s. However, he spiked a fever to 101.2 on [9-14] with no obvious source. He then triggered for delirium on [9-15] and labs were notable for worsening renal function, Cr 2.3 from 1.8, and WBC 13.2 from 9.7. Med consult was called for fever workup and management of delirium. Patient then spiked another fever to 102.3, and triggered again for hypotension with systolics in the 80s. A voiding trial was attempted on [9-15] but patient could not urinate so a foley was replaced. He was written for 1L bolus and started on Vanc/Cipro to cover for possible knee infection, given recent operation, though no signs of infection of the left knee. Prior to transfer to the MICU, his VS were 102.3 90/48, 74, 98% on 2LNC. On arrival to the MICU patient complained of pain in his right arm and wrist, which he attributed to overuse from writing multiple notes on Facebook. Patient was continued on vanc/cipro and given 2 more liters of IVF. His blood pressure stabilized and he was discharged back to the general medicine floor on [9-16]. Ortho will follow closely. On transfer from MICU, vitals were: 98, 102/60, 76, 16, 96% on RA. ROS: Patient complains of being asked too many questions. He reports pain in his right shoulder and wrist. Discomfort on his left thigh from traction device. No chest pain, shortness of breath, nausea, vomiting, diarrhea. Denies chills or feeling feverish. Has foley in place. Has not moved his bowel since surgery. Past Medical History: - bipolar d/o - sinus bradycardia - 1st degree AV block - HTN - OSA on CPAP - obesity - h/o urinary retension - CKD (Baseline Cr 1.8) - BPH Social History: Lives with wife (or ex-wife). Denies any alcohol use. Stopped smoking in [2133]. Family History: Father and mother died of CAD and DM. Two brothers with DM. Physical Exam: Admission exam: PHYSICAL EXAM [2152-9-16] VS: 98, 102/60, 76, 16, 96% on RA GENERAL: Elderly appearing gentleman, obese, no acute distress HEENT: Mucous membranes dry NECK: No cervical, submandibular, or supraclavicular LAD CARDIAC: RRR, no MRG ABDOMEN: +BS, obese, soft, non-tender, non-distended EXTREMITIES: Left knee dressing clean, dry, and intact, left leg in traction device, pneumoboots in place, right wrist in soft cast (not removed at this time) SKIN: Ruddy complexion, skin is moist NEURO: Alert and oriented, keeps complaining that people are asking him to name the days of the week and months backward, tangential, usually appropriate but very easily distracted, short attention span Discharge exam: VS: T 99.1 also Tm, BP 152/79, HR 76, R 20, SvO2 95% RA. GENERAL: Elderly appearing gentleman, obese, no acute distress HEENT: MMM NECK: No LAD CARDIAC: RR, nl rate, no MRG Pulm: CTAB, bibasilar crackles, no wheezes, comfortable breathing ABDOMEN: +BS, obese, soft, non-tender, non-distended EXTREMITIES: Left knee dressing clean, dry, and intact, stables in place, right wrist slightly swollen, mildly warm, able to move with limited range of motion secondary to pain, right knee with small effusion, no warmth, able to move freely, pneumoboots in place. NEURO: Alert and oriented, keeps complaining that people are asking him to name the days of the week and months backward, tangential, usually appropriate but very easily distracted, attention stable. Pertinent Results: Admission Labs: [2152-9-14] 07:20AM BLOOD WBC-9.7 RBC-3.83* Hgb-11.5* Hct-34.0* MCV-89 MCH-29.9 MCHC-33.7 RDW-13.4 Plt Ct-147* [2152-9-14] 07:20AM BLOOD Plt Ct-147* [2152-9-14] 07:20AM BLOOD Glucose-128* UreaN-28* Creat-1.8* Na-139 K-4.7 Cl-106 HCO3-27 AnGap-11 Imaging: CHEST (PORTABLE AP) Study Date of [2152-9-15]: IMPRESSION: New pleural effusions, left greater than right RIGHT WRIST FILM [2152-9-16]: RIGHT WRIST: Extensive degenerative changes are present within the right wrist. It is maximal at the radial-carpal junction. There is, however, no evidence of a fracture present. IMPRESSION: Degenerative changes within the carpal bones. CXR: FINDINGS: Single frontal image of the chest demonstrates new opacity at the left lateral lung base which could be consistent with fluid and/or atelectasis. It is difficult to assess this opacity fully given the patient's extremely rotated position. Lungs are otherwise clear. There is no pneumothorax. Cardiomediastinal silhouette is unchanged from prior imaging. IMPRESSION: New left lateral lung base opacity consistent with pleural effusion and/or atelectasis. [2152-9-24] 07:50AM BLOOD WBC-20.0* RBC-3.32* Hgb-9.9* Hct-30.6* MCV-92 MCH-29.7 MCHC-32.2 RDW-13.6 Plt Ct-449* [2152-9-23] 07:30AM BLOOD Neuts-84* Bands-3 Lymphs-5* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-1* [2152-9-23] 07:30AM BLOOD Glucose-148* UreaN-42* Creat-1.6* Na-141 K-4.6 Cl-104 HCO3-30 AnGap-12 [2152-9-23] 07:30AM BLOOD Calcium-10.0 Phos-2.7 Mg-2.0 [2152-9-16] 05:49AM BLOOD Lactate-1.1 [2152-9-24] 07:55AM BLOOD Vanco-12.6 [2152-9-20] 06:05AM BLOOD ALT-39 AST-41* LD(LDH)-221 AlkPhos-101 TotBili-0.6 [2152-9-25] 05:45AM BLOOD WBC-16.6* RBC-3.17* Hgb-9.4* Hct-29.3* MCV-92 MCH-29.6 MCHC-32.1 RDW-13.7 Plt Ct-443* Brief Hospital Course: 69M with hist [Last Name (un) ] of OSA, HTN, sinus bradycardia, CKD (baseline cr 1.8), bipolar disorder, BPH with history of urinary retention who presents after revision of left knee replacement. The course was complicated by hypotension, fevers, urinary retention, gout and pneumonia. # Pneumonia: The patient had fevers to 102, a rising leukocytosis, productive cough and delirium. He had an CXR which showed an opacity in the left base. It was not clearly infectious in etiology, however, given the clinical symptoms we treated him for health care associated pneumonia with vancomycin and cefepime for a 7 day course to be completed on [2152-8-31]. The fevers resolved, his delirium improved as did his cough. The patient and his family refused any further studies such at CT of the chest. Given his clinical improvement we felt that he was safe to discharge with a course of antibiotics to be completed at rehab. After completion of his antibiotics, he should be monitored for temperature or othesigns of infection. # Acute gout: The patient had significant right wrist swelling and pain worse with active or passive movement. Given his fevers there was some concern for gout vs septic arthritis. He had a joint aspiration which was consistent with crystalopathy. Given his kidney function he was treated with a prednisone taper with significant improvement in his wrist pain and mobility. He has a total of 4 more days of prednisone (as outlined in medication list). # Left knee revision: Per report of our orthodist service went well. No evidence of infection of left knee. The joint is warm but the incision is clear/dry/intact. The recommendations of orthopedists are listed below: - Please keep your wounds clean. You may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out at first follow up appointment two weeks after your surgery. - Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). This is important given your chronic kidney disease. - ANTICOAGULATION: Please continue your lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). If you were taking aspirin prior to your surgery, it is OK to continue at your previous dose while taking this medication. [Male First Name (un) ] STOCKINGS x 6 WEEKS. - WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed AT FIRST POST OP APPOINTMENT in two (2) weeks. - VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks. - ACTIVITY: Weight bearing as tolerated on the operative extremity. Mobilize. ROM 0-60 x 1 week (until [2152-9-20]) then advance as tolerated. No strenuous exercise or heavy lifting until follow up appointment. # Hypotension: He was given IVF and broad spectrum antibiotics. An infectious work up was negative and he initially became afebrile. His blood pressure responded to IV fluids. The antibiotics were discontinued (later restarted for suspected pneumonia -- see above). Atenolol and losartan initially held. Restarted once blood pressure improved. # Hypertension: He did have some hypertension at the time of discharge. Blood pressures ranged from SBP 110s to 150s. He was discharged on losartan and atenolol. Hydrochlorothiazide was held. # Acute on chronic renal failure: Improved with IVF to his baseline chronic kidney disease (baseline around 1.8). He was resumed on his losartan. He was educated on avoiding NSAIDs (which he states that he understands but will refuse to comply with the recommendations as he has been "taking NSAIDs for 70 years and it hasn't hurt him yet" -- he acknowledges and can repeat our concerns but chooses to ignore the recommendations). # Delirium: He had acute change in mental status that was waxing and [Doctor Last Name 688] in nature. He was evaluated by psychiatry who agreed with the diagnosis of acute delirium. The likely etiology was medication effect, hypotension and hospital setting. With usual delirium precuations he returned to his baseline mental status. He did require some haldol for agitation while he was delirius. # Right knee pain: He states that a transporter dropped him. It is unclear as it is not documented and no nurses are aware of this happening. I cannot confirm or deny that he was dropped. His right knee improved at the time of discharge and he has his baseline range of motion. # BPH/URINARY RETENTION: On tamsulosin and finasteride. Failed voiding trial x2 and had a foley placed. He will follow up with Dr. [Last Name (STitle) 3748] for outpatient management of his acute on chronic urinary retention. # OSA: Continue BiPap at night. # Anemia: He had stable anemia. After starting prednisone, his differential was atypical. This should be checked after resolution of prednisone and infectious symptoms to make sure no more atypical cells are present in his blood. # Social issues: The patient was intermittently very upset with the care he received at the hospital. The son was definitely upset. After significant conversations with the patient and his family, the major complaints were: 1) he was held in the hospital against his wishes, 2) he was not medically cleared to go to rehab sooner, 3) we were not able to definitively say he had pneumonia (and refused to undergo CT chest which would have been helpful in the diagnosis), 4) he states we "drilled a hole into his hand" referring to the joint aspiration, he states this was against his wishes despite obtained consent, 5) he refuses to accept that he had fevers or an infection in the hospital (as does the son), 6) he states that we gave him gout, 7) his son was unhappy that he was cared for by a hospitalist, 8) the son accused the hospital of medicare fraud -- given that he didn't have fevers or infections or other issues other than his knee and gout, 9) the son states he will [Doctor Last Name ] the hospital and the physician for multiple reasons including the above and a reported incident with the transporter. After long discussions the patient seems agreeable with the explanations of the issues involved in his case and the care that he received. The wife, [Name (NI) ], is also agreeable and thankful. The son, [Name (NI) ], is very angry and seemed only to get more angry with discussion of any of the above issues. He states that he is in "the medical field" however, seemed to have a limited vocabulary or knowledge of the situation regarding his father. Attempting to explain the situation did not go well and ended in him stating "you better contact your lawyers". I offered the number for patient relations to the family (his son [Name (NI) ] refused - please see [Name (NI) ] note) and I contact[Name (NI) ] our risk management office. # COMMUNICATION: Patient, Wife [Name (NI) ] [Name (NI) 60992] [Telephone/Fax (1) 60993], Son [Name (NI) ] [Telephone/Fax (1) 60994] # CODE: Full Transitional issues: - rehab - ortho follow up - removal of staples, further assessment - urology follow up - consider voiding trial, blood in UA - remove PICC after antibiotics - monitor for signs of infection - PCP follow up regarding gout issues, also, would check CBC with differential to evaluate atypical cells resolve with treated infection and off prednisone Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Zolpidem Tartrate 10 mg PO HS:PRN insomnia 2. Atenolol 50 mg PO DAILY hold for SBP < 110, HR < 60 3. Baclofen 10 mg PO BID 4. Tamsulosin 0.8 mg PO DAILY hold for SBP < 110, HR < 60 5. Hydrochlorothiazide 25 mg PO DAILY hold for SBP < 110, HR < 60 6. Lorazepam 1 mg PO HS:PRN insomnia 7. Losartan Potassium 100 mg PO DAILY hold for SBP < 110, HR < 60 8. Mobic NF (meloxicam) 15 mg Oral daily 9. Multivitamins 1 TAB PO DAILY 10. Gabapentin 400 mg PO BID 11. vardenafil NF 20 mg Oral PRN 12. Finasteride 5 mg PO DAILY 13. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: Life Care Center at [Location (un) 2199] Discharge Diagnosis: failed left uni-compartmental knee replacement Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Followup Instructions: Provider: [First Name11 (Name Pattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3260], [MD Number(3) 3261]:[Telephone/Fax (1) 1228] Date/Time:[2152-9-29] 1:40 ICD9 Codes: 486, 2930, 5849, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8443 }	Medical Text: Admission Date: [2173-3-30] Discharge Date: [2173-3-31] Service: MEDICINE Allergies: Bactrim Attending:[Last Name (NamePattern4) 290] Chief Complaint: Found unresponsive, cardiac arrest (PEA) Major Surgical or Invasive Procedure: 1. Intubation [2173-3-30] 2. Mechanical ventilation 3. Central line 4. Femoral arterial line History of Present Illness: 88 year old woman with dementia (A&OX2), congestive heart failure (EF50%), coronary artery disease with stent to RCA and otherwise three-vessel disease, mild-moderate MR/AR, complete heart block s/p pacemaker, h/o UTI with MDR E. Coli, recent admission for NSTEMI (2/8-9/[2173]), who was in her usual state of health until found unresponsive this morning at her nursing home ([Hospital3 537]), at 7am. Per the patient's family, she had "not been feeling well" the day prior and had been complaining of left thigh pain. . When EMS arrived at the Nursing Home, patient had [Initials (NamePattern4) ] [Last Name (NamePattern4) 2611] Coma Score of 3. She was intubated. Patient reportedly had spontaneous movements and faint carotid pulse en route to the hospital. . Upon arrival to the ED, the patient became pulseless upon transfer from stretcher to bed. The initial rhythm was PEA. Chest compressions were started and 1 mg of epinephrine given. Patient had return of spontaneous circulation, although [Last Name (NamePattern4) ] pressures were systolic 50-60. RIJ central line was placed and levophed gtt started. Patient was bolused 1L normal saline. Patient's [Last Name (NamePattern4) ] pressure remained labile, from 50-60 to 140s intermittently over a course of 20 minutes before pulse was lost again, with the rhythm being PEA. Patient received an additional 1 mg of Epinephrine. Femoral arterial line was placed. Her pulse returned and her [Last Name (NamePattern4) ] pressures have been systolic 130s since. She was started on phenylephrine as well as the levophed gtt after the second PEA arrest. . Stat labs returned with Lactate 13.7 and Hct initially 18 (baseline from [3-24] was 30), troponin 0.54. Given the hematocrit, patient had FAST done at bedside which was negative, guaiac positive (brown stool), received 2 units of uncrossed pRBC. She received 2mg Versed for sedation but was not started on a drip. Also empirically given Vancomycin/Zosyn. . The patient was sent for CT head and torso. The CT torso showed a left sided retroperitoneal bleed in the setting of PTT of 150 (possibly secondary to heparin flushes for her PICC line). The patient received 50mg IV protamine to reverse the PTT prior to transfer to CCU. Also had received a total of 2.5L normal saline IV. Surgery evaluated patient briefly in the ED following RP bleed seen on CT and did not recommended operative therapy. Upon transfer, patient HR78, BP164/64, vent settings (Assist Control, FiO2100%, RR 28, TV 450) but satting 100%. . On review of systems, patient intubated/sedated and unable to provide history. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: Hypertension Hyperlipidemia CAD s/p NSTEMI in [3-23]-9/[2173], in [2169] with BMS, and another MI in [6-15] with stent to proximal RCA Complete heart block status post pacemaker in 03/[2166]. 3. OTHER PAST MEDICAL HISTORY: - Asthma - s/p thyroidectomy in [11/2163] - Osteopenia, osteoarthritis, and chronic pain - GERD - Chronic diaphoresis: TSH and PPD normal - Glaucoma - Shoulder bursitis - MDR E. coli UTI with bacteremia: sensitive only to Meropenem, Zosyn, Amikacin [2173-3-9] Social History: Retired, worked as a [Month/Day/Year ]. Currently living in senior living home. Has 3 children ([Last Name (LF) ], [First Name3 (LF) 402], and [Female First Name (un) 108632]) who live nearby and are very involved in her care. She also has a granddaughter, [Name (NI) ], who is also involved. -Tobacco history: Denies -ETOH: Denies -Illicit drugs: Denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Mother with MI at age 70. No other cardiac hx, DM, or cancer. Physical Exam: ADMISSION PHYSICAL EXAM: GENERAL: Intubated. Synchronous with vent. Responds to commands. HEENT: NCAT. Sclera anicteric. Left pupil round and reactive. Right pupils appears post-surgical. NECK: Right IJ in place. CARDIAC: RRR, normal S1, S2. No m/r/g. LUNGS: Ventillated breath sounds. Clear to auscultation anteriorly. ABDOMEN: Soft, mildly tender. No rebound or guarding. EXTREMITIES: 2+ bilateral pitting edema. NEURO: Oriented x 2. Responds to commands. Moves upper extremities but not lower extremities. Says she can sense light touch in lower extremities. Toes downgoing bilaterally. . DISCHARGE Physical: N/A Pertinent Results: Pertinent Laboratories Results [2173-3-31] 05:39PM [Month/Day/Year 3143] WBC-10.1 RBC-2.71# Hgb-8.5# Hct-24.4* MCV-90 MCH-31.2 MCHC-34.8 RDW-16.7* Plt Ct-72* [2173-3-30] 11:00AM [Month/Day/Year 3143] WBC-7.2 RBC-2.02* Hgb-5.7* Hct-18.9* MCV-94 MCH-28.4 MCHC-30.3* RDW-20.9* Plt Ct-173 [2173-3-31] 04:44PM [Month/Day/Year 3143] PT-15.2* PTT-48.1* INR(PT)-1.3* [2173-3-30] 11:00AM [Month/Day/Year 3143] PT-15.9* PTT-150* INR(PT)-1.4* [2173-3-31] 11:09AM [Month/Day/Year 3143] Fibrino-138* [2173-3-31] 03:01AM [Month/Day/Year 3143] Fibrino-149* [2173-3-30] 01:59PM [Month/Day/Year 3143] Fibrino-124* [2173-3-31] 04:44PM [Month/Day/Year 3143] Creat-1.3* Na-132* K-4.3 Cl-107 [2173-3-30] 11:00AM [Month/Day/Year 3143] Glucose-93 UreaN-21* Creat-1.1 Na-141 K-5.1 Cl-104 HCO3-8.0* AnGap-34* [2173-3-31] 04:44PM [Month/Day/Year 3143] CK(CPK)-951* [2173-3-31] 03:01AM [Month/Day/Year 3143] ALT-112* AST-458* LD(LDH)-910* CK(CPK)-727* AlkPhos-77 TotBili-1.2 [2173-3-30] 11:00AM [Month/Day/Year 3143] ALT-51* AST-154* CK(CPK)-336* AlkPhos-99 TotBili-0.3 [2173-3-31] 04:44PM [Month/Day/Year 3143] CK-MB-14* MB Indx-1.5 cTropnT-0.60* [2173-3-30] 01:59PM [Month/Day/Year 3143] CK-MB-7 cTropnT-0.49* [2173-3-31] 04:44PM [Month/Day/Year 3143] Calcium-7.2* Mg-2.2 [2173-3-30] 11:00AM [Month/Day/Year 3143] Albumin-1.4* Calcium-6.5* Phos-6.1* Mg-2.1 [2173-3-31] 05:22PM [Month/Day/Year 3143] Type-ART Temp-33.8 pO2-181* pCO2-29* pH-7.20* calTCO2-12* Base XS--15 [2173-3-31] 11:27AM [Month/Day/Year 3143] Type-ART Tidal V-350 PEEP-5 FiO2-50 pO2-84* pCO2-28* pH-7.33* calTCO2-15* Base XS--9 -ASSIST/CON Intubat-INTUBATED [2173-3-30] 03:22PM [Month/Day/Year 3143] Type-ART pO2-174* pCO2-27* pH-7.30* calTCO2-14* Base XS--11 Intubat-INTUBATED [2173-3-30] 01:57PM [Month/Day/Year 3143] Type-ART pO2-444* pCO2-22* pH-7.36 calTCO2-13* Base XS--10 [2173-3-31] 05:22PM [Month/Day/Year 3143] Lactate-7.6* [2173-3-31] 03:12AM [Month/Day/Year 3143] Lactate-3.7* [2173-3-30] 01:57PM [Month/Day/Year 3143] Glucose-181* Lactate-8.3* Na-133* K-3.9 Cl-109 [2173-3-30] 11:49AM [Month/Day/Year 3143] Lactate-13.7* [2173-3-30] 11:07AM [Month/Day/Year 3143] Glucose-89 Lactate-14.1* Na-136 K-4.8 Cl-111 [2173-3-31] 06:49AM [Month/Day/Year 3143] freeCa-1.14 [2173-3-30] 01:57PM [Month/Day/Year 3143] freeCa-0.93* . STUDIES: CXR [2173-3-30]: IMPRESSION: 1. ET tube ending 3.1 cm above the carina. 2. No acute radiographic cardiac or pulmonary process. . CTA TORSO [2173-3-30]: 1. Large left retroperitoneal hematoma extending from the left hemidiaphragm into the left pelvis. No areas of active extravasation are identified, although this study was not optimized for evaluation of the distal aorta and iliac vessels. Given the patient's history of recent heparinization, this hematoma could be consistent with a spontaneous retroperitoneal hemorrhage. 2. Nonspecific peripancreatic fat stranding could be due to third spacing or pancreatic trauma. Recommend clinical correlation. 3. Transverse lucency through part of the superior aspect of the L3 vertebral body could represent a fracture of uncertain chronicity. Recommend correlation with physical examination and recent history of trauma. Also recommend further evaluation with MR [First Name (Titles) ] [Last Name (Titles) 11197] for ligamentous injury following resolution of patient's acute illness. 4. Moderate bilateral pleural effusions. 5. Exophytic hypodense left renal lesion is not fully assessed on this study and could be further evaluated with non-emergent ultrasound. 6. No evidence of pulmonary embolism or aortic dissection/aneurysm. 7. Bilateral rib fractures as above, possibly related to recent CPR. . CT HEAD W/O [2173-3-30]: IMPRESSION: No acute intracranial process. . MICRO: [Month/Day/Year 3143] CX [2173-3-30]: PENDING Brief Hospital Course: HOSPITAL COURSE: 88 year old woman with history of coronary artery disease (three vessels) status post three MIs (two NSTEMIS, one unknown), complete heart block status post dual chamber pacemaker, CHF (EF 50%), mild dementia, mild-moderate MR/AR and recent functional decline who presented in hypovolemic shock, PEA arrest two times in setting of severe anemia from large left sided retroperitoneal bleed. Pt was intubated and made full-code initially, with subsequent change to CMO as code status below. . GOALS of CARE: On the day following admission, the patient's condition continued to deteriorate as she developed multiorgan failure in the setting of retroperitoneal bleed, hypovolemic shock and PEA arrest. Multiple family meetings were held on admission indicating full code, despite the patient's prior DNR status during recent hospitalization. On HD 2, a family meeting was held, with two of her daughters, one son and multiple grandaughters were present. The social worker, attending, resident, intern and two nurses were present. The patient was made comfort measures only. The endotracheal tube remained in place at room oxygen. Levophed was discontinued. All non-comfort medications were discontinued. She expired shortly thereafter. . ACTIVE ISSUES: # RETROPERITONEAL BLEED /ACUTE [Month/Day/Year 3143] LOSS ANEMIA: The patient came in with a hematocrit of 18.9, elevated PTT. A CTA of her torse revealed a large left retroperitoneal hematoma extending from the left hemidiaphragm into the left pelvis, without obvious extravasation. She had been on heparin SC and flushes with PICC at outside facility. No evidence of trauma on history or exam. Surgery was [Month/Day/Year 4221], and recommended reversal of coaugulopathy, serial hematocrits and repeat imaging when the patient was stabilized. Her coagulopathy was reversed with protamine and 2 units of FFP. Hct and coags were monitored. She was transfused 5 total units of PRBC's, with stabilization of Hct. . # PEA ARREST: Two PEA arrests in the [Hospital1 18] ED in the setting of hypovolemic shock from large retroperitoneal hemorrhage. She was not placed on cooling protocol given risk of coagulopathy. . # HYPOVOLEMIC SHOCK: Likely secondary to retroperitoneal bleed with two PEA arrests. She initially required 2 pressors and transfusions as outlined above. She was bolused with 500cc to 1 liter normal saline bolues regularly for pressure support receiving nearly 9 liters of volume rescussitation in the CCU. Despite aggressive rescusitation, and ventilatory support, the patient developed multiorgan failure; she was anuric, with evidence of shock liver. An ABG on the afternoon following admission was pH 7.2/29/181/15. Her lactate rose to 7.8 after improvement ovenight from initial insult to 14.1 hematocrit continued to drop and require transfusion support and her extremities were cool and mottled as her condition continued to deteriorate. A family meeting was held to discuss the patient's condition and goals of care. As above, pt was made CMO, and pressors were discontinued. . # RESPIRATORY DISTRESS: Pt required intubation due to inability to protect her airway in setting of PEA arrest. She was monitored on the ventilator with frequent ABG's. Pt was oxygenating well, with respiratory alkalosis due to correcting for metabolic acidosis from lactate. When pt was made CMO, vent settings were maintained at current settings. She expired after pressors were discontinued. . # GUAIAC POSITIVE GASTRIC LAVAGE: Not grossly bloody. As above, coagulopathy reversed with protamine and FFP. Aspirin and Plavix were held. She was started on Protonix IV BID. . # CORONARY ARTERY DISEASE with recent NSTEMI: Known 3VD. She was status post bare metal stent over 12 months ago. and recent admission for medical management of an NSTEMI one week prior. EKG without significant changes although difficult to interpret in setting of demand with bleed. Held aspirin and plavix in setting of retroperitoneal bleed. Continued on atorvastatin. As above, metoprolol and losartan were initially held. CE's were cycled and showed elevated cardiac enzymes in the setting of likely demand ischemia that continued to trend upwards as the patient decompensated. . # CONGESTIVE HEART FAILYRE: Chronic, systolic and diastolic with EF 50%. On admission, she appeared intravascularly depleted (anemic/hemorrhage) but extravascularly volume up with lower extremity edema. Home regimen of furosemide, HCTZ, losartan, and metoprolol were held in setting of hypontension. . # ANION GAP METABOLIC ACIDIOSIS: Likely lactic acidosis in the setting of hypovolemic shock and PEA arrest. Culture date negative at time of patient's death. . INACTIVE ISSUES: . # HYPERTENSION: Home regimen of furosemide, HCTZ, losartan, and metoprolol were held in setting of hypontension. . # ASTHMA: Patient was ventilated on admission. Her lungs were without wheezes. She was continued on albuterol MDI. . # SEVERE OA AND CPPD DISEASE: She was followed by rheumatology as an outpatient and has been on prednisone 10mg to 7.5mg daily. She was placed initially on stress dose steroids. . # GERD: Patient on omeprazole at home. She was started on pantoprazole. . # HISTORY OF FALLS/PRESYNCOPE: Per rheumatology, recent orthostasis and loss of consciousness with question of history of adrenal insufficiency given ongoing prednisone use. Stress-dose steroids were givenin setting of shock and prednisone use at home were started as above. . # DYSLIPIDEMIA: Last lipid panel in [2-23] showing Chol 195 TG 63 HDL 65 LDL 117. Her simvastatin was changed to atorvastatin 80 mg daily given NSTEMI during last admission. Continued on same dose of home atorvastatin 80mg daily. . # HYPOTHYROIDISM: Recent TSH 0.36 with free T4 1.4. Continued on home dose of levothyroxine. . # ELEVATED LDH: During previous admission and since [2170]. Etiology remains unknown but were trending downward as outpatient. Elevated on admission. . # STAGE III SACRAL DECUBITUS UCLER: Ulcers noted during last admission. Routine wound care continued per prior recommendations. Wound consult nurse [First Name (Titles) ] [Last Name (Titles) 4221] and evaluated patient prior to her death. . # GLAUCOMA: Continued latanoprost and brimonidine eye drops. . # DERESSION: Home regimen of mirtazapine, fluoxetine were held on admission. . TRANSITIONAL ISSUES: The patient was made comfort measures only. Patient expired. Autopsy was requested by the family to determine cause of death. Medications on Admission: * Heparin, porcine (PF) 5,000 unit/0.5 mL Syringe Sig: 5000 (5000) units Injection three times a day. * Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). * Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO once a day. * Metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. * Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). * Vitamin D-3 400 unit Capsule Sig: One (1) Capsule PO once a day. * Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). * Albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. * Alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 mL PO four times a day as needed for nausea. * Latanoprost 0.005 % Drops Sig: One (1) drop Ophthalmic qHS. * Senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime. * Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three times a day. * Calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. * Docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. * Brimonidine 0.15 % Drops Sig: One (1) drop Ophthalmic twice a day. * Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime. * Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) spray nasal Nasal twice a day. * Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. * Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. * Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO once a day. * Losartan 25 mg Tablet Sig: One (1) Tablet PO once a day. * Potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. * Ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO once a day. * Miralax 17 gram/dose Powder Sig: One (1) packet PO once a day. * Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO once a day as needed for constipation. * Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. * Meropenem 500 mg IV Q6H Duration: 6 Days end date: [2173-3-26] * Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day: end date: [2173-3-24] Change to prednisone 7.5 mg on [2173-3-25]. * Prednisone 1 mg Tablet Sig: 7.5 Tablets PO once a day: start date: [2173-3-25]. * Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. * Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: patient expired Discharge Condition: patient expired Discharge Instructions: patient expired Followup Instructions: patient expired [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2173-4-1] ICD9 Codes: 2762, 2851, 4241, 4240, 4280, 4275, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8444 }	Medical Text: Admission Date: [2203-9-21] Discharge Date: [2203-9-24] Date of Birth: [2168-10-6] Sex: F Service: MED Allergies: Insulin Pork Purified / Insulin Beef / Erythromycin Base / Codeine / Aspirin / Compazine / Peanut Attending:[First Name3 (LF) 759] Chief Complaint: s/p DKA Major Surgical or Invasive Procedure: Debridement of R toe osteomyelitis [2203-9-22] EGD [2203-9-22] History of Present Illness: 34 yo female with T1DM, poor compliance with insulin and BG monitoring, ESRD with recently placed PD catheter but has not started PD, recent admit for n/v and partial amputation R 3rd toe, severe gastroparesis, presents w/N/V/hemetemesis/DKA. Was seen in ER 1 day prior to presentation for hypoglycemia, received glucagon prior to coming to ED, bg 240 in ED--> left AMA. Now presents w/above sx and hyperglycemia, anion gap (chronic AG due to renal failure), small serum ketones. Pt basically anuric. ED--5 units IV insulin, gentle hydration, GI consult, NG lavage 400cc with coffee grounds, did not clear, pulled out NG tube. Refused EGD at that time. Past Medical History: 1. Diabetes mellitus type 1, diagnosed at age 7. The patient has had multiple episodes of diabetic ketoacidosis in the past. Her DM is complicated by neuropathy, nephropathy, and retinopathy. 2. Chronic renal insufficiency, now failure with creatinine around 7, starting peritoneal dialysis 3. History of gastroparesis, with episodes of nausea and vomiting. 4. Atypical chest pain. 5. Htn 6. Asthma 5. Hypertension. 6. Asthma. 7. Chronic right foot ulcer being followed by Dr. [Last Name (STitle) 108352] of [Last Name (STitle) ]. 8. Chronic diarrhea. 9. Recurrent pyelonephritis. 10. ECHO [3-6]: <b>EF 75%</b>. No WMA/valvular abnormalities. Social History: The patient lives in [Location 686]. Her PCP is [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. Per his OMR note, her children have recently been taken by DSS, hence they no longer live with her. She has a long history of medical noncompliance.She notes that she smokes 2 packs of cigarettes every 5 days. She has smoked for the past 7 years. She denies use of alcohol or illicit drugs. Had been in abusive home relationship but has recent restraining order against fiance, who is in jail. Has close support with multiple family members nearby. [Name2 (NI) 1403] as nurse's aide in [Hospital1 2025] psych [Hospital1 ]. Currently attending classes for nursing degree. Family History: Father with type 2 DM Physical Exam: vitals: temp 98.8 HR 87 bp 160-180/80-90 RR 12 100% RA pt wretching, exam very abbreviated perrl. sclerae anicteric o/p with MMM lungs: CTA posterior fields, minimally cooperative w/inspiratory effort cv: rrr nl s1s2, tachy to 90-100, regular extrem: R foot bandaged skin: warm, flaky/dry on LEs. Pertinent Results: [2203-9-20] WBC-13.4* RBC-3.63# Hgb-11.1# Hct-33.7# MCV-93 MCH-30.5 MCHC-32.8 RDW-15.6 Plt Ct-395 [2203-9-24] WBC-10.1 RBC-3.28* Hgb-9.5* Hct-31.2* MCV-95 MCH-28.9 MCHC-30.4* RDW-15.3 Plt Ct-366 [2203-9-20] Neuts-74.4* Bands-0 Lymphs-16.3* Monos-3.7 Eos-5.0* Baso-0.6 [2203-9-21] Neuts-71.6* Lymphs-23.9 Monos-1.9* Eos-2.1 Baso-0.5 [2203-9-20] Glucose-286* UreaN-70* Creat-7.1* Na-144 K-3.9 Cl-110* HCO3-17* [2203-9-24] Glucose-172* UreaN-46* Creat-6.6* Na-139 K-3.7 Cl-107 HCO3-21* [2203-9-21] Calcium-8.4 Phos-5.0# Mg-1.9 [2203-9-24] Calcium-8.0 Phos-5.8* Mg-1.6 [2203-9-21] ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2203-9-21] Type-[Last Name (un) ] pH-7.30* [2203-9-21] 8:33 pm SWAB Source: Right foot ulcer. GRAM STAIN (Final [2203-9-21]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final [2203-9-24]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE GROWTH. YEAST. MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2203-9-23]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. [9-21] FOOT X-RAY: 1. Status-post debridement and partial amputation of the right 3rd digit. 2. Soft tissue swelling and increase in periosteal reaction; cannot exclude osteomyelitis at the site of prior partial amputation. An MR is recommended to further evaluate this area. 3. Prominent vascular calcifications. [9-22] CXR: 1. Removal of left IJ catheter. 2. Placement of left subclavian and right-sided PICC lines in satisfactory positions with no pneumothorax. 3. Resolving bibasilar atelectasis. [9-22] CXR: 1. PICC in satisfactory position. 2. No pneumothorax. Brief Hospital Course: She was in the [Hospital Unit Name 153] from [9-21] - [9-24], during which time her course was as follows: 1. Diabetes--She was found to be in mild DKA/hyperglycemia. Her AG was thought to be due to both DKA and renal failure. Her DKA was thought to be secondary to medication non-compliance, as she did not take her HS lantus the night before admission secondary to low blood sugar. Blood cultures are still pending at the time of this discharge summary. She was continued on an insulin drip plus D10 at 50 cc/hr until stabilized and transferred to the floors on an insulin sliding scale plus her usual insulin medications. She was followed by [Last Name (un) ] in the ICU, and was instructed to follow up with them on discharge. 2. ESRD--The patient had a PD catheter placed during her last admission on [9-2]. Since then she has reportedly not showed up for her scheduled dialysis sessions, though she claims to have gone. Her creatinine is markedly elevated. She only received saline flushes while in house, and was followed by renal. She was instructed to attend her PD on Monday after discharge. 3. Hematemesis--She had multiple episodes of hematemesis while in the FIU. She has a history of [Doctor First Name 329] [Doctor Last Name ] tears, and an EGD was attempted as an outpatient in [6-5] but was aborted because the patient could not tolerate the procedure. She was convinced to have an EGD as an inpatient during this hospitalization, which showed grade IV esophagitis, plus gastritis. She was started on protonix 40mg IV bid, and instructed to continue taking 40 mg PO BID on discharge, and to follow up in [Hospital ] clinic as an outpatient in [12-3] months. She had no further hematemesis. 4. [Date Range ]-- She is s/p R 3rd toe partial amputation earlier this month, and has been on zosyn q8h via PICC, though has been very non-compliant, to the point that her IV company refuses to help in the future. She had another debridement while in the hospital, and more cultures were drawn, which grew skin flora. She was instructed to continue her Zosyn as an outpatient, and to follow up with [Date Range ]. 5. Psych--This patient has a long history of non-compliance, with an extremely poor home situation, bordering on dangerous. Numerous services have declined to continue to follow due to safety concerns. She was seen by psych as an inpatient, who feel that she has a terrible psychosocial situation, although the patient doesn't feel that her situation at home affects her illness. 6. Access--She came in with a PICC line w/one port, which was changed over a wire to multiple lumens while in house. She also had a central line placed, which was removed prior to discharge. On the floors: On the morning after arrival to the floors she was found to be downstairs smoking. On return to her room, she wanted to be discharged. Renal and [Date Range ] were [Name (NI) 653], who felt that she could leave with instructions for follow up. She was given phone numbers for appropriate follow up appointments, and instructed to show up for her peritoneal dialysis the following week. She still has Zosyn as well as the IV maching at home and agreed to take the abx. She will perform twice daily dressing changes. Her fingers sticks were in good control on the floors, between 80 and 140. She was told to remain non-weight bearing on her R foot, yet she persisted in walking. She said that she was given crutches and a wheelchair at home that she will use. Prio to her leaving, her condition was discussed with her, as well as the importance of follow up. She listened and indicated understanding. Medications on Admission: As on discharge, with the exception of increased protonix to [Hospital1 ]. Discharge Medications: 1. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig: Thirty (30) ML PO BID (2 times a day). 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 8 weeks. 3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 4. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a day). 6. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 7. Loperamide HCl 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for loose stools. 8. Piperacillin-Tazobactam 2-0.25 g Recon Soln Sig: 2.25 grams Intravenous Q8H (every 8 hours). Discharge Disposition: Home with Service Discharge Diagnosis: Grade IV esophagitis Gastritis DKA Chronic renal failure R foot osteomyelitis, s/p debridement [8-22] Discharge Condition: Fair, stable. Discharge Instructions: Call [Doctor First Name 3040] on Monday [Telephone/Fax (1) ], or go to your PD training. Keep taking the Zosyn until you are seen by your podiatrist. Continue your home insulin regimen. Follow up in [Hospital ] clinic for your esophagitis. Increase your protonix to TWICE a day instead of once a day. Followup Instructions: Please make an appointment in [Hospital ] clinic with Dr. [First Name (STitle) ]: [Telephone/Fax (1) 1954]. Please call [Doctor First Name 3040] or show up at your PD training on Monday: [Telephone/Fax (1) ] Call Dr. [Last Name (STitle) ] ([Last Name (STitle) ]) for an appointment: [Telephone/Fax (1) 543]. ICD9 Codes: 2761
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8445 }	Medical Text: Admission Date: [2109-9-1] Discharge Date: [2109-9-6] Date of Birth: [2047-9-9] Sex: M Service: MEDICINE Allergies: Compazine / Codeine / Atenolol Attending:[First Name3 (LF) 1928] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: A 61 year old gentleman was seen in the ED with after reporting he was having lower extremity swelling, dizziness, and falling down. He feels this was related to an atenolol allergy. In the ED, his vitals were T 100.8, BP 135/72, HR 45, and 94% on RA. He was given lasix 20 mg and aspirin in the ED. He additionally complained of chest pain, dyspnea and diaphoresis though he was unreliable in the ED. Per there report, he was responsive to sternal rub and answered limited questions for them. He reports that he was given a prescription for atenolol at [Hospital1 2177] but has a history of atenolol allergy. . In the ED, VS: 100.8 135/72 45 16 94%RA. He received Aspirin 325mg, albuterol, Lasix 20mg PO. . Upon arrival to the floor, patient was altered and minimally responded to strenal rub. He was given narcan with good effect. He was transiently hypotensive, though became hypertensive without any intervention. He underwent Head CT which was negative for bleed. Upon arrival to the MICU, unable to obtain further history due to patient's altered mental status. Past Medical History: - h/o Anti-social personality disorder - s/p STEMI w/ BMS in LAD in [10-1], due to GI bleed stopped plavix cont only aspirin - Malignant hypertension: thought to be secondary to medication non-compliance, but had hypotension during recent admission in [10-31] and BP meds were cut back. (most likely due to Clonidine effect: overdose/withdrawal) - Pulmonary embolus: Recurrent [Month/Year (2) 11011] s/p IVC filter, not on coumadin due to noncompliance - Heroin abuse: methadone maintenance clinic [Street Address(2) 11016] daily at 7AM (most recent daily dose on [Month (only) 462] 135 mg daily. - Hepatitis B previous infection, now sAg negative - Hepatitis C, undetectable HCV RNA [3-29] - Chronic obstructive pulmonary disease - Gastroesophageal reflux disease - PTSD ([Country 3992] veteran) - Anxiety / Depression - Antisocial personality disorder - Microcytic anemia - Vitamin B12 deficiency - Chronic kidney disease baseline Cr 1.5 Social History: Unable to obtain, reports of homelessness. Not currently employed; recieves "money from the government". Denies smoking, ETOH or recent drug use. Family History: Father died of myocardial infarction at unknown age. Mother died of pancreatic cancer. Physical Exam: Vitals: HR 79, BP 152/75, RR 23, 92% on ???, afebrile Gen: moaning in bed, one word answers HEENT: dilated pupils, equal round and reactive to light CV: RRR, no m/r/g Pulm: diffuse wheezes Abd: obese, soft, NT, ND, bowel sounds present Ext: pitting b/l LE edema Neuro: moving all extremities Exam on discharge: vitals: stable, 95-99% RA, afebrile > 48 hours psych- mood appropriate lungs- CTA bilaterally, no wheezes CV- RRR, no m,r,g Abd- soft, NT, ND, active BS, decreased superficial venous distention Ext- lower extremity chronic venous stasis Pertinent Results: Labs on admission: GLUCOSE-126* UREA N-33* CREAT-1.7* SODIUM-142 POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-22 ANION GAP-17 ALT(SGPT)-18 AST(SGOT)-38 LD(LDH)-290* CK(CPK)-166 ALK PHOS-76 TOT BILI-0.4 ALBUMIN-4.1 CALCIUM-8.9 PHOSPHATE-3.7 MAGNESIUM-1.9 WBC-4.2 RBC-3.19* HGB-8.5* HCT-27.3* MCV-86 MCH-26.6* MCHC-31.1 RDW-15.5 PLT COUNT-150 PT-14.7* PTT-31.0 INR(PT)-1.3* PT-15.9* INR(PT)-1.4* TYPE-ART PO2-249* PCO2-36 PH-7.37 TOTAL CO2-22 BASE XS--3 O2 SAT-99 URINE HOURS-RANDOM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-POS GLUCOSE-100 UREA N-32* CREAT-1.7* SODIUM-143 POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-20* ANION GAP-20 ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG WBC-6.8 RBC-3.52* HGB-9.8* HCT-31.2* MCV-89 MCH-28.0 MCHC-31.5 RDW-15.3 PLT COUNT-150 TYPE-ART PO2-95 PCO2-41 PH-7.37 TOTAL CO2-25 BASE XS--1 LACTATE-0.7 O2 SAT-97 URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.021 URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.021 LACTATE-1.7 cTropnT-<0.01 CK-MB-4 proBNP-8124* ALBUMIN-4.4 D-DIMER-1008* WBC-5.6# RBC-3.02* HGB-8.3* HCT-25.9* MCV-86 MCH-27.3 MCHC-31.9 RDW-15.7* NEUTS-76.2* LYMPHS-16.6* MONOS-3.9 PLT COUNT-170 . IMPRESSION: No evidence of acute intracranial abnormalities. The study and the report were reviewed by the staff radiologist. Head CT- No evidence of acute intracranial abnormalities Repeat CXR- Rapidly improving right lower lobe opacity favoring aspiration or atelectasis over an infectious pneumonia Labs at discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 3.9* 3.06* 8.4* 26.1* 85 27.3 32.0 16.2* 156 PT PTT INR(PT) 13.5* 31.0 1.2* Glucose UreaN Creat Na K Cl HCO3 AnGap 161* 18 1.3* 139 3.6 102 28 13 Brief Hospital Course: Patient is a 61 year old male with coronary artery disease status post myocardial infarction, history of pulmonary embolus status post inferior vena cava filter not on coumadin due to med non-compliance, chronic obstructive pulmonary disease, and history of drug abuse, admitted with dyspnea and altered mental status. 1. Altered mental status: The patient presented with altered mental status upon admission to the floor from the emergency department. He was then immediately transferred to the ICU for further care, as there was concern for an atenolol overdose, with a heart rate in the 40s. He has a history of overdosing on medications while hospitalized. Narcan was given with good response, suggestive of a narcotic overdose. The patient then had an episode of flash pulmonary edema, which was managed well with lasix IV. Urine tox screen was positive for methadone and benzodiazepines. The patient's altered mental status improved on [9-2], and the patient became alert and oriented x 3. CIWA scale was started after transfer from the ICU to the floor, and was discontinued the next day after patient did not score. Initially, psychotropic meds were held. As mental status improved, methadone and benzodiazepine therapy were restarted with recommendations from the psyciatry consult service. The patient tolerated this well, and seroquel and duloxetine were also restarted. It was thought that the patient's diminished mental status upon presentation was secondary to mild renal insufficiency in the setting of methadone and benzodiazapine therapy. The patient was evaluated by psychiatry, given his history of anti-social personality disorder, depression/anxiety, and polysubstance abuse in remission. Psychiatric evaluation revealed a patient who was not psychotic, and did not have any active, acute psychiatric issues, and was deemed to have capacity. There were no further mental status changes during the remainder of his hospitalization. 2. Pulmonary Edema: The patient developed acute shortness of breath, tachypnea, and wheezing upon arrival to the ICU. Plain chest film at this time showed evidence of pulmonary edema and fluid overload. It was likely that the patient developed pulmonary edema, possibly in the setting of hypertension following Narcan administration. The patient responded well to lasix IV. Patient also experienced brief increased oxygen requirement on the floor, which again improved with lasix and bronchodilator/anti-cholinergic therapy. The patient was discharged on room air with clear lung sounds and no subjective shortness of breath. 3. history of pulmonary embolus status post inferior vena cava filter. He was initially placed on heparin gtt in the ICU; however, after a conversation with the patient's PCP, [Name10 (NameIs) ] heparin gtt was stopped and the patient's anticoagulation was held. The patient is a poor candidate for Coumadin, given his persistent noncompliance. Anti-coagulation was held during his hospitalization secondary to medical non-compliance, and the patient was discharged without anti-coagulation. 4. polysubstance abuse in remission. Patient has history of substance abuse. He is on methadone maintance at baseline. The methadone clinic was called today, and the patient's current dose is 125 mg daily. He was thus restarted on his methadone after his mental status improved, and was continued on this dose for the duration of his hospital course. 5. UTI - The patient began complaining of dysuria and found to have a urine culture postive for pansensitive E. coli. He was started on ciprofloxacin and told to complete a 7 day course 6. CAD - He had been discharged previously on metoprolol, but this was not restarted while in the hospital secondary to systolics in the 100s. He is scheduled for follow up and should restart his metoprolol at that time. He was continued on his outpatient dose of Aspirin, simvastatin and lisinopril. 7. COPD - He was maintained on his nebulizers (albuterol, atrovent). 8. GERD - Stable. continuted pantoprazole. All other medical issues remained stable. No other medication changes were made. Medications on Admission: Med List per OMR: Albuterol Clonazepam 2mg PO TID Duloxetine [Cymbalta] 30mg PO daily Fluticasone-Salmeterol 1 puff PO BID Furosemide 40mg PO daily Methadone 135mg Sig unknown Nadolol 20mg PO daily Omeprazole 20mg PO BID Oxycodone-Acetaminophen [Percocet] dose unknwon Quetiapine [Seroquel] 100mg PO daily Simvastatin 40mg PO QHS Spironolactone 25mg PO Daily Tamsulosin [Flomax] 0.4mg PO Daily Tiotropium Bromide 18mg Inh Daily Aspirin 325mg PO daily Docusate Sodium 100mg PO BID Multivitamin 1 tab PO Daily Senna 8.6 mg PO BID:PRN Discharge Medications: 1. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) for 5 doses. Disp:5 Tablet(s) Refills:0 2. Pantoprazole 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. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily) for 5 doses. Disp:5 Capsule, Delayed Release(E.C.)(s) Refills:0 4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath, wheezing. Disp:1 MDI Refills:0 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:10 Tablet(s) Refills:0 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. Advair HFA 115-21 mcg/Actuation Aerosol Sig: One (1) Inhalation twice a day. Disp:1 disc Refills:0 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 10. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:120 Tablet(s) Refills:0 11. Colace 50 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: altered mental status urinary tract infection acute on chronic congestive heart failure Secondary Diagnoses: - h/o Anti-social personality disorder - s/p STEMI w/ BMS in LAD in [10-1], due to GI bleed stopped plavix cont only aspirin - Hypertension: thought to be secondary to medication non-compliance, but had hypotension during recent admission in [10-31] and BP meds were cut back. (most likely due to Clonidine effect: overdose/withdrawal) - Pulmonary embolus: Recurrent [Month/Year (2) 11011] s/p IVC filter, not on coumadin due to noncompliance - Heroin abuse: methadone maintenance clinic [Street Address(2) 11016] daily at 7AM (most recent daily dose on [Month (only) 462] 135 mg daily. - Hepatitis B previous infection, now sAg negative - Hepatitis C, undetectable HCV RNA [3-29] - Chronic obstructive pulmonary disease - Gastroesophageal reflux disease - PTSD ([Country 3992] veteran) - Anxiety / Depression - Chronic kidney disease baseline Cr 1.5 Discharge Condition: Stable, at baseline mental status, no longer somnolent, tolerating psychotropic medications. Discharge Instructions: You were admitted to the hospital with some shortness of breath, chest discomfort, and leg pain. You were also very sleepy. After being admitted, your medical team had difficulty waking you up, and you were transferred to the ICU. You received medication to help you wake up and breath better, and you were transferred to the general medical floor. You then continued to get better, and you started receiving your regular medications. You were seen by your psychiatrist in the hospital as well. You had another episode of shortness of breath, which was likely due to mild bronchitis and a small amount of fluid in your lungs. IV medication improved your symptoms. You received some physical therapy, did well, and you were discharged on [2109-9-6], and will follow up with your doctors next week. No changes were made to your medications. You will continue to receive your daily methadone from the Narcotic [Hospital 11026] Clinic Methadone Services at [Street Address(2) 11027]. Please follow up with Dr. [Last Name (STitle) 10990], on [2109-9-11] at 11:00 a.m. and please see your PCP on the same day at 3:55 p.m. Please call your PCP [Last Name (NamePattern4) ] 911 if you develop shortness of breath, chest pain, difficulty urinating, trouble walking, excessive diarrhea, sleepiness, or any other concerning medical symptoms. Followup Instructions: Please follow up with your Psychiatric provider, [Last Name (NamePattern4) ]. [Last Name (STitle) 10990], on [2109-9-11] at 11:00 a.m. Appointment with PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 11028], at [Hospital1 2177] on [2109-9-11] at 3:55 pm. You have an appointment with gastroenterology on [2109-9-25] at [Hospital1 2177] ICD9 Codes: 5849, 5990, 4280, 5859, 412, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8446 }	Medical Text: Admission Date: [2103-12-11] Discharge Date: [2103-12-14] Date of Birth: [2103-12-11] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Baby boy [Known lastname 58734] is the 1500 gram product of a 30 and [12-24] week gestation born to a 33-year- old para 1, para 0 (now 1) mother with prenatal screens blood type A positive, antibody negative, RPR nonreactive, rubella immune, hepatitis B negative, group B strep status positive. The pregnancy was complicated by abruption on [2103-11-11] and [2103-11-16]. Mother was on bed rest since [24] weeks gestation. There was premature rupture of membranes at 29 weeks gestation on [2103-12-1] - 10 days prior to delivery. The mother was treated with ampicillin and erythromycin for seven days after rupture. She was also made betamethasone complete prior to delivery. Baby boy [Known lastname 58734] was born by cesarean section because of concern for chorioamnionitis, preterm labor, and transverse lie. He emerged breech. He had a good respiratory effort in the Operating Room, and Apgar scores were 8 at 1 minute and 8 at 5 minutes of life. He began to have some grunting and nasal flaring, so he was intubated immediately after arrival to the Neonatal Intensive Care Unit. PHYSICAL EXAMINATION ON ADMISSION: Birth weight was 1500 grams (75th percentile), head circumference was 27.5 cm (25th to 50th percentile), and length was 40.5 cm (50th percentile). In general, baby boy [Name (NI) 58734] appeared consistent with his gestational age and was in mild respiratory distress. HEENT examination revealed a normocephalic infant with an anterior fontanel that was open and flat. Red reflex present bilaterally. Palate intact. The mucous membranes were moist. His neck was supple. His lungs had coarse bilateral breath sounds with intercostal retractions and intermittent grunting. His heart was regular in rate and rhythm without a murmur. His femoral pulses were 2 plus bilaterally. His abdomen was soft with some bowel sounds. No masses or distention. His umbilical stump was erythematous and mildly edematous, and the umbilical remnant was discolored and pea-green. His GU examination revealed a normal preterm male with a patent anus. His hips were stable. His spine had no sacral dimple. His clavicles were intact. Neurologically, he had good tone and moved all his extremities equally. SUMMARY OF HOSPITAL COURSE BY SYSTEM: 1. RESPIRATORY: Baby boy [Known lastname 58734] was intubated shortly after arrival to the Neonatal Intensive Care Unit secondary to increasing respiratory distress. He received a single dose of surfactant and was extubated by about 12 hours of life, straight to room air. He has remained on room air since that time. He was loaded with caffeine at the time of his extubation and is presently on caffeine therapy. He has had no episodes of apnea and bradycardia. 2. CARDIOVASCULAR: Baby boy [Known lastname 58734] has been hemodynamically stable throughout his hospital stay with good perfusion and normal blood pressures. He has not had a murmur. 3. FLUIDS, ELECTROLYTES AND NUTRITION: Baby boy [Known lastname 58734] was held nothing by mouth and begun on starter PN and intravenous fluids with a total fluid of 100 cc/kg per day on admission. Feedings were begun at 24 hours of life after respiratory distress had completely resolved. By the time of this dictation total fluids had been advanced to 150 cc/kg per day, and feedings were of breast milk or Special Care 20 at 40 cc/kg per day, advancing 15 cc/kg per day twice daily. Dextrostix's have been stable. Electrolytes were normal at 24 hours of life and subsequently. Baby boy [Known lastname 58734] has been voiding appropriately but has not yet had stool out. 4. HEMATOLOGIC: Baby boy [Known lastname 58734]'s initial hematocrit was 39.3 percent, consistent with history of placental abruption. He has not yet required any blood products. His bilirubin at 24 hours of life was 7.5 with a direct bilirubin of 0.3; so single phototherapy was begun. At the time of this dictation, he remains on single phototherapy with the most recent bilirubin of 4.1 on [12-14]. 5. INFECTIOUS DISEASE: Secondary to the maternal history consistent with chorioamnionitis and to baby boy [Known lastname 58735] reddened/infected appearing umbilical cord, a 7- day course of ampicillin and gentamicin has been planned. Initial complete blood count was concerning with a white count of 16.8 with 31 percent polys and 13 percent bands. Platelet count was normal at 282,000. Gentamicin levels have been appropriate with a peak of 6.3 and a trough of 0.6. The day of this dictation is day three of seven. A LP was performed to rule out meningitis and was normal with a white blood cell count of 3, red blood cells of 65, a glucose of 47, and total protein of 102, and no organisms. Blood cultures and CSF cultures remain no growth to date. Placental pathology was consistent with chorioamnionitis and funisitis. 6. NEUROLOGIC: Baby boy [Known lastname 58734] has had a normal neurologic examination. He will have his first head ultrasound on day of life seven. 7. SENSORY: Hearing screening has not yet been performed but is recommended prior to discharge. 8. OPHTHALMOLOGIC: Baby boy [Known lastname 58734] has not yet been examined but is due for his first eye examination at four to six weeks of life. CONDITION AT TIME OF INTERIM SUMMARY: Stable. NAME OF PRIMARY PEDIATRICIAN: Dr. [Last Name (STitle) 58736] in [Location (un) 14663]. DISCHARGE DIAGNOSES AT TIME OF INTERIM SUMMARY: 1. Respiratory distress syndrome - resolved. 2. Apnea of prematurity. 3. Advancing feedings. 4. Hyperbilirubinemia. 5. Suspected sepsis. 6. Prematurity at 30 and [12-24] week gestation. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 55750] Dictated By:[Doctor Last Name 56593] MEDQUIST36 D: [2103-12-14] 12:24:56 T: [2103-12-15] 08:43:25 Job#: [Job Number 58737] ICD9 Codes: 7742, 769
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8447 }	Medical Text: Admission Date: [2172-3-9] Discharge Date: [2172-3-14] Date of Birth: [2112-2-18] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 905] Chief Complaint: anemia Major Surgical or Invasive Procedure: EGD [2171-3-14] History of Present Illness: 60M with PMH of CAD s/p 3 vessel CABG, IDDM and anemia who presents with one day of dizziness. The patient states that he woke up at 4am to go to the bathroom this morning and felt dizzy. He returned to bed and was persistenly dizzy with all subsequent attempts to get out of bed. Patient notes that he had a dark bowel movement this morning. He also vomited once this orning. This afternoon, he came to dermatology clinic for scheduled biopsy of an umbilic nodule. On [2172-3-3], the patient had had a CT scan of his abdomen that revealed a 4.5cm pancreatic mass with mesenteric and umbilical nodules concerning for metastases. Following the derm appointment, the patient came to the ED for further evaluation. . In the ED, initial vs were: T 97.6 P 106 BP 94/61 R 18 O2 100% RA Patient did not take his insulin this am and had a blood glucose of 707 in the ED for which he received 10 units of insulin. Repeat FSBS was 489. The patient was also noted to have a positive troponin of .27 and an index of 9.1. Cardiology was contact[Name (NI) ] and it was thought to be due to demand in the setting of a hematocrit of 20. Cardiology recommended giving the patient and aspiring, which was done. In addition, the patient received 2L NS. CXR showed no acute cardiopulmonary process. EKG showed T wave inversions in inferior leads, ST elevation in [Last Name (LF) 1105], [First Name3 (LF) ] depression in V5 and V6. . On arrival to the ICU, vitals 98.5 102 101/55 12 95% on 2L. Pt had no complaints. ROS as below. Pt received additional 10 units of insulin for persistently elevated blood glucose. . Review of systems: (+) Per HPI. In addition, constipation on Fe, dry cough, and loss of appetite for the last few weeks. He also notes a 7 pound intentional weight loss since [Month (only) 956]. (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Pancreatic Tumor with Abdominal Lymphadenopathy Anemia Insulin-Dependent Diabetes Mellitus Chronic Renal Insufficiency [1-13] Diabetic Nephropathy Bilateral Hernia Repair age 5 Congestive Heart Failure Coronary Artery Disease s/p 3-vessel CABG Hypertension Hyperlipidemia Atrial Septal Defect Repair [Doctor Last Name ] [Location (un) ] Exposure in [Country 3992] Diabetic Retinopathy Social History: Mr. [Known lastname ] works as a data center manager for [Hospital1 ], has been quite stressed and busy at work in the past 5 years. He is married, has 3 children. He never smoked, drinks only occasionally. He was exposed to [Doctor Last Name 360] [Location (un) ] in [Country 3992]. Family History: His father died at the age of 84 from liver cancer, had HTN. Mother is in her 80s and alive, had breast ca. He has one brother who has asthma, his children are healthy. Physical Exam: Vitals: T: 97.1 BP: 130/80 P: 80 R: 18 O2: 100% 2L General: NAD HEENT: No oropharyngeal erythema or exudate. Lungs: Decreased breath sounds, rales at basees. CV: RRR. No m/r/g. Abdomen: +BS. Soft. NTND. Palpable LN umbilicus s/p bx incision. Rectal: Dark brown, guaiac positive stool. Ext: No c/c/e. Pertinent Results: Images: CT Abd - [2172-3-3] - 1. 4.5-cm spiculated mass centered in the distal pancreas, highly concerning for malignancy. Mesenteric nodule and umbilical nodules are compatible with metastatic foci. 2. Splenomegaly. 3. Cholelithiasis, no evidence of acute cholecystitis. 4. Limited assessment of solid organs due to lack of IV contrast. . CXR - [2172-3-9] - No acute cardiopulmonary process. . EKG: Regular rate and rhythm, Q waves in II with questionable ST segment elevations. New T wave inversion in II, ST segment depression in V5 and V6. . ECHO [2171-11-15] - The left atrium is mildly dilated. A possible secundum type atrial septal defect is seen with left to right flow (clips 43/46 - vs. prominent caval flow). There is mild (non-obstructive) focal hypertrophy of the basal septum. The left ventricular cavity size is normal. There is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis of the basal half of the inferior septum, inferior, and inferolateral walls. The remaining segments contract normally (LVEF = 35 %). Right ventricular chamber size is normal. with mild global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild to moderate ([12-13]+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2169-4-3], the regional left ventricular systolic function is more extensive and the severity of mitral regurgitation has increased. A possible secundum type atrial septal defect is now seen. If the clinical suspicion for an ASD is high, a TEE or follow-up TTE with saline contrast is suggested. Brief Hospital Course: 60M with h/o DM1, CAD s/p 3 vessel CABG and new pancreatic mass and abdominal lymphadenopathy concerning for metastatic presenting with symptomatic anemia. # [Name (NI) 3674] Pt most likely GIB from mets to the GI tract from known pancreatic mass. Other possibilities include gastritis/duodenitis, PUD, AVMS, or colonic lesions. Pt received a total of 8units PRBC, and stable to 32 [Hospital 29715] transferred to the floor. EGD/[Last Name (un) ] [9-17] revealed only gastritis/duodenitis and coffee grounds in stomach. Capsule [1-20] with coffee grounds as well. Pt had black loose stool, first BM since admission, expected to pass old blood. Pt was continued on IV PPI and had hct remained stable, and was sent out with close follow up. # Elevated trop- demand ischemia vs. [Name (NI) 7792] - Pt has WMA on echo, Discussed with cards, and since clinically stable, and overall CE trending downward, and EKG not associated w/ new CP, cardiology agrees w/ EGD tomorrow. Concerning troponin 2.0 from 1.7, overall trending down from peak 2.5, and reassuring that CK, CKMB [Last Name (un) 8636]. Continued ASA, statin. # Pancreatic mass- newly diagnosed with pancreatic cancer, deferred treatment to outpatient. # Congestive Heart Failure - Last EF 35%, got 2L NS in ED. NO O2 requirement. Pt remained euvolemic. # [Name (NI) 29716] Pt was below baseline of 3.0 during admission. Medications on Admission: ATORVASTATIN [LIPITOR] - 80 mg po daily CALCITRIOL - 0.5 mcg po daily INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - sliding scale once a day as needed for sq injection dm METOPROLOL TARTRATE - 12.5mg po bid OMEPRAZOLE - 20 mg po bid CYANOCOBALAMIN - 2,000 mcg po daily FERROUS GLUCONATE - 325 mg po bid INSULIN NPH HUMAN RECOMB [HUMULIN N] - 100 unit/mL Suspension - inject ut dict for dm NIACIN - 500 mg Tablet po daily VITAMIN A-VIT C-VIT E-ZINC-CU [OCUVITE PRESERVISION] - 1 tablet po daily Senna Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. Calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 6. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 8. Ocuvite PreserVision Tablet Sig: One (1) Tablet PO daily (). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Insulin Regular Human 100 unit/mL Cartridge Sig: other Injection once a day: per sliding scale as needed. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: - Upper GI bleed - gastric wall invasion vs. gastric varices - Demand ischemia of the heart (while you had low blood counts) Secondary diagnosis: - metastatic pancreatic cancer - chronic renal disease - diabetes - Coronary Artery Disease s/p 3-vessel CABG - Hypertension - Hyperlipidemia - Atrial Septal Defect Repair - Diabetic Retinopathy Discharge Condition: good, hematocrit stable Discharge Instructions: You had a GI bleed that may be due to metastasis from your pancreatic cancer or from gastritis. You were hospitalized until your blood counts remained stable. You may expect [12-13] more dark stools while the remaining blood is passing through, but if you have persistent black stools, or start feeling light-headed or weak please return to the ED or contact Dr. [First Name (STitle) 679] immediately. Also return if you have a fever >101, or new chest pain Medication changes: - start taking Omeprazole 40mg twice a day until you see Dr. [First Name (STitle) 679] - take Aspirin 81mg once per day Followup Instructions: After speaking with you, you said you prefer to make the appointment with your primary care doctor, Dr. [Last Name (STitle) 12872], for convenience of coordinating with your work. Please make sure to follow up in [12-13] weeks. You already have an appointment with Dr. [First Name (STitle) 679], your GI doctor [First Name (Titles) ] [Last Name (Titles) 7712] at 12:45pm. At time of discharge the pathology report for your skin biopsy was still pending, please have him follow up with this. You also mentioned you already have an appointment with your cardiologist, Dr. [Last Name (STitle) ]. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 593], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2172-3-16] 3:30 Provider: [Name10 (NameIs) 11021] [Name11 (NameIs) 11022], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2172-3-16] 3:30 [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910] Completed by:[2172-4-1] ICD9 Codes: 5789, 2851, 5859, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8448 }	Medical Text: Admission Date: [2130-10-4] Discharge Date: [2130-10-6] Service: HISTORY OF PRESENT ILLNESS: The patient is a [Age over 90 ]-year-old female admitted on [10-4] with an acute MI. She was transferred from an outside hospital with an acute MI, intubated. Family had discussed the case with cardiology attending at [Hospital1 69] and the decision was made to attempt and restore circulation by cardiac catheterization but they did not want to attempt coronary artery bypass grafting or any other further intervention. The patient was taken to the cardiac catheterization lab on [10-5], shown to have one vessel coronary artery disease but successful PTCA and stenting of the LAD. Resting hemodynamics revealed elevated filling pressures on Dopamine, left ventricular hypertrophy was not performed at that time because of the elevated filling pressures and for fear of damaging her kidneys. HOSPITAL COURSE: The patient was admitted to the coronary Intensive Care Unit for observation where she continued to demonstrate abnormal hemodynamics and echocardiogram obtained on [10-6] revealed moderate regional left ventricular systolic dysfunction with a post infarction ventricular septal defect. Patient's condition was discussed with the family because of the ventricular septal defect which could only be closed through a risky surgical attempt. The family decided to make the patient comfort measures only. This was done and the patient expired on [2130-10-6]. FINAL DIAGNOSIS: Coronary artery disease, status post myocardial infarction with ventricular septal defect. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 15176], M.D. [MD Number(1) 15177] Dictated By:[Name8 (MD) 4430] MEDQUIST36 D: [2130-12-7] 14:44 T: [2130-12-12] 17:04 JOB#: [Job Number 97190] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8449 }	Medical Text: Admission Date: [2108-6-17] Discharge Date: [2108-6-22] Date of Birth: [2031-5-18] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 8104] Chief Complaint: Fever, flank pain Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: Ms. [Known lastname 4027] is a 77 yo F w/PMH waldenstrom's macroglobulinemia, recent hospitalization for fever, back pain and leukocytosis at the [Hospital3 2783] who presented to the ED with acute onset left sided flank pain. She reports that she was resting at home when she had sudden on set of left side pain, [9-14] in severity, constant. She denies any hematuria, change in urine output, dysuria or other urinary symptoms. She does report taking percocet 1 tab q6 hours for the past year for hip pain. . She initially presented to [Hospital ] [Hospital 1459] hospital at 1AM on [5-18] where T100.7 BP 158/40 HR 114 RR 20. She had a non contrast CT scan [6-17] reviewed by our ED radiologist confirming impression which reads: "moderate left pelvocalyceal and ureteral dilation with perirenal stranding and fascial thickening. No demonstrable ureteral calculus, limited visualization of protion of distal L ureter/UVJ. Findings could be [1-7] recently passed or tiny occult calculus. Pyelonephritis can not be excluded. Also dilation of right renal pelvis and minimal perirenal stranding. 2.6 cm indeterminate lesion lateral aspect of right kidney." She was given tylenol 650mg PR, morphine 2mg IV, torradol 30mg, zofran 4mg IV, ativan 1mg IV x2, and ciprofloxacin 400mg IV. Temp spiked to 102 at 2AM with drop in BP to 87/41 at 3:30 AM for which she was given 1L NS. Pertinent labs prior to transfer included creatinine of 1, TSH 6.24, normal LFT's, WBC 3.2 with 21% bands, HCT 37.9. . Of note she was recently admitted at [Hospital3 2783] from [2108-6-9] - [2108-6-14] where she presented with hematuria and back pain. WBC was 13.8 on admission and rose to 19.1 with fever up to 102. She was initially treated with Zosyn for a UTI however this was stopped when her culture returned with only 20,000 colonies ESBL E.col (resistant to ampicillin, cefazolin, ciprofloxacin, augmentin, ceftriaxone, levofloxacin, sensitive to gent, nitrofurantoin, tobramycin, TMP/SMX). HCT on admission was 27, she was transfused 1 unit PRBC with increase in HCT to 28, with drop to 23 on repeat for which she was transfused antother 2 units with bump to 30 where she remained for the duration of her admission. She was followed by renal, urology and hematology and had several radiologic studies. CT abdomen did not show any stones but did show hemorrhage in intrarenal collecting system. She had CT urogram [2108-6-10] which showed "moderate hydro on right, mild hydro on L, blood in both intrarenal collecting systems, R>L, focal filling defect in proximal left interrenal collecting systmes, proximal ureter renal pelvis region measuring 9mm. Renal U/S [2108-6-13] showed "the right kidney does not have hydronephrosis, echogenic material in right renal pelvis". She was not discharged on any antibiotics. . In the ED VS on presentation with 86/44, HR 122 T 100.9 RR 32 96% on 2L NC. She was initially given 2l IVF with improvement in BP to 100-130's, she was also given vancomycin 1gIV and Zosyn 4g IV. After one hour her blood pressure dropped to 70's-80's systolic, she was given IVF X4L, RIJ was placed and she was started on levophen and dopamine gtt and transferred to the ICU. Past Medical History: Waldonstrom's macroglobulinemia (diagnosed [12-12]) episodic erosive gastritis Bilateral severe osteoarthritis of the hips spinal stenosis s/p L hip total arthroplasty in [4-12] Chronic anemia (iron deficiency by report with HCT drops to low 20's) Social History: Lives at home with her husband, no tobacco for 20-30 years prior to that smoked about 1PPD for about 35 years. She denies ETOH use. Retired, used to work in food services at a hospital. Family History: Non-contributory Physical Exam: VS:TM 99.6 HR 115 (94-129), BP 109/50 (90/46 - 144/63) RR 14-24 CVP 11([8-18]) I=8L O = 250 HEENT: NC AT, PERRL, dry mucosa, JVP elevated at angle of jaw CV: RRR, s1 s2, no appreciable murmur Lungs: harsh crackles to [12-7] way bilaterally, no wheezes Abd: soft, NT, ND, BS +, no flank tenderness on exam Ext: warm, no pedal edema, DP's full bilaterally Skin: no rashes or lesions noted Pertinent Results: ADMISSION LABS: Na 140 K 3.9 Cl 107 HCO 19 BUN 24 Creat 1.2 Gluc 127 lactate 3.5 CK 50 MB - Trop 0.26 WBC 13.5 HCT 33.2 PLT 337 UA: trace leuk, lg blood, nitr neg, 500 protein, 0-2 WBC, few bacteria, 0-2epis Micro: [2108-6-17] Blood Cultures: 4/4 bottles GNR [2108-6-17] Urine Cultures: no growth Imaging: [2108-6-17] CXR: There is a new right IJ central venous catheter with distal lead tip in the proximal SVC. There is no pneumothoraces. Lungs are grossly clear. [2108-6-17] Renal U/S - (dictation) mild to moderate hydronephrosis of left kidney, echogenic material in several papillae and renal pelvis, right kidney with no hydronephrosis, echogenic material in renal pelvis and several calyces, collapsed bladder with foley catheter in place. DDX included papillary necrosis, hemorrhagic products and non-calcified stone. [2108-6-19] MRI Abdomen: Limited study, but no evidence of hydronephrosis or renal obstruction. Evidence of hemosiderosis with secondary iron deposition in the liver, spleen, and bone marrow. Extensive anasarca. [2108-6-20] Noncontrast CT Head: (preliminary) Normal unenhanced study Brief Hospital Course: A/P: Mrs.[Known lastname ] is a 77 yo F with PMH Waldenstrom's macroglobulinemia, recent UTI admitted with urosepsis on two pressors. . #Urosepsis: Blood cultures from admission yielded GNR bacteremia, with 4/4 bottles positive in <12 hours. Most likely source is pyelonephritis given echogenic material in pelvices bilaterally on ultrasound. Pt also had ESBL E.coli grow out on urine culture from previous week. On admission to ICU patient was oliguric bordering on anuric despite adequate CVP of [9-16] after getting 8L IVF and maintaining a MAP of 65 on levophed/vasopressin. Pt also had dramatic increase in WBC count from 13 on admission to 75.3, raising suspicion that intrarenal pus accumulation secondary to pylonephritis is causing leukocytosis and oliguria via obstruction. Pt was started on meropenem. Goal CVP was maintained with IVF boluses of LR or sodium bicarb. Pressors were successfully weaned. Pt underwent chest x-ray showing no evidence of pneumonia or pulmonary source of infection. Renal and Urology were consulted. Decision was made to obtain MRI of Abdomen. MRI showed no hydronephrosis, abscess or obstruction. However, there is some concern of abnormal structure causing obstruction per review by attending nephrologist and radiologist. Urology deemed no invasive intervention necessary at this time. Patient was followed by renal and medically managed. Meropenem was switched to Zosyn. At time of discharge, follow-up culture data remained negative. Patient was afebrile for over 48 hours. #Acute renal failure/Oliguria: Baseline creatinine 0.8, rose as high as 2.2 during admission before returning to 1.3. Initial renal ultrasound reportedly concerning for papillary necrosis with most likely causes in this case being pyelonephritis, analgesics nephropathy (given longterm daily percocet use) or hypotension in the setting of sepsis. All medications were renally dosed. Urine output and renal function gradually returned with stabilization of hemodynamics. Patient will need follow-up with nephrology given findings MRA. . #Altered mental status: Pt appeared disoreinted and somnolent with no focal deficits after MRI of abdomen. Noncontrast CT was obtained showing no acute pathology. Presentation consistent with delirium most likely induced by MRI sedation. Further sedation was held and serial neuro exams completed. Pts confusion improved over the course to the next 72hours. #Coagulopathy - elevated PT/PTT with INR at 1.6 from normal baseline likely secondary to sepsis. Platelets slowly declined initially during hospitalization. Pt was evaluated for DIC secondary to sepsis. No evidence of DIC was found. Platelets began to rise on Day 5 of admission. Medications were reviewed and proton pump inhibitor was held. Heme/Onc classified elevated INR and decreased platelets as a leukemoid reaction that would require no further evaluation at this time. #Demand myocardial ischemia - with isolated bump in troponin on admission with peak of 0.26, CK and MB flat, likely due to severe hypotension in setting of sepsis. Now trending down. She has no chest pain or EKG changes concerning for ACS. No further evaluation was warranted. Echo eas performed that showed an EF of 45-50%. Patient had mild sinus tachycardia (rate at 100) at time of discharge. This will need outpatient follow-up . Medications on Admission: percocet 1 tab q6 hours for right hip pain for the past year Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 2. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 3. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours): last day [6-30]. 4. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 5. Outpatient Lab Work Please check CBC/CR in 2 days to assure counts are correcting Discharge Disposition: Extended Care Facility: Bear [Doctor Last Name ] Nursing Center - [Location (un) 2199] Discharge Diagnosis: 1) E.Coli (ESBL) urosepsis 2) Acute renal failure 3) Thrombocytopenia 4) Leukocytosis 5) Delirium Discharge Condition: Stable Discharge Instructions: Please return if you experience worsening fevers, chills, or other concerning symptoms. Followup Instructions: 1. You will need to follow-up as an outpatient with our nephrology clinic within the next 1-2 months. ([Telephone/Fax (1) 773] 2. You should follow-up with Dr. [Last Name (STitle) 13959] within the next [12-7] weeks ICD9 Codes: 5849, 2930, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8450 }	Medical Text: Admission Date: [2173-10-9] Discharge Date: [2173-10-15] Date of Birth: [2094-5-11] Sex: M Service: MEDICINE Allergies: Iodine Attending:[First Name3 (LF) 3967] Chief Complaint: SOB Major Surgical or Invasive Procedure: OptEase IVC filter placement on [10-9] History of Present Illness: 79 yo M with IgA myeloma s/p velcade (incomplete course) and recent Revlimid, history of PE on warfarin, presented with shortness of breath with minimal exertion x 2 days similar to his prior PE episode in [2169]. . Per patient, he reports that he was having worsening lower extremity edema over the last 3 months. No pain in his legs. He had no recent travel. No cough, pleuritic chest pain, or chest pain. Dyspnea and dyspnea on exertion developed over the course of last 2 days. Patient thought it was similar to his prior episode of PE but milder symptoms; therefore, presented himself to the ED. Of note, he stopped his Revlimid . While in the ED, initial vitals were 98.9 104 194/79 24 92% RA. Per report EKG showed evidence of right heart strain, new TWI III, avF, V2-3, and troponin was mildly elevated to 0.04 Given his symptoms, patient underwent CTA (after receiving IVF) of the chest which showed PE straddling the bifurcation of the left pulmonary artery that extends segmental branches. Per report, patient was guaic negative. Subsequently, patient was started on heparin gtt. Oncology was consulted who agreed with heparin and IVC filter placement with + U/S LENIS. Upon sign out, reported vitals were 97.8, 18, 95% on 2L, 84, 129/87. . On the floor, patient reports feeling better with his breathing. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough 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: - multiple myeloma diagnosed [3-/2171], s/p Velcade (incomplete course) and Revlimid - history of PE in [10/2170] on warfarin, + for prothrombin/facter 2 mutation on gene analysis - OA bilateral knees - BPH, s/p TURP in [2162], complicated by PE - h/o hematuria while on anticoagulation - LE weakness, followed by neuromuscular clinic - HTN - history of phlebitis in the left ankle 20 years ago Social History: - retired business executive - Tobacco: never - Alcohol: non - Lives at home with wife - ambulate with walker/cane Family History: - mother deceased at 101 - father deceased at 59 - Mother and sister with proximal muscle weakness, but no definitive diagnosis. Physical Exam: On Admission: Vitals: T:96.9 BP:121/75 P:83 O2: 93% on 3L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated CV: RRR, no m/r/g Resp: diminished lung sounds at the basis, no wheeze or rhonchi Abd: soft, NT, ND, BS+ Extremities: cool, dry, barely palpable DP bilaterally, edematous up right below the knees, no cyanosis or clubbing GU: no Foley Skin: without rash On Discharge: VSS No change in physical exam other than swelling which was very promienent bilaterally but R>L, had decreased. Lungs CTA Heart RRR with no m/r/g. Presence of premature beats. Pertinent Results: [2173-10-10] 12:00AM WBC-5.4 RBC-4.56* HGB-13.5* HCT-40.9 MCV-90 MCH-29.6 MCHC-33.0 RDW-15.0 [2173-10-10] 12:00AM PLT COUNT-54* [2173-10-10] 12:00AM PT-27.5* PTT-150* INR(PT)-2.6* [2173-10-9] 09:45AM GLUCOSE-110* UREA N-30* CREAT-1.1 SODIUM-141 POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-22 ANION GAP-17 [2173-10-9] 09:45AM CK-MB-4 proBNP-6437* [2173-10-9] 09:45AM cTropnT-0.04* [2173-10-9] 09:45AM CK(CPK)-36* [2173-10-9] 04:10PM cTropnT-0.04* [2173-10-10] 12:00AM CK-MB-3 cTropnT-0.04* Urine after temperature spike: [2173-10-12] 04:58PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG [2173-10-12] 04:58PM URINE RBC-4* WBC-1 Bacteri-FEW Yeast-NONE Epi-<1 Urine culture negative Discharge Labs: [2173-10-15] 03:45PM BLOOD LMWH-0.72, this is therapeutic [2173-10-15] 06:30AM BLOOD WBC-4.0 RBC-4.07* Hgb-12.2* Hct-35.9* MCV-88 MCH-30.1 MCHC-34.0 RDW-15.3 Plt Ct-104* [2173-10-14] 06:25AM BLOOD Neuts-36* Bands-4 Lymphs-49* Monos-8 Eos-2 Baso-1 Atyps-0 Metas-0 Myelos-0 [2173-10-15] 06:30AM BLOOD Glucose-85 UreaN-25* Creat-1.2 Na-142 K-4.0 Cl-107 HCO3-28 AnGap-11 [2173-10-11] 01:20AM BLOOD ALT-16 AST-13 AlkPhos-44 TotBili-0.6 [2173-10-15] 06:30AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.1 Microbiology (for fever): Blood culture negative x2 Urine culture negative Imaging: CTA chest: IMPRESSION: Left nonocclusive pulmonary emboli. B/L LE US IMPRESSION: 1. Right posterior tibial deep venous thrombosis. 2. Nonocclusive left popliteal deep venous thrombosis. 3. Left calf veins and right peroneal veins not well evaluated. IVC OptEase filter placement: IMPRESSION: Successful placement of an OptEase IVC filter described above. Echo: The left atrium and right atrium are normal in cavity size. The right ventricular cavity is moderately dilated with depressed free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be excluded. The right ventricle is at least moderately dilated with evidence of pressure/volume overload. Pulmonary artery pressures could not be assessed. Mild aortic regurgitation. Compared with the prior study (images reviewed) of [2171-9-4], the right ventricle is now dilated and hypokinetic with evidence of RV pressure/volume overload. Brief Hospital Course: 79 yo M with IgA myeloma s/p velcade (incomplete course) and recent Revlimid, history of PE ([2169]) on warfarin, presented with shortness of breath with minimal exertion x 2 days found to have left pulmonary artery PE. . # Pulmonary Embolism Patient was initially admitted to the medical ICU for close monitoring for saddle PE as found on CTA. IR was consulted and placed an IVC filter. Pt was started on heparin gtt in setting of thrombocytopenia given clot burden. Pt was monitored overnight and then transferred to the inpatient oncology floor. On the floor, pt remained hemodynamically stable. Echo revealed new right heart strain. Pt transitioned from heparin to lovenox, which he will need life-long as he has failed warfarin. Swelling in lower legs decreased dramatically and patient denied chest pain and endorsed improvement in breathing. However, pt had 82% O2 saturation while ambulating and was set-up for home O2. Will need follow-up as to whether IVC filter should be removed. Because pt will be on life-long anticoagulation, it may be safe to keep in the IVC filter in the hopes of preventing large clots from entering the pulmonary bed, however, if patient is to have more chemo or has other reason for withholding anticoagulation, this will serve as a nidus for future clots. Pt was told to discuss this issue with Dr. [First Name (STitle) ] as this is a retrievable filter, but is often best removed within a month from placement per IR. . # Fever: Pt developed a fever x 1. Cultured and started on zosyn and vancomycin. Pt defervesced. Antibiotics were discontinued one at a time without recurrence in fever. All cultures were negative. Fever was most likely [1-27] to inflammatory response from DVT and PE. . # Thrombocytopenia. This was thought most likely [1-27] Revlimid. Could also be consumption. Unlikely DIC given improving platelets, stable Hct, and normal fibrinogen. Platelets increased over course of stay. . # IgA Myeloma. Currently off Revlimid. Will need to discuss future treatment options with Dr. [First Name (STitle) ] given propensity to develop clots on this medication. On prednisone taper for Hives from revlimid. . # Hypertension. currently normotensive and holding Lasix and Metoprolol for now in setting of PE. Pt's blood pressures are about 120s/80s. . Transitional: Will need follow up regarding the need to keep in IVC filter. Will need to address future MM treatment Tapering down prednisone. Medications on Admission: - Diclofenac sodium 1% gel [Hospital1 ] for shoulder pain - finasteride 5 mg qd - furosemide 20 mg daily - metoprolol succinate 50 mg daily - nystatin 100,000 unit/gram powder to the affected area TID - 20 mEq KCl - prednisone 5 mg daily - warfarin 1 mg or 4 mg daily Discharge Medications: 1. O2 Sig: Two (2) L/Min Ambulation: By NC, for ambulation O2 saturation of 82%. Disp:1 unit Refills:0 2. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Injection Subcutaneous twice a day: Subcutaneously. Disp:60 Injection Refills:2 3. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. prednisone 1 mg Tablet Sig: As directed Tablet PO once a day: 4 tabs x 7 days start [10-16], then 3 tabs x 7 days, then 2 tabs x 7 days, then 1 tab x 7 days. Disp:70 tabs Refills:0 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:60 Capsule(s) Refills:0 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for constipation. Disp:30 Tablet(s) Refills:2 7. diclofenac sodium 1 % Gel Sig: Apply to shoulder Topical twice a day as needed for pain. 8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day: Take both pills with food in AM . 9. nystatin 100,000 unit/g Powder Sig: As directed Topical three times a day: Apply to affected area. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: Pulmonary Embolism, Bilateral lower extremity deep vein thromboses Secondary: Multiple Myeloma, Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname 23], It was a pleasure taking care of you at [Hospital1 18]. You were admitted for shortness of breath and found to have a pulmonary embolism. You were also found to have bilateral lower extremity deep vein thromboses. A temporary inferior vena cava filter was placed to help prevent further embolism from your legs to your lungs. You were treated initially with heparin and this was transitioned to lovenox, which you must keep taking. In the future, your OptEase IVC filter which was placed on [10-9] be removed. Please address this question with Dr. [First Name (STitle) ]. You also had a fever while you were here and treated with broad spectrum antibiotics. No infectious source was found and you were afebrile after discontinuation of antibiotics. It was felt that this fever was most likely from your DVT and PE. STARTED LOVENOX injections STARTED DOCUSATE STARTED SENNA STOPPED WARFARIN HOLDING METOPROLOL HOLDING LASIX DECREASE PREDNISONE dose Followup Instructions: Department: HEMATOLOGY/BMT When: WEDNESDAY [2173-10-20] at 1:30 PM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3919], RNC [Telephone/Fax (1) 3241] Building: SC [Known lastname 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Known lastname 23] Garage Department: HEMATOLOGY/BMT When: WEDNESDAY [2173-10-20] at 1:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4380], MD [Telephone/Fax (1) 3237] Building: SC [Known lastname 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Known lastname 23] Garage Department: BMT CHAIRS & ROOMS When: WEDNESDAY [2173-10-20] at 2:30 PM [Name6 (MD) ] [Last Name (NamePattern4) 3974] MD, [MD Number(3) 3975] Completed by:[2173-10-20] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8451 }	Medical Text: Admission Date: [2131-4-17] Discharge Date: [2131-4-23] Date of Birth: [2057-10-17] Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3645] Chief Complaint: neurogenic claudication Major Surgical or Invasive Procedure: L4/5 laminectomy History of Present Illness: As you know, he comes to us with a chief complaint of right-sided leg pain. This has been ongoing since [2130-11-2]. He states he was in [Location 29174]celebrating his grandson's birthday and was walking and began having a sensation of weakness in his right leg. He had trouble walking three blocks due to a combination of both pain and weakness. It became progressively worse. Upon returning back to [State 350], he went back to a local emergency room and was given oxycodone. He had been visiting the [Location (un) 1121] Spine Center and they have recommended that he do an epidural steroid injection. He underwent an injection for treatment of his right foot pain in [11/2130] and that was very helpful. He also began a course of physical therapy. He was doing quite well. However, on [2131-1-23], he was exercising on the treadmill per the recommendation of physical therapy and began having pain in the sole of his foot. He was diagnosed initially with cellulitis and then with gout. He saw both a podiatrist as well as Dr. [Last Name (STitle) ]. He was treated with indomethacin, but is now weaning off of that per the recommendation of his nephrologist. His right leg pain persists. He has significant difficulty walking. Prior to this, he did have a chronic low back pain, was able to manage this and was walking about 40 minutes a day. More recently, he has not been able to do this. He is sent here for an evaluation for a lumbar stenosis. Past Medical History: Heart disease, triple bypass in [2124], lung resection for TB 40 years ago, and kidney problems, anemia, prostate removal for cancer. Surgical History: Include prostate removal in [2127], bypass grafting [2124], cataract surgery bilaterally in [2123]. Medications: Atenolol, Hectorol, [Doctor First Name ], furosemide, Apidra, Crestor, Kayexalate, Diovan, alpha lipoic acid, vitamin C, baby aspirin, ferrous sulfate, folic acid, Centrum Silver, and Metamucil. Allergies: No known allergies. Social History: He is retired and he was working as a city engineer for [Hospital1 ] up until last year. He does not smoke. He drinks alcohol. He is married. Family history includes pancreatitis and strokes. Review of Systems: He reports he is in good health other than diabetes. Denies recent unexplained weight loss. He is deaf in his right ear. He is currently having gout in his right foot. A 13-point review of systems is otherwise negative. On physical exam, Mr. [Known lastname 29175] is a pleasant 73-year-old male accompanied by his wife. [Name (NI) ] is alert and oriented x3. Affect within normal limits. He appears well groomed and well nourished. He has significant difficulty walking. He is able to stand up on his toes and his heels but with much difficulty. Bilateral lower extremity strength demonstrates slight weakness in his left [Last Name (un) 938] at 4/5, but otherwise it is [5-19]. Sensation grossly intact. Straight leg raise negative. No pain with internal and external rotation of his hips. Imaging Studies: MRI of the lumbar spine obtained on [2131-2-27], demonstrates a disc protrusion at L4-L5, and severe spinal canal stenosis at this level. At L5-S1, there is a left foraminal disc extrusion impinging the left L5 and left S1 nerve root. This was read by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. Assessment and Plan: Mr. [Known lastname 29175] is a 73-year-old male who since [2130-11-2] has had severe right-sided leg pain. Symptoms are consistent with neurogenic claudication. Although he does have a large foraminal disc extrusion on the left, his symptoms are more right-sided. Symptoms are more consistent with severe canal narrowing at L4-L5. Dr. [Last Name (STitle) 1352] reviewed surgery with him, which would be a L5 laminectomy and L4 partial laminectomy. He understands the goal of surgery is to alleviate his right leg pain and increase his walking tolerance. His personal goal is to be able to walk on the beach in [Location (un) ], [State 1727] with his grandchildren. Surgical details were reviewed and consents signed. He will be scheduled at a mutually convenient time. I will be in contact with Dr. [Last Name (STitle) ] to ensure that he can be off aspirin during the periop period. Past Medical History: Coronary Artery Disease s/p NSTEMI Hypertension Hypercholesterolemia Diabetes Mellitus Dilated Cardiomyopathy Peripheral Vascular Disease s/p Right Fem-[Doctor Last Name ] Bypass Left foot ulcer (healed) Chronic Renal Insufficiency s/p Left Lung Resection d/t Tuberculosis s/p Right Breast Tumor removal (benign) Social History: -Tobacco, +ETOH (2 gin/d), -IVDA Lives with wife Family History: Non-contributory Physical Exam: see HPI Pertinent Results: [2131-4-17] 08:15PM GLUCOSE-72 UREA N-32* CREAT-1.5* SODIUM-142 POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-27 ANION GAP-12 [2131-4-17] 08:15PM estGFR-Using this [2131-4-17] 08:15PM CALCIUM-8.8 PHOSPHATE-4.3 MAGNESIUM-2.3 [2131-4-17] 08:15PM WBC-5.9 RBC-3.69* HGB-11.4* HCT-34.3* MCV-93 MCH-30.9 MCHC-33.2 RDW-13.0 [2131-4-17] 08:15PM PLT COUNT-244 [2131-4-17] 03:55PM TYPE-[Last Name (un) ] TEMP-37 PO2-47* PCO2-46* PH-7.43 TOTAL CO2-32* BASE XS-4 COMMENTS-RA [2131-4-17] 03:55PM GLUCOSE-110* NA+-140 K+-5.0 [2131-4-17] 03:55PM HGB-12.7* calcHCT-38 Brief Hospital Course: Patient was admitted to the [Hospital1 18] Spine Surgery Service and taken to the Operating Room for the above procedure. Refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with a PCA. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#2. Drain out POD2, then restarted [Last Name (un) ]. [Hospital ] clinic was consulted and helped managed his sugars. Sugars well controlled on insulin pump. . POD3 patient developed low grade temp. U/A was negative for infection. Chest xray was normal. . [Last Name (un) ] was consulted for management of Inslin pump. . Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: atenolol 50 mg Tablet one Tablet(s) by mouth once a day doxercalciferol [Hectorol]2.5 mcg Capsule 1 Capsule(s)every day fexofenadine [[Doctor First Name ]] 180 mg Tablet 1 Tablet(s) by mouth as needed furosemide 40 mg Tablet 1 Tablet(s) in morning and 1 tab in evening rosuvastatin [Crestor]40 mg Tablet 1 (One) Tablet(s) once a day Kayexalate Powder 15 grams Powder(s) by mouth once a day valsartan [Diovan]80 mg Tablet 1 (One) Tablet(s) once a day ascorbic acid 500 mg Capsule, Sustained Release 1 Capsule(s) daily Aspirin Oral 81 mg every day last dose [2131-4-6] ferrous sulfate 325 mg (65 mg Elemental Iron) Tablet 1 daily [Centrum Silver] Tablet 1 Tablet(s) by mouth daily folic acid Oral 400 mcg every day p.m Crestor Oral 40 mg every day p.m(dinner) Metamucil Oral 1 tsp every day as needed for constipation oxyCODONE Oral 5 mg as needed as needed for pain Glucagon Subcutaneous 1 mg emergency dose as needed for hypoglycemia . Apidra Subcutaneous 100 unit/mL dose varies at meals and as needed for snacks or based on activity administer within 15 minutes before breakfast, lunch, and supper correction=BS level-120 divided by 30 then based on [Doctor Last Name ] and bld glucose/a.m=14u bolus,noon=6-7u bolus,dinnertime =approx 12u) . Indomethacin Oral 50 mg 3 times per day as needed for gout flare alpha lipoic acid 300mg daily as needed for gout flare dinnertime Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take while on narcotics to prevent constipation. Disp:60 Capsule(s) Refills:2 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for constipation. Disp:30 Tablet(s) Refills:0 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [1-15] Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for constipation. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [4-20] hours as needed for fever, pain. 5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: no driving or alcohol. Disp:90 Tablet(s) Refills:0 6. doxercalciferol 2.5 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). Capsule(s) 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. sodium polystyrene sulfonate 15 g/60 mL Suspension Sig: One (1) PO DAILY (Daily). 14. Insulin Pump IR1250 Miscellaneous 15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Home With Service Facility: VNA of [Location (un) 270]-East & Visiting Nurse Hospice Discharge Diagnosis: lumbar central stenosis, neurogenic claudication Discharge Condition: good Discharge Instructions: You have undergone the following operation: Lumbar Decompression Without Fusion Immediately after the operation: ?????? Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without moving around. ?????? Rehabilitation/ Physical Therapy: ◦ 2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. ◦ Limit any kind of lifting. ?????? Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. ?????? Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing and call the office. ?????? You should resume taking your normal home medications. ?????? You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [Hospital Ward Name 23] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. ?????? Follow up: ◦ Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. ◦ At the 2-week visit we will check your incision, take baseline X-rays and answer any questions. We may at that time start physical therapy. ◦ We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: No restrictions Treatments Frequency: dressing only if draining Followup Instructions: Provider: [Name10 (NameIs) ] XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2131-5-7] 1:20 Provider: [Last Name (NamePattern4) ]. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Phone:[Telephone/Fax (1) 8603] Date/Time:[2131-5-7] 1:40 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7779], MD Phone:[Telephone/Fax (1) 3241] Date/Time:[2131-8-16] 10:00 ICD9 Codes: 4254, 3572, 412, 2720, 4439
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8452 }	Medical Text: Admission Date: [2164-1-28] Discharge Date: [2164-2-12] Date of Birth: [2095-1-22] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Theophylline Attending:[First Name3 (LF) 12174] Chief Complaint: Jaundice Major Surgical or Invasive Procedure: Transjugular liver biopsy Nasogastric tube placement PICC line placement History of Present Illness: The pt is a 69 year old woman w/ PMHx of poly-substance abuse including EtOH and oxycodone, breast cancer s/p mastectomy, diverticulitis s/p resection, and DVTs, now presenting with jaundice. The jaundice started approx 6 weeks ago, with associated weakness, lightheadedness, chalky stools, and dark urine. She has also noted increasing diffuse abdominal pain, nausea, gassiness, and diarrhea, but no vomiting. She has had chills x1 day, but no fevers or sweats. Her abdominal pain is diffuse and worse with certain movements, [6-15], without radiation. She does note new low back pain, but thinks this is different from her abdominal pain. She denies any hematemesis, melena, hematochezia, or pruritus. Her symptoms have been progressively getting worse, so she presented to [Hospital 73458] Hospital today, where she was found to have elevated LFTs and reportedly a negative RUQ U/S but a contrast abdominal CT that showed findings c/w pancreatitis. She was transferred given concern for her elevated LFTs and the potential for developing fulminant liver failure. Of note, she was recently moved here from [State 108] by her family, to undergo rehabilitation at [Hospital1 882]. She completed this approx 2 mo ago, at which point she stopped drink EtOH and was started on naltrexone (last drink [2163-11-7]). She first noted her symptoms approx 1 week later. She was seen as an outpatient approx [6-15] days ago for her jaundice, which was thought to be [1-9] naltrexone, so this medication was stopped, but her symptoms have continued to worsen. ROS: See HPI and below. Otherwise reviewed in complete detail and negative. (+) palpitations: for approximately 1 year, with some left-sided chest and neck pain and shortness of breath; these symptoms may have been increasing in frequency over the last few weeks; they are quickly relieved with rest (+) urinary frequency and nocturia: approximately every 2 hours; no hematuria or dysuria (+) bilateral upper arm pain: chronic, positional (+) recent cough and nasal congestion Past Medical History: - h/o Poly-substance abuse, including EtOH, oxycodone, and Xanax - DVTs: one in setting of abdominal surgery and other in setting of long flight - Factor V Leiden deficiency, not currently anti-coagulated - Breast cancer s/p left mastectomy [2153] - h/o Diverticulitis s/p resection Social History: Pt's family moved her here from [State 108] in [Month (only) 1096] for rehab at [Hospital1 882]. She has 3 children: 2 sons and 1 daughter. She has a distant h/o smoking, but heavy alcohol abuse as well as oxycodone and Xanax. She has been drinking [6-13] drinks of rum daily x30 years. Family History: Mother died of cancer (type unknown, possibly CRC). Father died of colon disease. No family history of liver disease. Physical Exam: VS: Temp 98.9F, BP 152/72, HR 85, R 18, SaO2 96% RA; Wt 117lbs. GEN: Thin middle-aged woman in NAD, comfortable, appropriate. HEENT: NC/AT, PERRL/EOMI, +icteric sclera, dry MM, OP clear. NECK: Supple, no LAD or JVD. CV: RRR, nl S1-S2, no MRG. CHEST: CTAB, no crackles, wheezes or rhonchi. ABD: NABS, soft/ND; +hepatomegaly w/ liver edge [2-8] finger breadths below RCM, +TTP over liver edge; no splenomegaly, no rebound/guarding. +Right CVA tenderness. RECTAL: light brown stool, Guaiac negative, ? posterior internal hemorrhoid. EXT: WWP, no c/c/e. SKIN: +jaundice, +spider angioma on chest but no other stigmata of chronic liver disease. NEURO: A&Ox3, Able to relate history without difficulty, CNs [1-19] intact, strength 4/5 throughout, sensation intact; No nystagmus, dysarthria, intention or action tremor; No asterixis. Pertinent Results: ADMISSION LABS: CBC: [2164-1-29] 02:20AM BLOOD WBC-8.8 RBC-3.87* Hgb-12.4 Hct-36.0 MCV-93 MCH-32.1* MCHC-34.5 RDW-16.5* Plt Ct-130* [2164-1-29] 02:20AM BLOOD Neuts-82.6* Lymphs-8.9* Monos-5.7 Eos-2.1 Baso-0.7 COAGS: [2164-1-29] 02:20AM BLOOD PT-23.4* PTT-46.8* INR(PT)-2.3* CHEMISTRIES: [2164-1-29] 02:20AM BLOOD Glucose-96 UreaN-9 Creat-0.9 Na-140 K-4.3 Cl-107 HCO3-26 AnGap-11 LFTs: [2164-1-29] 02:20AM BLOOD ALT-302* AST-287* LD(LDH)-292* AlkPhos-116 Amylase-27 TotBili-26.0* DirBili-17.0* IndBili-9.0 [2164-1-29] 02:20AM BLOOD Lipase-23 GGT-61* [2164-1-29] 02:20AM BLOOD TotProt-6.1* Albumin-3.0* Globuln-3.1 Calcium-9.0 Phos-2.3* Mg-2.1 Iron-150 [2164-1-29] 02:20AM BLOOD calTIBC-159* Hapto-<20* Ferritn-937* TRF-122* [2164-1-29] 02:20AM BLOOD CEA-2.6 AFP-25.9* [2164-1-29] 02:20AM BLOOD PEP-PND IgG-2405* IgA-616* IgM-65 [2164-1-29] 02:20AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [2164-1-29] 02:20AM BLOOD [Doctor First Name ]-POSITIVE Titer-1:40 [Last Name (un) ] [2164-1-29] 02:20AM BLOOD PEP-POLYCLONAL IgG-2405* IgA-616* IgM-65 IFE-NO MONOCLO [2164-1-29] 02:20AM BLOOD HCV Ab-NEGATIVE [2164-1-29] 02:20AM BLOOD CERULOPLASMIN-Negative [2164-1-29] 02:20AM BLOOD CA [73]-9 - Negative Liver, transjugular biopsy: 1. Established cirrhosis (confirmed by trichrome stain) with focal sinusoidal fibrosis and associated cholangiolar proliferation; mild cholestasis is present. 2. Mild to moderate portal/septal, mild periportal and lobular mixed inflammation consisting of lymphocytes, focally prominent plasma cells, neutrophils and eosinophils. Foci of piecemeal necrosis are identified; no definite collapse is seen on reticulin stain. 3. Mixed micro-macrovesicular steatosis involving approximately 30% of the non-fibrotic hepatic parenchyma. Rare balloon degeneration present; no intracytoplasmic hyalin seen. 4. Iron stain shows minimal iron deposition in rare periportal hepatocytes. Note: The steatosis, rare balloon degeneration and sinusoidal fibrosis are suggestive of a toxic/metabolic injury. Additionally, however, the focally prominent plasmacytic inflammation and piecemeal necrosis raise the possibility of a concomitant chronic active hepatitis, such as due to an autoimmune, drug or viral etiology. Further correlation with clinical and serological findings is required. The findings were discussed with Dr. [Last Name (STitle) ] [Last Name (NamePattern4) 696] on [2164-2-2]. Dr. [Last Name (STitle) ] . [Doctor Last Name 10165] reviewed the case and concurs. Brief Hospital Course: A 68-yo woman with long history of ETOH abuse, illicit substance abuse, breast cancer s/p mastecomy and nephrectomy, diverticulitis s/p resection, multiple DVTs who recently stopped drinking ETOH and presented to an OSH with jaundice and abdominal pain found to have elevated bilirubin. # Acute Hepatitis: Initially she was felt to have an acute on chronic alcoholic hepatitis and she was initiated on a course of pentoxyfilline 400 mg TID that was stopped after 5 days given uncertainty about whether this actually was acute on chronic hepatitis since time between patient's last alcoholic drink and onset of symptoms was nearly one month. The following were negative: Hepatitis panel, AMA, ceruloplasmin, CA [73]-9, SPEP, CMV Abs, EBV panel. [Doctor First Name ] was weakly positive. The IgG was >[2154] on two occasions. A transjugular liver biopsy showed cirrhosis, mixed micro-macrovesicular steatosis, and inflammation containing lymphocytes and plasma cells. This histologic picture suggested both toxic/metabolic injury and concomitant chronic active hepatitis, possibly due to virus or autoimmune condition. As a result of these findings she was started on prednisone, the thinking being that her hepatitis was autoimmune in nature. Steroid therapy was initiated after treatment of her urinary tract infection, as below. After the initiation of steroids, her bilirubin started to improve, and symptomatically she began to gain strength and her appetite increased. However, on the morning of [2-12], she was found to have rapidly declining mental status and confusion progressing to non-responsiveness. She was observed to cough up several hundred ML of coffee-ground emesis. As her code status was DNR/DNI, no resuscitation efforts were attempted. It is unclear what the source of her bleed was, but likely causes include gastritis, peptic ulcer, or variceal bleed. # Atrial Fibrillation: She was observed to go into atrial fibrillation with rapid ventricular response. She required transfer to the ICU and brief treatment with a diltiazem drip after which she converted back to sinus rhythm. She was started on oral diltiazem 60 mg four times daily and was able to be transferred back to the medicine floor. After transfer, she remained well-controlled, in normal sinus rhythm, on diltiazem. # Urinary Tract Infection: A urine culture grew out proteus vulgaris and enterococcus. She was treated with ciprofloxacin 250 mg twice a day for a total of seven days and her foley catheter removed. Unfortunatly, due to her high post-void residuals and suprapubic pain, we had to reinsert the foley catheter. Surveillance cultures grew out yeast, for which we gave one dose of fluconazole but then stopped due to concern of liver toxicity. # Leukocytosis: She developed a mild leukocytosis with a neutrophilic predominance prior to initiation of steroid therapy. We took cultures of the blood and urine, and measured the stool for C dif toxin. With the exception of the UTI above, which was treated, all cultures and micro data were negative. In addition, a CXR was negative for infiltrate. Abdominal ultrasound showed no ascites at admission, so SBP was felt to be unlikely. She remained afebrile with no localizing symptoms. Thus we initiated steroid therapy due to her worsening hepatitis. Once on prednisone, her white count continued to rise. This was likely due to the hepatitis (possibly with a component of EtOH hepatitis) and demargination of white cells on steroid therapy. # Hypertension: Her blood pressure was well controlled. Lisinopril was held given concern that medications could be playing a role in acute hepatitis. # Depression: Given that Paxil was started prior to her developing acute hepatitis this medication was held during admission. # Nutrition: Calorie count revealed poor caloric intake. An NG tube was placed and tube feeds were initiated. She was DNR/DNI during this admission. Medications on Admission: - Aspirin 81mg PO daily - Paxil 10mg daily - Trazodone 2tabs QHS --> has not been working - Lisinopril 10mg PO daily Discharge Medications: Deceased. Discharge Disposition: Expired Discharge Diagnosis: Primary: Acute hepatitis, autoimmune or alcohol-related Secondary: Cirrhosis, Hypertension, Atrial fibrillation, Depression Discharge Condition: Deceased. Discharge Instructions: Deceased. Followup Instructions: Deceased. Completed by:[2164-2-25] ICD9 Codes: 5849, 5990, 2761, 5715, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8453 }	Medical Text: Admission Date: [2111-6-12] Discharge Date: [2111-6-20] Date of Birth: [2049-8-29] Sex: M Service: CARDIAC SURGERY CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: The patient is a 61 year old male who presented to the Cardiac Medicine service with heartburn and discomfort which was treated with Nexium in [State 108] without relief. He had pain at rest. An electrocardiogram showed precordial T wave inversions. The patient was admitted for catheterization. PAST MEDICAL HISTORY: 1. Dyslipidemia. 2. Renal artery stenosis, status post bilateral stents. 3. Peripheral vascular disease, status post stents to bilateral iliacs, femoral. 4. Hypertension. 5. Cerebrovascular accident in [2095], with right leg numbness, weakness and dysarthria. 6. Left carotid artery occlusion. MEDICATIONS ON ADMISSION: 1. Enteric Coated Aspirin 325 mg q.d. 2. Norvasc 10 mg q.d. 3. Lasix 20 mg q.o.d. 4. Pravachol 20 mg q.d. 5. Labetalol 100 mg b.i.d. 6. Terazosin 2 mg q.h.s. At the outside hospital, the patient was started on: 1. Lovenox 60 mg subcutaneous b.i.d. 2. Norvasc increased to 12.5 mg q.d. HOSPITAL COURSE: The patient was admitted to the Medical service for radiologic catheterization. This revealed a 70 to 80% distal left main with normal ejection fraction lesion. He was evaluated for a bypass graft. On [2111-6-13], the patient underwent coronary artery bypass graft times two with left internal mammary artery to left anterior descending and saphenous vein graft to OM. He tolerated the procedure well and was transferred to the CSRU in intubated condition. He was extubated on postoperative day one. It was noted on postoperative day two that his creatinine had risen to 2.2 from a baseline of 1.6. Renal consultation was obtained, and the impression was a prerenal mild acute renal failure. He was started on a Dopamine infusion. On postoperative day three, he developed atrial fibrillation. He was started on Amiodarone. His creatinine continued to rise over the next day. On postoperative day four, his creatinine started trending down again. He continued to be in atrial fibrillation at this time. He was started on Heparin infusion for the atrial fibrillation. He was transferred to the floor on postoperative day five. At this point, he had converted back into normal sinus rhythm. His Heparin infusion was continued for some time. It was then discontinued. His pacing wires were discontinued on postoperative day six. He was ready for discharge on postoperative day seven in stable condition. He will be discharged home. MEDICATIONS ON DISCHARGE: 1. Aspirin Enteric Coated 325 mg q.d. 2. Lopressor 25 mg p.o. b.i.d. 3. Colace 100 mg b.i.d. 4. Lasix 20 mg q.d. times one week. 5. Potassium Chloride 20 mEq q.d. times one week. 6. Percocet one to two tablets q4-6hours p.r.n. 7. Amiodarone 400 mg q.d. 8. Pravachol 20 mg q.d. CONDITION ON DISCHARGE: Stable. DISPOSITION: To home. FO[Last Name (STitle) ]P: With primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 41882], in two weeks and with Dr. [Last Name (Prefixes) ] in four weeks. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 2209] MEDQUIST36 D: [2111-6-19] 17:30 T: [2111-6-20] 19:55 JOB#: [Job Number 41883] ICD9 Codes: 4111, 5845, 4439, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8454 }	Medical Text: Admission Date: [2196-2-8] Discharge Date: [2196-2-15] Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This is a 79-year-old white male patient with recent onset of substernal chest pain radiating to both arms several times a week. He was referred for an exercise tolerance test, which was markedly positive and referred for cardiac catheterization. This showed 70% ostial LAD lesion as well as a 90% right coronary, and normal left ventricular ejection fraction. Echocardiography revealed aortic stenosis with an aortic valve area of 1.5 and some moderate pulmonary hypertension as well. He was referred for coronary artery bypass grafting as well as aortic valve replacement. PAST MEDICAL HISTORY: 1. Rheumatoid arthritis predominantly in his knees. 2. Hypertension. PREOPERATIVE MEDICATIONS: 1. Arava 20 mg p.o. q.d. 2. Prednisone 5 mg alternating with 10 mg every other day. 3. Prevacid 30 mg p.o. q.d. 4. Enteric-coated aspirin 325 mg p.o. q.d. 5. Toprol XL 100 mg p.o. q.d. 6. Sulfasalazine 1000 mg b.i.d. ALLERGIES: Patient states allergy to penicillin, which causes hives as well as ACE inhibitors elicit a cough. PHYSICAL EXAMINATION UPON ADMISSION: Unremarkable. LABORATORY VALUES: Unremarkable. HOSPITAL COURSE: Patient was admitted directly to the preoperative holding area, and taken to the operating room on [2196-2-8], where he underwent an aortic valve replacement with a #21 mm [Last Name (un) 3843]-[Doctor Last Name ] pericardial valve as well as coronary artery bypass graft x3 with a LIMA to the LAD, saphenous vein to the OM, and saphenous vein to the PDA. Postoperatively, the patient was transported from the operating room to the Cardiac Surgery Recovery Unit in good condition on propofol drip. He had also received milrinone in the operating room, but was not ultimately placed on a drip. Postoperative day of surgery into postoperative day one, he was weaned from mechanical ventilation and successfully extubated. He had some anemia, which was treated with blood transfusions. He wound up on a nitroglycerin IV drip and had received some fluid boluses. On postoperative day one, the patient was weaned off his nitroglycerin and started on oral beta-blockers. However, remained a big hypertensive and was given some hydralazine. On [2-10], postoperative day two, the patient had some difficulties with rapid atrial fibrillation with rates to the 120s, which this was treated with IV Lopressor with success in control of the heart rate. On the following day, the patient converted to junctional rhythm and then ultimately to normal sinus rhythm and sinus bradycardia at times with the lowest rate in the 50s. The patient was asymptomatic at that time. He had brief periods of being atrially paced due to bradycardia, although he was not symptomatic. Patient's Lopressor and amiodarone, which had been started previously due to his rapid atrial fibrillation were decreased in dose and the patient remained hemodynamically stable throughout. He also had some postoperative problems with nausea and vomiting, which have subsequently resolved. On postoperative day four, patient remained hemodynamically stable and was transferred from the Cardiac Surgery Recovery Unit to the telemetry floor. Physical Therapy was initiated. The patient began to participate in cardiac rehabilitation and begun ambulation. Patient has remained in normal sinus rhythm without subsequent atrial fibrillation. Patient also had some difficulty urinating after his Foley catheter had been removed on postoperative day three. Foley catheter was reinserted. He was started on Flomax 0.4 mg p.o. q.d. and after another 48 hours, the Foley catheter was removed and he was able to urinate adequately at that time. Patient has continued to progress well from a cardiac rehabilitation standpoint. He is ambulating independently. Remains stable and ready to be discharged home today on postoperative day seven. His status today is as follows: Temperature 97.5, pulse 69 in normal sinus rhythm, respiratory rate 18, blood pressure 145/68, room air oxygen saturation is 96%. His weight today is 79 kg, his preoperative weight was 77 kg. His most recent laboratory values are from [2196-2-14], which revealed a white blood cell count of 10.5 thousand, hematocrit of 29.2, and a platelet count of 198. Sodium 144, potassium 4.0, chloride 106, CO2 31, BUN 30, creatinine 1.2, and glucose 100. Patient's most recent chest x-ray was from [2196-2-12], which showed no pneumothorax and no pleural effusion. Minor linear left lower lobe atelectasis, otherwise normal chest x-ray. DISCHARGE MEDICATIONS: 1. Flomax 0.4 mg p.o. q.d. 2. Amlodipine 5 mg p.o. q.d. 3. Prevacid 30 mg p.o. q.d. 4. Prednisone 5 mg p.o. every other day alternating with prednisone 10 mg p.o. every other day. 5. Amiodarone 200 mg p.o. b.i.d. x1 week, then decreased to 200 mg p.o. q.d. at the discretion of Dr. [Last Name (STitle) 1159], this should be continued until she feels appropriate to discontinue this. 6. Lopressor 50 mg p.o. b.i.d. 7. Lasix 20 mg p.o. b.i.d. x1 week. 8. Potassium chloride 20 mEq p.o. b.i.d. x1 week. 9. Percocet 5/325 one p.o. q.4h. prn pain. 10. Colace 100 mg p.o. b.i.d. 11. Enteric-coated aspirin 325 mg p.o. q.d. 12. Preoperative vitamins and supplements that the patient was taking. He may resume these upon discharge from the hospital. FOLLOW-UP INSTRUCTIONS: The patient is to followup with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 6051] in [12-29] weeks. He is to followup with his cardiologist, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1159] in [12-29] weeks post discharge, and he is to followup with the cardiac surgeon, Dr. [First Name (STitle) ] [Last Name (Prefixes) ] in approximately four weeks. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post coronary artery bypass graft. 2. Aortic stenosis status post aortic valve replacement. 3. Postoperative atrial fibrillation treated with Lopressor and amiodarone. 4. Postoperative urinary retention treated with Flomax. DISCHARGE CONDITION: Good. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Name8 (MD) 964] MEDQUIST36 D: [2196-2-15] 09:42 T: [2196-2-15] 09:45 JOB#: [Job Number 53371] ICD9 Codes: 4241, 9971, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8455 }	Medical Text: Admission Date: [2183-2-10] Discharge Date: [2183-3-3] Date of Birth: [2134-1-2] Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: This dictation reflects the events after the patient was transferred to the medical service. The patient is a 47-year-old woman with AIDS (CD4 positive, T cell count of 3, last viral load of 66,400) and seizures, status post cerebrovascular accident, who has had a long and complicated hospital course including initial intubation in the medical intensive care unit. She was transferred to the neurosurgical intensive care unit for status epilepticus, then to the neurology service and ultimately to the medicine service. The seizures were initially difficult to control. She was placed in a phenobarbital coma and then maintained on phenobarbital afterward. She has active infectious disease issues including methicillin-resistant Staphylococcus aureus pneumonia from the ventilator, for which she was treated with linezolid ultimately; persistence of fevers despite multiple antimicrobial agents. PAST MEDICAL HISTORY: 1. HIV with several opportunistic infections including Pneumocystis carinii pneumonia and esophageal candidiasis. 2. Psoriasis. 3. Status post cerebrovascular accident in the ventral pontine area. 4. Seizure disorder. MEDICATIONS ON PRESENTATION: 1. Keppra 750 mg b.i.d. 2. [Doctor First Name ]. 3. Azithromycin 1 gram once a week. 4. Dapsone. 5. Fioricet. 6. Kaletra. 7. Lamivudine. 8. Stavudine. 9. Variconazole. 10. Norvasc. 11. Sertraline. 12. Zoloft. ALLERGIES: The patient is allergic to sulfur-containing medicines. PHYSICAL EXAMINATION: On transfer to the medical service her temperature was 96.7 with a maximum of 100, heart rate 72, blood pressure 146/89, respiratory rate 20, oxygen saturation 100% on 12 liters. Generally she was in no acute distress. She was thin and weak appearing. Neck: The neck was slightly tender to palpation posteriorly along the band holding her sling to her right arm. Chest: The patient had a right subclavian line upon transfer to the medical service. The entry site was clean, dry and intact. Lungs: Clear to auscultation bilaterally. Heart: Regular rate and rhythm, normal S1 and S2, no extra sounds. Abdomen: Soft, slightly decreased bowel sounds, nontender, distended. Extremities: Her right arm was in a sling. Neurologic: The patient had a waxing mental status. She would recognize occasionally the people in her room, however there were times when she did not. She had hyperprosodic speech. She was able to follow some commands. LABORATORY DATA: White blood cell count was 7.4, hematocrit 37.4, platelet count 266. Chemistry panel was sodium 133, potassium 3.8, chloride 100, bicarbonate 20, BUN 17, creatinine 0.7, glucose 107. HOSPITAL COURSE: Upon transfer to the medical service the patient was continued on the following medications: 1. Linezolid 600 mg IV every 12 hours. 2. Nystatin 5 mg t.i.d. 3. Stavudine 20. 4. Lamivudine 1 tablet q.d. 5. Ritonavir/lopinavir 3 tablets b.i.d. 6. Dapsone 100 mg daily. 7. Azithromycin 1.2 grams every week. 8. Variconazole. 1. Infectious disease: The patient was maintained on her HAART, PCP prophylaxis and [Doctor First Name ] prophylaxis, as well as the antifungal [Doctor Last Name 360] and linezolid as stated above. While no new focal source of infection was identified, she had persistent blood cultures, serial blood cultures for bacteria, fungus and tuberculosis. Interval urinalysis likewise was normal. A panel of extra tests was also done revealing namely that the patient did not have C. difficile toxin present in her stool. She did not have CMV antigen in her blood. RPR and mycoplasma testing were also negative. 2. Seizure disorder: The patient was maintain on phenobarbital 50 mg IV every 12 hours and then switched to 60 mg b.i.d. p.o. For the duration of her hospital course she had no further seizure activity. 3. The patient had a right humerus fracture however she stated that the pain was mostly radiating to her neck under the area of her sling. The pain was readily controlled with occasional use of morphine sulfate solution by mouth as well as intravenously. 4. Hypertension: The patient's hypertension regimen ultimately settled on metoprolol 150 mg by mouth p.o. t.i.d. and amlodipine 5 mg daily. The patient underwent bedside speech and swallow evaluation and it was deemed safe for her to swallow, however she should receive a pureed diet with thick nectar liquids. It was also safe for her to swallow pills. On [2183-2-28] the patient's family stated that they wished to pursue comfort measures only. Intravenous medications were withdrawn and converted to p.o. The patient was encouraged to eat and drink ad lib. DISCHARGE DIAGNOSES: 1. AIDS. 2. Seizure disorder. 3. Hypertension. 4. Right humerus fracture. DISCHARGE MEDICATIONS: 1. Variconazole 200 mg tablets, 1 tablet every 12 hours. 2. Azithromycin 1.2 grams q. Friday. 3. Dapsone 100 mg tablet q.d. 4. Ritonavir/lopinavir 100-400/5 solution, one solution by mouth b.i.d. 5. Lamivudine 150 mg daily. 6. Stavudine 20 mg capsule once daily. 7. Acetaminophen 325 mg every 4-6 hours as needed. 8. Albuterol inhaler 1-2 puffs as needed. 9. Levetiracetam 1,000 mg b.i.d. 10. Amlodipine 5 mg daily. 11. Lorazepam 0.5 mg tablets, 1-4 tablets as needed every four to six hours. 12. Metoprolol 150 mg p.o. t.i.d. 13. Famotidine 20 mg p.o. b.i.d. 14. Phenobarbital 300 mg by mouth twice daily. 15. Morphine sulfate 0.5 to 4 mg by mouth as needed. 16. Nystatin swish and swallow as needed. 17. Ipratropium inhaler as needed. 18. Linezolid 600 mg tablets to complete a 10-day course. DISPOSITION: The patient was transferred to hospice. [Name6 (MD) 7158] [Last Name (NamePattern4) 7159], M.D. [MD Number(1) 102966] Dictated By:[Name8 (MD) 7102] MEDQUIST36 D: [2183-3-3] 08:02 T: [2183-3-3] 08:28 JOB#: [Job Number 108869] ICD9 Codes: 7907, 4019, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8456 }	Medical Text: Admission Date: [2185-8-31] Discharge Date: [2185-9-10] Date of Birth: [2108-5-8] Sex: F Service: SURGERY Allergies: Bactrim / Actonel / Codeine / Synthroid Attending:[First Name3 (LF) 598] Chief Complaint: fatigue, BRBPR Major Surgical or Invasive Procedure: exlap, tumor and small bowel resection History of Present Illness: 77F with PMH significant for previous endometriosis and benign tumor removed from uterus, who presented to [Location (un) 620] ED with GI bleeding and BRBPR. On the day of presentation, she felt fatigued and lightheaded like she was going to syncopize. She also felt increased abdominal pain and bloating. Upon going to the bathroom, she noticed a large amount of bright red blood in the toilet bowel. She called her PCP and was told to go to the [Location (un) 620] ED. There, her initial Hct was 22.8. She received 3 units of packed red blood cells and her Hct came up to 31.2, but then dropped to 26.1. Overnight she was prepped for colonoscopy with a GoLYTELY, but threw most of it up, so spent another day prepping. She still had continuous bleeding through her [Location (un) 1662]. She underwent a colonoscopy on the day of transfer showing continuous bleeding potentially above the ileocecal valve, but was not well-visualized. She had a CTA of the abdomen that showed a uterine mass that could be eroding into the intestinal wall. Patient was transferred here for potential hysterectomy and surgical repair of her small intestine. Of note, patient states she has been feeling more fatigued for the past 3-4 months, and has been worked up by both her PCP here and in [State 108] for anemia. Her [Hospital1 18] notes on anemia do not mention guaiac or GI bleeding. Of the past few weeks, she has also experienced more abdominal distention and pain, which she attributed to weight gain. The patient's last pelvic exam was by a gynecologist in [State 108] in [2185-1-29] and was normal per the patient. . In the ICU, her initial vitals on transfer were T 98.6 HR86 BP133/97 HR17 O2sat 100(RA). She denied shortness of breath, chest pain, or abdominal pain. No dizziness, confusion, does not feel like she's about to faint again. She is on a bed pan and still bleeding a little. Past Medical History: (per OMR) ECTOPIC PREGNANCY - [2138] - REMOVED 1 TUBE ENDOMETRIOSIS ENDOMETRIAL TUMOR - BENIGN - REMOVED ATROPHIC VAGINITIS D&C X 1 FOR EVAL POST MEN BLEEDING - HAD UTERINE POLYPS in [2178] SBO DUE TO ADHESIONS [2175] - RX CONSERVATIVELY CHOLECYSTECTOMY SQUAMOUS CELL CA X2 BASAL CELL CA X2 MACULAR DEGENERATION HYPOTHYROIDISM OSTEOPOROSIS HERPES ZOSTER [2179] HIATAL HERNIA ALLERGIC RHINITIS ROTATOR CUFF TEAR NEGATIVE STRESS TREADMILL TEST [2177] THROMBOCYTOPENIA WRIST INJURY Social History: Married lives with husband - lives in [Name (NI) 108] from [Month (only) 359] to [Month (only) 116] each year. retired from own business - had Kiosk in Fanueil [Doctor Last Name ] - Tobacco: 30 pack yr hx, stopped in 40s - Alcohol: none - Illicits: none Family History: Breast cancer - mother and sister Father had emphysema, asthma Sister and cousin had [Name (NI) 4522] Physical Exam: Admission Physical Exam: Vitals: T:98.6 BP:133/97 P:86 RR:17 SpO2:100(RA) General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: +BS, soft, non-distended, tenderness right of umbillicus, no rebound tenderness or guarding Ext: warm, well perfused, 2+ pulses, trace edema Pertinent Results: Admission Labs: [2185-8-31] 06:17PM WBC-9.0 RBC-3.62* HGB-10.9* HCT-31.1* MCV-86 MCH-30.0 MCHC-35.0 RDW-16.4* [2185-8-31] 06:17PM NEUTS-69.5 LYMPHS-23.4 MONOS-6.1 EOS-0.7 BASOS-0.3 [2185-8-31] 06:17PM PT-13.0 PTT-24.0 INR(PT)-1.1 [2185-8-31] 06:17PM CALCIUM-8.2* PHOSPHATE-2.0* MAGNESIUM-2.3 [2185-8-31] 06:17PM GLUCOSE-90 UREA N-9 CREAT-0.4 SODIUM-144 POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-22 ANION GAP-16 . [Hospital3 ]: Hct trend: . Microbiology: . Imaging: [2185-8-31] CT ABDOMEN AND PELVIS: ABDOMEN: There are several subcentimeter hypodense lesions in both lobes of the liver. These are too small to accurately characterize by CT. The left hepatic duct and common hepatic and common bile duct are moderately dilated down to the level of the sphincter of Oddi. No obstructing lesion is identified. The patient is status post cholecystectomy. The pancreas, spleen, and adrenal glands are unremarkable. There are bilateral circumscribed hypodense lesions in the kidneys consistent with cysts. Almost all of these are too small to accurately characterize by CT. No lymphadenopathy is apparent. PELVIS: The uterus is markedly enlarged and has an irregular lobulated contour. Its density is very inhomogeneous. Overall, it measures 17.2 cm longitudinal x 10.4 cm transverse x 9.5 cm AP. Endometrium is not delineated. There is a short segment of small bowel abutting the uterine fundus that demonstrates some ill-defined hyperemia or active bleeding. A cluster of numerous surgical clips in the right pelvic adnexa. The bladder is distended. No lymphadenopathy is apparent. The ureters are mildly prominent. Abdominal and pelvic wall structures are intact. No osteolytic or osteoblastic lesion is noted. IMPRESSION: ABNORMAL ENLARGED UTERUS AS DESCRIBED. FINDINGS ARE SUSPICIOUS FOR MALIGNANT NEOPLASM SUCH AS LEIOMYOSARCOMA OR ENDOMETRIAL CARCINOMA. THERE IS AN ADJACENT SHORT LOOP OF ABNORMAL SMALL BOWEL. ITS ENHANCEMENT SUGGESTS POSSIBLE INVASION BY TUMOR AND THERE [Month (only) ] BE ACTIVE BLEEDING AT THIS SITE. . MRI Pelvis w/ and w/o contrast: Large, heterogeneously enhancing, multilobulated mass within the pelvis, with central areas of necrosis and focal hemorrhage. Given its large size, its relationship to adjacent structures is difficult to discern. However, it appears to displace, rather than arise from, the uterus. It is intimately associated with and inseparable from a distal loop of small bowel. Given this relationship to the small bowel and its appearance, this is thought most likely to represent a small bowel GIST. While neither ovary is seen, this is thought less likely to be ovarian in origin given only the trace amount of free fluid and no evidence of metastatic disease within the pelvis. Discharge Labs: [2185-9-9] 11:00AM BLOOD Hct-29.1* [2185-9-6] 06:10AM BLOOD WBC-4.1 RBC-2.61* Hgb-8.4* Hct-24.2* MCV-93 MCH-32.1* MCHC-34.7 RDW-17.7* Plt Ct-210 Pathology: Small bowel, segmental resection: Atypical spindle and focally epithelioid neoplasm (13.5 cm in greatest dimension), consistent with gastrointestinal stromal tumor of high malignant potential; see note. Nine mesenteric lymph nodes with no tumor seen (0/9). Note: The tumor demonstrates a predominantly spindle cell pattern arranged in irregular fascicles, with focally epithelioid areas and foci of prominent necrosis. Tumor nuclei demonstrate areas of marked pleomorphism with coarse chromatin and irregular nuclear contours. Immunohistochemical stains of the tumor are diffusely, strongly positive for C-kit, focally, weakly positive for actin, and negative for desmin and S-100, consistent with a gastrointestinal stromal tumor (GIST) immunophenotype. Mitoses number greater than 15 per 50 high power fields and frequent tumor cell apoptosis is identified. The tumor size of greater than 10 cm and mitotic activity of greater than 15 per 50 high power fields confer a high risk of malignant potential The tumor appears to arise within the muscularis propria, but extensively involves the submucosa and subserosa, with focally marked attenuation of the overlying mucosa, and the exact layer of origin is difficult to discern; definitive mucosal invasion by tumor cells is not identified. The tumor is received partially disrupted, precluding definitive evaluation of the serosal surface for invasion in these areas. Where evaluable in non-disrupted areas, however, a thin (from <1 mm to 3 mm) rim of serosal tissue is present along the external surface. Brief Hospital Course: 77F with PMH significant for previous endometriosis and s/p benign uterine tumor removal, who presented to [Location (un) 620] ED with GI bleeding and BRBPR, found on colonoscopy to have bleeding from above the ileocecal valve, and on CTA to have a uterine tumor impinging on small bowel at OSH and she was transferred to [Hospital1 18] [Hospital Unit Name 153] . MRI pelvis here demonstrated that the primary mass was actually in the small bowel abutting the uterus. . #. Lower GI bleeding. Source of bleed appeared by [Location (un) 620] colonoscopy to be from above the ileocecal valve. Based on CTA at [Location (un) 620], there was suspicion for uterine tumor eroding into small bowel leading to GI bleeding. On arrival to [Hospital Unit Name 153], Hct was stable (at 31.1, up from 26 which was the last [Location (un) 1131] prior to transfer from [Location (un) 620]). Hemactocrits were checked every 6 hours. She was transfused 1 more unit of PRBCs on [8-31] for Hct 26. Gynecology and general surgery were consulted for managment of the tumor. Tumor markers were sent, CEA, CA [93]-9 and CA125 all came back normal. An MRI of the pelvis demonstrated that the primary tumor was in the small bowel and was abutting but not invading the uterus. Throughout the [Hospital Unit Name 153] course, patient was not lightheaded and did not have melena. Patient was then transferred to surgery service. . # Hypertension. The patient has hx of hypertension. Antihpertensive medications were held in the setting of active GI bleed. . #Hypothyroidism. Continued levothyroxine. . #Hx of [Doctor First Name ]. Patient has chronic cough from [Doctor First Name ] and followed by [Hospital1 ] pulmonology. Continued home guaifenasin and [Hospital1 ]. . The patient had a stable course on the floor. Her foley was d/c'd on POD #6 mostly due to patient anxiety about having to void on her own. Her pain was well controlled on PO Diluadid. She received HSQ for prophylaxis and encouraged to ambulate on her own. At the time of discharge on POD#8, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, passing gas and pain was well controlled. Medications on Admission: CLONAZEPAM - 1 mg PO daily ESTRADIOL [ESTRACE] 0.01 % Cream twice weekly LEVOTHYROXINE - 50 mcg PO daily MOM[Name (NI) ] [Name2 (NI) 4010] 100/50 Tessalon pearls NORTRIPTYLINE 10 mg PO qhs OMEPRAZOLE 40 mg po daily VAGIFEM weekly ZOLPIDEM 10 mg PO qhs PRN MVI CALCIUM 600 2X DAILY WITH 400 IU VIT D PER PILL VIT C OCCUVITE B12 VIT D [2174] IU QD Fish oil 1000mg Discharge Medications: 1. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:80 Tablet(s) Refills:0 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 5. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for before bed. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: GIST tumor Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the acute care surgery service for exploratory laparotomy for removal of a GIST tumor and a portion of small bowel. Since you have had an abdominal operation, this sheet goes over some questions and concerns you or your family may have. If you have additional questions, or [Male First Name (un) ]??????t understand something about your operation, please call your [Male First Name (un) 5059]. ACTIVITY: Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. You may climb stairs. You may go outside. But avoid traveling long distances until you see your [Male First Name (un) 5059] at your next visit. [Male First Name (un) ]??????t lift more than 20-25 pounds for 6 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. You may start some light exercise when you feel comfortable. You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. You may resume sexual activity unless your doctor has told you otherwise. HOW YOU [Month (only) ] FEEL: You may feel weak or ??????washed out?????? for 6 weeks. You might want to nap often. Simple tasks may exhaust you. You may have a sore throat because of a tube that was in your throat during surgery. You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. You could have a poor appetite for a while. Food may seem unappealing. All these feelings and reactions are normal and should go away in a short time. If they do not, tell your [Month (only) 5059]. YOUR INCISION: Your incision may be slightly red around the area where staples were. This is normal. You may gently wash away dried material around your incision. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that, it??????s OK. It is normal to feel a firm ridge along the incision. This will go away. Avoid direct sun exposure to the incision area. Do not use any ointments on the incision unless you were told otherwise. You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your [Month (only) 5059]. You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. Over the next 6-12 months, your incision will fade and become less prominent. YOUR BOWELS: Constipation is a common side effect of medicine such as Percocet or codeine. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as Milk of Magnesia, 1 tablespoon) twice a day. You can get both of these medicines without a prescription. Do not worry if you see blood with your first bowel movement. This is normal. After some operations, diarrhea can occur. If you get diarrhea, [Male First Name (un) ]??????t take anti-diarrhea medicines. Drink plenty of fluids and see if it goes away. If it does not go away, or is severe and you feel ill, please call your [Male First Name (un) 5059]. PAIN MANAGEMENT: It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as ??????soreness.?????? Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your [Name2 (NI) 5059]. You will receive a prescription from your [Name2 (NI) 5059] for pain medicine to take by mouth. It is important you take this medicine as directed. Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. Your pain medicine will work better if you take it before your pain gets too severe. Talk with your [Name2 (NI) 5059] about how long you will need to take prescription pain medicine. Please [Male First Name (un) ]??????t take any other pain medicine, including non-prescription pain medicine, unless your [Male First Name (un) 5059] has said it is OK. If you are experiencing no pain, it is OK to skip a dose of pain medicine. To reduce pain, remember to exhale with any exertion or when you change positions. Remember to use your ??????cough pillow?????? for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your [Name2 (NI) 5059]: sharp pain or any severe pain that lasts several hours pain that is getting worse over time pain accompanied by fever of more than 101 a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. In some cases, you will have a prescription for antibiotics or other medication. If you have any questions about what medicine to take or not to take, please call your [Name2 (NI) 5059]. DANGER SIGNS: Please call your [Name2 (NI) 5059] or go to the emergency room if you develop: Worsening abdominal pain Sharp or severe pain that lasts several hours Temperature of 101 degrees or higher Severe diarrhea Vomiting Redness around the incision that is spreading Increased swelling around the incision Excessive bruising around the incision Cloudy fluid coming from the wound Bright red blood or foul smelling discharge coming from the wound An increase in drainage from the wound Followup Instructions: Call the Acute Care Clinic at [Telephone/Fax (1) 600] upon discharge to arrange a follow up appointment in [3-3] weeks. Office is located at [Hospital1 18], [Hospital 2577] Medical Office Building, [Location (un) ]. [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601] Completed by:[2185-9-10] ICD9 Codes: 2449, 2875, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8457 }	Medical Text: Admission Date: [2144-9-2] Discharge Date: [2144-9-11] Date of Birth: [2077-8-14] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4748] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Thoracoabdominal aneurysm repair History of Present Illness: 66M c severe diffuse abdominal pain. Patient had dialysis during the day and at the end of the hemodialysis, patient complained on severe abodminal pain. Sudden onset around umbilicus radiating to the back. Patient went to the OSH where they obtained a CT of abdomen that showed aortic aneurysm concerning for rupture. He was then transferred to [Hospital1 18]. Past Medical History: ESRD CAD HTN PVD AAA Physical Exam: HR 85 BP 210/70 RR16 98% on 4L Alert and oriented x1 RRR decreased bs at base soft, diffusely tender, moderately distended, + rebound, + guarding + fem palses Pertinent Results: [2144-9-2] 10:33PM BLOOD WBC-25.5# RBC-4.06 Hgb-12.2* Hct-36.7* MCV-91 MCH-30.0 MCHC-33.2 RDW-16.6* Plt Ct-366 [2144-9-2] 10:33PM BLOOD PT-11.6 PTT-22.2 INR(PT)-0.9 [2144-9-3] 03:45AM BLOOD Fibrino-244 [2144-9-2] 10:33PM BLOOD Glucose-211* UreaN-45* Creat-6.6* Na-136 K-4.9 Cl-95* HCO3-25 AnGap-21* [2144-9-2] 10:33PM BLOOD CK(CPK)-21* [2144-9-2] 10:33PM BLOOD CK-MB-NotDone cTropnT-0.04* [2144-9-3] 03:45AM BLOOD Calcium-9.9 Phos-6.7# Mg-2.3 [2144-9-3] 12:19AM BLOOD Type-ART pO2-438 pCO2-41 pH-7.37 calHCO3-25 Base XS--1 Intubat-INTUBATED Vent-CONTROLLED [2144-9-2] 10:42PM BLOOD Glucose-205* Lactate-3.0* Na-137 K-5.1 Cl-96* c08/01/05 8:40 pm BRONCHOALVEOLAR LAVAGE FINAL REPORT [2144-9-9] GRAM STAIN (Final [2144-9-8]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2144-9-9]): ~5000/ML OROPHARYNGEAL FLORA. PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CIPROFLOXACIN--------- 2 I GENTAMICIN------------ <=1 S IMIPENEM-------------- 8 I MEROPENEM------------- 0.5 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S alHCO3-30 Brief Hospital Course: Patient was emergently taken to the operating room and he underwent thoracoabdominal aneurysm repair. Post operatively patient was taken to ICU for recovery. By systems: Neuro - Patient did not move his bilateral lower extremities nor the right upper extremity. Patient underwent CT of the head which did not show any signs of stroke. Per neurology recommendations we planned to obtain an MRI of the spine which we were unable to obtain due to his poor cardiac fuction. CV - Patient continued to require pressors. Towards the end of his hospital stay he had required three different pressors to maintain adequate blood pressue. Resp - He developed pseudomonas pneumonia which required increased ventilatory support and broad spectrum antibiotics. He was never weened from the full ventilatory support GI - He was kept NPO due to development of gut ischemia. Patient had bloody bowel movements and a sigmoidoscopy that showed ischemic colon. He was supported with fluids and TPN. Renal - Patient was placed on CVVHD. He was too unstable for HD. ID - Patient had rising WBC to 59 prior to expiration. He was on broad spectrum antibiotics and he was pan cultured throughout the hospital stay. Heme - He maintained his hct throughout but he developed thrombocytopenia during the hospital stay. His HIT was negative. Endo - Patient was on insulin drip at times to control his blood sugar. Patient developed multi organ failure on last hospital day. After a long discussion with the family. Patient was made DNR then CMO. Patient expired at 8:25 pm on [2144-9-11]. Family was present at the time of death. Medications on Admission: Imdur, Calcitral, Lexapro, Norvasc, Iron, Atenolol, Protonix, Nephrocaps, Tums Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: ruptured abdominal aortic aneurysm peripheral vascular disease coronary artery disease Discharge Condition: Death Completed by:[2144-9-11] ICD9 Codes: 5185, 2875, 0389, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8458 }	Medical Text: Admission Date: [2101-9-16] Discharge Date: [2101-9-19] Date of Birth: [2039-3-23] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1580] Chief Complaint: bright red blood per rectum Major Surgical or Invasive Procedure: none History of Present Illness: 62 yo male with Hep C cirrhosis and HCC who presented to OSH today after noting several weeks of worsening abd girth and associated diffuse pain, as well as new lower extr edema. The pt also experienced two episodes of BRBPR on the day of admission, which is what prompted him acutely to seek medication attention. Pt's HCT at the OSH was found to be 29 (unclear baseline) and he was noted to be hypotensive with an SBP first in the 80s-90s (close to baseline per pt) and then lower to the 70s. The pt was started on a dopamine gtt to support his BP and was transferred to [Hospital1 18] for further care. In the [Hospital1 18] ED, initial vitals were HR 98, R 16, 92/58, 96% RA. The pt had an NG levage which was negative and a transfusion of 2 units pRBCs was initiated. On ROS, the endorses occasional chills but no fevers. No chest pain or SOB. Abd pain as above but no nausea or vomiting. No urinary sxs. Blood per rectum as described above but otherwise no change in stool. No neuro or MSK sxs. Past Medical History: Hep C complicated by HCC CAD s/p LAD stenting and ICD impant COPD, 35 pack year smoking hx psoriasis Social History: Former construction worker, now diabled. Prior smoker. Denies EtOH. Family History: Pt is adopted and thus not aware of FH. Physical Exam: Gen: Adult male, chronically ill appearing but no acute distress. HEENT: PERRL, EOMI. MMM. Conjunctival icterus. Neck: Supple, without adenopathy or JVD. No tenderness with palpation. Chest: CTAB anterior and posterior. Cor: Normal S1, S2. RRR. No murmurs appreciated. Abdomen: Firm and distended with minimal diffuse tenderness. +BS, no HSM. Extremity: Warm, pitting edema to mid thighs bilat. 2+ DP pulses bilat. Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact in all extremities. Sensation intact grossly. Pertinent Results: [2101-9-16] 08:21PM WBC-11.5* RBC-3.18* HGB-9.8* HCT-29.6* MCV-93 MCH-30.9 MCHC-33.2 RDW-19.2* [2101-9-16] 08:21PM GLUCOSE-70 UREA N-87* CREAT-4.2* SODIUM-130* POTASSIUM-6.4* CHLORIDE-98 TOTAL CO2-13* ANION GAP-25* . CT Abd/Pelvis 1. Very limited examination due to no IV contrast and a minimal amount of oral contrast within loops of bowel. No CT findings to suggest obstruction. Gas-filled loops of large bowel, predominantly the transverse may suggest ileus. 2. Diffusely heterogeneous and enlarged liver consistent with patient's known cirrhosis and multifocal HCC. Mild-to-moderate amount of ascites within the abdominal cavity. 3. Atherosclerotic disease within the coronary circulation and aorta. 4. Known left renal cyst. 5. Small bilateral pleural effusions. Mild ascites. . Abd Ultrasound 1. Multiple confluent nodules in the right lobe of the liver. Multiple confluent solid masses identified in the left lobe of the liver. The liver is markedly enlarged but no biliary dilatation. 2. Patent hepatic vasculature. Brief Hospital Course: The pt was admitted to the medical ICU for closer care and monitoring. Although initial attempts were made to wean him from the dopamine he had arrived with, his pressor requirements actually increased, his renal failure worsened and his overall clinical status deteriorated. Radiologic evaluation of the abdomen demonstrated a markedly enlarged liver but no ascites that could be tapped. With clinical deterioration, the pt's mental status also declined. He and his family members made clear that he would not want aggressive measures to prolong his life in the face of a poor overall prognosis, and thus the pt's goals of care were transitioned to comfort. Pressors were stopped and morphine was used to relieve the pt's abdominal pain. Approximately one day after making this transition, the patient expired with his family at his side. The pt's PCP and oncologist were notified of his passing. An autopsy was declined. Medications on Admission: spironolactone 25 mg daily Coreg 3.125 mg [Hospital1 ] trazodone 50 mg daily Lipitor 80 mg daily Altace 5 mg [Hospital1 ] Plavix 75 mg daily Advair daily Spiriva daily Requip 2 mg daily Oxycodone 20 mg PRN Ativan 0.5 mg PRN Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: liver failure hepatocellular carcinoma renal failure Discharge Condition: expired [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1583] MD, MSC, MPH[MD Number(3) 1584] ICD9 Codes: 5849, 2762, 2761, 5715, 4280, 2767, 4589, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8459 }	Medical Text: Admission Date: [2104-2-22] Discharge Date: Date of Birth: [2104-2-22] Sex: F Service: NB HISTORY: Baby Girl [Known lastname 20948] is admitted to NICU for management of respiratory distress. She was born at 11:34 on [2-22] by Cesarean section at 36 weeks secondary to concern for placenta accreta on a 39-year-old, G2, P1, now 2 mom who is B positive, antibody negative, rubella immune hepatitis negative, RPR nonreactive, GBS unknown. Pregnancy was unremarkable except for placenta previa and concern for accreta. The baby was initially vigorous requiring only drying and suctioning in the OR. Apgars were 9 and 9. The patient began grunting at two hours of life and was brought to the NICU. PHYSICAL EXAMINATION ON DISCHARGE: SUMMARY OF HOSPITAL COURSE: Respiratory. After being admitted to the NICU, the patient required nasal cannula which was started at 250 mL at 100% 02 and was weaned down to room air by day of life four. Cardiology. The patient was hemodynamically stable throughout the hospital course and required no central lines. Fluids/Electrolytes/Nutrition. The patient was made initially NPO for tachypnea but was started on oral and gavage feeds on day of life three. She progressed to full oral feeds uneventfully. GI. The patient's max bilirubin was 8.4. Hematology. The patient had an initial hematocrit of 55.7. She did not receive any blood products. Infectious Disease. The patient had a white blood cell count on admission of 15.6, 62% polys, 5 bands. The patient was started on ampicillin and gentamicin. Blood cultures were sent which were negative and antibiotics were discontinued after 48 hours. Neurology. Head ultrasound was not indicated due to advanced gestational age of 36 weeks. Sensory. Audiology hearing scan was performed by Automated Auditory Brain Stem Responses. Results are normal bilaterally. Ophthalmology. Not examined due to patient's advanced gestational age. CONDITION AT DISCHARGE: Stable. DISCHARGE DISPOSITION: Home. NAME OF PRIMARY CARE PEDIATRICIAN: Dr. [Last Name (STitle) ] in [Location 51312]. CARE/RECOMMENDATIONS: Feeds. Continue ad lib PO feeds of 20 calorie or breast milk. Medications. No medications other than iron and vitamin D supplementation. Iron supplementation is recommended for preterm and low birth weight infants to 12 months' corrected age. All infants fed predominant breast milk should receive vitamin D supplementation of 400 international units, may be provided as multivitamin daily until 12 months' corrected age. Car seat. Car seat positional stability screening was passed prior to discharge date. Newborn screening was sent on [2-/2025]. Immunization. The patient received hepatitis B vaccination on [2-28]. Synagis. RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infant to meet the following criteria. (1) born less than 32 weeks' gestation, (2) born between 32 and 35 weeks with two of the following, daycare during RSV season, smoking, or have sudden neuromuscular disease, airway abnormalities, or school age sibling, (3) chronic lung disease, or (4) hemodynamically significant CHD. Influenza immunization is recommended yearly in the fall for all infants once they reach six months of age, and for household contacts and at home caregivers. This infant has not received the rotavirus vaccine by the American Academy of Pediatrics. Recommend initial vaccination of pre-term infants at or following discharge from the hospital if they are clinically stable or at least 6 but fewer than 12 weeks of age. The patient will require a hip ultrasound at 44 weeks corrected age due to breech position, female gender, and family history of significant developmental dysplasia of the hip in her sibling. DIAGNOSES: 1. Respiratory distress. 2. Rule out sepsis. 3. Breech. Reviewed By: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 53043], [MD Number(1) 53044] Dictated By:[Last Name (NamePattern1) 76457] MEDQUIST36 D: [2104-3-7] 17:44:05 T: [2104-3-7] 18:32:27 Job#: [Job Number 77876] ICD9 Codes: 769, V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8460 }	Medical Text: Admission Date: [2158-2-27] Discharge Date: [2158-3-6] Date of Birth: [2109-1-23] Sex: F Service: MEDICINE Allergies: Shellfish / Flexeril / Tricyclic Compounds Attending:[First Name3 (LF) 12174] Chief Complaint: Hypoglycemia Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Known lastname 68459] is a 49 year old female with history of Hep C Cirrhosis, currently listed for transplant with history of previous decompensation in way of encephalopathy and ascites requiring TIPS, with additional med history pertinent for secondary adrenal insufficiency, and DM who now presents from her chronic care facility. The patient was found unresponsive yesterday a.m. with fingerstick at that time of 8 and question of seizure activity at that time. The patient was transported to [Hospital3 ] where a CT Head was performed without evidence of bleed or acute intracranial pathology. The patient was transferred to [Hospital1 18] for further care. . ED Course: In the ED vitals were 94.2 HR-81 BP- 110/55 RR: 20 O2: 100% NRB. The patient has labs performed revealing no leukocytosis or bandemia. A CXR was performed revealing for new RLL consolidation. A [Name (NI) 5283] sono and abdominal ultrasound was performed revealing no ascites present. Fingerstick was 142. The patient received Levo/Zosyn/Vanc and is now transferred to the ICU for ongoing monitoring and care. . Patient being transferred to [Doctor Last Name 3271] [Doctor Last Name ] service, upon questioning patient is sleepy but arousable. She reports some back pain which is her baseline but otherwise has little complaints. On questioning she reports her breathing is comfortable, has been coughing little more than usual green sputum. She took 32 units of Glargine 2 nights ago per her usual regimen, reports she ate meals that night. She does not recall the exact events surrounding her event this a.m. and altered mental status. She was put on vanc and unasyn for consideration aspiration and ha-pna. Also put on stress dose steroids. Baseline bp 100-110. Stress dose steroids initially 50 q6 and decreased to 25 q6 currently. . On admit to the floor pt. near baseline mental status. Has NG tube and getting lactulose--> stooling a lot. HD stable and transferred to floor. Past Medical History: # HCV cirrhosis: - complicated by encephalopathy, thrombocytopenia, ascites and hydrothorax. - s/p TIPS [11-9] for ascites - currently On transplant list #. Hyponatremia baseline 128-133 #. Secondary Adrenal insufficiency: should receive stress dosed steroids when appropriate - microadenoma on MRI, prolactin elevated #. Asthma #. DM #. GERD #. Anxiety #. Recent ICU admission with intubation thought [1-7] transfusion-related acute lung injury. Led to prolonged ICU stay then rehab. Also treated for PNA #. h/o UTIs #. Hip fx and L4 compression fx on [2157-11-6] s/p ORIF of hip fx Social History: The patient is single with one child, she currently lives in a chronic care facility, [Hospital1 ] [Hospital1 3894] Nursing Facility in [Location (un) 29158]. She is currently on disability, formerly a waitress. Illicits: Past IV drug use with needle sharing, last use 7 years ago. Past drug-snorting. Alcohol: Past alcohol use, last drink at age 46. Tobacco: Past [Location (un) 1818] with 10 pack-year history Family History: Mother w/ DM2, HTN, and hyperlipidemia. Father w/ COPD and EtOH cirrhosis Physical Exam: VITALS: 97.1 122/56 88 18 97% on RA GEN: Patient is a middle aged female, appears older than stated age, jaundiced skin. Patient is lethargic but arousable, answers questions but need to keep awakening to hold attention. Oriented to person place and year. Knows why she is here. HEENT: NCAT, EOMI, sclera icteric. PERRL, OP clear, NGT in place NECK: JVP wnl LUNGS: Relatively clear anteriorly, bibasilar crackles Cor: II/VI SEM loudest at apex ABD: Obese, soft, nt/nd, bs+, live tip palpable just below costal margin. spleen tip not palpable EXT: 1+ LE non pitting edema to knees, mild diffuse erythema likely secondary to venous stasis Pertinent Results: [2-27] CXR IMPRESSION: AP chest compared to [2-27] and [2157-11-10]: Moderate cardiomegaly has increased since [Month (only) 1096]. Elevation of the left hemidiaphragm and ipsilateral basal atelectasis are stable. Increased opacification at the right lung base could be dependent edema but is concerning for pneumonia, unchanged since [59]:07 a.m. Small right pleural effusion is probably present. Nasogastric tube ends in the stomach, which is distended with air. -------------------- [3-3] CXR FINDINGS: In comparison with the study of [2-27], the patient has taken a somewhat better inspiration. Continued fullness of pulmonary vessels is consistent with overhydration and increased pulmonary venous pressure. There is increased opacification at both bases, consistent with pleural fluid and atelectatic change. The nasogastric tube has been removed. [3-5] u/s LEFT UPPER EXTREMITY ULTRASOUND: Grayscale and color Doppler son[Name (NI) 1417] of the left internal jugular, subclavian, axillary, brachial, and basilic veins was performed. The cephalic vein was not visualized. In the visualized veins there was normal flow, augmentation, compressibility, and waveforms demonstrated. No intraluminal thrombus was identified. IMPRESSION: No evidence of left upper extremity deep vein thrombosis. Cephalic vein not seen. d/c labs [2158-3-6] 04:23AM BLOOD WBC-4.6 RBC-2.94* Hgb-10.2* Hct-30.0* MCV-102* MCH-34.6* MCHC-33.9 RDW-19.3* Plt Ct-30* [2158-3-6] 04:23AM BLOOD Glucose-86 UreaN-13 Creat-0.6 Na-134 K-4.1 Cl-99 HCO3-31 AnGap-8 [2158-3-6] 04:23AM BLOOD ALT-36 AST-64* LD(LDH)-274* AlkPhos-214* TotBili-6.4* [2158-3-6] 04:23AM BLOOD Calcium-7.9* Phos-3.7 Mg-1.5* Brief Hospital Course: A/P: 49 y/o F h/o HCV cirrhosis, currently on transplant list, who presented with unresponsive episode and ? seizure episode 2 days prior in setting of hypoglycemia to 8, found to have RLL consolidation identified on CXR c/w pneumonia. Currently patient's mental status back at baseline. . # Altered mental status Long h/o admissions for somnolence secondary to hepatic encephalopathy although more likely etiology this admission would be hypoglycemia given documented low blood sugar in combination with underlying hepatic encephalopathy. Etiology for hypoglycemia itself not clear given no change in meds, diet, hepatic function. Possibly related to underlying pneumonia and adrenal insufficiency. Her mental status was back to baseline at time of discharge, alert and oriented times three. She is to continue with lactulose and rifaximin for hepatic encephalopathy. . #. DM Patient was previously on Lantus 36 units. She was placed on sliding scale to determine her insulin requirements. She had no hypoglycemic episodes as an inpatient. Her dose of Lantus was 34 units at the time of discharge and her fingersticks were running between 70-180. Of note she has been on a strict diabetic and low sodium diet so her Lantus requirements may need to be increased at her rehab facility. She is on a Humalog insulin sliding scale. . # PNA RLL consolidation, clinically afebrile without leukocytosis. Given chronic illness and aspiration risk was treated with Unasyn and Vancomycin given she came from a chronic care facility. PICC line placed for full 10 day course. Urine legionella negative, unable to provide sputum, blood cx NGTD. She will need to complete 2 more days of antibiotics at rehab. She should have a follow up CXR in 4 weeks to document resolution. . # Depression and Chronic back pain Psychiatry consulted to manage her depression related to component of pain and long wait for her liver transplant. She was started on venlafaxine. Chronic pain service evaluated her and continued her oxycodone, started Neurontin 300 mg QHS increase as tolerated every 5-7 days to 300mg TID. Continued Lidoderm patches to low back area. PT for core strength and endurance. Tizanidine for sleep and spasm Start at 1 mg po QHS. Would benefit from Pain Psychologist/ Psychiatry follow up to address depression and further psychological treatment options as CBT and Biofeedback. . # HCV Cirrhosis s/p TIPS [11-9] c/b hydrothorax, encephalopathy, ascites, thrombocytopenia. On transplant list, placed back on diuretics which were initally held. She was discharged on furosemide 40mg [Hospital1 ] and spironolactone 100mg daily. Her lactulose and rifaximin were continued. Electrolytes should be checked in 3 days given spironolactone was increased to 100mg daily at the time of discharge. Weekly labs are to be drawn and faxed to [First Name8 (NamePattern2) 1022] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 697] and should include CBC, [Name (NI) 53324], PT/INR, CHEM 7. . # Adrenal insufficiency Received stress dose steroids and was tapered back to prednisone 5mg daily. . # Osteoporosis Continued vitamin D and calcium citrate. History of fractures. . # Asthma Continued Singulair, Albuterol/Ipratropium . # Code: Full, HCP Mother [Name (NI) 2048] [Name (NI) 68659] [Telephone/Fax (1) 68660] Medications on Admission: Lactulose 30 ml QID Rifaximin 400 mg TID Aldactone 25mg Daily Lasix 40 mg [Hospital1 ] Lantus insulin 36 units qhs Humulog sliding scale as needed Singulair 10mg Daily Fluticasone 1 puff [Hospital1 ] Albuterol 1-2 puffs q4 Combivent inhaler 2 puffs QID Prednisone 5 mg Daily Multivitamin 1 tab Daily Folic acid 1 mg Daily Protonix 40mg [Hospital1 ] Vitamin D 50,000 units qWk Calcium citrate 950 mg TID Morphine Sulfate 15 mg Daily Oxycodone 5 mg q6h Lidoderm 5% patch as needed Discharge Medications: 1. Lactulose 10 gram/15 mL Syrup [Hospital1 ]: Thirty (30) ML PO QID (4 times a day): titrate to 4 bm daily. 2. Rifaximin 200 mg Tablet [Hospital1 ]: Two (2) Tablet PO TID (3 times a day). 3. Furosemide 40 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 4. Insulin Glargine 100 unit/mL Cartridge [Hospital1 ]: Twenty Four (24) units Subcutaneous at bedtime. 5. Humalog 100 unit/mL Cartridge [Hospital1 ]: One (1) Subcutaneous as directed: sliding scale. 6. Montelukast 10 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 7. Fluticasone 110 mcg/Actuation Aerosol [Hospital1 ]: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [Hospital1 ]: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Combivent 18-103 mcg/Actuation Aerosol [Hospital1 ]: Two (2) puffs Inhalation four times a day. 10. Prednisone 5 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 11. Hexavitamin Tablet [Hospital1 ]: One (1) Cap PO DAILY (Daily). 12. Folic Acid 1 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 14. Ergocalciferol (Vitamin D2) 50,000 unit Capsule [Hospital1 ]: One (1) Capsule PO MONDAY AND WEDNESDAY (). 15. Calcium Citrate 950 mg Tablet [Hospital1 ]: One (1) Tablet PO three times a day. 16. Oxycodone 5 mg Tablet [Hospital1 ]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [Hospital1 ]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 18. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr [Hospital1 ]: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 19. Gabapentin 300 mg Capsule [Hospital1 ]: One (1) Capsule PO HS (at bedtime). 20. Tizanidine 2 mg Tablet [Hospital1 ]: 0.5 Tablet PO QHS (once a day (at bedtime)). 21. Spironolactone 100 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 22. Vancomycin in Dextrose 1 gram/200 mL Piggyback [Hospital1 ]: One (1) Intravenous Q 12H (Every 12 Hours) for 2 days. 23. Ampicillin-Sulbactam 3 gram Recon Soln [Hospital1 ]: One (1) Recon Soln Injection Q8H (every 8 hours) for 2 days. Discharge Disposition: Extended Care Facility: [Hospital 5503] Rehabilitation Discharge Diagnosis: [Hospital ] Hospital acquired pneumonia HCV cirrhosis Hepatic encephalopathy Diabetes mellitus type II Discharge Condition: Stable, alert and oriented times 3 Discharge Instructions: You were admitted with low sugar causing you to be confused. You were treated for pneumonia. You were seen by psychiatry and the pain service to help manage your pain and depression. You were started on new medications to help with your depression and pain (venlafaxine, gabapentine, tizanidine). You are neing discharged to a rehab facility to regain your strength by working with physical therapy. You have follow up scheduled with Dr. [Last Name (STitle) 497]. You will need to have follow up with psychiatry and pain center. The numbers to the clinics are in your discharge paper work. Followup Instructions: Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2158-3-22] 9:00 Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2158-4-11] 3:30 Provider: [Name10 (NameIs) 21503] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 1803] Date/Time:[2158-4-11] 2:40 Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 327] Date/Time:[2158-4-20] 1:00 Call ([Telephone/Fax (1) 24780] to schedule a follow up appointment with psychiatry, you were seen by Dr. [Last Name (STitle) 16293]. Call ([Telephone/Fax (1) 30702] to schedule a follow up with [Doctor First Name ] P. [First Name4 (NamePattern1) 1193] [Last Name (NamePattern1) 1194] Management Center ICD9 Codes: 486, 2761, 5715, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8461 }	Medical Text: Admission Date: [2163-9-13] Discharge Date: [2163-9-23] Date of Birth: [2109-7-11] Sex: M Service: PRINCIPAL DIAGNOSIS: Squamous cell carcinoma of the floor of the mouth. HISTORY OF PRESENT ILLNESS: The patient is a 54 year-old male diagnosed with squamous cell carcinoma of the mouth who is here for resection. He has no other past medical history. No pertinent family history. He noticed this mass for which Dr. [Last Name (STitle) ] realized needed to be resected and for an osseocutaneous flap to be placed in his mandible that was resected. HOSPITAL COURSE: The procedure that he underwent was a resection of the floor of the mouth with a mandibulectomy, a bilateral neck dissection, tooth extraction, tracheostomy placement, and a free radial left osseocutaneous flap. As per the operative note the operation went without complications. Postoperatively, the patient did well. He had an nasogastric tube placed as well as two JP drains by plastic surgery. He was on Ancef and Flagyl postoperatively and was sent to the Intensive Care Unit. He remained in the Intensive Care Unit for three days at which time he was moved to the floor. On the floor he continued to progress well. His JP drains were taken out on postoperative three. He continued without any fever until postoperative day six where Ancef and Flagyl were discontinued. However, on postoperative day seven he was started on Keflex for noted erythema around his incision. He continued to receive tube feeds at goal, which were discontinued on [9-22] after a speech and swallow study that showed mild dysphagia. He was started on a puree diet, which he tolerated. The patient is being discharged on postoperative day ten with his nasogastric tube removed and his tracheostomy being taken out. The patient will go home with services to receive speech therapy and home services for wound care management. DISCHARGE MEDICATIONS: Keflex 500 q 6 hours times five days, Roxicet elixir 5 to 10 cc po q 4 hours prn, Prilosec 20 mg po q day, Thicket meal one with each meal to increase the thickness of his foods. FOLLOW UP APPOINTMENTS: The patient will follow up with Dr. [Last Name (STitle) ] next week. He should call for an appointment at [Telephone/Fax (1) 11389]. Follow up with plastic surgery in two weeks to call for an appointment [Telephone/Fax (1) ] and speech and swallow study to advance him to solid foods, which is for [9-29] at 9:00. DISPOSITION ON DISCHARGE: Good/stable. The patient is doing well. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 39], M.D. [MD Number(1) 11390] Dictated By:[Last Name (NamePattern1) 11391] MEDQUIST36 D: [2163-9-23] 08:15 T: [2163-9-28] 14:50 JOB#: [Job Number 11392] ICD9 Codes: 5180
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8462 }	Medical Text: Admission Date: [2156-12-1] Discharge Date: [2156-12-4] Date of Birth: [2107-8-6] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 330] Chief Complaint: tracheostomy failure Major Surgical or Invasive Procedure: Flexible bronchoscopy. History of Present Illness: The patinet is a 49 year old male with a history of sever scoliosis complicated by secondary restrictive lung disease (FEV 27% predicted,) OSA who presented to an OSH on [2156-11-19] with complaints of progressive dyspnea. . The patient has had worsening shortness of breath at rest over the last year. OSH records also indicate the patient dozing off throughotu the day, raising concerns of him falling alseep while driving. On presentation to the ED, the he was found to be hypoxemic (80s) and hypercapnic (ABG 7.29 / 89 / 83 / 42,) with episodes of bradycardia with 3-4 sec pauses, and was admitted to the ICU. He was started on BIPAP at night, with intermitent use during the day due to his severe hypercapnic respiratory failure, but did not have good tolerance of non-invasive ventilation. His respiratory status continud to worsen, and the patient was found somnolent and difficult to arouse at night. PCO2 was found during to be 130. Due to his severe scoliosis, and failed nasal intubation, and ENT was consulted for a semi-emergent tracheostomy. A #6 LTC cuffed Shiley trach was placed, but started on Passy-Muir valve during the day time. On [2156-11-27], the patient occluded the tracheostomy with severe hypoxia, requiring CPR, but resolved with trach manipulation to restablish the airway. A similar episode occured on [11-20], and a #7 Bavona hyperlexible tracheostomy was placed. He has remained on mechanic ventialation at night, AC, 400/14/5. . Per OSH records, there were concerns that the tracheostomy tube tip appeard to be eroding at the posterior wall of the trachea due to the patients baseline abnormal antatomy. The patient was transfered to [Hospital1 18] for evaluation of a potential customized tracheostomy vs other intervention. Past Medical History: Severe scoliosis Prior pneumothoraces Restrictive Lung Disease Chronic respiroatyr failure Cholecystectomy Social History: The patient is currently married, no alcohol, or tobacco Physical Exam: Trached, on trach mask, sitting in a chair Severe scoliosis, slgith erosis on neck from trach Abnormal resioatory movements Distant heart sounds, tachycardic, no m/r/g Abdominal ventral, soft, ntnd 1+ LE b/l Pertinent Results: [2156-12-3] 04:45AM BLOOD WBC-5.4 RBC-4.16* Hgb-12.1* Hct-38.2* MCV-92 MCH-29.1 MCHC-31.7 RDW-13.1 Plt Ct-308 [2156-12-2] 12:26AM BLOOD WBC-5.4 RBC-4.06* Hgb-11.9* Hct-38.0* MCV-93 MCH-29.3 MCHC-31.4 RDW-13.0 Plt Ct-277 [2156-12-3] 04:45AM BLOOD Glucose-103* UreaN-7 Creat-0.4* Na-141 K-4.1 Cl-94* HCO3-41* AnGap-10 [2156-12-2] 12:26AM BLOOD Glucose-119* UreaN-7 Creat-0.4* Na-141 K-3.7 Cl-91* HCO3-45* AnGap-9 [2156-12-3] 04:45AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.2 CXR [2156-12-1]: The interpretation of this radiograph is very limited due to the severe scoliosis and deformity of the thoracic cage. Tracheostomy tube tip is 5.5 cm above the carina. Cardiomediastinal contours cannot be evaluated. There is no evident pneumothorax. If any, there is a small right pleural effUsion. The main central pulmonary arteries appear to be enlarged. There are no prior studies available for comparison. The asymmetric increased density in the right hemithorax could be due to pleural effusion or lung opacities in the right lower lobe, I suspect that also is due to the deformity of the thoracic cage. If prior studies were available , comparison could be performed to assess new abnormality. Brief Hospital Course: The patient is a 49 year old male with a history of severe scoliosis, restrictive lung disease, OSA, who presented to an OSH with worsening dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent tacheostomy placement, now transfered for evaluation of posterior wall erosion. # Hypercapnic respiratory failure: likely secondary to both restrictive lung process due to severe scoliosis with additonal OSA. Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. Patient has been using trach valve during the day and CMV at night while at [Location (un) 8641]. He was transferred here for evaluation of posterior trach erosion. IP advanced the trach approximately 1 cm with overall improvement of airway patency given the posterior erosion. He was noted to have mild supraglottic edema as well. He still has a significant amount of secretions. When lying flat to sleep, he was placed on PS 10/5, but otherwise he is maintained on a trach mask the remainder of the time. On the day of transfer, the patients trach was switched from a flexible to a fixed bovina 7f, placed 1cm obove the [Female First Name (un) 5309] at 110cm. On bronchoscopy, continued supraglottic edema was noted, and should have an ENT evaluation when back at [Location (un) 8641]. The patient reports a 20lb weight gain in the last 2 years, and dietary modifications and weight loss techniques should be discussed with the patient on discharge planning. Pulmonary Rehab is also recommended on discharge. He will be transferred back to [Hospital 8641] hospital for further care. # Severe Scoliosis: He also was noted to have significant GERD as well. His PPI was increased to 40 mg [Hospital1 ]. He was maintained on tylenol for pain; we avoided narcotics. # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA. Mild reduced RV function. He appeared volume overloaded, and his furosemide was increased to 40 mg [Hospital1 ] (was transferred to us on 40 mg daily). His electrolytes will need to be monitored on this dose of furosemide. Medications on Admission: Ambien 5mg HS PRN Morphine 4-6mg q4h PRN pain Percocet [11-20] tab q4H PRN pain Claritin 10mg daily Magnesium oxide 400mg [Hospital1 ] DuoNeb PRN Protonix 40mg daily Lorazepam 45mg q4 PRN Colace 100mg [Hospital1 ] Humibid 1200mg [Hospital1 ] Lasix 40mg daily Arixtra 2.5mg daily ASA 81mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Bacitracin-Polymyxin B Ointment Sig: One (1) Appl Topical PRN (as needed) as needed for trach site. Discharge Disposition: Extended Care Discharge Diagnosis: Primary: Respiratory failure status post recent tracheostomy tube placement. Secondary: Severe scoliosis Prior pneumothoraces Restrictive lung disease S/P cholecystectomy Discharge Condition: Mental Status:Clear and coherent Activity Status:Ambulatory - requires assistance or aid (walker or cane) Level of Consciousness:Alert and interactive Discharge Instructions: You were admitted because of shortness of breath and problems with your tracheostomy. We performed a bronchoscopy and extended your tracheostomy by 1 cm. We also started you on pantoprazole for laryngeal inflammation caused by gastric reflux. Please take all of your medications as prescribed. Please keep all of your follow-up appointments. Please call your doctor or return to the hospital if you experience fevers, chills, sweats, chest pain, shortness of breath or anything else of concern. Followup Instructions: Scheduled Appointments : Provider [Name9 (PRE) 17853] CLINIC INTERVENTIONAL PULMONARY (SB) Phone:[Telephone/Fax (1) 3020] Date/Time:[2157-1-25] 11:00 Provider CDC INTAKE,ONE CDC ROOMS/BAYS Date/Time:[2157-1-25] 12:00 Provider [First Name8 (NamePattern2) ] [Name9 (PRE) ], MD Phone:[Telephone/Fax (1) 5072] Date/Time:[2157-1-25] 12:30 ICD9 Codes: 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8463 }	Medical Text: Admission Date: [2194-5-29] Discharge Date: [2194-6-5] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1561] Chief Complaint: shortness of breath w/ exertion- new x2 weeks Major Surgical or Invasive Procedure: Flexible bronchoscopy, diagnostic. 2. Cervical mediastinoscopy with biopsy. 3. Right thoracotomy with wedge excision and right upper lobectomy. 4. Mediastinal lymphadenectomy. 5. Attempted right thoracoscopy. History of Present Illness: delightful 83- year-old gentleman with COPD and pulmonary fibrosis with a long history of smoking. In recent years, he has been developing dyspnea, in the Spring, during the pollen season. Most recently, he developed an episode that required a visit to the Emergency Room and a three day pulmonary rehabilitation to date. The CT scan during this visit demonstrated a new 15 mm spiculated right upper lobe nodule. He denied any significant dyspnea other than these acute episodes that he has in the Spring; however, his wife reports that his wife is winded with minimal exertion, including climbing a flight of stairs. He does play golf on a daily basis but does so with a cart. He reports being reasonably active and not being particularly limited by shortness of breath. However, his wife disagrees with this. Pulmonary function tests demonstrated a FEV-1 of 2.04 which is 68% of predicted and a DLCO of 59% predicted but he has restrictive lung disease. A preoperative PET scan demonstrated activity within the lesion but not elsewhere within the body. I had a long discussion with the family preoperatively and I indicated to them that there is a high likelihood of an open resection given the extent of scarring seen on CT scan from the asbestosis. Additionally, I discussed the likelihood of performing a wedge excision for diagnosis and therapy given his extensive pulmonary disease and baseline dyspnea. Therefore, we proceeded forward with the following operation. Past Medical History: Hypertension, Coronary Artery Disease (s/p MIx2 [2187]), Chronic Obstructive Pulmonary Disease and restrictive lung disease (2secondary) to asbestos exposure Social History: Married x58 years, lives w/ wife on [Hospital3 ] 2 children (son and [Name2 (NI) 41859]), 4 grandchildren smoker 2ppd/x60 years, quit [2187], aslo cigars and pipes Right eye injury from WWII, now has prosthetic eye etoh- 1/day Family History: father died 40's melanoma mother died early 60's form heart surgery brother 87- good health 4 sisters- 1 died of breast cancer, 3 other are alive and well Physical Exam: General-vibrant elderly male HEENT-R eye replaced w/ prosthesis, L eye is ERR, sclera anicteric,minor inflammation at present. No cervical or supraclav adenopathy REsp- BS clear upper left, diminished RUL, clear bases Cor-RRR, no murmer Abd- + BS, NT, ND, soft Ext- R knee w/ minor edema and erythema- resolving- gout episode [6-1] Neuro- A&O x3, cooperative, appropriate Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2194-6-3] 05:45AM 8.0 3.15* 9.6* 28.1* 89 30.4 34.0 13.7 195 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [2194-6-5] 05:45AM 14.91 28.7 1.5 1 NOTE NEW NORMAL RANGE AS OF 12 AM [2194-3-22] Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2194-6-5] 05:45AM 1.0 Cardiology Report ECG Study Date of [2194-6-2] 12:50:46 PM Sinus rhythm First degree A-V delay Left atrial abnormality Prior anteroseptal myocardial infarction Since previous tracing of [2194-6-2], Poor R wave progression is more prominent Read by: [Last Name (LF) ],[First Name3 (LF) 177] W. RADIOLOGY Final Report CHEST (PA & LAT) [2194-6-2] 11:31 AM CHEST (PA & LAT) Reason: ? PTX [Hospital 93] MEDICAL CONDITION: 83 year old man with chest tube removal REASON FOR THIS EXAMINATION: ? PTX INDICATION: Status post chest tube removal, evaluate for pneumothorax. COMPARISON: [2194-6-1]. TECHNIQUE: PA and lateral chest. FINDINGS: There has been interval removal of two right-sided chest tubes. No definite pneumothorax is identified. There is pleural effusion layering along the lateral aspect of the right lung and stable parenchymal opacities within the right lung and at the left base. Left pleural effusion is unchanged. The osseous structures appear unchanged. Stable subcutaneous emphysema within the right chest wall. IMPRESSION: 1. No definite evidence of pneumothorax following chest tube removal. Stable subcutaneous emphysema. 2. Bilateral pleural effusions, right greater than left. 3. Stable patchy opacities within the right lung and left base. OPERATIVE REPORT [Last Name (LF) ],[First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] NOT REVIEWED BY ATTENDING* Name: [Known lastname ], [Known firstname 275] G Unit No: [Numeric Identifier 63552] Service: [Last Name (un) 7081] Date: [2194-5-29] Surgeon: [First Name11 (Name Pattern1) 951] [Last Name (NamePattern4) ], MD 2367 PREOPERATIVE DIAGNOSES: Right upper lobe lung cancer. POSTOPERATIVE DIAGNOSIS: Right upper lobe lung cancer. PROCEDURES PERFORMED: 1. Flexible bronchoscopy, diagnostic. 2. Cervical mediastinoscopy with biopsy. 3. Right thoracotomy with wedge excision and right upper lobectomy. 4. Mediastinal lymphadenectomy. 5. Attempted right thoracoscopy. ASSISTANT SURGEON: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1005]. ANESTHESIA: General endotracheal supplemented by multiple intercostal nerve blocks. The patient will receive an epidural at the end of the case. INDICATIONS FOR OPERATION: The patient is a delightful 83- year-old gentleman with COPD and pulmonary fibrosis with a long history of smoking. In recent years, he has been developing dyspnea, in the Spring, during the pollen season. Most recently, he developed an episode that required a visit to the Emergency Room and a three day pulmonary rehabilitation to date. The CT scan during this visit demonstrated a new 15 mm spiculated right upper lobe nodule. He denied any significant dyspnea other than these acute episodes that he has in the Spring; however, his wife reports that his wife is winded with minimal exertion, including climbing a flight of stairs. He does play golf on a daily basis but does so with a cart. He reports being reasonably active and not being particularly limited by shortness of breath. However, his wife disagrees with this. Pulmonary function tests demonstrated a FEV-1 of 2.04 which is 68% of predicted and a DLCO of 59% predicted but he has restrictive lung disease. A preoperative PET scan demonstrated activity within the lesion but not elsewhere within the body. I had a long discussion with the family preoperatively and I indicated to them that there is a high likelihood of an open resection given the extent of scarring seen on CT scan from the asbestosis. Additionally, I discussed the likelihood of performing a wedge excision for diagnosis and therapy given his extensive pulmonary disease and baseline dyspnea. Therefore, we proceeded forward with the following operation. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed under general endotracheal anesthesia with a single lumen endotracheal tube. We performed a flexible bronchoscopy and examined the entire tracheobronchial tree. We found no endobronchial lesions and found no anatomical abnormalities. We positioned the patient supine but we were unable to extend his neck due to degenerative joint disease. We prepped and draped his neck and chest in the usual sterile fashion. We made a 1 cm transverse incision 2 cm cephalad to the sternal notch and dissected down to the pretracheal plane. We bluntly developed the pretracheal plane with the mediastinoscope down the trachea and down bilateral mainstem bronchi. There was an extensive amount of fatty tissue within the mediastinum and vicinity of the lymph nodes. We found small lymph nodes in the 4-R position and biopsied two separate areas and sent them for frozen section analysis. We biopsied a lymph node from the pre carinal lymph node. We performed extensive dissection in the left paratracheal region, identifying the course of the left recurrent laryngeal nerve and dissecting down to the esophagus but found no identifiable lymph nodes to biopsy. I was unable to extend the scope into the subcarinal region, due to the patient's inability to extend his neck and the large size of this gentleman. The mediastinoscope was placed as deep as it would go and it was barely within reach of the subcarinal space, due to the lack of extension of his neck and the depth, I was unable to safely biopsy the subcarinal lymph nodes. On frozen section, there was no evidence of malignancy and, therefore, we closed the wounds after achieving meticulous hemostasis. We then returned the patient to the anesthesia service who successfully placed a double lumen endotracheal tube. We positioned the patient in the left lateral decubitus. We took great care to avoid injury to the fascial nerve on the left side. We positioned him carefully to avoid pressure points and hyperextension of extremities. We then prepped and draped his right chest in the usual sterile fashion. We attempted to place a single thoracoscopy port in the mid axillary line at approximately the seventh intercostal space. We dissected down to the pleura and encountered a very thick fibrotic pleura that we were unable to break through but there was no pleural space to dissect within. We, therefore, aborted the idea of a thoracoscopic approach. We then made a posterior lateral thoracotomy dividing the latissimus dorsi muscle but sparing the serratus anterior as well as the trapezius and rhomboids. We entered the chest through the fourth intercostal space to shingle the fifth rib posteriorly. We immediately encountered intense adhesions from the asbestosis. We had to carve the lung down using electrocautery off of the asbestosis plaques. Eventually, we were able to completely carve free the right upper lobe apically, posteriorly along the paravertebral sulcus, laterally, anteriorly and medially off the mediastinum. We were able to develop the fissure between the upper and superior segment of the lower lobe and we developed a fissure between the middle and the lower lobe. There was an incomplete fissure between the upper and middle lobe. The middle lobe was extremely small and thin. We then palpated the tumor which measured approximately 3 cm on palpation. It was located in the periphery at the junction between the anterior and apical segments. We mobilized the pleura around the anterior apical and posterior hilum, sweeping the lung off the hilum as much as possible to gain mobility for a large wedge excision. We then used the US Surgical thoracoscopic stapler with a 6 cm long, wide mouth thick tissue staplers to perform a wedge excision down to near the hilum. We performed the wedge excision with several firings of the stapler and sent specimens for pathological analysis. This with the deepest possible wedge we could obtain safely as it was abutting the hilum. On gross analysis, the tumor came close to the margin but I felt I had a clean margin. Frozen section analysis demonstrated the margin to be free of tumor, although it was close. I broke scrub and spoke with the family and had a discussion as to whether or not we should perform a lobectomy. Our discussion was centered around the fact that a lobectomy would run the risk of pushing him into respiratory failure and worsening his dyspnea. I was particularly concerned by the fact that he had dyspnea on several occasions and at least one of them, requiring hospitalization. His wife reports that he is quite dyspneic around the house and is concerned about his breathing. His pulmonary function tests demonstrated restrictive lung disease and he has a history of pulmonary fibrosis and COPD. Although his pulmonary function tests suggest that he might tolerate a lobectomy, his physiological status and his history suggests that he would not. I spoke with his son and his wife about whether or not we should proceed forward with a lobectomy. We also discussed the possibility that it could recur locally and that if it did, a back-up option would be radiotherapy. Ultimately we came to the group's consensus that we should not proceed forward with a lobectomy but accept a compromise wedge excision. The plan will be to follow him closely with 3 month serial CT scans. I then scrubbed back into the case. Of note, prior to scrubbing out of the case, initially I performed a complete mediastinal adenectomy. We resected the right paratracheal lymph node in a complete packet with sharp dissection. We used as our margins the superior vena cava, anteriorly the esophagus posteriorly and the azygos inferiorly. Similarly, we performed a clean dissection of this subcarinal packet of lymph nodes using as our margins the left main, subcarina and right main as well as the pericardium anteriorly and the esophagus posteriorly. These were sent separately. I then also freed the lower lobe as much as I could from the chest wall, without performing a counter incision. We expanded the lung under observation and found that it completely spread the apical space. We then placed two 28 French chest tubes, one anteriorly, one posteriorly. We placed multiple intercostal nerve blocks with a total of 20 cc of [11-26] strength Marcaine with epinephrine. We then closed the chest in layers and expanded the lung under observation. Dr. [Last Name (STitle) 952] was present for the entire case. Sponge, instrument and needle counts were reported correct times 2. [First Name11 (Name Pattern1) 951] [Last Name (NamePattern4) ], [MD Number(1) 15911] Intervals Axes Rate PR QRS QT/QTc P QRS T 90 [Telephone/Fax (3) 63553]/425.71 26 7 16 ([-3/3308]) Brief Hospital Course: Patient admitted SDA [2194-5-29] for large RUL wedge resection for RUL nodule. Patient tolerated procedure fairly well, extubated in PACU, R chest tubesx2 to sx, pain control w/epidural of bupivicaine/ dilaudid and toradol iv x4 doses. Patient admitted to SICU post-op for hypotension and low urine output requiring fluid boluses and neo gtt. These resoved and pt transferred to floor on POD#2. POD#3-CT to H2O seal w/ leak in 1 tube; good thorax pain control w/ epidural but ++R knee pain- found to be gout episode via joint aspiration by Rheumatology consult and treated initially w/ indocin w/o pain relief and changed to cochicine qod mwith close monitoring of ranl fx in settingof hx CRI.(Last attack >20yrs ago). PO intake encouraged, ivf cont, OOB/ IS/PT. POD#4- Pain control-D/C epidural and trasitioned to po meds started; HR 1st AV block as is baseline w/ episode of SB to 32, and AF/Af w/ variable block w/ c/o palpitations.- spontaneous conversion to SR in < 24 hours. Cardiology/EP consult obtained-advised NO amiodarone and treat w/ low dose atenolol 25 mg qd and anticoag for at least 3 months. Heparin gtt started w/ goal PTT 60-80, and coumadin started. CT x2 to H2o seal w/o leak;poor appetite, IVF cont, poor u/o- unable to void post foley d/c, foley replaced, flomax given. BM today; Cr 1.7 on cholchicine w/ good R knee pain relief, ambulation w/ PT and nsfg assistance, oob>chair. POD#5- Pain uncontrolled on po meds, PCA started and decreased in pm for lethergy; SR of 1 AV block, Heparin gtt cont, coumadin given iin pm; CT x2 d/c w/o complication; BS decreased at bases, IS and PT done; fair po intake, ivf @50/hr; foley d/c w/ successful void; labs Cr 1.4 on cholchicine for acute episode duration per [Name (NI) 63554] pt asym today.Ambulation/ IS/ PT. POD#6-Pain control w/ PCA lower dose w/ good control and transitioned totylenol and po dilaudid w/ good control; CT dsg w/ mild ser sang drainage; episode of bradycardia 50's and 1 episode to 40- cardiology called and advised no change in RX of atenolol, isordil, lipitor, lisinopril. Ambulation w/ pt and nsg, appetite improved. POD#7- Good pain cotrol on minimal dilaudid and tylenol; Cards consult prior to d/c to cont meds as above. Patient stable for d/c to [Hospital3 ] [Hospital ] rehab facility w/ Cardiology and INR follow-up by [First Name8 (NamePattern2) 4115] [Last Name (NamePattern1) ]. Medications on Admission: asa, atorvastatin, lisinopril, atenolol, levothyroxine, isosorbide dinatrate Discharge Disposition: Extended Care Facility: Cape Regency Nursing & Rehabilitation - [Location 41366] Discharge Diagnosis: Hypertension, coronay disease (s/p MIx2 [2187]) stents placed [2188], Chronic obstructive pulmonary disease and restrictive lung disease (2ndary to asbestos exposure?, hypothyroidism, R eye prosthesis from WWII injury, hx prostate cancer-s/p XRT, hx skin cancer-resected now on back, s/p cholycystectomy. Discharge Condition: good Discharge Instructions: Call Dr.[Name (NI) 1816] office for any post surgical issues questions [Telephone/Fax (1) 170] Followup Instructions: Appointment with Dr. [Last Name (STitle) 952] in 2 weeks when discharged from REhab facility- [Telephone/Fax (1) 170] Completed by:[2194-6-5] ICD9 Codes: 496, 9971
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8464 }	Medical Text: Admission Date: [2170-11-2] Discharge Date: [2170-11-12] Date of Birth: [2170-11-2] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: A 35 and [3-23] week gestation male born to a 38-year-old gravida 4, para 3, woman. Prenatal screens revealed B positive, antibody negative, hepatitis B surface antigen negative, Rubella immune, rapid plasma reagin nonreactive, and group B strep status unknown. The mother was admitted on the day of delivery with a low-grade fever, suprapubic pain, and a white blood cell count of 16,000. The decision was made to deliver because of concerns for previous cesarean section dehiscence. The infant's Apgar scores were 7 at one minute of age and 8 at five minutes of age. The patient was admitted to the Neonatal Intensive Care Unit on the day of delivery and treated with oxygen for a course consistent with transitional tachypnea of newborn and received 48 hours of antibiotics. Bandemia on the day of delivery which showed 27 polys, 27 neutrophils, and 9 bands. The infant's blood culture was negative at 48 hours, and at that time the antibiotics were discontinued. The infant was transferred to the Newborn Nursery on day of life two. On day of life four, the infant returned to the Neonatal Intensive Care Unit with a rectal temperature of 101 and 99.8 axillary. At the time of admission the infant was also noted to have spontaneous desaturations with cyanosis. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed a pink, large for gestational age, well-appearing infant in no acute distress. On day of life four, the infant had a erythematous macular eruption over his torso and extremities. Anterior fontanel was soft and flat. Patella was pink. The palate was intact. The mucous membranes were moist. No grunting, flaring, or retracting. Breath sounds were clear bilaterally. Cardiovascular examination revealed a grade 2/6 systolic murmur. The abdomen was soft and nondistended. No hepatosplenomegaly. Normal perfusion. Normal phallus, testes, and scrotum. The hips were stable. Normal tone and activity for gestational age. Birth weight was 4690 grams (greater than the 90% percentile), length was 51.5 cm (greater than the 90% percentile), and head circumference was 37.5 cm (greater than the 90% percentile). CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. RESPIRATORY ISSUES: Respiratory examination revealed the infant was placed on low-flow nasal cannula receiving 13 cc to 50 cc for desaturations. The infant respiratory rates were 30s to 60s. The infant was transferred to room air on day of life eight. The infant did not have bradycardia during this hospitalization. 2. CARDIOVASCULAR ISSUES: Cardiovascular examination revealed the infant noted to have a systolic murmur that was still noted on day of life four. Therefore, at that time a cardiac evaluation was performed. A chest x-ray revealed normal cardiac silhouette with clear lung fields situs solitus. The infant received an electrocardiogram which revealed a superior access. Four extremity blood pressures were within normal limits. The infant passed the hyperoxia test which was 320. At that time, Cardiology was consulted, and an echocardiogram on [11-7] showed a structurally normal heart. No followup was recommended. 3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was feeding ad lib Enfamil 20 or breast milk 20 calories per ounce by mouth, taking 100 cc to 110 cc/kg per day. The infant was tolerating feedings without difficulty. The weight on discharge was 4255 grams. 4. GASTROINTESTINAL ISSUES: The infant was noted to have a loose stool on day of life seven which resolved by day of life nine. A bilirubin level on day of life four showed a total bilirubin of 10.1 with a direct bilirubin of 0.3. The infant's ALT on day of life four was 12 and AST was 38. 5. HEMATOLOGIC ISSUES: The infant's complete blood count on the day of delivery revealed a white blood cell count of 16.2, his hematocrit was 41.1%, and his platelets were 285,000. Differential with 27 neutrophils and 9 bands with an I:T ratio of 0.25. The infant received 48 hours of ampicillin and gentamicin which were discontinued, and the blood cultures remained negative to date. 6. INFECTIOUS DISEASE:On day of life four, the infant was noted to have an elevated temperature to 101 rectally. A complete blood count was drawn at that time which showed a white blood cell count of 19, his hematocrit was 43.3%, and his platelets were 319,000. Differential with 73 neutrophils and 22 bands with an I:T ratio of 0.23. The infant did not receive any blood transfusions during this hospitalization. The most recent complete blood count drawn on day of life eight revealed a white blood cell count of 9.2, a hematocrit of 44.1%, and platelets of 469,000. Differential with 31 neutrophils and 0 bands. The infant was restarted on ampicillin and gentamicin and was also started on acyclovir on day of life four. Due to an elevated temperatures and desaturations, a lumbar puncture was done which showed 4 white blood cells, 1 red blood cell, 33% polys, 1% bands, a protein of 87, and a glucose of 48. The infant received a total of 48 hours of ampicillin and gentamicin. Blood cultures remained negative to date. On day of life four, viral cultures were sent from the nasopharynx which remained negative to date. Stool was sent for a viral culture on day of life nine, and there was no virus isolated so far. A cerebrospinal fluid and HSV PCR was sent on day of life four which was negative, and acyclovir was discontinued on day of life eight. The infant developed an intravenous infiltrate in the right foot and was receiving Bacitracin at the time of this dictation. Plastics was consulted, and the infant was due for followup with Dr. [First Name8 (NamePattern2) 122] [Last Name (NamePattern1) 5385] in two weeks. Blood cultures remained negative to date and spinal fluid culture remained negative to date. 7. NEUROLOGIC ISSUES: A normal neurologic examination. No issues. 8. SENSORY ISSUES: A hearing screen was performed with automated auditory brain stem responses. The infant passed in both ears. 9. PSYCHOSOCIAL ISSUES: [Hospital1 188] Social Work was involved with the family. The contact social worker can be reached at telephone number [Telephone/Fax (1) 8717]. CONDITION AT DISCHARGE: Former 35 and [3-23] week gestation male, stable on room air. DISCHARGE STATUS: Discharge status was to home with parents. PRIMARY PEDIATRICIAN: Name of primary pediatrician is Dr. [First Name (STitle) ] [Name (STitle) ] (telephone number [Telephone/Fax (1) 50519]). CARE RECOMMENDATIONS: 1. Feedings at discharge: Enfamil 20 calories per ounce or breast milk 20 calories per ounce ad lib by mouth. 2. Medications: None. 3. Car seat position screening was performed, and the infant passed. 4. State newborn screens was sent on [11-6], and the results were pending at the time of this dictation. 5. Immunizations received: The infant received hepatitis B vaccine on [2170-11-4]. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The infant was to follow up with primary pediatrician (Dr. [First Name (STitle) ] [Name (STitle) ]). 2. The infant was to follow up with Dr. [First Name8 (NamePattern2) 122] [Last Name (NamePattern1) 5385] with Plastic Surgery at The [Hospital3 1810] (telephone number [0-0-]). DISCHARGE DIAGNOSES: 1. Prematurity at 35 and 3/7 weeks gestation. 2. Large for gestational age. 3. Status post transitional tachypnea of newborn. 4. Rule out cardiac anomaly; ruled out. 5. Presumed viral infection- ? enterovirus. [First Name11 (Name Pattern1) 37693] [Last Name (NamePattern4) 37927], M.D. [MD Number(1) 37928] Dictated By:[Last Name (NamePattern1) 43219] MEDQUIST36 D: [2170-11-13] 18:12 T: [2170-11-13] 18:41 JOB#: [Job Number 50520] ICD9 Codes: V053, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8465 }	Medical Text: Admission Date: [2116-5-12] Discharge Date: [2116-5-18] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Increasing shortness of breath Major Surgical or Invasive Procedure: [2116-5-13] Aortic Valve Replacement(21mm St. [Male First Name (un) 923] Porcine) [2116-5-12] Cardiac Catheterization History of Present Illness: This is a [Age over 90 ] year old female who presented with increasing shortness of breath with exertion. She has known severe aortic stenosis by echocardiogram. Prior to aortic valve replacement surgery, she was admitted for cardiac catheterization. Past Medical History: Aortic Stenosis Type II Diabetes Mellitus Depression History of Pneumonia [2113] s/p Cataract Surgery Social History: Lives: alone in CT - staying with daughter currently Occupation: retired teacher Tobacco: None ETOH: None Illicit Drugs: None Family History: No premature coronary artery disease Physical Exam: On Admission Pulse: 81 Resp: 16 O2 sat: 97 RA B/P Right: 161/75 Left: 157/69 Height: 5'2" Weight: 63.5 kg General: Elderly female in no acute distress Skin: Dry [x] areas under breast bilateral with minimal skin breakdown - history of problems, chest with moles [Name (NI) 4459]: [Name (NI) 22031] [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur 3/6 systolic Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no palpable masses Extremities: Warm [x], right foot cooler than left Edema: trace Varicosities: multiple superficial bilat LE Neuro: Grossly intact, nonfocal exam Pulses: Femoral Right: cath site Left: +2 DP Right: +1 Left: +1 Radial Right: +2 Left: +2 Carotid Bruit Right: trans murmur Left: trans murmur Pertinent Results: [2116-5-12] WBC-7.2 RBC-3.85* Hgb-10.9* Hct-33.5* Plt Ct-243 [2116-5-12] PT-13.5* PTT-21.8* INR(PT)-1.2* [2116-5-12] Glucose-187* UreaN-16 Creat-1.0 Na-138 K-4.3 Cl-103 HCO3-26 [2116-5-12] ALT-10 AST-17 AlkPhos-82 Amylase-72 TotBili-0.4 [2116-5-12] %HbA1c-7.4* [2116-5-12] Cardiac Catheterization: 1. Selective coronary angiography in this right dominant system demonstrated no angiographically apparent coronary artery disease. The LMCA, LAD, LCx, and RCA were all free of angiographically apparent flow-limiting coronary artery disease. There was a fistula seen from the proximal LAD to the left pulmonary artery. 2. Limited resting hemodynamics revealed moderate arterial systolic hypertension (SBP 163mmHg). [2116-5-13] Intraop TEE: PRE-BYPASS: There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results before CPB. POST-BYPASS: Normal biventricular systolic function. LVEF 55%. Intact thoracic aorta. There is an aortic bioprosthesis located in the native aortic position, well seated and functioning well with a residual mean gradient of 12mm of Hg. There is no perivalvular leak. Mild TR. [2116-5-17] 04:25AM BLOOD WBC-10.9 RBC-3.52* Hgb-10.3* Hct-31.1* MCV-88 MCH-29.1 MCHC-33.0 RDW-15.0 Plt Ct-171 [2116-5-18] 09:44AM BLOOD PT-17.9* PTT-25.6 INR(PT)-1.6* [2116-5-18] 09:44AM BLOOD UreaN-29* Creat-1.5* Na-130* K-4.5 Cl-96 Brief Hospital Course: Mrs. [Known lastname 85196] was admitted and underwent routine preadmission testing which included a cardiac catheterization. Left heart catheterization revealed normal coronary arteries. The remainder of her preoperative workup was unremarkable and she was cleared for surgery. [2116-5-13] Dr. [Last Name (STitle) ] performed aortic valve replacement surgery. See operative report for further details. After surgery, she was brought to the CVICU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated without incident. On postoperative day one, she was noted to have an asymptomatic 15 beat run of ventricular tachycardia. Electrolytes were repleted per protocol and beta blockade was resumed. All lines and drains were discontinued in a timely fashion. Beta-blocker/Statin/Aspirin was intitiated. POD#3 Ms.[Known lastname 85196] went into postoperative rapid atrial fibrillation. Anticoagulation was initiated with Coumadin. It was treated with Amiodarone, increased dosage of B-Blocker and she converted to NSR. POD#3 was transferred to the step down unit for further monitoring. Physical therapy consulted for evaluation of strength and mobility. She continued to progress and on POD# 5 she was cleared by Dr.[Last Name (STitle) ] for discharge to [Location (un) 1514] [Hospital ] rehabilitation. All follow up appointments were advised. Medications on Admission: Januvia 100 mg daily, Glipizide 10 mg daily, Metformin 500 mg [Hospital1 ], Lipitor 10 mg daily Discharge Medications: 1. Aspirin 81 mg [Hospital1 8426], Delayed Release (E.C.) Sig: One (1) [Hospital1 8426], Delayed Release (E.C.) PO DAILY (Daily). 2. Ranitidine HCl 150 mg [Hospital1 8426] Sig: One (1) [Hospital1 8426] PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Metoprolol Tartrate 25 mg [Hospital1 8426] Sig: Three (3) [Hospital1 8426] PO TID (3 times a day). 5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. 6. Lasix 40 mg [Hospital1 8426] Sig: One (1) [Hospital1 8426] PO once a day for 10 days. 7. Glipizide 5 mg [Hospital1 8426] Sig: Two (2) [Hospital1 8426] PO BID (2 times a day). 8. Metformin 500 mg [Hospital1 8426] Sig: One (1) [Hospital1 8426] PO BID (2 times a day). 9. Acetaminophen 325 mg [Hospital1 8426] Sig: Two (2) [Hospital1 8426] PO Q4H (every 4 hours) as needed for pain/temp. 10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 11. Atorvastatin 10 mg [Hospital1 8426] Sig: One (1) [Hospital1 8426] PO DAILY (Daily). 12. Hydralazine 25 mg [Hospital1 8426] Sig: One (1) [Hospital1 8426] PO Q6H (every 6 hours). 13. Warfarin 1 mg [Hospital1 8426] Sig: [Name8 (MD) ] MD [First Name (Titles) 8426] [Last Name (Titles) ] Once Daily at 4 PM: INR goal 2-2.5 for AFib. 14. Warfarin 2 mg [Last Name (Titles) 8426] Sig: One (1) [Last Name (Titles) 8426] PO ONCE (Once) for 1 days. 15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 16. Amiodarone 200 mg [Last Name (Titles) 8426] Sig: Two (2) [Last Name (Titles) 8426] PO BID (2 times a day): 400 mg twice daily x 7 days, then decrease to 200 mg twice daily x 7 days, then decrease to 200 mg once daily. 17. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [Hospital 1514] Health Care Center - [Location (un) 1514] Discharge Diagnosis: Aortic Stenosis, s/p AVR Type II Diabetes Mellitus Depression Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge 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: Dr. [Last Name (STitle) ] #[Telephone/Fax (1) 170] appointment set up for [6-18] at 1:15pm Dr. [First Name (STitle) 487] or Dr. [Last Name (STitle) 42367] in [12-14] weeks, call for appt Dr. [Last Name (STitle) ] in [12-14] weeks, call for appt Completed by:[2116-5-18] ICD9 Codes: 4241, 9971, 4271, 311, 4589, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8466 }	Medical Text: Admission Date: [2173-6-23] Discharge Date: [2173-6-30] Date of Birth: [2110-8-12] Sex: M Service: [Last Name (un) 7081] HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old male with a history of right lower lobe stage III, non-small- cell lung cancer of the squamous type who has had two cycles of induction chemotherapy initiated on [2172-12-22] and radiation therapy times six weeks. The patient was planning to have a surgical resection on [2173-4-26] but developed a small bowel obstruction requiring an emergent exploratory laparotomy. Two bowel perforations were found, and postoperatively the patient was sick and in the Intensive Care Unit with evidence of a septic physiology. He was discharged to rehabilitation at that time and was home for three weeks prior to his current admission. He gained about five pounds per week over those weeks, and his appetite was much improved. He has an occasional dry cough and reports that he had pneumonia while in the rehabilitation facility; however, his breathing is quite good. Repeat scans showed increased activity within the tumor and within the right hilar and right paratracheal lymph nodes. This was quite concerning given that the induction chemoradiotherapy did not eradicate lymphatic involvement and that it is progressing rapidly. The patient was thought to have a poor prognosis despite the addition of surgical therapy; but nonetheless, after discussions with Dr. [Last Name (STitle) 952] and the patient's wife, the patient opted for further surgery. PAST MEDICAL HISTORY: Right lower lobe stage III non-small- cell lung cancer of the squamous type; status post radiation therapy and chemotherapy. Hypertension. History of a small-bowel obstruction. PAST SURGICAL HISTORY: Exploratory laparotomy/lysis of adhesions. Anal sphincterotomy. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Metoprolol 100 mg twice per day. 2. Lisinopril 2.5 mg once per day. 3. Protonix 40 mg once per day. 4. Percocet. 5. Megace. PHYSICAL EXAMINATION ON PRESENTATION: In general, the patient appeared well. Thinner than usual but walked without difficulty. Vital signs revealed his temperature was 98.6, his heart rate was 100, his blood pressure was 130/80, his respiratory rate was 18, and 98 percent on room air. Weight was 163 pounds. Head, eyes, ears, nose, and throat examination revealed the extraocular movements were intact. The sclerae were anicteric. The oropharynx was clear. The neck was supple. No palpable cervical, supraclavicular, or axillary lymph nodes. Chest revealed occasional expiratory wheezes. Good air movement. Cardiovascular examination revealed a rate and rhythm. The abdomen was soft and nontender. A well-healed surgical scar. A small opening in the inferior umbilical area. Extremities were thin. No edema or asymmetric swelling. PERTINENT LABORATORY VALUES ON PRESENTATION: White blood cell count was 10.1, his hematocrit was 33.9, and his platelets were 218. Sodium was 137, blood urea nitrogen was 11, and his creatinine was 1.1. His albumin was 3.7. His calcium was 9.6. SUMMARY OF HOSPITAL COURSE: On [2173-6-23] the patient underwent a right pneumonectomy, a radical mediastinal lymph node dissection with a muscle flap. The patient tolerated the procedure well. The intraoperative course was complicated by recurrent hypotension into the low 60s. The patient had an intraoperative transesophageal echocardiogram which showed multiple areas of hypokinesis with tricuspid regurgitation, right ventricular dilatation, and an ejection fraction of 40 percent. However, this was no change from preoperatively. Please see the dictated operative note for further details. Postoperatively, the patient remained hypotensive with a blood pressure of 94/62 on a Neo-Synephrine drip. The patient remained intubated. The patient was ultimately extubated on postoperative day three without incident. Postoperatively, cardiac enzymes were drawn and the CK/MB fraction was found to range from 3 to 5 postoperatively with a troponin of 0.06. Also, on postoperative day one, the patient's temperature spiked to 102.6. The patient had blood, urine, and sputum cultures sent. The blood and urine cultures ultimately came back negative, but the sputum culture later grew out methicillin-resistant Staphylococcus aureus. As a consequence, the patient was placed on vancomycin and was transitioned to linezolid on discharge for a total of a 10- day course. On postoperative day two, the patient's chest tube was removed but he continued to require Neo-Synephrine to maintain his blood pressure at 99/57. His pulse remained high at 109, and his hematocrit slowly drifted down from a preoperative value of 37.8 to 25.9 on postoperative day three; at which point the patient received a transfusion of 1 unit of packed red blood cells. Following this transfusion, the patient's hematocrit bumped to the 28 to 29 range where it remained stable for the remainder of his hospital course. By postoperative day three, the patient's epidural was taken out and he was started on a morphine patient-controlled analgesia. He was able to come off the Neo-Synephrine, and his blood pressure was maintained at 137/70. Diuresis was begun with Lasix, and the patient was receiving aggressive chest physical therapy. On postoperative day five, the patient was switched to oral pain medications. Chest physical therapy was continued, and the patient was begun on Lopressor for his tachycardia. The patient remained afebrile throughout his hospital course following his initial temperature spikes in the Intensive Care Unit. The patient was transferred to the floor late on postoperative day five. On postoperative day six, the patient continued to require aggressive chest physical therapy for his coarse breath sounds and a productive cough. His metoprolol dose was increased ultimately to 100 mg by mouth twice per day. On postoperative day seven, the patient was discharged to a rehabilitation facility with a 7-day course of linezolid and recommendation that the patient receive aggressive chest physical therapy and frequent walking. On the day of discharge, the patient continued to have rhonchi on the left with a productive cough; however, his oxygen saturations were good at 97 percent on 2 liters with a respiratory rate of 20. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: To a rehabilitation facility. DISCHARGE DIAGNOSES: Identical to the admission diagnoses listed in the Past Medical History with the addition of the following: Status post right pneumonectomy, radical mediastinal lymph node dissection and muscle flap on [2173-6-23]. MEDICATIONS ON DISCHARGE: 1. Linezolid 600 mg by mouth twice per day (times seven days). 2. Percocet 5/325-mg tablets one to two tablets by mouth q.4- 6h. as needed. 3. Colace 100 mg by mouth twice per day. 4. Protonix 40 mg by mouth once per day. 5. Furosemide 20 mg by mouth twice per day. 6. Ipratropium bromide 2 puffs inhaled four times per day. 7. Metoprolol 100 mg by mouth twice per day. [First Name11 (Name Pattern1) 951] [Last Name (NamePattern4) ], [MD Number(1) 15911] Dictated By:[Last Name (NamePattern1) 15517] MEDQUIST36 D: [2173-6-30] 12:04:34 T: [2173-6-30] 13:02:29 Job#: [Job Number 50996] ICD9 Codes: 2765
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8467 }	Medical Text: Admission Date: [2104-2-18] Discharge Date: [2104-2-23] Date of Birth: [2057-12-31] Sex: M Service: CARDIOTHOR HISTORY OF PRESENT ILLNESS: Asked by Dr. [Last Name (STitle) ] to see this 46 year old man who had an abnormal EKG at his primary care provider and was referred for a stress test, which was positive. He was referred to [Hospital1 188] for cardiac catheterization. PAST MEDICAL HISTORY: 1. Insulin dependent diabetes mellitus. 2. Hypertension. 3. High cholesterol. 4. Tobacco use. ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: 1. Atenolol 50 mg q. day. 2. Lipitor 10 mg q. day. 3. Actos 45 mg q. day. 4. Lotensin 10 mg q. day. 5. Glucophage 850 mg twice a day. 6. Aspirin 325 mg q. day. 7. Humulin NPH 20 units q. a.m. and 25 units q. p.m. His cardiac catheterization showed an ejection fraction of 50% with an left ventricular end diastolic pressure of 17, 70% diagonal 1 lesion, 80% mid left circumflex lesion and a 90% ramus lesion. SOCIAL HISTORY: Married and lives with his wife and two sons. Positive tobacco use, one to two packs per day. Denies alcohol use. Works for a printing company. REVIEW OF SYSTEMS: Denies cerebrovascular accident, transient ischemic attack, no gastrointestinal bleeds, no claudication. Positive peripheral neuropathy. No bleeding, no clotting problems. LABORATORY: White blood cell count 10.3, hematocrit 38, platelets 295. Sodium 136, potassium 3.9, chloride 103, carbon dioxide 22, BUN 15, creatinine 0.6, glucose 97. ALT 27, AST 18, alkaline phosphatase 68. Total bilirubin 1.0. PT 13, PTT 30.8. INR 1.1. PHYSICAL EXAMINATION: Heart rate 78 and sinus rhythm; blood pressure 122/77; respiratory rate 14; 02 saturation 98% on room air. Neurologically, alert and oriented times three, moves all extremities. Pupils are equal, round and reactive to light. Cardiovascular is regular rate and rhythm; S1 and S2 without murmur. Respiratory: Scattered rhonchi, left greater than the right. GI: Soft, nontender, nondistended, with positive bowel sounds. Extremities are warm and well perfused with no edema or varicosities. Pulses of the right femoral is catheterization site; femoral two plus, popliteal one plus bilaterally. Dorsalis pedis two plus bilaterally. Carotids two plus without bruits. HOSPITAL COURSE: The patient was accepted for coronary artery bypass grafting and on [2-18], he was brought to the Operating Room. Please see the OR report for full details and summary. The patient had a coronary artery bypass graft times three with the left internal mammary artery to the diagonal; saphenous vein graft to the left DL; saphenous vein graft to the obtuse marginal 2; his bypass time was 84 minutes with a cross clamp time of 46 minutes. He tolerated the operation well and was transferred to the Cardiothoracic Intensive Care Unit. At the time of transfer, he had a mean arterial pressure of 72 and central venous pressure of 10; heart rate of 78 in sinus rhythm. He had Propofol at 10 micrograms per kilogram per minute and Neo-Synephrine at 0.3 micrograms per kilogram per minute. The patient did well in the immediate postoperative period. His anesthesia was reversed. He was weaned from the ventilator and successfully extubated on the morning of postoperative day one. The patient remained hemodynamically stable, requiring a Nitroglycerin drip for blood pressure control. On postoperative day one he was started on beta blockade as well as diuretics. His chest tubes remained in as he was draining a fair amount of serosanguinous fluid. The patient remained hemodynamically stable. On postoperative day two, his Nitroglycerin was weaned to off. His beta blockade was increased. He was transferred to the floor for continuing postoperative care and cardiac rehabilitation. On the floor, on postoperative day three, the patient remained hemodynamically stable. His beta blockade was again increased. His chest tubes were removed as were his temporary pacing wires and his Foley catheter and additionally his central venous access. His activity level was increased with the assistance of the nursing staff and Physical Therapy. Over the next two days, he had an uneventful hospitalization and on postoperative day four, it was decided that the patient would be stable and ready to be discharged the following morning to home with visiting nurses. At the time of discharge, the patient's physical examination is as follows: Temperature 99.0 F.; heart rate 90 and sinus rhythm; blood pressure 104/67; respiratory rate 20; 02 saturation 100% on room air. Weight preoperatively was 65 kilograms and at discharge is 64.8 kilograms. Laboratory data is white blood cell count of 8.9, hematocrit 27.5, platelets 234. Sodium 138, potassium 4.0, chloride 103, carbon dioxide 28, BUN 10, creatinine 0.6, glucose 172. PHYSICAL EXAMINATION: At discharge, Neurological is alert and oriented times three; moves all extremities. Follows commands. Respiratory: Breath sounds are clear to auscultation bilaterally. Cardiac is regular rate and rhythm with S1, S2 with no murmurs. Sternum is stable. Incision with Steri-Strips, open to air, clean and dry. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are warm and well perfused with no edema. Right saphenous vein graft site with Steri-Strips, open to air, clean and dry. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg q. day. 2. Lopressor 75 twice a day. 3. Lasix 20 q. day times one week. 4. Potassium chloride 20 q. day times one week. 5. Lipitor 10 mg q. day. 6. Actos 45 mg q. day. 7. Glucophage 850 twice a day. 8. Insulin, NPH 20 q. a.m. and 25 q. p.m. 9. Regular insulin sliding scale. 10. Percocet 5/325, one to two tablets q. four hours for pain. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post coronary artery bypass grafting times three with a left internal mammary artery to the diagonal; saphenous vein graft to the LDL and saphenous vein graft to the obtuse marginal. 2. Insulin dependent diabetes mellitus. 3. Hypertension. 4. Hypercholesterolemia. 5. Tobacco use. DISPOSITION: The patient is to be discharged to home with Visiting Nurses Association. DISCHARGE INSTRUCTIONS: 1. He is to have follow-up in the [Hospital 409] Clinic in two weeks. 2. Follow-up with Dr. [Last Name (STitle) 7659] in three to four weeks. 3. To follow-up with Dr. [Last Name (STitle) 70] in six weeks. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Doctor Last Name ] MEDQUIST36 D: [2104-2-22] 16:46 T: [2104-2-22] 19:22 JOB#: [Job Number 54596] ICD9 Codes: 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8468 }	Medical Text: Admission Date: [2146-8-18] Discharge Date: [2146-8-25] Date of Birth: [2146-8-18] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: Baby Girl [Known lastname ] was born at 32 weeks to a 33 year old gravida 3, para 0, 1, mom. Pregnancy was complicated by growth restriction beginning around 25 weeks at less than 10th percentile, progressing to less than 3rd percentile. Mother was admitted for observation and was treated with betamethasone on [8-10]. On the day of delivery, she was noted to have FHR decelerations and was therefore taken for cesarean section. A prenatal ultrasound was notable for two vessel cord and a question of bilateral club feet. Maternal history is notable for previous ectopic pregnancy and ruptured appendix. Prenatal screens - blood type O positive, antibody screen negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune. No sepsis risk factors. Delivery room course: She had copious oral secretions requiring bag mask inhalation. She pinked up and had increased heart rate quickly. She continued to need frequent suctioning and required intubation. Apgars 3 and 7. She was brought to the Newborn Intensive Care Unit for further treatment. ADMISSION PEX: BW 1365 gm, well perfused pink infant in room air. Her skin was without lesions. Her cardiac examination was normal without murmurs. LUNGS: Crackly with equal breath sounds bilaterally. ABDOMEN: Benign. EXTREMITIES: Her left foot was held in the equinovarus position but was easily reducible to normal position. Her right foot was normal. NEUROLOGICAL: Grossly normal. HOSPITAL COURSE TO THIS INTERIM SUMMARY: RESPIRATORY: She was ventilated and received 3 total doses of surfactant. She was extubated and remains on nasal cannula at this time. She began having apnea and bradycardia on day of life 7. She was loaded with caffeine but is also undergoing sepsis evaluation at this time due to increased apnea. CARDIOVASCULAR: She was noted to have a murmur on day of life 3. She had an echocardiogram at that time that revealed a moderate membranous ventricular septal defect as well as large patent ductus arteriosus. She was treated with indomethacin and had a repeat echocardiogram that revealed a smaller patent ductus arteriosus as well as the prior finding of ventricular septal defect. She has currently just finished dose No. 3 of her second course of indomethacin. She will have a follow up echocardiogram on [2146-8-26]. Her blood pressures and perfusions have been normal. FLUIDS, ELECTROLYTES AND NUTRITION: She has been NPO throughout her stay here secondary to indomethacin therapy. She has a non-central PICC line in place and has been receiving peripheral nutrition through that. Her urine output has been normal and her electrolytes have been stable. GASTROINTESTINAL: She has had no significant abdominal distention or concerns throughout her stay. She was placed on double phototherapy on day of life 3 for bilirubin of 8 which was at its peak. She remains on single phototherapy and her latest bilirubin is 4.1 on [2146-8-25]. HEMATOLOGY: Her admission hematocrit was 41.6 percent. INFECTIOUS DISEASE: She was in ampicillin and gentamycin for 48 hours around her birth. She has had no additional infectious disease issues until this afternoon, [8-25], when she started having more frequent apnea and bradycardia. At this time blood count and blood culture are pending. NEUROLOGY: She had a head ultrasound on day of life 7 that showed a small bilateral grade 1 hemorrhages. DISCHARGE DIAGNOSES: 1. Prematurity at 32 weeks. Rule out sepsis. 2. Respiratory distress syndrome. 3. Patent ductus arteriosus. 4. Ventricular septal defect. 5. Bilateral grade 1 intraventricular hemorrhages. [Last Name (LF) ], [First Name3 (LF) ] R. 50-549 Dictated By:[Last Name (NamePattern1) 57083] MEDQUIST36 D: [2146-8-25] 19:20:58 T: [2146-8-25] 21:30:01 Job#: [Job Number 57084] ICD9 Codes: 769, 4280, 7742, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8469 }	Medical Text: Admission Date: [2170-8-24] Discharge Date: [2170-9-4] Date of Birth: [2123-12-16] Sex: M Service: [Last Name (un) ] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3223] Chief Complaint: s/p being struck by car Major Surgical or Invasive Procedure: closed reduction percutaneous pinning pelvis open reduction internal fixation right patella embolization gluteal artery intubation central line placement History of Present Illness: 46 y/o male who was struck by car. No LOC. GCS 15. Hemodynamically stable throughout transfer. Patient complaining of left flank/abdominal pain and R hip pain. Past Medical History: MI Hypercholesterolemia Social History: Mechanic No drugs No ETOH 20 pack-year hx of tobacco Family History: Non-contributory Physical Exam: 99.2 HR 61 123/52 18 98% 3L Gen: GCS 15, in pain HEENT: complex lac on superior forehead, PERRL, Nares patent, L TM clear, R TM obscured Neck: C-collar Chest: CTAB, non-tender CV: RRR, no MGR Abd: soft, mildly tender L flank, obese, FAST neg Back: non-tender, no deformity, no step offs Ext: R hip hematoma, 8 cm R knee lac, 2+ DP bilaterally Pelvis: R hip tenderness Pertinent Results: [2170-8-24] 08:16AM BLOOD WBC-15.6* RBC-4.60 Hgb-14.6 Hct-41.1 MCV-89 MCH-31.8 MCHC-35.6* RDW-12.8 Plt Ct-226 [2170-8-24] 11:01PM BLOOD WBC-9.5 RBC-3.24# Hgb-10.2 Hct-28.6* MCV-88 MCH-31.4 MCHC-35.6* RDW-13.5 Plt Ct-109# [2170-9-3] 06:00AM BLOOD WBC-10.5 RBC-3.37 Hgb-10.4* Hct-30.5* MCV-91 MCH-30.9 MCHC-34.1 RDW-14.2 Plt Ct-140* [2170-9-2] 09:59PM BLOOD WBC-11.1* RBC-3.35* Hgb-10.2* Hct-30.2* MCV-90 MCH-30.3 MCHC-33.7 RDW-14.4 Plt Ct-143* [2170-8-31] 08:15PM BLOOD ALT-82* AST-71* AlkPhos-189* TotBili-3.9* [2170-9-2] 09:59PM BLOOD ALT-98* AST-54* AlkPhos-217* Amylase-44 TotBili-2.9* [2170-9-3] 12:15PM BLOOD ALT-106* AST-52* AlkPhos-245* Amylase-47 TotBili-3.0* [2170-8-31] 08:15PM BLOOD CK-MB-2 cTropnT-<0.01 [2170-8-31] 08:15PM BLOOD Ammonia-45 INLET AND OUTLET VIEWS OF THE PELVIS: A displaced inferior pubic ramus fracture is evident on the right, and fracture through the base of the superior pubic ramus into the acetabulum is evident on the right. The left- sided interruption of the iliopectineal line is not as well appreciated on this exam. The diastasis of the right SI joint is again noted, though the right iliac [Doctor First Name 362] fracture is not well seen. The contrast filled bladder is elongated in a craniocaudad dimension and pushed leftward suggesting the presence of hematoma related to fractures, probably enlarged compared with the prior CT. In addition there is a cloud-like areas of density over the right mid to lower pelvis probably representing injected contrast material contained within the hematoma from previous active bleeding at this site. There is an angiographic coil present as well in this vicinity. IMPRESSION: Pelvic fractures as above. A large pelvic hematoma post-coiling with mass effect on the bladder. COMMENTS: Two radiographs of the pelvis obtained in the O.R. are limited by technique. There has been interval placement of two screws across the right sacroiliac joint. Again noted are fractures of the right acetabulum, superior and inferior pubic rami. A curvilinear metallic structure overlying the inferior aspect of the right pelvis is unchanged when compared with the previous radiographs obtained earlier the same day. AP and lateral radiographs of the right knee obtained in the O.R. demonstrate two screws across a patellar fracture. There are skin staples and a drain in place. A small amount of soft tissue air is present, consistent with the recent surgical procedure. IMPRESSION: S/P internal fixation of a right patellar fracture and of the right SI joint. Fractures noted within the right acetabulum, right superior and inferior pubic rami as on the radiographs from earlier the same day. A Foley catheter is again noted within the bladder. THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST. IMPRESSION: Massive active extravasation from the right internal pudendal artery. This was successfully embolized with two 3 mm x 3 cm microcoils with good angiographic success. Horseshoe kidney with a dilated right upper moiety.Small size of the right renal artery is likely related to longstanding hydronephrosis of the upper right moiety. Normal sized nonstenotic left renal artery. Brief Hospital Course: The patient was admitted s/p pedestrian struck, no LOC, GCS 15 & found to have the fractures listed above. He was hemodynamically stable in the Emergency Department. He was taken to the angio for embolization of bleeding vessels, and taken to the OR by othropedics for closed reduction & percutaneous pinning of pelvis, open reduction internal fixation right patellar fracture. On HD 1, he had a decrease in hematocrit & was transfused 4 units packed red blood cells. He also developed hematuria, and on HD 2 clotted his Foley catheter. Urology was consulted & started continuous bladder irrigation. On HD 4, he was weaned off the ventilator & was extubated. He remained hemodynamically stable & on HD 5 was transferred to the floor. His CBI was weaned off & by HD 7, his foley was d/c'd & he was voiding spontaneously without difficulty. On HD 7, he was evaluated by the neurology service for change in MS [First Name (Titles) 767] [Last Name (Titles) 5348] (not following multi-step cpmmands, sl confused as per family). A repeat Head CT was negative, and a metabolic w/u was negative, except for sl elevated LFTs. A RUQ ultrasound showed sludge, but no evidence of cholecystitis. By HD 10, he remained hemodynamically stable, but was having occasional (approx once daily) episodes of vomiting (usually in evening). His LFTs remained stably slightly elevated, and the nausea & vomiting subsided by HD 11. He was evaluated by PT/OT who worked with him for passive ROM exercises to his R knee. He was evaluated by the behavioral neurology team for decreased attention and difficulty following multi-step commands. They noted some mild cognitive difficulties most consistent with post-concussive changes and recommended full neuropsychiatric workup as an outpatient, especially if his deficits persisted. He was discharged to rehab on HD 11. Medications on Admission: Imdur ASA Pravachol Lopressor MDI Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal QD (once a day) as needed. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Lovenox 30 mg/0.3 mL Syringe Sig: Thirty (30) mg Subcutaneous twice a day. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Pelvis fracture Right patella fracture Pelvic arterial bleed s/p embolization Discharge Condition: good Discharge Instructions: Nonweight bearing right lower extremity. Passive range of motion exercises right knee as directed by physical therapy Followup Instructions: With your doctor (Dr. [Last Name (STitle) ] as soon as possible With Dr. [Last Name (STitle) 1005] (Orthopedics) in 10 days. Please call their office at [Telephone/Fax (1) 5499] as soon as possible to schedule an appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226] ICD9 Codes: 2762
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8470 }	Medical Text: Admission Date: [2127-10-6] Discharge Date: [2127-10-28] Date of Birth: [2083-9-20] Sex: M Service: MEDICINE Allergies: Reglan Attending:[Last Name (NamePattern4) 290] Chief Complaint: altered mental status, unresponsive Major Surgical or Invasive Procedure: none History of Present Illness: 43 year old man with end-stage liver disease transferred to [Hospital1 18] from [Hospital3 ] Hospital with altered mental status. According to his wife he has been taking extra lactulose lately because of asterixis. He seemed more confused this morning and he went to [Hospital3 ] hospital. She denies that he has had recent sickness or other symptoms other than some vomiting last night. He was intubated for airway protection. Of note, he was discharged on [9-30] with similar sx of hepatic encephalopathy and was treated for a pneumonia with levofloxacin (last dose as outpt [10-3]). He was also taken off of the [Month/Day (2) ] list due to malnutrition. . Review of sytems: (+) Per HPI; Patient unable to answer ROS questions . Past Medical History: -Alcoholic cirrhosis diagnosed [3-9] c/b portal vein thrombosis, severe portal htn gastropathy, 3 cords of grade I varices; no history of variceal bleed; currently gets paracentesis q1-2 weeks. -Seizures from EtOH withdrawal -No evidence of HCC on recent CT Past Medical History: -Alcoholic cirrhosis diagnosed [3-9] c/b portal vein thrombosis, severe portal htn gastropathy, 3 cords of grade I varices; no history of variceal bleed; currently gets paracentesis q1-2 weeks. -Seizures from EtOH withdrawal -No evidence of HCC on recent CT Social History: Lives on cape with wife, no kids, previous heavy etoh for 20 years ([6-8] drinks per day; vodka, sober since diagnosis of cirrhosis in [3-9], attends AA). No other drugs or smoking. Worked as a chef. Family History: NC Physical Exam: Physical Exam: T 96 HR 106 BP 125/72 HR 85 RR 20 O2 100% on RA GENERAL: Sedated, cachectic man in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/conjugate gaze. MM dry. Sm blood in mouth. Neck Supple, No LAD CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. JVP flat LUNGS: CTA b/l, decreased breath sounds at b/l bases ABD: +BS, very distended, dull to percussion EXTREMITIES: dry, warm and well perfused SKIN: No rashes/lesions, ecchymoses. No jaundice NEURO: Somnolent but reponds to painful stimuli. does move all limbs. Pertinent Results: Please see OMR for lab results/reports during hospitalization. Brief Hospital Course: 43 year old man with end-stage liver disease admitted with altered mental status, thought to be [2-3] hepatic encephalopathy. . # Altered Mental Status: Acute change in mental status per wife. Ammonia level very elevated and he was noted to have asterixis when he was not sedated. No clear precipitant was identified. Given history of multiple previous admissions for encephalopathy, he was treated with aggressive lactulose and rifaximin. He was put on ciprofloxacin for SBP prophylasis. He was also worked up for infection, which was negative. Blood and urine tox screens were negative for illicit substances. His mental status progressively worsened. He became significantly more obtunded. On [10-8] he developed new seizures, for which he was empirically treated for viral and bacterial mengingits. CT of the head showed diffuse cerebral edema, thought to be [2-3] end stage liver disease. . # Acute on chronic renal failure- Creatinine worse than prior admissions at 3.3. Pt appeared to be volume depeleted. He received several boluses of fluid challenge, with catution given affinity of fluids to settle in the abdomen. His urine output however continued to worsen. It was believed that he had a component of hepatorenal syndrome, for which treatment was initiated. He showed some response, which was shortlived. His kidney function continued to worsen until he was anururic. He developed a significant metabolic acidosis which was treated with IVF with bicarbonate which which temporized his electrolyte disturbances. Dialysis was not initiated as it is not considered a treatment for hepatorenal syndrome. . # Seizures - Seizure activity was thought to be due [2-3] to cerebral edema. However LP was done to rule out infectious etiology. LP was negative. Antibiotics were discontinued. He was started on seizure prophylaxis per neurology, who followed his course through the remainder of his hospitalization. # Respiratory: On ventilator for airway protection. He continued on mechanical ventilation until he passed away from distrubances of the cardiac conduction system. . # ETOH cirrhosis - GI was consulted for consideration of liver [Month/Day (2) ]. Unfortunatley, given h/o of poor nutritional status with history of inability to gain wait, he was not considered to be an ideal candidate. This was solidified after images of his CT scan which showed defiinitive cerebral edema. He was maintained on TPN for nutrition as his bowel was unable to tolerate sufficient tube feeds. There were numerous interdisciplinary meetings to discuss with the family the prognosis of Mr [Known lastname ], which was generally poor even prior to the acute causes leading to his hospitalization. The decision to not pursue aggressive measures was made several weeks into his hospitalization. . #Cardiac failure: Pt was noted to develop bradycardia and conduction abnormalities most likely due to electrolyte disturbances before his heart stopped beating. No intervention was made as pt was DNR/DNI. Medications on Admission: 1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day): Should have [3-5] bowel movements daily. Increase if confusion or not 3 bowel movements. 2. Clotrimazole 10 mg Troche Sig: One (1) troche Mucous membrane every 4-6 hours as needed for thrush. 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. Prochlorperazine Maleate 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 7. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 10. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO QOD for 2 doses: To be given [2127-10-1] and [2127-10-3]. Disp:2 Tablet(s) Refills:0 . Discharge Medications: . Discharge Disposition: Expired Discharge Diagnosis: primary: end stage liver disease, hepatorenal disease, cerebral edema, seizure disorder, respiratory failure, cardiac failure Discharge Condition: deceased Discharge Instructions: . Followup Instructions: . [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2127-11-4] ICD9 Codes: 5849, 486, 2762, 5789, 2768, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8471 }	Medical Text: Admission Date: [2174-3-12] Discharge Date: [2174-4-15] Date of Birth: [2096-8-7] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 398] Chief Complaint: hypoxic respiratory failure hypotension Major Surgical or Invasive Procedure: Endotracheal intubation Subclavian central line Thoracostomy tube placement History of Present Illness: 77 yo M with dementia, schizophrenia, HTN, DM presents to ED after removing his PEG tube. When he initially arrived from [Location ] he was doing well. Enroute his vital signs were T 97.9 BP 128/70 HR 72 RR 20 O2sats 95% RA. He was sent to the ED for replacement of his PEG tube. In the ED he vomited and developed hypotension and hypoxia. His sats dropped into the 80's on room air and BP into the 80's. CXR then showed RLL/RML infiltrate. He was found to have significant bandemia and then was treated as code sepsis. He was given 3 L of NS with good response in his BP. He was continued on NRB with appropriate bump in oxygen level. He was also given Zosyn/Vanco for antibiotic coverage. He is only able to respond with yes or no answers. At this time he denies ant chest pain or abd pain. Otherwise unable to obtain history from this gentleman. I spoke to both his guardian and son who were not aware he was brought to the hospital. They said at baseline he is only able to give yes/no answers. Past Medical History: Dementia Paranoid Schizophrenia DM2 Prostate Ca Hypertension GERD Angina Bipolar d/o COPD Hearing impaired Social History: Patient lives in [Location ] Manor nursing [Last Name (un) ], wheelchair bound. He has one son who lives in the area. He smokes 10 cigarettes/day. Baseline ADL/IADLs unknown. - Guardian has been appointed by family in past given difficulties with relationship between son and patient re: forced psychiatric hospitalizations Family History: Noncontributory Physical Exam: T 94 BP 89/58 HR 92 RR 24 O2sats 93% NRB CVP 3 Gen: Agitated gentleman, who is tachypneic. Responds to yes/no questions but otherwise non-communitative HEENT: PERRL, dry mm, anicteric Neck: No obvious LAD Lungs: Course rhonchi bilaterally Heart: Tachy, difficult to appreciate any murmurs given lungs sounds Abd: Soft, NT, ND, hypoactive bowel sounds. Site of PEG tube with pink tissue no obvious infection Ext: No edema, 1+ DP/PT's Neuro: Only answers yes/no questions. Moving all 4 extremities. Unable to otherwise assess due to lack of cooperation. Pertinent Results: From [Location (un) ] [3-11] WBC 5.2 Hct 32 plts 212 Na 138 K 4.9 Cl 101 CO2 31 BUN/Cr 45/1.1 ALT 31 AST 27 . CXR #1- Continued diffuse mild fluffy opacity in the right lung with interval development of a more focal area of consolidation in the right mid lung and interval improvement in aeration in the right lower lung. There is overall improved appearance of the left retrocardiac region with a residual streaky opacity. . CXR #2- Left subclavian in place in SVC. . ECG: NSR at 81, nl axis, nl intervals, Qwave in inferior leads, no ther acute/ischemic ST/Twave changes Brief Hospital Course: 77M schizophrenia, advanced dementia, initially presented for PEG dislodgement, subsequently complicated by sepsis, pneumothorax complicating central line placement, hypoxic respiratory failure, ventilator associated pneumonia, ultimately leading to withdrawal of care and expiration. Briefly, the pt was initially brought to [Hospital1 18] for replacement of feeding tube, however, his course was complicated by shock thought to be [1-21] sepsis. Pt underwent central line placement which was complicated by pneumothorax requiring thoracostomy tube placement. In addition, pt's course was also complicated by hypoxic respiratory failure requiring intubation, ultimately further complicated by ventilator associated pneumonia. Multiple attempts to wean towards extubation failed as a result of 1) asystolic arrest, 2) tachypnea to 40s-50s, 3) agitation and discomfort. Given extended endotracheal intubation time, discussion was had with guardian who felt that this was not according to pt's wishes. In addition, guardian refused further invasive procedures as pt's clinical status continued to decline. However, guardian felt uncomfortable initially with moving towards comfort measures due to an isolated statement made by the pt in the distant past. Nevertheless, following a court hearing, it was decided by all parties including pt's sons that pt would not have wanted continued aggressive care given his extremely poor quality of life and prognosis. Pt was made comfort measures only and extubated. He expired [2174-4-15]. Medications on Admission: 1. Aspirin 81 mg qday 2. Atenolol 12.5 mg qday 3. Rosiglitazone 2 mg qday 4. Ferrous Sulfate 220 mg/5mL Elixir Sig: 7.5 ml PO qday 5. Amlodipine 5 mg qday 6. Clopidogrel 75 mg qday 7. Haloperidol Decanoate 25mg IM Intramuscular Every other Wed. 8. Olanzapine 5 mg qday 9. Zantac 150 mg [Hospital1 ] 10. Benztropine 1 mg TID 11. Haloperidol 1 mg [Hospital1 ]:PRN 12. Ipratropium Bromide 0.02 % Q6hrs:prn 13. Albuterol Sulfate 0.083 % Q6hrs:prn 14. RISS Discharge Disposition: Expired Discharge Diagnosis: Septic Shock Pneumothorax Severe dementia Schizophrenia Hypoxic respiratory failure Probable Community acquired pneumonia Ventilator associated pneumonia Discharge Condition: Expired ICD9 Codes: 0389, 496, 5070, 5845, 2760, 2875, 4275, 2930
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8472 }	Medical Text: Admission Date: [2196-11-17] Discharge Date: [2196-11-18] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: dyspnea, nausea Major Surgical or Invasive Procedure: None History of Present Illness: 89 year old female with history of dementia, recent hospitalization for fall/UTI/CHF, diagnosed at rehab the day prior to admission with C difficile, presented with hypotension (70s SBP), tachypnea, and tachycardia (140s). Labs showed lactate 6.4, WBC 17.2 with 23% bands, elevated LFTs, tense/distended abdomen. CT abdomen showed diffuse infectious vs ischemic colitis. ED attending Dr. [Last Name (STitle) 78073] spoke with son/HCP over phone and confirmed DNR/DNI status. Son wanted to continue supportive care until he and his wife could reach the hospital, with plan to focus on comfort care after that point. Central line was placed with 4L IVF given and CVP 8-12. Phenylephrine was then started for persistent hypotension. She received vancomycin, piperacillin-tazobactam, and metronidazole. VS prior to ICU transfer were: 82/48, 90-100s, 20-28 on 12 liters FM. In the ICU, the patient was awake, but speech was infrequent and incoherent. Past Medical History: Orthostatic hypotension (diagnosed [12/2194]) Chronic kidney disease, stage 3 -baseline Cr 1.5 Dementia HTN CHF Chronic venous insufficiency Gout Iron deficiency anemia Social History: Lived in [Hospital3 ]. No recent alcohol or tobacco use. Per prior notes, son [Name (NI) ] [Name (NI) 78071] [Telephone/Fax (1) 78072] is very involved and helpful in her care. He is listed as next of [Doctor First Name ] and was co-HCP with his brother in [Name (NI) 5256]. Family History: Unable to obtain due to dementia Physical Exam: GENERAL: Elderly woman on non-rebreather, does not respond appropriately verbally but does moan in discomfort CARDIAC: RRR no m/r/g LUNGS: CTAB ABDOMEN: NABS. Soft, diffusely TTP without rebound or guarding, very distended and tympanitic. EXTREMITIES: 2+ LE edema. Cool distal extremities. LLE with leg brace. Pertinent Results: [2196-11-17] 07:56PM LACTATE-3.3* [2196-11-17] 07:56PM TYPE-ART TEMP-36.6 O2 FLOW-12 PO2-281* PCO2-55* PH-7.20* TOTAL CO2-22 BASE XS--6 INTUBATED-NOT INTUBA COMMENTS-NON-REBREA [2196-11-17] 01:45PM PT-13.3 PTT-32.7 INR(PT)-1.1 [2196-11-17] 01:45PM PLT SMR-NORMAL PLT COUNT-337 [2196-11-17] 01:45PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-1+ SCHISTOCY-1+ [2196-11-17] 01:45PM NEUTS-52 BANDS-23* LYMPHS-14* MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-3* MYELOS-0 NUC RBCS-5* [2196-11-17] 01:45PM WBC-17.2# RBC-5.10 HGB-12.0 HCT-39.6 MCV-78# MCH-23.6* MCHC-30.3# RDW-18.2 [2196-11-17] 01:45PM CORTISOL-113.6* [2196-11-17] 01:45PM cTropnT-0.02* [2196-11-17] 01:45PM ALT(SGPT)-65* AST(SGOT)-136* CK(CPK)-51 ALK PHOS-73 AMYLASE-154* TOT BILI-0.2 [2196-11-17] 01:56PM LACTATE-6.4* Brief Hospital Course: The patient was maintained on phenylephrine, which was started in the ED, until her son and daughter-in-law arrived for a family meeting and to spend some time with her. The patient's son, who is her health care proxy, expressed that the patient would choose to have Comfort Measures Only if she could make the decision for herself. She was started on an IV morphine drip, titrated to comfort. The phenylephrine was stopped in the late evening on [11-17]. Her blood pressure dropped quickly to the 40s systolic and MAPs in the mid 40s, where she remained until about 6am. The patient was saturating 100% on a non-rebreather; her respiratory rate slowly decreased. She passed at 7:05AM on [2196-11-18] with no heart beating on the telemetry. The patient was examined at that time with her daughter-in-law at the bedside. The patient's son declined post-mortem autopsy. Medications on Admission: 1. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): to superior part of shoulder. 9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): to anterior part of knee. 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 15. Acetaminophen 500 mg/5 mL Liquid Sig: 1000 (1000) MG PO every eight (8) hours: for arthritis pain. 16. Divalproex 125 mg Capsule, Sprinkle Sig: Two (2) Capsule, Sprinkle PO Once Daily at 4 PM. 17. Divalproex 125 mg Capsule, Sprinkle Sig: One (1) Capsule, Sprinkle PO Q8H (every 8 hours) as needed for confusion, insomnia. 18. Divalproex 125 mg Capsule, Sprinkle Sig: Four (4) Capsule, Sprinkle PO HS (at bedtime). Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Septic Shock secondary to Clostridium Difficile Colitis Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None ICD9 Codes: 0389, 2762, 4280, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8473 }	Medical Text: Admission Date: [2170-10-30] Discharge Date: [2170-11-5] Date of Birth: [2086-4-8] Sex: F Service: SURGERY Allergies: Influenza Virus Vaccine Attending:[First Name3 (LF) 2777] Chief Complaint: Ruptured TAA Major Surgical or Invasive Procedure: 1. Ultrasound-guided puncture of bilateral common femoral arteries. 2. Bilateral introduction of catheter into the aorta. 3. Arch aortogram. 4. Endovascular stent graft repair of ruptured thoracic aortic aneurysm with [Doctor Last Name 4726] TAG 31 x 15 and [Doctor Last Name 4726] TAG 31 x 10 and [Doctor Last Name 4726] TAG 37 x 10 endoprosthesis. 5. Bilateral Perclose closure of common femoral arteriotomies. 6. Exploration of right groin. 7. Repair of common femoral arterial dissection with bovine pericardial patch angioplasty. History of Present Illness: 84 y/o female transfered from OSH with a ruptured TAA. No active extravasation but mediastinal and pleural blood noted. Patient stable at OSH. Put on nitroprusside to lower blood pressure and medflighted to [Hospital1 18] to the CVICU. 2wks ago noted back pain but only sought medical attn when had "ripping" back pain at 1AM at night and a syncopal episode. Past Medical History: Hypertension Hypercholesterol Sciatica Cold feet PSH: Hysterectomy Social History: Social History: lives with husband. active and independent in ADLs. no tobacco (husband was a smoker in the house). no etoh Family History: No CAD Physical Exam: Alert and oriented x3 NAD RRR CTA b/l Abd soft, nondistended LE warm and pink bilaterally. Pulses: radial Fem DP PT R/L 2+/2+ 2+/2+ 2+/2+ trip/trip Moving all extremities Pertinent Results: [2170-11-4] 07:00AM BLOOD WBC-10.4 RBC-3.62* Hgb-11.3* Hct-31.8* MCV-88 MCH-31.1 MCHC-35.4* RDW-14.0 Plt Ct-200 [2170-11-2] 06:30PM BLOOD PT-12.8 PTT-23.1 INR(PT)-1.1 [2170-11-4] 07:00AM BLOOD Glucose-102 UreaN-18 Creat-0.7 Na-141 K-3.8 Cl-104 HCO3-27 AnGap-14 [2170-11-4] 07:00AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.0 [2170-10-30] 10:14PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]->1.050URINE Blood-NEG Nitrite-NEG Protein-25 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [2170-10-30] 10:05 pm MRSA SCREEN NASAL SWAB. MRSA SCREEN (Final [2170-11-1]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. CXR: FINDINGS: Aortic stent graft remains in place within a right-sided aortic arch and descending thoracic aorta. Interval extubation and removal of nasogastric tube. Cardiomediastinal contours are unchanged. Increasing left effusion with adjacent left basilar atelectasis. New patchy opacity at right base which may reflect acute aspiration, atelectasis, and less likely developing infection. Small right pleural effusion has also increased. CTA: FINDINGS: Right-sided aortic arch is seen with left subclavian artery as the first branch arising from the aortic arch. At the level of the distal part of the arch, beginning of the descending thoracic aorta, there is pseudoaneurysm in the left anterior direction. Findings are accompanied by high density soft tissue in the mediastinum compatible with mediastinal hematoma. No active extravasation is seen. Bilateral pleural effusions are seen, on the right of a small amount and on the left, small to moderate amount. The effusions are of high density with the hematocrit effect. Findings are consistent with pleural hematoma. Further noted return of descending aorta to the right posterior thorax. Low trachea and bronchial tree are compressed from the hematoma to the AP diameter of 6 mm in the lower trachea and to the diameter of 4 mm at the level of the carina. Further noted linear atelectases in the right lower lobe, left lower lobe and right middle lobe. Liver of normal size and attenuation. No intrahepatic or extrahepatic bile dilatation is noted. Right adrenal is unremarkable. Left adrenal is diffusely thickened. Upper part of the right and left kidney are within normal limits. A single lymph node is seen to the right of the celiac axis measuring 0.7 cm. Pancreas is within normal limits. OSSEOUS STRUCTURES: Degenerative changes of the thoracic spine are seen. IMPRESSION: Ruptured pseudoaneurysm of a right-sided aortic arch with mediastinal hematoma and bilateral hemothoraces. No evidence of active extravasation is seen. Brief Hospital Course: [2170-10-30] Patient was emergently medflighted to [Hospital1 18] for ruptured AAA. Taken to the OR for TEVAR with Vascular and Cardiac surgery. A-line monitoring and BP control for goal SBP 100. Recieved IVF and 1 unit of PRBC intra-op. Kept intubated overnight. Groins stable without hematoma. On esmolol, propofol and fentanyl IV gtts post-op. [2170-10-31] Stable in ICU intubated with labile BP. NPO. ETT, OGT and foley in place. [2170-11-1] Extubated and resp status stable. Recieved 2 additional units of blood. Following commands. OOB, PT consult. Sips of clears and bowl regimen. Pedal pulses palpable. Transferred to VICU. [2170-11-2] Stable overnight. Tmax 100.3 Advanced to ADAT. Continue to diuresis. PT eval recommends Rehab at fist evaluation. Fall precautions in place. [2170-11-3] Stable. Afib on tele. Continue to diuresis and replete electrolytes. CXR shows small rith effusion and moderate left effusion and atelectasis. [2170-11-4] Stable overnight. Continue PT and diuresis. [2170-11-5] PT cleared for home with home physical therapy. Discharged home. Will f/u with Dr. [Last Name (STitle) ] with CT scan in 1 month. Medications on Admission: lovastatin 10, motrin 400 tid, premarin, enalapril 10, HCTZ 25. Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) Inhalation three times a day. 4. Premarin 0.625 mg Tablet Sig: One (1) Tablet PO once a day. 5. Enalapril-Hydrochlorothiazide 10-25 mg Tablet Sig: One (1) Tablet PO once a day. 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing/sob. 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for Wheezing. Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Ruptured thoracic aortic aneurysm Plueral Efussion Discharge Condition: Stable Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm (AAA) Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [1-30] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [4-2] weeks for post procedure check and CTA What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2170-12-6] 11:45 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD Phone:[Telephone/Fax (1) 2625] Date/Time:[2170-12-6] 1:30 Completed by:[2170-11-5] ICD9 Codes: 9971, 5180, 4019, 2720, 2768
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8474 }	Medical Text: Admission Date: [2185-5-24] Discharge Date: [2185-6-10] Date of Birth: [2124-1-16] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3619] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Endoscopy s/p cauterization Intubation x 2 Central line placement History of Present Illness: The Pt is a 61y/o M with a PMH of primary sclerosing cholangitis dx w/ cholangiocarcinoma [8-28] during routine change of stent placed for recurrent biliary obstruction (CA19-9 at diagnosis about 3). Cholangiocarcinoma found when CT scan [9-27] demonstrated a 2.4 x 3.2 cm diameter low attenuation mass surrounding the common duct, extending into the region of the pancreatic head and through the retroperitoneum down to the renal vein and encasing the proximal portal vein as well as the hepatic artery. There was evidence also that the duodenum was encroached upon by the tumor, although not circumferentially. Based on the CT findings he was deemed unresectable. Received 6 cycles of Gemcitabine/oxaliplatin [10-28] to [4-28]. Pt found to have progression of pulmonary disease and chemo regimen was changed to second line of cisplatin/5FU [4-28]. Course complicated by thrush and fatigue. . Pt presented to ED with hematochezia and hematemesis with BRB. Hct 19 at OSH from 26 yesterday. Here hemodyamically stable. S/p 2U PRBC, 2LIVF at OSH in the setting of SBPs of 70s-->90s. Past Medical History: Onc history: Dx [8-28] with cholangiocarcinoma -- local extension including encasing the portal vein and hepatic artery, extending into the head of the pancreas and encircling the duodenum. (Not surgical candidate) -- Chemotherapy: 6 cycles Gemcitabine/Oxaliplatin with progression ([Date range (1) 111295]), 1 cycle 5FU and cisplatin (Currently day 16 cycle 1) Other PMHx: -Primary sclerosing cholangitis (followed by Dr. [Last Name (STitle) 497] -melanoma resection mid back approx 10 years ago with negative sentinel node -Cholecystectomy >20 years ago Social History: Physics teacher at [Location (un) 5028] High School. Family History: Married x 30 years. 2 children. No smoking, no etoh Physical Exam: afebrile, HR 90s, BP 110s/60s, 100% RA NAD- alert and talkative, jaundiced lungs clear RRR, soft SM abdomen protuberant, liver edge palpable just below costal margin, splenomegaly not detected no peripheral edema Pertinent Results: [2185-5-23] 03:35PM BLOOD WBC-5.2 RBC-3.17* Hgb-8.8* Hct-26.2* MCV-83 MCH-27.7 MCHC-33.6 RDW-18.3* Plt Ct-82# [2185-5-24] 03:20AM BLOOD WBC-4.5 RBC-2.57 Hgb-7.4* Hct-22.0* MCV-86 MCH-29.0 MCHC-33.9 RDW-17.7* Plt Ct-74* [2185-5-24] 07:41AM BLOOD WBC-3.7* RBC-2.78* Hgb-8.4* Hct-23.4* MCV-84 MCH-30.1 MCHC-35.7* RDW-16.3* Plt Ct-80* [2185-5-24] 10:25AM BLOOD WBC-3.9* RBC-3.14* Hgb-9.6* Hct-26.4* MCV-84 MCH-30.6 MCHC-36.4* RDW-15.4 Plt Ct-72* [2185-5-24] 09:50PM BLOOD Hct-30.7* [2185-5-27] 05:39AM BLOOD WBC-2.4* RBC-3.31* Hgb-10.2* Hct-28.8* MCV-87 MCH-30.8 MCHC-35.4* RDW-16.1* Plt Ct-245 [2185-5-27] 01:15PM BLOOD WBC-2.8* RBC-4.07* Hgb-12.1* Hct-34.7* MCV-85 MCH-29.8 MCHC-35.0 RDW-15.6* Plt Ct-215 [2185-5-23] 03:35PM BLOOD Neuts-84* Bands-2 Lymphs-4* Monos-9 Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 [2185-5-27] 05:39AM BLOOD Neuts-67 Bands-0 Lymphs-18 Monos-9 Eos-4 Baso-0 Atyps-2* Metas-0 Myelos-0 [2185-6-2] 12:00AM BLOOD PT-12.9 PTT-25.4 INR(PT)-1.1 [2185-5-24] 03:20AM BLOOD PT-15.7* PTT-27.9 INR(PT)-1.4* [2185-5-24] 03:20AM BLOOD Glucose-181* UreaN-22* Creat-0.9 Na-135 K-3.7 Cl-103 HCO3-24 AnGap-12 [2185-5-27] 09:55AM BLOOD Glucose-112* UreaN-33* Creat-0.9 Na-137 K-3.4 Cl-108 HCO3-21* AnGap-11 [2185-5-27] 05:39AM BLOOD ALT-39 AST-45* LD(LDH)-228 AlkPhos-442* TotBili-1.9* [2185-5-24] 03:20AM BLOOD ALT-64* AST-53* CK(CPK)-42 AlkPhos-322* TotBili-1.0 [2185-5-24] 03:20AM BLOOD Lipase-15 [2185-5-25] 04:36AM BLOOD Lipase-7 [2185-5-24] 03:20AM BLOOD Albumin-2.5* Calcium-7.2* Phos-3.2 Mg-1.7 [2185-5-27] 09:55AM BLOOD Calcium-7.5* Phos-2.2* Mg-2.0 [2185-5-27] 04:11PM BLOOD Type-ART pO2-152* pCO2-40 pH-7.35 calTCO2-23 Base XS--3 [2185-5-24] 03:20AM BLOOD Glucose-166* Lactate-1.5 Na-132* K-3.6 Cl-103 calHCO3-24 [2185-5-27] 04:35PM BLOOD freeCa-1.06* [2185-5-24] 01:57PM BLOOD freeCa-1.12 Angiogram #1 Selective arteriograms were performed within the celiac trunk and SMA without signs of active bleeding. Embolization of the gastroduodenal artery was performed with one 3-mm coil, four 4-mm coils and one 5-mm coil. Delayed images demonstrated no opacification of the portal vein, suggesting occlusion of this vessel. Note: The patient has been stable with no further bleeding over a 24 hour period. The study and the report were reviewed by the staff radiologist. Angiogram # 2 IMPRESSION: Selective arteriograms were performed in the celiac, SMA and [Female First Name (un) 899] without signs of active bleeding. There is no flow within the GDA that was previously embolized with coils. The study and the report were reviewed by the staff radiologist CT Abd/Pelvis: 1. Marked interval increase in intra-abdominal and intrapelvic ascites with anasarca. 2. Bilateral pleural effusions, right greater than left. 3. Small bowel loops are dilated up to 4.2 cm with air seen distally, suggestive of an ileus. No evidence of free air. 4. Evaluation of vasculature could not be performed due to lack of IV contrast. 5. Sigmoid colonic wall thickening could be suggestive of procto-sigmoiditis. Abdominal Ultrasound [6-2]: IMPRESSION: Large amount of ascites in all four abdominal quadrants with marking of right lower quadrant for paracentesis to be performed by clinical staff. Abdominal Ultrasound [6-6]: Limited evaluation of the four abdominal quadrants was performed. Small pockets of ascites were identified in each quadrant with a moderate-sized pocket above the bladder. No site was large enough to mark for paracentesis. IMPRESSION: Moderate ascites without adequate spot for paracentesis marking Brief Hospital Course: 61M w/ primary sclerosing cholangitis diagnosed with cholongiocarcinoma who presented hematemsis and BRBPR. This stopped by the time he came to the ER. Endoscopy saw a clot in the second portion of the duodenum, and during the procedure a large amount of bleeding began apparently out of the second part of the duodenum. The procedure was stopped and the patient was transfused ~8-10U PRBC. An emergent angio did not find the source of bleeding. The gastroduodenal artery was embolized as the most likely source. 24 hours later the patient rebled and was intubated for airway protection. ERCP found a bleeding vessel in an ulcerated part of the tumor in the second part of the duodenum. This was injected w/ epi and cauterized. A repeat angio showed no clear target for embolization as the tumor was well-vascularized, so given that the patient was likely to rebleed and that the next bleed would be untreatable, the decision was made to make the patient CMO. He was extubated and actually did well. He remained hemodynamically stable and was transferred to the floor. On the floor, his only complaint was his abdominal distension from his ascites. This was drained for palliative purposes on [6-2] by paracentesis. This made him feel much better and allowed him to eat. He had an abdominal port placed by interventional radiology on [6-9] without incidence for repeat paracenteses. Mr. [Known lastname ] has a very high chance of the bleeding vessel rebleeding and there is no medical intervention that can be done to alleviate it at this time. In discussion with the family, the patient, his primary oncologist, and the palliative care team, the decision was made to focus on his comfort. His daily needs are minimal but when his bleeding starts again, he will likely need an NGT quickly for managment of bleeding as well as possible associated nausea/hematemesis. He may also need a flexiseal or other similar stool management system if he begins having bright red blood per rectum. Medications on Admission: pancrease suppl qac ursodiol 300mg tid Dexamethasone Compazine Clotrimazole Zofran Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 3. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for diarrhea. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed. 9. Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. 10. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, instill Heparin as above per lumen. 11. Morphine Sulfate 2-6 mg IV Q1H:PRN 12. Lorazepam 0.5-2 mg IV Q1H:PRN anxiety, tachypnea 13. Ondansetron 4 mg IV Q8H:PRN Discharge Disposition: Extended Care Facility: The [Hospital1 656] Family Hospice House Discharge Diagnosis: Upper gastrointestinal bleed Cholangiocarcinoma Primary Sclerosing Cholangitis Discharge Condition: All vital signs stable, comfortable. Discharge Instructions: You were admitted with a severe gastrointestinal bleed. It was stabilized temporarily but will bleed again and at that time there is no treatment available to stop it. You also have acculmulations of fluid in your abdomen. You underwent one drainage procedure and then had an abdominal port placed to allow for easier drainage procedures in the future. We have stopped all medications that do not contribute to your comfort. Followup Instructions: None. Please call Dr. [Last Name (STitle) ] (primary oncologist) at ([Telephone/Fax (1) 83254] with any questions. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 3621] ICD9 Codes: 5789, 7907, 5849, 2875, 2851, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8475 }	Medical Text: Admission Date: [2107-12-9] Discharge Date: [2107-12-15] Date of Birth: [2061-12-8] Sex: M Service: MEDICINE Allergies: neurontin Attending:[First Name3 (LF) 2195] Chief Complaint: Seroquel overdose. Major Surgical or Invasive Procedure: None. History of Present Illness: This is a 46 year-old male PMH bipolar, depression, substance abuse, suicidal ideation who presents with seroquel overdose. . Per report patient presented to an OSH. There he reported ingestion of 23 tablets of Seroquel 400 mg around 6 PM following an arguement. Denied any other ingestions. He reportedly became increasingly lethargic, and was intubated for airway protection and given charcoal. He was transferred here due to lack of psychiatry at the OSH. He drinks alcohol daily - last drink yesterday. On lithium for presumed bipolar disorder but denies taking more than prescribed dose. . In the ED, presenting VS: T 96.9, HR 92, BP 153/72, RR 11, 100% on vent. CT head ordered due to lack of history. CXR confirmed location of ET tube and NG was replaced. Toxicology was consulted - amp of bicarb given for prolonged QT and then patient placed on bicarb drip. No family presented with patient. Vital signs on transfer 86 102/69 15 96% RA. . ROS: Unable to provide as intubated. Past Medical History: Bipolar Depression with h/o previous suicidal ideation and attempts Substance abuse Social History: Per OSH records: Drinks everday - last drink yesterday. [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) 8214] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 45079] ([12-9]): "His stepmother [First Name8 (NamePattern2) 8214] [Last Name (NamePattern1) ] and Lauritz [Doctor Last Name 45079] live in [Location (un) 5131] [Telephone/Fax (1) 88328], but are vacationing in [State 108] for the winter phone number [Telephone/Fax (1) 88329] after [12-22]. He also has a sister, [Name (NI) 13762] [Name (NI) 81431] in [Name (NI) 88330], NY. He has a 12 year old daughter in [Name (NI) 108]. His mother [Name (NI) ] has passed away. He drug and drinking problem started in HS and was triggered after his [Name (NI) ] divorced at age 13. His previous suicide attempt was laying on train track. It involved the cops as he threatened he was armed with attempted rescue. Last year had been at east [Doctor Last Name ] medical center for suicide attempt, sent to therapy was promised place to live and a job afterward. He is not in touch with his family, last contact with step mother and father was 1 year ago when hospitalized after suicide attempt. This was the first time in 11 years that he was in contact. His [Name2 (NI) ] would be happy to hear from him." Family History: Unknown. Physical Exam: On Admission: Vitals: BP: 113/71 HR: 95 RR: 17 O2Sat: 100% vented. GEN: Intubated and sedated. Wearing hard collar. HEENT: PERRL, charcoal outlining mouth COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB anteriorly, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: OSH: Rate 96. Normal axis. QRS 102, OTc 417. 2:01 HR 90. Normal axis. QRS 112. OTc 418. 2:25 following bicarb challenge. HR 108. Normal axis. QRS 102. QTc 398. 6:17: QRS 112, QTc 432. . Admission Labs: [2107-12-9] 02:00AM WBC-5.3 RBC-3.69* HGB-11.4* HCT-34.5* MCV-94 PLT COUNT-288 PT-12.9 PTT-24.9 INR(PT)-1.1 LITHIUM-0.6 ALT(SGPT)-34 AST(SGOT)-38 ALK PHOS-66 TOT BILI-0.2 GLUCOSE-123* LACTATE-1.3 NA+-140 K+-3.3* CL--103 TCO2-27 UREA N-11 CREAT-1.3* ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG . Imaging: CT Head: No acute intracranial process. CXR: Bibasilar atelactasis. ET 5 cm above carina Discharge Labs: [2107-12-13] 06:15AM WBC-7.9# RBC-4.23* Hgb-13.3* Hct-40.3 MCV-95 Plt Ct-269 [2107-12-14] 06:50AM Glucose-88 UreaN-14 Creat-1.0 Na-138 K-4.6 Cl-102 HCO3-25 AnGap-16 Brief Hospital Course: 46 year-old male with history of bipolar, depression, ETOH abuse, suicidal ideation who presents with seroquel overdose. # Overdose. Per patient report at outside hospital ingested 23, 400mg tablets of seroquel: total of 9.2gms. He denied additional ingestions. The main clinical findings in quetiapine overdose are hypotension, tachycardia, and somnolence, all of which were seen. Patient was intubated for airway protection at OSH. Admission labs were notable for LFTs wnl, tox screen + for benzos (which he received at OSH), otherwise negative including tylenol level. Lithium level within normal limits. Patient's admission EKG demonstrated qrs 112, QTc 418 - toxicology recommended trial bicarb amp with which qrs improved to 102 consequently recommended bicarb drip which was stopped on [12-9] after EKG with evidence of nl QTc. Patient was monitored on telemetry. FS monitored QID as hyperglycemia known side effect but he did not need insulin from a sliding scale. Psych was consulted after extubation, suicide precautions and 1:1 sitter in place. Patient section 12'ed. He experienced a hypermanic delirium for the next 48 hours of admission, requiring 4 point restraints. This was treated with frequent Haldol dosing per psychiatry recommendations, however. His delirium gradually resolved on its own. He required no Haldol for the last 48 hours of his stay. # Respiratory distress. Likely secondary to Seroquel sedation. CXR with bibasilar atelactasis but no acute process. Remained intubated during overdose phase and sedated with propofol. Patient extubated without difficulty on [12-9], and was subsequently on room air. # ETOH abuse: He was monitored for signs of withdrawal with a CIWA scale and placed on daily MVI, thiamine, folate. He was agititated on [12-10] and received a total of 60mg of Valium. On [12-11] agitation thought secondary to anxiety and not outright withdrawal as patient without signs of autonomic dysregulation. Valium discontinued and agitation treated with prn haldol. # Renal insufficiency: Unclear of baseline. Trial of continous fluids. Creatinine trended daily. Renally dosed meds, avoid nephrotoxic medications. Creatinine stable at 1.0 at time of transfer. # Depression/Bipolar: Held all medications on admission. Psych consulted once extubated. Recs to continue to hold all bipolar and antidepressant medications. Use haldol intermittently to treat agitation. Patient sectioned. Awaiting psychiatric placement. # Elevated TSH. On day of transfer TSH found to be 6.6. Free T4 4.1. These should be repeated in the outpatient setting after his acute illness has resolved. # Penile lesions: Suspicious for HPV. Patient reports they have been present for several months and have not increased in size or number; no associated pain, pruritus, or discharge. Further evaluation deferred to the outpatient setting. Medications on Admission: Per OSH list: Seroquel Lithium Discharge Medications: 1. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 2. haloperidol 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for agitation. 3. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for agitation, insomnia. Discharge Disposition: Extended Care Discharge Diagnosis: Depression Alcohol abuse Seroquel overdose 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 following a Seroquel overdose and were intubated for airway protection. You had mild renal failure on presentation, which resolved. You were seen in consultation by psychiatry and it was determined that you would require inpatient psychiatric care for your depression and alcohol abuse. Followup Instructions: Please follow-up with your primary care physician within two weeks of discharge. ICD9 Codes: 5849, 5180, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8476 }	Medical Text: Unit No: [Numeric Identifier 60325] Admission Date: [2199-2-9] Discharge Date: [2199-2-22] Date of Birth: [2199-2-9] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Baby [Name (NI) ] [Known lastname ] [Last Name (NamePattern1) 60326] [Known lastname 60320], twin number two, is the 2315 gram product of a 34 and 2/7 weeks gestation, admitted to the Neonatal Intensive Care Unit from labor and delivery for management of prematurity. Mother is a 32 year-old, Gravida I woman with estimated date of confinement of [2199-3-20]. The pregnancy was conceived by in- [Last Name (un) 5153] fertilization. Prenatal screens included blood type B positive, antibody screen negative, hepatitis B surface antigen negative, RPR nonreactive, Rubella immune and GBS unknown. The pregnancy was complicated by twin gestation and pregnancy induced hypertension. The decision was made to deliver by Cesarean section for elevated blood pressure in the Mom. This twin emerged crying and vigorous but cyanotic. He was dried, bulb-suctioned and given free flow oxygen. His Apgar scores were 8 at one minute and 8 at five minutes. PHYSICAL EXAMINATION: On admission, weight was 2315 grams (50 to 75 percentile); length 45.5 cm (50 percentile); head circumference 33 cm (75 percentile). Alert and active infant. Breath sounds coarse with fair aeration, mild retractions, regular rate and rhythm without murmur. Good femoral pulses. Abdomen soft, nondistended, without masses or hepatosplenomegaly. Pink and well perfused. Normal male genitalia. Testes descended, patent anus. Moves all extremities equally. HOSPITAL COURSE: Respiratory: This infant had transitional respiratory distress, requiring continuous positive airway pressure of 6 cm, without oxygen requirement. He weaned off C- Pap to room air at 12 hours of age and has remained in room air since with comfortable work of breathing. His respiratory rate is in the 30's to 50's. No apnea of prematurity. Cardiovascular: He has been hemodynamically stable throughout hospitalization. No murmur. His heart rate ranges in the 140's to 160's. A recent blood pressure was 73 over 35 with a mean of 50. Fluids, electrolytes and nutrition: Initially managed with intravenous fluid of 10 percent dextrose water. Started feeds with Special Care 20 on day of life one and the intravenous fluid was discontinued. He required partial gavage feeds while learning to p.o. The last gavage feed was on [2199-2-20] at day of life 11. On discharge, he was taking breast milk with Enfamil powder to equal 24 calories per ounce ad lib, taking about 2 ounces per feed. Discharge weight was ; length was 46 cm; head circumference 33 cm. Gastrointestinal: He had mild neonatal jaundice. A bilirubin drawn on day of life one showed a total of 3.7, direct of .2. Did not require phototherapy. On the day prior to discharge, was noted to have guaiac positive stools. Abdominal exam was normal as was a KUB. The patient continued to tolerate feedings well and was discharged home. Hematology: Hematocrit on admission was 43 percent. He did not require any blood products during this admission. Infectious disease: A CBC and blood culture were drawn on admission. He did not receive antibiotics. Blood culture was negative. Neurologic: His examination is age appropriate. Sensory: Hearing screening was performed with automated auditory brain stem response. He passed in both ears. CONDITION ON DISCHARGE: 13 day old, 36 and 1/7 weeks post menstrual age infant, feeding well. DISCHARGE DISPOSITION: Discharged home with parents. NAME OF PRIMARY PEDIATRICIAN: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D., [Hospital 47763] Medical Associates, telephone number [Telephone/Fax (1) 60327]. CARE AND RECOMMENDATIONS: 1. Feeds: Breast milk 24 with Enfamil powder or Enfamil 24 with iron ad lib demand. 2. Medications: Ferrous sulfate 0.1 ml orally once a day. 1. Passed car seat test. 2. State newborn screen was done on [2199-2-12] and is pending. 3. Immunizations received: Received hepatitis B immunization on [2199-2-14]. 4. Circumcision was performed on [2199-2-20] and is healing well. FOLLOW UP: 1. Follow up appointment with pediatrician to be scheduled. 2. VNA visit scheduled for [2199-2-23] with Care Group Home Care, telephone number [Telephone/Fax (1) 60322]; fax number [Telephone/Fax (1) 38333]. DISCHARGE DIAGNOSES: 1. Prematurity at 34 and 2/7 weeks, appropriate for gestational age. 2. Mild newborn jaundice, resolved. 3. Sepsis, ruled out, no antibiotics. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Last Name (NamePattern1) 56160] MEDQUIST36 D: [2199-2-21] 18:24:16 T: [2199-2-21] 18:58:32 Job#: [Job Number 60328] ICD9 Codes: 7742, V053, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8477 }	Medical Text: Admission Date: [2170-1-6] Discharge Date: [2170-1-17] Date of Birth: [2095-6-11] Sex: M Service: MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 73 year-old male with a history of coronary artery disease, congestive heart failure, history of deep venous thrombosis and PEs who presents with complaints of worsening shortness of breath. The patient was recently admitted to [Hospital1 190] from [12-18] to the 4th for an asthma exacerbation. He was treated with Albuterol and Atrovent nebulizers and placed on Flovent and started on a rapid steroid taper. The patient showed some mild to moderate improvement in his shortness of breath. He was noted at that time to have a known vocal cord polyp, which was believed to be stable on laryngoscopy down in the Emergency Department. Since that time the patient was seen by Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 217] of pulmonary in clinic on [2169-12-28]. Pulmonary function tests at that time revealed mild restrictive lung disease and flow volume loop revealed extra thoracic obstruction. The patient was diagnosed with vocal cord polyps in [2169-6-16] by ENT and it was felt by Dr. [Last Name (STitle) 217] that this was the etiology of the patient's worsening shortness of breath. Although the patient's symptoms seem to improve with inhalers and steroids after discharge he noted a one week worsening shortness of breath upon exertion, worsening hoarseness and orthopnea. Concurrently the patient's Lasix dose was changed to 20 mg po q.d. to 40 mg po q.d. on account that there was a question of whether the patient's congestive heart failure was exacerbating. The patient denies any fever, productive cough, change in peripheral edema, pleurisy or chest pain. The patient denies any dysphagia with food or liquids, no weight change or night sweats. The patient had a 25 pack year smoking history, but has quit times several years. No prior history of chewing tobacco. No hemoptysis. The patient presented to the Emergency Department on [1-6] with increase of inspiratory [Last Name (un) 15883]. Chest x-ray was found to be negative. The patient was satting over 98% on room air. Given the patient's previous history of pulmonary emboli a CTA was performed, which showed no PEs. The patient was also seen by ENT in the Emergency Department secondary to significant inspiratory and expiratory [Last Name (un) 15883] on examination. The patient was evaluated at that time with laryngoscopy and it was noted that there was significant edema and erythema of the false cords and folds bilaterally. The left true vocal cord was not able to be visualized and the right vocal cord was immobile. The bilateral arytenoid was mobile during phonation and inspiration, but without much mobility at the glottic level. Given the question of a supraglottitis versus laryngeal mass CT of the neck was performed simultaneously with the CT angiogram and showed fullness and thickening of the vocal cords bilaterally with narrowing of the airway. There was no discreet mass or abnormal lymphadenopathy noted at that time. Given the significant narrowing of the airway the patient was started on Decadron and Ceftriaxone and transferred to the Intensive Care Unit for monitoring of airway. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft in [2163]. 2. Congestive heart failure last echocardiogram from [2166] shows biventricular enlargement, systolic dysfunction with an EF of 25%, moderate mitral regurgitation and pulmonary artery hypertension. 3. History of atrial fibrillation status post duel chamber pacemaker and AICD in [2166] 4. History of lower extremity deep venous thrombosis status post IVC filter secondary to PEs bilaterally in [2168-6-16]. 5. History of retroperitoneal bleed. 6. Hypertension. 7. Gastroesophageal reflux disease. 8. Restrictive lung disease. 9. Hypercholesterolemia. ALLERGIES: Codeine equals gastrointestinal upset. OxyContin equals mental status change. MEDICATIONS: 1. Flovent 220 micrograms four puffs b.i.d. 2. Combivent inhaler four puffs b.i.d. 3. Coumadin 2.5 mg po q.h.s. 4. Lasix 20 mg po q.d. increased recently to 40 mg po q.d. 5. Digoxin .125 mg po q.d. 6. Spironolactone 25 mg po q.d. 7. Zantac 150 mg po b.i.d. 8. Nexium 40 mg po q.d. SOCIAL HISTORY: No alcohol, 25 pack year smoking history, quit 40 years ago. Lives with wife. [Name (NI) ] history of chewing tobacco. The patient is a singer. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Temperature 98.2. Heart rate 50. Blood pressure 144/85. Respiratory rate 26, 98% on 2 lites. General, obese male moderately uncomfortable using accessory muscles to breath. HEENT mucous membranes are moist. Oropharynx is clear. Neck audible inspiratory and expiratory [Last Name (un) 15883]. No visible abnormalities. Chest diffusely transmitted inspiratory and expiratory wheeze and [Last Name (un) 15883] bilaterally, decreased breath sounds at the right base. Cardiac irregularly irregular rhythm, normal S1 and S2. Abdomen soft, obese, nontender, nondistended, positive bowel sounds. Extremities left greater then right, 1+ lower extremity edema, tender to palpation in the bilateral calf. No clubbing, cyanosis or edema. Neurological alert and oriented times three, moving all extremities, no focal abnormalities. LABORATORY: White blood cell count 19.3, hematocrit 49.4, platelets 227. Diff 87% neutrophils, 10% lymphocytes. Chemistry 136, 4.8, 94, 29, 35, 1.0 and glucose 221. Digoxin level .9, calcium 9.7, phos 3.8, mag 2.0, PT 16.9, PTT 25.8 and INR 1.9. Chest x-ray showed no pneumonia or congestive heart failure. Neck and CTA showed no PE and fullness and thickening of the bilateral vocal cords with narrowing of airway as described above, no discreet mass or lymphadenopathy. Electrocardiogram showed atrial fibrillation with frequent premature ventricular contractions. Significant bigeminy with normal axis, QRS prolongation, old significance of S wave or R wave in lead V1, old T wave inversion in lead 1. This was compared with electrocardiogram from [2169-12-18]. HOSPITAL COURSE: The patient was transferred to the MICU for observation overnight while placed on humidfied air, 10 mg of Decadron and Ceftriaxone. The plan was in place so that the patient's status decompensated. He would be started on Heliox and likely intubated. If intubation were required fiberoptic assistance would be likely needed. The patient was started on CPAP at night in order to prevent soft tissue collapse and was placed on cool nebs throughout the day. Repeat fiberoptic examination on [1-7] revealed mild epiglottic edema, bilateral false vocal cord edema, limited PVC motion and limited visualization of the left posterior vocal cord. Slightly improved laryngeal edema. The follow up plan was for endoscopy in the Operating Room for performance of biopsy of the left laryngeal lesion. For preparation of the procedure the patient's Coumadin was held and he was started on a heparin drip. The patient was also evaluated by cardiology and with echocardiogram to rule out any valvular abnormalities or significant atrial thrombus secondary to atrial fibrillation. Repeat echocardiogram showed an EF less then 20% with severe left ventricular dilatation. The plan was for the patient to continue Carvedilol at 6.25 mg b.i.d., Aldactone, Lasix and Digoxin. Of note the patient also had significant atrial fibrillation with tachybrady events. He was rate controlled with beta blockade and Digoxin. At times he dropped his rate down into the 40s, but with over symptomatic or dropped his blood pressure. When evaluated by EP to assess his pacemaker EP noted that the patient's pulse was only palpable every other beat secondary ventricular bigeminy and that his pacer was functioning perfectly well. Ultimately on [2170-1-10] the procedure was performed after the patient's INR was satisfactory. Biopsy of the left vocal cord lesion and right vocal cord lesion were done by Dr. [First Name (STitle) ]. Following the procedure the patient was given 12 mg of intraoperative Decadron and an endotracheal tube was placed secondary to narrow airway. The patient was returned to the MICU following the procedure. Pathology quickly returned, which showed a squamous cell carcinoma of the larynx. The left true vocal cord and commissure lesion showed an invasive and in situ squamous cell carcinoma moderately differentiated. On the right vocal cord lesion there was an invasive squamous cell carcinoma also moderately differentiated. In addition to biopsy there was small amount of debulking, which was done at the time of the procedure. Following the procedure the Ceftriaxone which discontinued as it was used as a prophylactic medication for any possible laryngeal infection. Following the biopsy it was known that the edema was more consistent with tumor and therefore the Ceftriaxone was discontinued. Dexamethasone was continued as was Albuterol and Atrovent and the patient's intubation. A repeat laryngoscope was performed on [1-11] through the ET tube. Trachea was found to be clear with slight secretions. The nose, tongue base and epiglottis were all found to be stable. The larynx showed some edema, but decreased erythema. The patient was extubated on [2170-1-12] in the presence of anesthesia. The possibility for tracheostomy following the extubation or any time in the future was discussed with the patient and the family, but was not felt to be necessary during this hospital stay. On [1-13] the patient was transferred from the MICU out to the medical [Hospital1 ]. The patient showed no further evidence of [Last Name (un) 15883] status post extubation. The Dexamethasone was tapered. In regard to the patient's vocal cord lesion and new diagnosis of squamous cell carcinoma he was followed by his ENT Dr. [First Name (STitle) ] while in house. The plan is for the patient to follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3311] at [Hospital3 328] Cancer Institute. The patient was given the phone number [Telephone/Fax (1) 15884] to contact Dr. [First Name (STitle) 3311] since Dr. [First Name (STitle) ] was unable to arrange an inpatient consult. Given the patient's airway has remained stable for several days he was evaluated by physical therapy and felt to be an excellent rehab candidate. The plan is for the patient to follow up with Dr. [First Name (STitle) 3311] for a possible chemotherapy versus radiation next week. It is possible still that the patient may require tracheostomy during his cancer treatment. Of note, the patient also experienced left upper extremity edema in the last few days during his hospital stay. An ultrasound revealed a deep venous thrombosis in the left axillary vein extending to the brachial veins. No deep venous thrombosis was evident in the jugular or subclavians. The patient was restarted on heparin and his Coumadin dose was increased to 5 mg po q.h.s. secondary to his previous INR goal for atrial fibrillation. The patient denies any new shortness of breath and reported that his [Last Name (un) 15883] symptoms had significantly improved. The patient was persistently hoarse and noted more psychosocial damage secondary to the fact that he would never be able to sing again. The patient completed his Decadron taper on [2170-1-15] and is presently being evaluated for rehab placement. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSES: 1. Squamous cell carcinoma of the bilateral vocal cords. 2. Left upper extremity deep venous thrombosis. 3. Atrial fibrillation. 4. Congestive heart failure. 5. Coronary artery disease. 6. Asthma. 7. History of PEs status post IVC filter placement. 8. Status post pacemaker and AICD placement. DISCHARGE MEDICATIONS: 1. Digoxin .125 mg po q.d. 2. Captopril 12.5 mg po t.i.d. 3. Carvedilol 6.25 mg po b.i.d. 4. Albuterol MDI four puffs q 6 hours prn wheezing. 5. Lansoprazole 30 mg po q.d. 6. Lasix 40 mg po q.d. 7. Ativan .5 to 1 mg po q 4 to 6 hours. 8. Atrovent MDI two puffs q.i.d. 9. Flovent 110 micrograms four puffs b.i.d. 10. Colace 100 mg po b.i.d. 11. Senna 8.6 mg tab po b.i.d. prn. 12. Albuterol nebulizes q 6 hours prn. 13. Coumadin 5 mg po q.h.s. 14. Regular insulin sliding scale as described and page one. FOLLOW UP PLANS: The patient is being transferred to a rehabilitation facility where he will receive physical therapy. The plan is for the patient to follow up next week with Dr. [First Name (STitle) 3311] at [Hospital3 328] Institute for possible treatment of his squamous cell carcinoma. The patient will also follow up with his primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 1270]. The patient's INR should be followed given his recent change in Coumadin dose and recent antibiotic Ceftriaxone. Additionally, the patient's finger sticks should be done on a q.i.d. basis until they have normalized and sliding scale insulin should be administered prn. Most likely the patient's glucose should resolve to normal in the immediate future given that his Decadron has since been discontinued. The patient is to follow up in the Device Clinic in three months to have his pacemaker checked. The patient's sodium should also be followed. It was slightly low during his hospital stay on the [1-16] it was 132. This is believed to be secondary to the patient's Lasix. No intervention is required at this time, but follow up so it does not continue to decrease should be continued. The patient should be continued on a cardiac diet. [First Name4 (NamePattern1) 1730] [Last Name (NamePattern1) ], M.D. [MD Number(1) 2362] Dictated By:[Name8 (MD) 15885] MEDQUIST36 D: [2170-1-17] 09:59 T: [2170-1-17] 10:08 JOB#: [Job Number 15886] ICD9 Codes: 4280, 4240, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8478 }	Medical Text: Admission Date: [2142-4-26] Discharge Date: [2142-5-3] Date of Birth: [2076-2-5] Sex: F Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 1973] Chief Complaint: Perforated appendix, COPD Exacerbation, Atrial Fibrillation with Rapid Ventricular Response, Pre-existing Leg Ulcers Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [Known lastname ] is a 66 year old woman with severe COPD (FEV1 1.23L in [2140], 45%), active tobacco abuse and history of DVT/PE with IVC filter placement as well as possible embolic CVA who was admitted to [Hospital3 7571]on [4-23] with severe RLQ abdominal pain, w/ CT findings concerning for perforated appendicitis with fluid collection. Patient was initially treated w/ IV Unasyn 3g q6h and Flagyl 500mg IV q8h (day 1= [4-23]) and maintained on her outpatient antihypertensives and COPD treatment. Coumadin was held in light of possible surgery and pt's pain was controlled on q1h PRN Dilaudid. Dr [Last Name (STitle) 41912], general surgeon at [Location (un) ] planned for percutaneous drainage without surgical intervention for potential developing intra-abdominal abscess. Patient improved on 2nd hospital day ([4-24]) and had decrease in WBC 15-->12. INR decreased from 3 ([4-23]) to 1.8 ([4-24]). She tolerated clears and low fiber diet. On the night of [4-24], pain worsened- plan was for open appy in the AM of [4-25]; however, pt developed severe respiratory distress around 0600 that AM w/ hypertension (SBP 160), tachycardia (HR 160->Afib RVR) and tachypnea (RR 26) w/ desats to 95% on NRB. ABG at that time was reported as 7.21/ 56/ 93 on NRB. (no prior ABGs for comparison). She was treated w/ back-to-back doses of Duoneb x2, 1 dose of solumedrol and 750mg IV levaquin. CXR revealed bibasilar infiltrates and thought was aspiration when pt was vomiting related to appendicitis. Repeat ABG on 6L NC was 7.32/32/95. She was treated w/ Unasyn, Flagyl and Levaquin (d1= [4-25]) to broaden gram-negative coverage. She was transferred to [Hospital1 18] ICU due to her respiratory distress from b/l aspiration pneumonia. On arrival, Ms. [Known lastname ] was hemodynamically stable, c/o slight abdominal discomfort in RLQ, denies nausea/vomiting, difficulty breathing, chest discomfort. Past Medical History: - Mitral regurgitation & MVP (EF 60% per TTE [1-/2142]) - Paroxysmal atrial fibrillation-back on coumadin - Hyperlipidemia - Coronary artery disease w/ NSTEMI [2142] - History of CVA in [2111] w/ L-sided hemiparesis - DVT/PE (IVC filter placed)-coumadin was held in setting of stroke - History of venous stripping on RLE in [2139] - History of R carotid endarterectomy - Hypertension - OA - COPD, (FEV1 1.2L, 45%) - Right lower extremity ulcerations - Venous insufficiency and bilateral venous stasis ulcers Social History: Lives in [Location 20756], MA. Active heavy tobacco use 1PPD. not interested in quitting. Occasional ETOH. No IVDU. Works as a people-greeter at [Company 39532]. Family History: Non-contributory. Physical Exam: Vitals: afebrile, HR 65 BP 112/66 SaO2 94 % GEN: comfortable, NAD HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition Neck: supple, JVP not elevated, no LAD Lungs: CTA B/L CV: irregularly irregular rate, S1, S2 nl, no appreciable murmur Abdomen: +BS, soft, slightly distended. Mild TTP RLQ, no rebound/ no guarding, no TTP LLQ, no Rovsing's sign Ext: b/l chronic venous stasis changes, Foot ulcers w/ multiple guaze bandages, 1+ distal pulses, onychyomycosis NEURO: A&Ox3 Pertinent Results: [2142-5-2] 08:26AM BLOOD WBC-9.8 RBC-4.20 Hgb-12.8 Hct-38.9 MCV-93 MCH-30.4 MCHC-32.8 RDW-13.6 Plt Ct-386 [2142-4-29] 07:20AM BLOOD WBC-5.7 RBC-3.89* Hgb-12.1 Hct-36.0 MCV-93 MCH-31.2 MCHC-33.7 RDW-13.3 Plt Ct-330 [2142-4-26] 05:57PM BLOOD WBC-7.1 RBC-3.60* Hgb-11.2* Hct-34.9* MCV-97 MCH-31.0 MCHC-32.0 RDW-13.1 Plt Ct-232 [2142-4-27] 04:45AM BLOOD Neuts-88.4* Lymphs-6.0* Monos-5.0 Eos-0.5 Baso-0.1 [2142-4-26] 05:57PM BLOOD Neuts-92.5* Lymphs-4.9* Monos-2.3 Eos-0.1 Baso-0.2 [2142-4-30] 06:35AM BLOOD PT-21.9* PTT-30.5 INR(PT)-2.0* [2142-4-28] 06:35AM BLOOD PT-18.0* PTT-26.6 INR(PT)-1.6* [2142-4-26] 05:57PM BLOOD PT-18.7* PTT-30.2 INR(PT)-1.7* [2142-5-2] 08:26AM BLOOD Glucose-97 UreaN-11 Creat-0.8 Na-139 K-3.4 Cl-101 HCO3-31 AnGap-10 [2142-4-29] 07:20AM BLOOD Glucose-146* UreaN-18 Creat-0.7 Na-138 K-3.6 Cl-102 HCO3-28 AnGap-12 [2142-4-26] 05:57PM BLOOD Glucose-134* UreaN-15 Creat-0.8 Na-139 K-5.0 Cl-108 HCO3-21* AnGap-15 [2142-4-27] 04:45AM BLOOD ALT-13 AST-16 LD(LDH)-140 AlkPhos-74 Amylase-39 TotBili-0.4 [2142-4-26] 05:57PM BLOOD ALT-16 AST-17 LD(LDH)-162 AlkPhos-82 TotBili-0.4 [2142-4-27] 04:45AM BLOOD Lipase-28 [2142-4-27] 04:45AM BLOOD proBNP-[Numeric Identifier 54709]* [2142-4-26] 05:57PM BLOOD CK-MB-3 cTropnT-<0.01 [2142-5-2] 08:26AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.9 [2142-4-27] 04:45AM BLOOD Albumin-2.9* Mg-1.8 [2142-4-26] 05:57PM BLOOD Calcium-8.1* Phos-2.6* Mg-1.8 [2142-4-27] 10:30 am BLOOD CULTURE Source: Venipuncture. x2 FINAL REPORT [2142-5-3] Blood Culture, Routine (Final [2142-5-3]): NO GROWTH. CHEST (PORTABLE AP) Study Date of [2142-4-26] 5:17 PM Final Report REASON FOR EXAM: Patient with appendicitis in respiratory distress. Assess for aspiration pneumonia. Comparison is made with prior outside study from [4-23] and the same day earlier in the morning. Interstitial opacities are consistent with mild interstitial edema. Cardiac size is top normal. Bibasilar consolidations larger on the right side have worsened consistent with pneumonia. Small bilateral pleural effusions greater on the right side have increased from prior study. Portable TTE (Complete) Done [2142-4-27] at 2:38:49 PM FINAL GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - body habitus. Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([12-2]+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Mild-moderate mitral regurgitation. CT PELVIS W/CONTRAST Study Date of [2142-4-28] 4:35 PM IMPRESSION: 1. Interval improvement in the inflammatory change in the right lower quadrant with development of a cystic lesion at the base of the cecum which is likely an evolving abscess within the cecal wall, now 2.5 cm. There is no drainable fluid collection seen. 2. 1.5 cm enhancing mass lower pole right kidney suspicious for renal cell carcinoma. 3. New bilateral pleural effusions as well as free fluid in the abdomen, retroperitoneum, and diffuse subcutaneous edema consistent with diffuse third spacing. CHEST (PORTABLE AP) Study Date of [2142-4-29] 6:13 PM FINDINGS: Comparison is made to previous study from [2142-4-26]. There is again seen small bilateral pleural effusions. There is bibasilar consolidation, however, they have improved since the previous study. The degree of interstitial edema has also improved as well since the prior study. ART EXT (REST ONLY) Study Date of [2142-5-1] 1:14 PM Final Report ARTERIAL STUDY HISTORY: Nonhealing ulcer (side of symptoms not stated). The [Date Range ] on the right is 0.92 and on the left is 1.02. Doppler tracings are triphasic diffusely on the right except at the DP level and diffusely triphasic on the left except at both the PT and DP levels. The volume recordings are in [Location (un) ] with the Doppler tracings. IMPRESSION: Findings as stated above which indicate bilateral tibial disease, left to a greater extent than the right. The relatively high [Name (NI) ] measurements on the left in light of monophasic waveforms suggest some vessel non-compressibility. Brief Hospital Course: 1. Acute Appendicitis - The patient was ultimately determined to not need acute surgery, and instead will be treated with antibiotics with a "cool off" period. She was initially treated with vancomycin and zosyn, which was changed over to cipro/flagyl for a 14 day course. - Surgery was consulted, and the patient will be following up with Dr. [Last Name (STitle) 468] in the future for ultimate surgical therapy. - The patient was afebrile, with mild residual RLQ abdominal pain at time of discharge. She was tolerating a full diet. 2. Atrial Fibrillation with Rapid Ventricular Response, Acute Diastolic CHF - The patient was transitioned to diltiazem for better rate control - Her heart failure resolved with appropriate rate control - Telemetry was monitored with no further events 3. Probable Malignant Neoplasm - Kidney - Incidental finding on imaging as above - Patient urgently referred to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] clinic for evaluation. Letter placed in OMR to PCP and Dr. [Last Name (STitle) 3748] and patient informed. 4. COPD with Acute Exacerbation, Bacterial Pneumonia - Cipro/flagyl will cover - Patient was breathing normally at time of discharge - Advair 5. CAD Native Vessle, Stroke Prior with late effects, History of Deep Venous Thrombosis/Pulmonary Embolism - Aspirin and coumadin initially held, but this was restarted after surgery was determined ot not be needed - Rate controlled 6. Chronic Foot Ulcers (preexisting) - [Last Name (STitle) ] were performed as above - Wound care consultation was obtained - F/U with PCP (letter sent with results) Medications on Admission: ASA 81 toprol 25mg [Hospital1 ]-takes only once a day because makes her tired simva 10 coumadin 2mg q day xopenex 2 puffs q4prn Ca +Vit D [Hospital1 ] Vit D qd mag ox 400mg qd Zinc 30mg qd MVI no other inhalers Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:60 Disk with Device(s) Refills:0 3. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation 2 puffs every 4-6 hours () as needed for as needed for SOB. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:30 Cap(s) Refills:1 6. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:30 Capsule, Sustained Release(s) Refills:2 7. Petrolatum Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed for venous stasis bilateral LE. 8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 9. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: resume your prior dose. 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 11 days. Disp:22 Tablet(s) Refills:0 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 11 days. Disp:2 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) ] Nursing Services Discharge Diagnosis: Acute appendicitis with perforation afib RVR acute diastolic CHF Acute aspiration pneumonia COPD exacerbation nonhealing LE ulcers h/o CVA, embolic Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [Location (un) ] with acute appendicitis. There you had difficulty breathing from your COPD, and pneumonia, and your rapid heart rate and were transfered to [Hospital1 18]. Here you improved with antibiotics for your pneumonia and your appendicitis. You were followed by surgeons who reviewed your repeat CT scan and did not feel there was a need for urgent drainage or surgery. You tolerated food well after this. your breathing was stable on the inhalers. You are started on advair and spiriva to help with you COPD. Please try to stop smoking. you have bad leg ulcers. You have some arterial blockages in your legs, and you should follow up with your PCP on this. Your heart rate was fast due to atrial fibrillation. Your toprol was not covering this well at the doses you were taking. You said higher doses make you tired and they can worsen your COPD. Thus you are switched to a new medication called diltiazem for this. Your coumadin and aspirin were initially held because we were planning surgery. however, these have now been started. Please resume your prior arrangement to monitor your coumadin levels and dosing. You will still require surgery, but Dr. [Last Name (STitle) 468] will arrange this. Flagyl: You are being discharged on an antibiotic called Metronidazole (Flagyl). This medication interacts very seriously with even tiny quantities of alcohol. You should not drink or eat any food with ANY alcohol in it or uncontrollable vomiting will result. If you use mouthwash that contains alcohol do not use it while on this medication. This medication can also make you sun sensitive, so you should avoid direct sun if possible, or use high SPF+ sunblock even if dark skinned. Finish all this medication even if you feel better. Cipro: You are being discharged on an antibiotic called Ciprofloxacin. This medication can weaken your tendons while taking it, so you should avoid strenuous sports or activities. If you feel palpitations in your heart, contact your doctor or go to the Emergency Room. Finish all this medication even if you feel better. Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) 1955] F. When: Tuesday, [5-8], 1pm Location: LUNENBERG FAMILY PRACTICE Address: [Street Address(2) 20589], [Location (un) 20590],[Numeric Identifier 20591] Phone: [Telephone/Fax (1) 20587] Department: SURGICAL SPECIALTIES/ UROLOGY When: TUESDAY [2142-5-15] at 2:30 PM With: DR. [First Name (STitle) ] [Doctor Last Name ] [Telephone/Fax (1) 3752] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: SURGICAL SPECIALTIES/ GENERAL SURGERY When: MONDAY [2142-5-28] at 9:15 AM With: [First Name8 (NamePattern2) 251] [Name8 (MD) ], MD [Telephone/Fax (1) 2835] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage ICD9 Codes: 5070, 5119, 4280, 4019, 412, 2724, 4240, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8479 }	Medical Text: Admission Date: [2129-2-21] Discharge Date: [2129-2-25] Date of Birth: [2066-8-5] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: mitral regurgitation Major Surgical or Invasive Procedure: [2129-2-21] - Mitral Valve Repair (34mm Annuloplasty ring) History of Present Illness: This 62 year old gentleman with no signficant past medical history has had a heart murmur for most of his life. He was diagnosed with mitral valve prolapse and regurgitation 3 years ago. At that time he began to be followed with serial echocardiograms. His mitral regurgitation has worsened over time with his most recent echo showing severe mitral regurgitation with partial flail of anterior mitral leaflet. Given the severity of his mitral valve regurgitation he has been referred for surgical management. He denies any symptoms of exertional dyspnea, fatigue, chest pain,orthopnea or palpitations. Past Medical History: Mitral valve prolapse/regurgitation Undescended testicle - Left Nephrolithiasis Basal Cell skin cancer Inguinal hernia repair Social History: Last Dental Exam: Recent exam/cleaning Lives with: Wife in [Name2 (NI) 5450] Contact: Phone # Occupation: Carpenter Cigarettes: Smoked no [X] yes [] last cigarette _____ Hx: Other Tobacco use: ETOH: < 1 drink/week [] [1-11] drinks/week [X] >8 drinks/week [] Illicit drug use Family History: Father died of MI at 57 Physical Exam: Vital Signs sheet entries for [2129-2-9]: BP: 141/93. Heart Rate: 81. Resp. Rate: 18. Pain Score: 0. O2 Saturation%: 99. Height: 5'[27]" Weight: 165lbs General: NAD Skin: Dry [X] intact [X] Recent face peel which has left him with a sunburned appearance. HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP benign, teeth in good repair. Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR, Nl S1-S2, III/VI holosystolic murmur 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 - Transmitted vs. Bruit Pertinent Results: [2129-2-24] 06:00AM BLOOD WBC-5.6 RBC-3.56* Hgb-10.3* Hct-30.9* MCV-87 MCH-28.8 MCHC-33.3 RDW-13.3 Plt Ct-119* [2129-2-21] 11:02AM BLOOD WBC-11.7# RBC-3.24# Hgb-9.2# Hct-27.9# MCV-86 MCH-28.5 MCHC-33.1 RDW-13.0 Plt Ct-151 [2129-2-24] 06:00AM BLOOD Glucose-96 UreaN-19 Creat-0.8 Na-137 K-4.2 Cl-103 HCO3-27 AnGap-11 [2129-2-21] 12:01PM BLOOD UreaN-20 Creat-0.8 Na-142 K-4.3 Cl-113* HCO3-26 AnGap-7* 3/19/12PRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Please note the global LV systolic function might be reduced in the presence of 3+ MR. [Name13 (STitle) 167] ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 40 cm from the incisors. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. There is moderate/severe anterior leaflet mitral valve prolapse. The entire leaflet was prolapsing almost suggestive of a parachute appearance. An eccentric, posteriorly directed jet of Moderate to severe (3+) mitral regurgitation is seen. The posterior leaflet appeared normal. There was no mitral annular calcification. The mitral annulus in the AP direction was 40mm.T here is no pericardial effusion. Dr.[Last Name (STitle) ] was notified in person of the results before surgical incision.. POST-BYPASS: Patient was on propofol only. Preserved biventricular systolic function. LVEF 55%. The mitral ring is in place, stable and functioning well. No gradient across the mitral valve during diastole. [Doctor Last Name ] was a mild residual MR that was conveyed to the surgeon. Both the leaflets appeared to coapt very well. Two neo chords supporting the anterior leaflet going to both the papillary muscles was visualized. Rest of the valves appear unchanged from the prebypass period. Intact thoracic aorta. Brief Hospital Course: Mr. [Known lastname ] was admitted to the [Hospital1 18] on [2129-2-21] for surgical management of his mitral valve disease. He was taken directly to the Operating Room where he underwent repair of his mitral valve using a 34mm annuloplasty ring. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next several hours, he awoke neurologically intact and was extubated. On postoperative day one, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The Physical Therapy service was consulted for assistance with his postoperative strength and mobility. He did pass 2 kidney stones on POD 2. This, apparently, is not unusual for him and he will give them to his PCP for analysis. He continued to progress and was ready for discharge on POD4. All follow up appointments were made and instructions given. He did have some mild supraventricular ectopy and this resolved with the addition of oral Amiodarone. Medications on Admission: None Discharge Medications: 1. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:135 Tablet(s) Refills:2 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 5. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 6. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 7 days. Disp:7 Tablet, ER Particles/Crystals(s) Refills:0 7. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2 times a day): 400mg(2tablets) twice daily for two weeks,then 200mg(one tablet) twice daily for two weeks, then 200mg(one tablet )daily until directed to discontinue. Disp:100 Tablet(s) Refills:2 8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain for 4 weeks. Disp:50 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Mitral valve prolapse/regurgitation s/p Mitral valve annuloplasty h/oNephrolithiasis h/o Basal Cell skin cancer s/p orchiopexy Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Dilaudid Incisions: Sternal - healing well, no erythema or drainage Edema:none Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Wound check: [2129-3-3] at 10AM in [Hospital Unit Name ], [Hospital Unit Name ] Surgeon: Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 170]) on [2129-3-30] at 1:15PM Cardiologist: Dr.[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 8421] [2129-3-9] at 2pm Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) 62438]([Telephone/Fax (1) 51033]) in [3-10] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2129-2-25] ICD9 Codes: 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8480 }	Medical Text: Admission Date: [2137-10-22] Discharge Date: [2137-11-1] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 19193] Chief Complaint: Seizure and IPH Major Surgical or Invasive Procedure: Intubation for airway protection. History of Present Illness: 84 YO right-handed female transferred from [Hospital1 25991]Hospital after presenting with witnessed GTC seizure per EMS. Per the patient's daughters, the patient seemed fatigued with decreased appetite but otherwise normal self until just prior to presentation. She appeared tired and did not eat much for dinner but was well enough to read her mathematics journal and do her usual routine before going to bed including brushing teeth at 2:30 am. At 6:30 on the morning of presentation, her daughter heard her cough but no stirring. The patient's daughter went to check on her mother and found her in bed unable to get up. She was awake and was saying "[Last Name (un) ], what is wrong with me?" in Hindi. EMS was called and patient was brought to the [Hospital 8] Hospital. Per EMS record, patient was noted to have GTC seizure but the daughter denied any shaking, LOC, gaze deviation and etc. The family denies any prior history of seizure. Upon presentation, the patient had head CT that demonstrated 2 discrete hemorrhages in L frontal and parietal lobes with no mass effect. (Of note, the patient is known to have a left frontal meningioma discovered on CT done in [2135]). Patient was intubated for airway protection at OSH after being given paralytics including succinylcholine, vercuronium and sedatives including Ativan 4mg and propofol. Patient was also loaded with Dilantin 1g prior to transfer to [Hospital1 18] where her primary caregivers are. Her history was otherwise unobtainable at presentation as she was intubated and sedated. Past Medical History: 1. HTN 2. hx of L breast tumor - ductal carcinoma in-situ s/p excisional bipsy in [2131] with 2 weeks of radiation. Normal follow-up since per family. 3. DM - HbA1C of 10.2 in [3-18] but not on meds 4. R cataract s/p laser therapy Social History: Lives at home with daughters - independent of all ADLs. Mathematician and currently writing a book. Daughters are [Name2 (NI) 2759] - full code ([Telephone/Fax (1) 25992], [Telephone/Fax (1) 25993], and [Telephone/Fax (1) 25994].) Family History: Non-contributory. Physical Exam: ON ADMISSION: T 97.2 BP 173/64 HR 72 RR 16 O2Sat 100% RA Gen: Lying in bed, intubated and sedated. CV: RRR, no murmurs/gallops/rubs Lung: Clear anteriorly Abd: +BS, soft, nontender Ext: No edema Neurologic examination: MSE: Intubated and sedated. No spontaneous movements or opening of eyes. Does not follow commands. CN: R pupil slightly irregular - both reactive (3->2mm). Face appears symmetric but no blinking to visual threats. No OCR. No corneals bilaterally and no gag. Motor: Normal tone. Localizes to painful stimuli for both UEs but does not withdraw LEs to noxious stim. Some spontaneously L foot movements. [Last Name (un) ]: Appears intact to noxious stim in all extremities. Reflexes: 2s for biceps and [Last Name (un) ] but none in LEs. R toe upgoing and L mute. . At the time of discharge, the patient was alert and oriented to person, place and time. She was able to ambulate with assistance. Exam was otherwise pertinent for bibasilar crackles and mild non-pitting lower extremity swelling slightly worse on the right as compared to the left. Pertinent Results: Admission Labs: . WBC-13.5# RBC-4.65 Hgb-12.4 Hct-39.0 MCV-84 MCH-26.8 MCHC-31.9 RDW-13.8 Plt Ct-407 Neuts-79.8* Lymphs-16.1* Monos-2.8 Eos-0.8 Baso-0.5 PT-11.0 PTT-20.6* INR(PT)-0.9 Glucose-324* UreaN-16 Creat-0.8 Na-137 K-5.4* Cl-103 HCO3-23 AnGap-16 CK-MB-NotDone cTropnT-0.03* Calcium-8.5 Phos-3.2 Mg-2.1 . Discharge Labs: . Imaging: MR HEAD W & W/O CONTRAST ([2137-10-22]) IMPRESSION: 1. Hemorrhagic lesion in the left parietal lobe, with surrounding vasogenic edema and local mass effect. While no definite underlying mass lesion is identified, differential diagnosis includes a hemorrhagic metastatic focus versus hemorrhage secondary to hypertension. Amyloid angiopathy is a less likely consideration given the lack of other susceptibility foci in the parenchyma. There is no evidence of a developmental venous anomaly or other abnormal vessels, but an underlying vascular malformation could also be considered. 2. Meningioma overlying the left frontal lobe, stable in appearance and size compared to the prior CT from [2135], when accounting for differences in technique. 3. Areas of white matter hyperintensity are a nonspecific finding, but likely represent the sequela of chronic microangiopathy given the patient's age. . CT Chest, Abdomen, Pelvis ([2137-10-25]): Enhancing heterogenous mass in right lower quadrant, may represent a conglomerate nodal mass, metastasis, less likely a primary mesenteric neoplasm such as carcinoid. 2. Bilateral pulmonary opacities and multiple pulmonary nodules. Could reflect an infectious or inflammatory process, however given high risk for malignancy,dedicated follow-up chest CT within three months is recommended. 4. Endometrial fluid and right adnexal fullness, correlation with ultrasound is recommended. 5. Indeterminant subcentimeter hepatic lesions, too small to characterize. 6. Coarse pancreatic calcifications, with mild dilation of the proximal pancreatic duct measuring up to 3.5 mm, chronic pancreatitis or calcified mucinous neoplasm are potential considerations. [Month (only) 116] be further evaluation with MRCP. . Long-Term Monitoring EEG ([2137-10-23]): IMPRESSION: This is an abnormal portable EEG due four electrographic seizures in the right occipital region consisting of rhythmic sharp waves and at times sharp and slow wave discharge for 1-2 minutes in duration without obvious clinical correlate on video. The background rhythm is also noted to be of low voltage. Would recommend further EEG monitoring given multiple subclinical seizures detected on this recording. . Long-Term Monitoring EEG ([Date range (3) 25995]): IMPRESSION: This telemetry captured no pushbutton activations. Background EEG showed a widespread encephalopathy. Medications, metabolic disturbances, and infection are among the most common causes. There were no prominent focal abnormalities, but encephalopathies may obscure focal findings. There were no epileptiform features. No electrographic seizures were recorded. . Chest X-ray ([2137-10-26]): New left lower lobe retrocardiac consolidation and ill-defined opacities in the remaining left lower lobe are new worrisome for infectious process Small bilateral pleural effusions, left greater than right, are unchanged. Moderate cardiomegaly is stable. . Sputum cytology [10-29]: ATYPICAL. Atypical epithelial cells, squamous cells, neutrophils, bacteria, and rare macrophages. . CXR [10-29]: Overall, the examination is unchanged. There is stable moderate cardiomegaly and stable mild pulmonary congestive pattern. Retrocardiac consolidation and ill-defined opacities in left lower lung are unchanged. There is a small left pleural effusion. There is no pneumothorax. IMPRESSION: Overall unchanged examination; mild pulmonary congestion. Brief Hospital Course: 84 YO woman with hypertension, NIDDM, meningioma, and left ductal carcinoma in situ who presented to [Hospital1 25991]Hospital following a generalized tonic clonic seizure and was found to have a new intraparenchymal hemorrhage. She was transferred to [Hospital1 18] on [2137-10-22] where she was initially admitted to the neurology service. . At the time of admission, an MRI of the head was performed to better characterize the lesion and identify contributory structural abnormalities. The study revealed an acute hemorrhagic lesion in the left parietal lobe with surrounding vasogenic edema and local mass effect. While there were also findings consistent with chronic microangiopathy, there was no suggestion of amyloid angiopathy. The hemorrhage was also though to be in a location atypical for hypertensive bleeds. In the setting of the patient's history of malignancy, the appearance of the lesion raised concern for a hemorrhagic metastasis. . Accordingly, a CT of the torso was performed to evaluate for malignancy. The imaging showed an enhancing heterogenous mass in right lower quadrant, bilateral pulmonary opacities with multiple pulmonary nodules, endometrial fluid and right adnexal fullness, subcentimeter hepatic lesions, enlarged lymph nodes, pancreatic calcifications with mild dilation of the proximal pancreatic duct, and possible bony lesions. To gain advice regarding the optimal investigatory approach, a hematology/oncology consult was requested. Dr. [Last Name (STitle) ] (along with Dr [Last Name (STitle) 2148] of oncology felt that the visceral and bony lesions were consistent with metastatic disease, likely from a primary breast cancer. As a tissue diagnosis was necessary to confirm the diagnosis, it was recommended that the team contact radiology to determine the best site for a CT-guided biopsy. . As the patient presented after epileptiform activity and was thought to suffer a second witnessed seizure in the ED, the epilepsy team was asked to participate in the patient's care. Long-term electroencephalogram monitoring was also performed. Because the telemetry showed electrographic seizures, the patient was thought to be at a higher risk of further events. Accordingly, it was recommended that anti-epileptic therapy be continued for six to nine months (rather than the one to two week prophylactic course typically prescribed) and then gradually tapered. Since the patient's family believed the patient was sedated with keppra, the [Doctor Last Name 360] was discontinued in favor of dilantin (with a target trough of 10 to 12). . The patient was transferred to the medicine team in order to arrange for CT-guided biopsy of the right lower quadrent lesion seen on CT. This was scheduled but the patient and her family declined the procedure. The biopsy was therefore arranged to be done as an outpatient with further outpatient oncology follow up depending on the pathology of the biopsy. . The patient also complained of shortness of breath and cough. Exam and CXR were consistent with pneumonia so the patient was started on vancomycin, cefepime, and ciprofloxacin. Shortly after it was ordered, she refused this regimen and, thereafter, refused IV access. Her antibiotics were therefore switched to linezolid and ciprofloxacin as these were the only antibiotics that she would accept. She was also only intermittently willing to accept dilantin. Neurology spoke with the patient on several occasions and discussed the need for anti-epileptic medication but she declined dilantin and keppra. Just prior to dischange neurology suggested she may be able to take trileptal. This was discussed with Dr [Last Name (STitle) 16258] with a plan to switch to trileptal as an outpatient after further discussion given increased risk of hyponatremia in the setting of likely lung lesions/malignancy seen on CT. . Given that the patient refused IV access, recommended antibiotics, recommended anti-hypertensives, and recommended anti-epileptics, her medical team became unable to provide standard of care to this patient and she failed to meet ongoing criteria for hospitalization. This was discussed with the patient and her family as well as case management. The patient was also evaluated by physical and occupational therapy with a recommendation for inpatient rehab which the family also refused. The patient was therefore discharged with a plan for 24 hour home care, her home pre-hospitalization anti-hypertensive management regimen, a course of antibiotics partially treating hospital acquired pneumonia, and recommendation to continue dilantin until follow up with Dr [Last Name (STitle) 16258]. Outpatient CT guided RLQ biopsy, PCP follow up, and neurology follow up with repeat head MRI were arranged prior to discharge. . During hospitalization, she was also noted to have asymmetric LE swelling. She refused lower extremity ultrasound reporting that her legs have been swollen for years and that they are persisently asymmetric. Her blood sugars were also elevated in the 180-300 range. She intermittently accepted finger sticks for blood sugar measurements as well as insulin. She was discharged on glyburide which she reported taking prior to this admission. Medications on Admission: 1. Avapro 2. Vitamin D 3. MVI 4. Glyburide Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for T>100.4 or pain. 2. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). Disp:180 Tablet, Chewable(s) Refills:2 3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days. Disp:8 Tablet(s) Refills:0 4. Irbesartan 150 mg Tablet Sig: 0.5 Tablet PO qam (). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days. Disp:8 Tablet(s) Refills:0 8. Outpatient Lab Work Please draw a CBC with differential and have the results faxed to Dr[Name (NI) 16259] office. Phone #[Telephone/Fax (1) 16260]. 9. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: VNA of [Location (un) ] Discharge Diagnosis: Primary: Intra-cranial hemorrhage Parietal lobe mass of unknown etiology Right lower quadrent necrotic mass Multiple pulmonary nodules Endometrial and ovarian abnormalities seen on CT T5 and T7 lucent osseous lesions Subcentimeter hepatic lesions Hospital Acquired Pneumonia Hypertension Seizures Secondary: Breast Cancer Discharge Condition: Hemodynamically stable with normal vitals. Ambulating several feet with walker. Discharge Instructions: You were admitted to the hospital after being found unresponsive at home. Imaging of your brain showed two lesions. One of these lesions was a meningioma which was seen on prior imaging in [2135]. The other area was new and showed signs of bleeding. It was not clear what this area was composed of but, given your history of breast cancer and the appearance of the area on head imaging, a CT scan of your torso was done. The CT showed several concerning areas in your lungs, vertebrae and abdomen. The abdominal lesion is the best candidate for sampling for diagnostic purposes. After discussion, we came to the concensus that having the abdominal lesion sampled should be done after you regain some strength after this illness. This has been ordered for you but cannot be scheduled yet for logistical reasons. Someone from the radiology department will call you to schedule. The procedure should be done in approximately 10 days. Should you decide not to pursue the biopsy at that time, please call the radiology department to cancel or reschedule. Given your clinical presentation and concern for seizures, an EEG was done. This showed that you were having seizures. You were started on dilantin. Keppra was also tried. You were unable to tolerate either of these drugs. We continue to recommend that you take dilantin as recommended by the epilepsy specialists. An alternative medication is called trileptal although this medication puts you at risk for low sodium. You are scheduled to follow up with Dr [Last Name (STitle) ] as below. You were also noted to have a pneumonia. As this was acquired in the hospital after a brief intubation when you first arrived, we recommended that you take broad spectrum antibiotics. Because you felt that IV access was unnecessary, we could not give you the proper treatment for this pneumonia. As you agreed to take cipro and linezolid, you are being discharged on these medications which you should complete at home. You should have blood work checked in 2 days by your VNA to ensure you are not experiencing bone marrow suppression from linezolid. These labs should then be faxed to Dr [Last Name (STitle) 16258]. Your blood pressure was, at times, very high but you did not feel as though you tolerated blood pressure medications aside from a small dose of avapro. While we continue to recommend that you have better blood pressure control, you are being discharged on avapro. Please follow up with Dr [Last Name (STitle) 16258] regarding increasing this dose or adding another [Doctor Last Name 360] for improved control. It is vital to have excellent blood pressure control as high blood pressure could contribute to more bleeding in your head. You were noted to have asymetric lower extremity swelling on exam. You were scheduled for an ultrasound and went to the exam but you did not feel this was necessary so the exam was not done. You are at high risk for a blood clot that could break off and go to your lungs given that you have been mostly in bed for several days. . Your blood sugars were also very high during this admission. While in the hospital, you were given insulin when you agreed to take it. You should be on oral medications at home which were not started given your desire to not be on medications. Please discuss with Dr [Last Name (STitle) 16258] at your upcoming appointment. . Please call Dr. [Last Name (STitle) 16258] or return to the emergency room if you experience decreased alertness, confusion or unawareness, abnormal arm or leg movements, headache, change in vision speech or facial expression, weakness, numbness, or tingling in your arms or legs, chest pain, shortness of breath, increased sputum production, coughing up blood, abdominal pain, fevers, chills, nightsweats, diarrhea, dark black stool or bloody stool. Followup Instructions: A biopsy of your abdominal lesion has been ordered. One of the radiologists still has to review the order in order to protocol the study. The radiology department will call you once the study has been protocoled. Should you not hear from them within the next 48 hours, please call [Telephone/Fax (1) 327] to schedule. The study should be done in approximately 10 days. You have a follow up appointment with Dr [Last Name (STitle) 16258] on [11-20] at 3:30pm. Please call Dr[Name (NI) 16259] office at [Telephone/Fax (1) 19196] should you need to cancel or reschedule. You have an MRI of your brain scheduled on [11-29] at 7:30am. This can then be reviewed at your appointment with Dr [Last Name (STitle) ] at 2:00pm on the same day. Should you need to change, cancel or reschedule your MRI, please call [Telephone/Fax (1) 327]. Should you need to change, cancel or reschedule your appointment with Dr [Last Name (STitle) ], please call [Telephone/Fax (1) 44]. The MRI is in the [Hospital Ward Name 23] Building, [Hospital Ward Name ] on the [Location (un) ]. You should have a pelvic ultrasound to evaluate the endometrial and ovarian abnormalities seen on CT. This is ordered and can be scheduled by called [Telephone/Fax (1) 327]. ICD9 Codes: 431, 486, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8481 }	Medical Text: Admission Date: [2124-4-19] Discharge Date: [2124-4-25] Date of Birth: [2049-3-26] Sex: M Service: MEDICINE Allergies: Benadryl Attending:[First Name3 (LF) 759] Chief Complaint: Hypoxia, thalamic bleed Major Surgical or Invasive Procedure: none History of Present Illness: 75 M with recent right thalamic cerebellar bleed, chronic c.diff colitis, h/o aspiration s/p PEG came to ER from rehab after fall 3 days ago and subsequent headache. He went to [Hospital 487] Hospital where he was found to have saturation in 80s. CXR showed aspiration, CTH showed "acute posterior right corona radiata intraparenchymal hemorrhage with mild mass effect" unclear if this was acute or chronic. He was then transferred. Here CT shows right thalamic bleed, unclear if acute or chronic without seeing prior image. Neurosurgery saw patient, no surgical indication. Neurology saw patient and rec holding lovenox, ASA, dilantin and getting films from [4-4] bleed, MRI if becomes stable. Patient was confirmed DNR/DNI. CXR confirms right aspiration PNA and right clavicle fracture. He was given 1.5 L NS and placed on NRB with saturations 92-96%. ECG with SR, TW flat V5 V6 and no acute ST-T changes. In the ER vitals 92/48, was 70s systolic briefly, HR 90s, NRB 100% with sats 92-96% . Review of sytems: (+) Per HPI Past Medical History: Right thalamic hemorrhage, diagnosed [2124-4-4] Chronic C. difficile colitis on daily vancomycin Aspiration s/p PEG [2124-4-11] c/b aspiration PNA Bilateral DVT, previously on Coumadin CAD Hypertension AAA s/p repair Cervical spinal stenosis History of lumbar disc surgery Left cataract surgery Social History: Patient at rehab, 50 pack year smoking history. decline in ability to ambulate past 6 months, minimal head nodding at baseline in recent months. He stopped smoking cigarettes 12 years ago, but previously smoked 1 ppd x40 years. He drinks 1 bottle of wine/week. Denies illicit drug use. The patient is DNR/DNI (confirmed with sons). Family History: There is no family history of hypertension, DM, stroke. His father had lung cancer and was a smoker. Physical Exam: Vitals: T: BP: P: R: 18 O2: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2124-4-20] CXR: As compared to the previous radiograph, the pre-existing right sided parenchymal opacities have massively increased in extent. They now occupy the entire right lung bases. The presence of a combined dense lung parenchyma and air bronchograms suggests pneumonia. Mild increase in density is also seen at the left lung bases. The presence of a small right-sided effusion cannot be excluded, no larger left-sided pleural effusion. The size of the cardiac silhouette is unchanged. Round linear structure in the left lung base is caused by a skin fold. [2124-4-19] CT Head: Right thalamic hemorrhage. Given the report of this having occurred on [4-15], without comparison study, cannot assess whether this appearance represents evolution of that hemorrhage or re-bleed. Recommend re-evalution when previous (OSH) study becomes available, or short-interval f/u study. [2124-4-24] CHEST (PORTABLE AP): FRONTAL CHEST RADIOGRAPH: A right-sided PICC line is in unchanged position with tip in the mid SVC. The cardiomediastinal silhouette is stable. Diffuse right sided parenchymal opacities and a small right-sided pleural effusion are not significantly changed. A new opacity in the left lung base representing a developing consolidation possibly secondary to aspiration. There is a left sided small pleural effusion as well. Brief Hospital Course: Mr. [Known lastname 56494] is a 75 year-old man w/ recent thalamic hemorrhage likely secondary to combination of supratheraputic INR and hypertension admitted with altered mental status and hypoxia likely due to aspiration pneumonia. 1) Aspiration pneumonia: He had a witnessed aspiration event immediately prior to becoming hypoxic and confused. CXR demonstrated a large RLL infiltrate consistent with aspiration pneumonia. He was initially treated with vancomycin and levofloxacin and zosyn was added on [4-21] for expanded coverage of hospical acquired aspiration pneumonia because his improvement was slow. His respiratory function gradually improved and his supplemental oxygen requirement decreased. Levofloxacin was also discontinued. A PICC line was also placed to facilitate IV antibiotics, and he will complete a 10-day course of vancomycin on [4-28] and zosyn on [4-30]. He was also given albuterol, ipratropium, and budesonide nebulizer treatments to help his oxygenation and ventilation, and to treat likely COPD given his extensive smoking history. Aspiration precautions were also taken, including keeping the head of bed elevated to 30 degrees at all times. He was also continued on tube feeds. 2)Right thalamic bleed: He suffered a CVA in his right thalamus on [2123-4-5] that was thought to be secondary to hypertension and an elevated INR. He was on warfarin for a DVT that was diagnosed in [10-26]. After he was stabilized (INR was corrected and patient was monitored to assess for resolution of bleed), he was started on ASA 325 mg daily and Lovenox 40 SC daily. He was then discharged to [Hospital6 ] Institute, where he fell and hit his head on [4-17]. He was complaining of a headache, however, and was readmitted for evaluation. At this time, there was concern that the patient may have had a recurrent bleed but his CT head was stable x 2. Lovenox was stopped nonetheless. Heparin SC for DVT prophylaxis was continued. 3) Right fractured clavicle/Left chest pain: The patient was placed in a sling and will need to follow-up appointment with orthopedics as an outpatient. His left chest pain was secondary to costochondritis and was managed with tylenol and ibuprofen. 4) C.diff colitis: He has had recurrent c. diff and has been on a long taper with recent recurrence of cdiff after stopping po vanco. He was continued on po vancomycin and will need a long taper after abx course completed. 5) h/o DVT: Diagnosed in [10-26] and treatment was stopped after his thalamic bleed, as described above, and then restarted with lovenox. He has completed approximately six months of anticoagulation. A hypercoagulability evaluation has not been performed, however. 6) CAD/HTN: Continued on lopressor, ASA, and lisinopril. 7)FEN: Fibersource HN (Full) - [2124-4-20] 05:07 PM 40 mL/hour 8)Access: PICC placed [4-22] 9)PPX: SQ UF Heparin, PPI 10) Code status: DNR/DNI. We had a long discussion with family and they would not want CVL, a-line, or other aggresive therapies. Medications on Admission: Medications on transfer: -Lisinopril 20 mg PG [Hospital1 ] -Prevacid 30 mg PG daily -Vancomycin 250 mg PG qid (changed from 125 mg on [4-18]) -Flagyl 500 mg PO tid x14 days (started [4-17]) -Vitamin D 1000 U PG daily and [Numeric Identifier 1871] U weekly x10 weeks -Zanaflex 4 mg PG qhs -Florastore 1 tab [Hospital1 ] x3 months -Metoprolol 50 mg PG [Hospital1 ] -ASA 325 mg PG daily -Lovenox 40 mg SC daily -Potassium 20 mEq PG daily -Jevity 1.2 at 63 cc/hr, H2O bolus 150 mL q6 hr -Duoneb qid -Fe gluconate 300 mg PG [Hospital1 ] -Colace 100 mg [Hospital1 ] -Tylenol 650 mg PG q4 hr -MOM 30 mL qhs -Bisacodyl 1 supp PR daily -Mg oxide PG [Hospital1 ] x2weeks Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed for wheezing. neb 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 3. Vancomycin 125 mg Capsule Sig: One [Age over 90 ]y Five (125) mg liquid PO Q6H (every 6 hours): per PEG. 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): per PEG. 5. Acetaminophen 160 mg/5 mL Solution Sig: Six [Age over 90 1230]y (650) mg PO Q6H (every 6 hours): per PEG. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): per PEG. 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): per PEG. 9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed: per PEG. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 11. Budesonide 0.25 mg/2 mL Suspension for Nebulization Sig: Two (2) ML Inhalation [Hospital1 ] (). 12. Ibuprofen 100 mg/5 mL Suspension Sig: Six Hundred (600) mg PO Q6H (every 6 hours). 13. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 14. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: 4.5 g Intravenous Q8H (every 8 hours) for 6 days. 15. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) g Intravenous Q 12H (Every 12 Hours) for 4 days. Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: Primary: Aspiration pneumonia Subthalamic hemorrhage Secondary: Coronary artery disease Hypertension Discharge Condition: Stable Discharge Instructions: You were admitted because of shortness of breath. We diagnosed you with pneumonia and treated you with antibiotics. You were breathing more comfortably at the time of discharge. Please take all of your medications as prescribed. Please keep all of your follow-up appointments. Please call your doctor or return to the hospital if you experience fevers, chills, sweats, chest pain, shortness of breath or anything else of concern. Followup Instructions: Schedule an appointment with your PCP [Name Initial (PRE) 176] 2-4 weeks. PCP: [Name10 (NameIs) 82669],[First Name3 (LF) ] J. [Telephone/Fax (1) 80299] Completed by:[2124-4-27] ICD9 Codes: 5070, 431, 2761, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8482 }	Medical Text: Admission Date: [2142-5-23] Discharge Date: [2142-6-30] Date of Birth: [2142-5-23] Sex: F Service: Neonatology HISTORY OF PRESENT ILLNESS: [Known lastname 636] [Known lastname 14323] is the former 1.2 kg product of a 32 week gestation pregnancy born to a 36 year old Gravida 2, Para 1, now 2 Caucasian female. Prenatal screens, blood type 0 positive, antibody negative, RPR nonreactive, hepatitis B surface antigen negative, Rubella immune, Group B Streptococcus status unknown. Pregnancy was complicated by pregnancy-induced hypertension. Obstetrics history, significant for a prior delivery at 32 weeks gestation but the infant is now 2 years old and doing well. This pregnancy was marked by multiple admissions since [68] weeks for elevated blood pressure, intrauterine growth restriction and fetal heartrate decelerations. The mother received betamethasone on [4-27] and [2142-4-28]. Her most recent admission was on [2142-5-9] and she remained hospitalized from that time. The estimated fetal weight was less than a third percentile by a physical profile of 8 out of 8. On the day of delivery blood pressure was 152/96 mm of mercury. The mother was treated with magnesium sulfate and a pitocin induction ensued. Onset of labor occurred after one dose of Cytotec, artificial ruptures was two hours of delivery. There was no maternal fever or intrapartum antibiotic treatment. The infant was born by precipitous vaginal delivery. She was vigorous and required only blow-by oxygen for resuscitation. Apgars were 8 at one minute and 9 at five minutes. She developed respiratory distress and was admitted to the Neonatal Intensive Care Unit for treatment of prematurity and respiratory distress. PHYSICAL EXAMINATION: Physical examination on admission to the Neonatal Intensive Care Unit was weight 1200 gm at the 10th percentile, length was 40.5 cm, 25th percentile, head circumference 25.5 cm, less than the 10th percentile. Examination was notable for audible grunting with flaring and retractions, poor air entry, a nondysmorphic female. Head, eyes, ears, nose and throat, anterior fontanelle open and level. Sutures open, symmetric facial features. Positive red reflex bilaterally. Palate intact. Neck supple without masses. Cardiovascular, regular rate and rhythm without murmur. Normal S1 and S2, femoral pulses +2. Abdomen is soft, nontender, no masses. Three vessel cord. Genitourinary, normal preterm female. Spine straight, limbs straight with normal nails and creases. Neurological examination, appropriate for gestational age. HOSPITAL COURSE BY SYSTEM INCLUDING PERTINENT LABORATORY DATA: 1. Respiratory - [Known lastname 636] was intubated shortly after admission to the Neonatal Intensive Care Unit. She received one dose of surfactant. Her peak ventilatory settings were a peak inspiratory pressure of 24 over positive end-expiratory pressure of 5, intermittent mandatory ventilatory rate of 20. She weaned rapidly and was extubated to continue positive airway pressure by day of life #1. She remained on continuous positive airway pressure through day of life #5 when she weaned to room air. On day of life #12 she developed increasing respiratory distress with cyanosis. She was initially treated with nasal cannula oxygen but was then placed back on the continuous positive airway pressure for another week. She weaned to room air and remained in room air from day of life #19. She was also treated for apnea of prematurity with caffeine. The caffeine was discontinued on [2142-6-17]. She has not had any spontaneous episodes of apnea or bradycardia since her caffeine was discontinued. 2. Cardiovascular - An intermittent soft murmur was noted on day of life #2 and remained audible at the time of discharge. Four extremity blood pressures are within normal limits. Chest x-ray is normal. She is [Age over 90 ]% saturated in room air at rest. The murmur is felt to be consistent with peripheral pulmonic stenosis. 3. Fluids, electrolytes and nutrition - [Known lastname 636] was initially NPO and treated with intravenous fluids. She received supplemental total parenteral nutrition while advancing to full feeds. She reached full volume enteral feeds by day of life #9 and then was augmented to 30 cal/oz. At the time of discharge her weight remains less than the 10th percentile at 1.915 kg, her length is 44 cm at the 25th percentile and her head circumference is 30 cm which is again less than the 10th percentile. She is being discharged home on supplemented breast milk to 26 cal/oz, 4 cal by NeoSure powder an 2 cal by corn oil. Serum electrolytes were normal throughout admission. She is ad lib p.o. feeding at the time of discharge. 4. Infectious disease - Due to the prematurity and pulmonary disease, [Known lastname 636] was evaluated for infection upon admission to the Neonatal Intensive Care Unit. A white blood cell count was 6,000 with a differential of 10% polys, 1% bands, platelets 243,000. A blood culture was drawn prior to initiation of intravenous antibiotic therapy with ampicillin and gentamicin. The blood culture was no growth and the antibiotics were discontinued. On day of life #12, with a deterioration in her clinical status, a complete blood count and blood culture were repeated. The white blood cell count was 13,500 with a differential of 78 polys, and 4% bands. Due to the further deterioration in her clinical status she was changed from vancomycin and gentamicin to ampicillin, cefotaxime and acyclovir. A lumbar puncture performed at that time had 1 red blood cell and 81 white blood cells per high power field. The differential on the white blood cell count was 22% polys, 2% bands, 61% lymphocytes. Glucose and protein were normal. Due to the pleocytosis and the clinical condition at the time there was high suspicion for meningitis and [Known lastname 636] received a 21 day course of ampicillin and cefotaxime. Blood and cerebrospinal fluid cultures were negative. Herpes simplex virus, PCR was sent and was negative and the acyclovir was discontinued. 5. Hematological - [Known lastname 636] is Blood type 0 positive, Coombs negative. Her hematocrit at birth was 52.4%. Her most recent hematocrit on [2142-6-22] was 35.4%. She did not receive any transfusions of blood products. She is being discharged home on supplemental iron. 6. Gastrointestinal - [Known lastname 636] required treatment for unconjugated hyperbilirubinemia with phototherapy. Her peak serum bilirubin occurred on day of life #6 at a total of 7 total/3.3 mg direct mg/dl. She received phototherapy for approximately one week. Her rebound bilirubin on day of life #13 was 3.7 total/0.2 direct. 7. Neurological - Two head ultrasounds which were within normal limits, most recently on [2142-6-11]. 8. Sensory - Ophthalmological examination was performed, initially on [2142-6-13] showing immature retinas to zone 3. A follow up ophthalmological examination on [2142-6-27] showed mature retina. Recommend ophthalmology follow up at 8 months of age. Hearing screening was performed on [2142-6-28] with automated auditory brainstem responses and passed in both ears. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with parents. PRIMARY CARE PEDIATRICIAN: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Hospital3 40497], [Location 4288] [Numeric Identifier 40498], phone [Telephone/Fax (1) 40499]. CARE RECOMMENDATIONS AT DISCHARGE: 1. Feeding - Ad lib p.o. breast milk supplement 26 cal/oz, 4 cal by NeoSure powder, 2 cal by Corn oil. 2. Medications - Poly-Vi-[Male First Name (un) ] 1 cc p.o. q.d., this is required as the infant is on breast milk and will be required if the infant continues on full strength NeoSure. Fer-In-[Male First Name (un) ] 0.2 cc p.o. q.d., 25 mg/ml dilution. 3. Carseat position screening test - Performed without problems. 4. [Name2 (NI) ] newborn screen - Sent on three occasions and remains with no abnormal results reported to date. 5. Immunizations administered - No immunizations thus far administered. 6. Immunizations recommended - Synagis respiratory syncytial virus prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria: 1. Born at less than 32 weeks; 2. Born between 32 and 35 weeks with plans for daycare during respiratory syncytial virus season, with a smoker in the household or with preschool siblings; or 3. With chronic lung disease. Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. Before this age the family and other caregivers should be considered for immunization against influenza to protect the infant. FOLLOW UP APPOINTMENTS: Pediatrician on Monday [2142-7-2]. Ophthalmology at age 8 months. DISCHARGE DIAGNOSIS: 1. Prematurity at 32 weeks gestation 2. Respiratory distress syndrome 3. Suspicion for sepsis, ruled out 4. Presumptive meningitis 5. Apnea of prematurity 6. Unconjugated hyperbilirubinemia 7. Cardiac murmur - probable peripheral pulmonary artery stenosis 8. Small for gestational age [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 37237], M.D. [MD Number(1) 37238] Dictated By:[Name8 (MD) 40500] MEDQUIST36 D: [2142-6-30] 07:56 T: [2142-6-30] 11:14 JOB#: [Job Number 40501] ICD9 Codes: V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8483 }	Medical Text: Admission Date: [2119-4-17] Discharge Date: [2119-4-21] Date of Birth: [2071-7-6] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1781] Chief Complaint: Expanding right groin hematoma, status post cardiac catheterization. Major Surgical or Invasive Procedure: Evacuation of hematoma with repair of profunda History of Present Illness: 48 yo F with no past cardiac hx. was found with a new LBBB during a routine checkup with her PCP. [Name10 (NameIs) ] only complaint was exertional dyspnea. A subsequent p-MIBI showed anterior and anterolateral defects and an EF of 35%. A subsequent echo at [Hospital1 1474] did not show a depressed EF. She precented for ardiac catherization Past Medical History: PMH: depression, anxiety, cardiomyopathy/EF 40 % (clean coronaries per cath [4-17]), sp LLE bpg sec trauma/MVC 23 yrs ago, sp open CCY, morbid obesity Social History: significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: YSICAL EXAMINATION: VS: T BP HR RR O2 Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of * cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. R Groin inc: C/D/I Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [2119-4-21*] 05:45AM BLOOD Hct-25.5 Brief Hospital Course: 48 yo F with no past cardiac hx. was found with a new LBBB during a routine checkup with her PCP. [Name10 (NameIs) ] only complaint was exertional dyspnea. A subsequent p-MIBI showed anterior and anterolateral defects and an EF of 35%. A subsequent echo at [Hospital1 1474] did not show a depressed EF. Here for cardiac catheter. Cardiac cath showed no angiographically apparaent coronary disease. There was no gradient acress the aortic valve. There is moderate diastolic dysfunction with an LVEDP of 25mmHG. An LV gram shows an EF of 40-45%. By report, there was some difficulty obtaining access was due to body habitus and approximately 25 min after the sheath removal a large hematoma began to form and the patient became hypotensive to 66/70 requiring pressor support with Dopamine (10). Her pressure improved, however she continued to ooze from her groin operative site. A clamp was placed for hemostasis. Transfered to the CCU, the patient was tachycardic and her hematoma continued to expand. She received 1 unit of blood and a urgent vascular consult was obtained. She was taken to the OR for clot removal and repair of the arterial bleed. She tolerated the procedure well transfered to the floor in stable condition PT Pt stable for home with services Medications on Admission: Meds: buspar 5"", ambien prn, topamax 200", vicodin "", klonopin prn, paxil?, (recently started on asa, carvedilol 3.125", lisinopril 10' for ? MI) Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed for breakthrough only. Disp:20 Tablet(s) Refills:0 2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:30 Tablet(s) Refills:0 3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 5. Buspirone 10 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6 hours). 6. TOPAMAX 200 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 ] vna Discharge Diagnosis: R groin hematoma / s/p cardiac catheter Discharge Condition: Stable Discharge Instructions: Post Surgery Wound Care Overview Your doctor has placed sutures (stitches) to keep the incision closed for proper wound healing. Sometimes, sutures need to be removed in a few weeks. Sometimes, the sutures are all under the skin and will eventual dissolve on their own and do not need to be removed. In either case, please follow these routine wound care instructions. Leave the original bandage that was applied at the time of your surgery in place for 48 hours. If the bandage should become loose, reinforce the dressing with surgical tape. After approximately 48 hours, you can gently remove the bandage. If you have steri-strips on your incision (little white paper tapes), keep them in place until they begin to fall off on their own. Do not pull the steri-strips off as this could put stress on the incision line. When the steri-strips start to peel off, they can be gently washed off. Please try to keep the incision line clean and dry. You can shower and gently wash the incision line with soap and water. Dry the incision area and keep the incision line open to air. It is not necessary to apply antibiotic ointment, alcohol, hydrogen peroxide, or a new bandage to the incision line. If your sutures get caught on your clothing or there is a small amount of drainage from the incision, you may want to cover it with small gauze for your own comfort. If so, please use as little tape as possible to hold the gauze in place as tape can irritate the skin. A small amount of drainage from the incision in the first few days after surgery is not unusual and it will probably resolve on its own. However, if you should notice bleeding from the surgical site, apply firm direct pressure for ten minutes. If the bleeding persists, reapply firm direct pressure for an additional ten minutes. If the bleeding does not stop after 20 minutes, call our contact phone numbers or go to the nearest emergency room for assistance. What to Avoid Please avoid the following: Do not submerge the incision line under water for a prolonged period of time with activities like taking a bath, swimming, or sitting in a hot tub. Do not participate in any vigorous activities or exercises that may put stress on the incision. Do not take aspirin, ibuprofen, or any other nonsteroidal anti-inflammatory medication that may cause problems with bleeding unless instructed by your doctor. Do not apply perfumes or scented lotions to the sutures as this may cause irritation. When to Call the Doctor Please contact us immediately if you develop: Fevers, chills, or night sweats Increasing redness, pain, or pus at the incision Bleeding that does not stop with firm pressure Followup Care If your sutures need to be removed, this is usually done [12-7] weeks after surgery. Even if your sutures will dissolve, the doctor usually likes to examine the incision while it is healing. Therefore, you should have been scheduled for a follow-up appointment in clinic at the time of your discharge from surgery. As this appointment is very important, please contact the clinic if you do not have one scheduled or you need to change the date and/or time. Followup Instructions: Call Dr [Last Name (STitle) ] office at [Telephone/Fax (1) 2395]. Schedule an appointment for 2 weeks after you get discharged Completed by:[2119-4-21] ICD9 Codes: 4254, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8484 }	Medical Text: Admission Date: [2184-7-11] Discharge Date: [2184-8-7] Date of Birth: [2117-11-24] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 5018] Chief Complaint: agitation, vision loss Major Surgical or Invasive Procedure: None History of Present Illness: This is a 66yo man with a history of ischemic cardiomyopathy, atrial fibrillation on dabigatran, diabetes mellitus (history of poor glycemic control), tobacco abuse, hyperlipidemia, alcohol abuse and prior stroke who presents to the ED by EMS today after a change in his mental status. We are able to obtain limited a history by a combination of sources including the patient's daughter, EMS personnel. The patient has been in his USOH. He is retired and lives at home, and is unmarried. His kids visit him from time to time. His daughter reports that he drinks alcoholic beverages everyday and is an active smoker. Apparently, he had been complaining about asthma symptoms more recently. They spoke with him this morning around 11AM. Later in the afternoon, around 4PM, his son visited with him and they spent some time together, and had a couple of beers for Father's day. After returning from the bathroom, he had a sudden change in his mental status. All of a sudden, he started to scream and complain of difficulty breathing. He seemed confused. EMS was called, and transported him to the [Hospital1 18] ED. Initial ED physical examinations were concerning for a toxic metabolic encephalopathy, and routine bloods were largely unrevealing. He appeared confused and disoriented and was not able to provide any type of a coherent history. Language was not the problem here: his knowledge of English was quite reasonable. Later, it was noticed that he was having difficulty seeing. Neurology was called. A complete review of systems was above, a more thorough ROS was not able to be obtained Past Medical History: - Coronary artery disease, nonocclusive - Recurrent UTIs, ? [2-26] DMII - DMII, most recent A1c ~7.5, has been as high as ~10 in the past. Currently on insulin - Hyperlipidemia - Atrial fibrillation, previously on coumadin, currently on dabigatran therapy - mild Systolic Heart Failure (previous echo showing EF ~45-50%) - Fatty liver disease - Hypertension Social History: He is retired and lives at home, and is unmarried. His kids visit him from time to time. His daughter reports that he drinks alcoholic beverages everyday and is an active smoker. Family History: Father and paternal uncle both had heart problems, s/p ?CABG. Paternal uncle's course complicated by diabetic infection. Older brother died after a stroke. [Name (NI) ] brother with gastric cancer. All brothers ([Name (NI) 22772]) have diabetes. Physical Exam: Physical Exam on Admission: V/S: 98.2, 110, 156/92 (later upto ~180s systolic), 18, 99% RA General: Lying in bed supine, moderate distress, staring around, appears confused. Strong odor of beer and cigarettes. Diaphoretic. Intermittent strong wet hacking cough. HEENT: NC/AT, no conjunctival icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no masses or lymphadenopathy Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: Irregularly irregular, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, no masses or organomegaly noted, large vertical abdominal scar of unknown origin Extremities: warm and well perfused Skin: no rashes or lesions noted. Neurologic examination (limited) - Mr. [Known lastname 22771] was awake and alert and made poor eye contact. [Name (NI) ] appeared agitated at times and confused. He was able to tell me his name, but could not recall his age, home address, name of this country, the President, the date or the reason why he was in the hospital. He could tell me that he was from [Male First Name (un) 1056] originally. He could not recall what he ate for lunch earlier that day, nor could he name his [Hospital1 ] names. - PERRL, EOMI without nystagmus on command, he had difficulty tracking objects and performing smooth pursuit. He had a dense visual field cut on the left. Objects placed on the right side of his vision would be seen and recognized easily, and he often neglected the left side of his world. No asymmetries in facial movement or sensation. - Full strength in all major muscle groups tested with diffusely increased tone. Symmetrically poor reflexes (he would not relax for a proper reflex examination). - Sensation was grossly intact bilaterally, although he had definite double simultaneous extinction to stimuli on the left (by sensory). - Could not test typical cerebellar tests at the bedside, gait examination was deferred. Physical Exam on Discharge: Patient is oriented to self, hospital, [Hospital1 18], [Location (un) 86], says it is "[2175-9-25]," repetition intact, names low and high frequency objects, visual fields difficult to assess but has some deficit on R, tongue protrudes midline, motor [5-29] in UEs and [Name Prefix (Prefixes) ] [Last Name (Prefixes) ]/l, sensation intact to light touch throughout, finger to nose intact Pertinent Results: ADMISSION LABS: [2184-7-11] 06:49PM LACTATE-2.5* [2184-7-11] 06:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2184-7-11] 06:20PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.009 [2184-7-11] 06:20PM URINE [Month/Day/Year 3143]-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM [2184-7-11] 06:20PM URINE RBC-0 WBC-29* BACTERIA-FEW YEAST-NONE EPI-<1 TRANS EPI-<1 [2184-7-11] 06:03PM TYPE-[Last Name (un) ] PO2-53* PCO2-39 PH-7.44 TOTAL CO2-27 BASE XS-1 INTUBATED-NOT INTUBA COMMENTS-GREEN TOP [2184-7-11] 06:03PM LACTATE-2.6* [2184-7-11] 05:50PM GLUCOSE-230* UREA N-16 CREAT-1.3* SODIUM-138 POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-25 ANION GAP-16 [2184-7-11] 05:50PM estGFR-Using this [2184-7-11] 05:50PM ALT(SGPT)-42* AST(SGOT)-26 ALK PHOS-126 TOT BILI-1.1 [2184-7-11] 05:50PM LIPASE-40 [2184-7-11] 05:50PM cTropnT-<0.01 [2184-7-11] 05:50PM proBNP-651* [2184-7-11] 05:50PM ALBUMIN-5.0 [2184-7-11] 05:50PM OSMOLAL-294 [2184-7-11] 05:50PM ASA-NEG ETHANOL-17* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2184-7-11] 05:50PM WBC-6.6 RBC-4.86 HGB-15.2 HCT-46.0 MCV-95 MCH-31.3 MCHC-33.1 RDW-14.2 [2184-7-11] 05:50PM NEUTS-75.6* LYMPHS-16.1* MONOS-5.8 EOS-1.5 BASOS-0.9 [2184-7-11] 05:50PM PLT COUNT-173 [2184-7-11] 05:50PM PT-10.9 PTT-32.1 INR(PT)-1.0 DISCHARGE LABS: ?????????????????? CT head [2184-7-11]: IMPRESSION: No acute intracranial hemorrhage. CTA [2184-7-11]: IMPRESSION: 1. Likely old lacunar infarcts involving the right basal ganglia region and left pons. No evidence of acute territorial infarct. 2. Significant motion degradation of CTA making it impossible to rule out [First Name9 (NamePattern2) 22776] [Last Name (un) 22777], aneurysm or dissection. Please consider use of sedation and repeat the exam if clinically indicated. CT [2184-7-12]: IMPRESSION: Evolving bilateral occipital infarctions, larger on the right than the left, in the regions of the bilateral PCAs. There is mild associated mass effect with effacement of the adjacent sulci, but no evidence of herniation. No hemorrhagic conversion. EEG [7-12]: IMPRESSION: This is an abnormal EEG during brief wakefulness and sleep, because of mild background slowing indicative of a mild diffuse cerebral dysfunction of nonspecific etiology. No epileptiform discharges or electrographic seizures are present. Note is made of an irregularly irregular cardiac rhythm as well as wide-complex premature beats Transthoracic echo [7-12]: The left atrium is mildly dilated. No thrombus/mass is seen in the body of the left atrium. 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 regional left ventricular systolic dysfunction with inferior and infero-lateral hypokinesis to akinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size is normal. with borderline normal free wall function. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. An eccentric jet of mild to moderate ([1-26]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2183-7-24], the LVEF has slightly increased. The degree of pulmonary hypertension detected has decreased. CXR [7-11]: IMPRESSION: Pulmonary edema with tiny pleural effusions and top normal heart size. CXR [7-18]: FINDINGS: The NG tube tip is in the stomach. The apices of the lungs are off the film. The visualized portions of the lung are clear without infiltrate. The heart continues to be mildly enlarged. There is no pleural effusion or pneumothorax. CT head [2184-8-1]: Areas of increased density in the previously noted bil. occipital lobe [Month/Day/Year 22778]- partly gyriform and partly nodular. Though the gyriform foci can relate to mineralization from laminar necrosis in subacute [Last Name (LF) 22778], [First Name3 (LF) ] acute component of hemorrhage cannot be completely excluded given the lack of recent studies. Consider close followup in a few hours to assess interval change and stability. Moderate surrounding vasogenic edema noted. CT head [2184-8-2]: Comparison to [2184-8-1] exam shows no significant change. Gyriform hyperattenuation in the bilateral PCA territory is consistent with previous cortical hemorrhage. No new areas of infarct or hemorrhage. Bilateral Shoulder x-ray [2184-8-1]: RIGHT SHOULDER: There are no signs for acute fractures or dislocations. There are degenerative changes seen of the AC and glenohumeral joints. Visualized right lung apex is clear. LEFT SHOULDER: There are no acute fractures or dislocations. There is normal osseous mineralization. There are minimal degenerative changes of the AC and glenohumeral joints. The visualized left lung apex is clear. Labs on Discharge: none Brief Hospital Course: 66yo M with a history of HTN, HL, DMII, CAD, ischemic cardiomyopathy with mild systolic heart failure, atrial fibrillation on dabigatran, prior stroke, and tobacco and alcohol abuse who presents with a sudden alteration in mental status, found to have a dense left visual field cut and a left sided sensory neglect on exam. A NCHCT confirmed the absence of intracranial hemorrhage, but CTA/CTP was limited by motion artifact. However, no major intracranial stenosis noted. Mr. [Known lastname 22771] likely sustained a cerebral infarction in the right parietal and occipital lobes, possibly as a consequence of a right PCA occlusion by a cardioembolic event. It is not clear whether has been taking his medications reliably, and consequently, we did know whether the patient was anticoagulated or not on admission. Thus TPA was not a consideration, and neuro-intervention was deferred, particularly given the relative lack of severity of symptoms and the invasive nature of the procedure. He was initially admitted to the neuro ICU for further investigation, as well as close monitoring of his respiratory status given finding of pulmonary edema on admission CXR. Did well and was and was transferred to the floor. Neuro: He remained disoriented, very uncooperative, and intermittently agitated initially. Examination was limited but did appear to reveal loss of vision, L>R, with confabulation at times when asked to count fingers or recognize objects. Repeat CT on [7-12] showed bilateral R>L PCA infarcts. Vessel imaging was unable to completed due to agitation. EEG showed mild background slowing with no epileptiform activity. Dabigatran was held and he was maintained on a heparin drip with goal PTT 50-70. He was started on coumadin on [7-19]. He was contined on his home atorvastatin. A1c was 8.5%, lipid panel revealed total chol 196, TG 83, HDL 85, LDL 94. He was placed on a CIWA scale given his history of alcohol use and was treated with IV ativan prn. He was also started on thiamine and folate supplements. His agitation slowly improved. An NGT was placed and he was started on PO seroquel 25mg [Hospital1 ] along with valium 5mg PO Q6hrs. He was transferred to the floor once his agitation was better controlled and he passed a swallow evaluation, so the NGT was removed His seroquel was increased to 25mg QAM and 50mg QPM and his valium was slowly tapered to off. Of note, pt was found on the floor of his room on [8-1]. NCHCT showed hemorrhage into stroke bed. Pradaxa was held. Repeat NCHCT the next day was unchanged, so re-started pradaxa. On discharge, pt's exam was much improved. Cardiovascular: He was maintained on tele monitoring which showed a fib. Cardiac enzymes were negative x 2. TTE [7-12] showed EF 40-45%, no thrombus or PFO. His home antihypertensives were held except for 1/2 dose beta blocker and lasix for volume overload. He was continued on his home atorvastatin. Endo: He was maintained on fingersticks, and ISS for [Month/Year (2) ] glucose control. HbA1c was 8.5%. Pulmonary: CXR on admission was consistent with pulmonary edema. Respiratory status was monitored closely and remained stable. He was started on lasix for volume overload. Renal: He developed intermittent urinary retention but a foley was unable to be placed [2-26] urethral stricture. Urology was consulted and did not feel that any acute interventions were warranted. His retention subsequently resolved with gentle IV hydration and lasix, and he was able to void via condom catheter. Electrolytes were monitored and repleted PRN. Infectious disease: Initial UA appeared to be positive and he was started on ceftriaxone empirically. Cx subsequently came back negative on [7-13] and abx were stopped. He remained afebrile with no signs of infection. Musculoskeletal: Pt intermittently complained of L shoulder pain. Obtained an x-ray which did not show any abnormalities. FEN: An NGT was placed for PO access given his severe disorientation and intermittent agitation. He was seen by speech and swallow on [7-19] but was recommended to remain NPO at that time given his persistent lethargy and poor cooperation. However, he did pass a swallow eval once he was transferred to the neurology floor, and the NGT was removed. Prophylaxis: He was maintained on pneumoboots and a heparin GTT for DVT prophylaxis. He was maintained on famotidine and a bowel regimen for GI prophylaxis. TRANSITIONAL CARE ISSUES: -will f/u in stroke clinic with Dr. [Last Name (STitle) ] [Name (STitle) 4800] need titration of lantus and anti-hypertensive meds (goal SBP 120-130) Medications on Admission: ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 Tablet(s) by mouth daily DABIGATRAN ETEXILATE [PRADAXA] - 150 mg Capsule - 1 Capsule(s) by mouth twice a day pt will stop Coumedin [11-17] and start Pradaxa [11-19], call me if not covered FLUTICASONE [FLOVENT HFA] - (Prescribed by Other Provider) - Dosage uncertain FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth once a day INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 26 units in am daily in the morning LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day METFORMIN [GLUCOPHAGE] - (Prescribed by Other Provider) - 850 mg Tablet - 1 Tablet(s) by mouth twice daily Hold for 48 hours after cardiac catheterization. Resume on [2182-1-26] METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth daily NIFEDIPINE - 90 mg Tablet Extended Release - 1 Tablet(s) by mouth daily NITROGLYCERIN [NITROSTAT] - 0.3 mg Tablet, Sublingual - 1 Tablet(s) sublingually prn as needed for chest pain RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. Atorvastatin 20 mg PO DAILY 2. Dabigatran Etexilate 150 mg PO BID 3. Fluticasone Propionate 110mcg 2 PUFF IH [Hospital1 ] 4. Furosemide 20 mg PO DAILY 5. Lisinopril 40 mg PO DAILY hold for sbp less than 100 6. Metoprolol Tartrate 25 mg PO TID hold for hr less than 60 and bp less 100 7. Quetiapine Fumarate 50 mg PO HS 8. Quetiapine Fumarate 25 mg PO QAM 9. Thiamine 100 mg PO DAILY 10. Glargine 12 Units Breakfast Insulin SC Sliding Scale using REG Insulin 11. FoLIC Acid 1 mg PO DAILY 12. Acetaminophen 650 mg PO Q6H:PRN pain 13. Docusate Sodium 100 mg PO BID 14. Ibuprofen 600 mg PO Q8H:PRN pain 15. Senna 1 TAB PO BID constipation 16. Polyethylene Glycol 17 g PO DAILY:PRN constipation 17. NIFEdipine CR 30 mg PO DAILY 18. Nitroglycerin SL 0.3 mg SL PRN chest pain take for chest pain, up to 3 tabs 5 minutes apart; if chest pain persists, call your doctor or call 911 19. Ranitidine 150 mg PO DAILY Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Ischemic infarct in PCA territory bilaterally Discharge Condition: Patient is oriented to self, hospital, [Hospital1 18], [Location (un) 86], says it is '[2175-9-25],' repetition intact, names low and high frequency objects, he is able to read '[85]' and 'Friday' and '[2184]' on calendar page (large letters), he is able to discriminate red and blue and green accurately, he no longer confabulates when asked to describe or count or name objects that are not present; his visual fields are difficult to assess but has more deficit on R than L, face symmetric, tongue protrudes midline, motor [5-29] in UEs and [Name Prefix (Prefixes) ] [Last Name (Prefixes) ]/l, sensation intact to light touch throughout, finger to nose intact Discharge Instructions: Dear Mr. [Known lastname 22771], You were admitted to the hospital with confusion and difficulty with your vision. You had a CT scan of the brain which showed that you had strokes in the back of your brain on both sides --- this was determined to be the cause of your symptoms. Gradually, your symptoms improved over the course of the admission. We have made the following changes to your medications: START Seroquel 25mg in the morning and 50mg at night Thiamine 100mg daily DECREASE Lantus to 12 U in the morning Nifedipine to 30mg daily On discharge, please follow up with Dr. [Last Name (STitle) ], your new neurologist as scheduled below. It was a pleasure taking care of you, we wish you all the best. Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [2184-9-1] at 10:20 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: NEUROLOGY When: TUESDAY [2184-9-21] at 3:30 PM With: [Name6 (MD) ] [Name8 (MD) ], M.D. [Telephone/Fax (1) 2574] Building: [Hospital6 29] [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023] Completed by:[2184-8-7] ICD9 Codes: 431, 5849, 2724, 3051, 4019, 4280, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8485 }	Medical Text: Admission Date: [2118-9-4] Discharge Date: [2118-9-10] Date of Birth: [2046-8-18] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4765] Chief Complaint: ST segment elevation myocardial infarction Major Surgical or Invasive Procedure: Heart Catheterization x2 Mechanical Ventilation Intraaortic Balloon Pump Thransvenous pacermaker wire History of Present Illness: 72 year old man DM2, HTN, hyperlipidemia, A-fib (but not taking coumadin for the past week), ASD, h/o PE s/p IVC filter placement, mild LV global dysfunction, mod MR, mild RV dysfunction, developed dizziness starting 8am (no chest pain). Went to OSH ER at 10:45 am- by this time symptoms resolved. Found to have ST elevation in inferior leads with reciprocal changes in in Av1 and AVL, anterior leads. BP 90's HR 60's in a-fib. ETA 30 minutes (from [Hospital 882] hospital). cath reealed multivessesl sx- midLAD 80%, D1 80-90%, mLCx 95-99%, mRCA 100%. C-[Doctor First Name ] decided not to take to OR related to prior sternotomy and chronic venous disease. In CCU- bradycardic , hypotensive --> PEA arrest--> fluids/dopamine--> hypertensive and tachy --> Vtach--> lidocaine --> BP high, SVT --> pt was coded for > 1hr --> taken back to cath lab--> rec'd three RCA stents, IABP, transvenous pacer. Past Medical History: 1. chronic AFib/aflutter 2. ASD s/p repair [2112] 3. HTN 4. Hypercholesterolemia 5. DMII 6. previous DVT w/ recurrent PE; s/p filter placement in [2095] c/b migration and urgent sternotomy w/ repair of atrial perforations x2 7. Recurrent LE venous stasis ulcers s/p failed skin grafts to site Social History: He lives with his sister and brother-in-law. Formerly worked for [Company 2318]. Denies alcohol, drug, or tobacco use. Family History: n/c Physical Exam: Gen: critically ill, unresponsive HEENT: vomiting Cards: Irregular distant sounds Pulm: Diffusely rhoncorous, on vent Abd: soft, no HSM Extrem: hemosideran deposition anterior tibia B. Pertinent Results: [2118-9-4] 03:00PM PT-16.9* PTT-62.2* INR(PT)-1.6* [2118-9-4] 03:00PM GLUCOSE-126* UREA N-19 CREAT-1.3* SODIUM-138 POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13 [2118-9-4] 05:30PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ [2118-9-4] 05:30PM WBC-20.3# RBC-3.55 HGB-11.1* HCT-33.9* MCV-96 MCH-31.4 MCHC-32.9 RDW-16.0* [2118-9-4] 09:42PM WBC-21.1* RBC-3.31* HGB-10.5* HCT-29.6* MCV-89# MCH-31.8 MCHC-35.6* RDW-16.3* [2118-9-4] 09:42PM CK-MB-196* MB INDX-12.0* cTropnT-10.02* [2118-9-4] 09:54PM LACTATE-2.7* [2118-9-4] 09:54PM TYPE-ART PO2-169* PCO2-38 PH-7.43 TOTAL CO2-26 BASE XS-1 ECHOCARDIOGRAM [2118-9-5] Conclusions: The left atrium is moderately dilated. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed. Resting regional wall motion abnormalities include inferior akinesis and inferolateral hypokinesis (estimated ejection fraction ?40%). The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic root is mildly dilated. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared to the prior study of [2118-9-4], findings are similar. Aortic regurgitation now may be slightly more prominent. CARDIAC CATHETERIZATION [2118-9-4] COMMENTS: 1) Initial angiography was unchanged from previous catherization. The RCA had a 100% mid vessel occlusion with collaterals to the distal vessel from the left system. The LAD and CX had high grade lesions. 2) Successful PTCA, thrombectomy, and stenting of the distal, mid, and ostial RCA with multiple Cypher stents. A 2.75x16 mm Taxus was deployed in the distal RCA and was postdilated with a 2.75 mm NC balloon. Overlapping 3.0x16 mm and 3.5x28 mm Taxus stents were placed in the mid RCA and the 3.5 mm stent was postdilated with a 3.5 mm NC balloon. A 3.5x16 mm Taxus stent was placed in the ostial RCA and postdilated with a 4.0 mm NC balloon. Final angiography revealed <10 % residual stenosis, no dissection, and TIMI 3 flow. (see PTCA comments) 3) Successful placement of an IABP and transvenous pacemaker given the bradycardic arrest and cardiogenic shock. 4) Resting hemodynamics revealed severely elevated right and left sided filling pressures, moderate pulmonary hypertension, and normal cardiac outputs. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Cardiogenic shock with severely elevated left and right sided filling pressures with normal cardiac outputs on IABP support. 3. Acute inferior myocardial infarction, managed by acute ptca, temporary pacemaker, and IABP. 4. PTCA of RCA vessel with multiple drug eluting stents. Brief Hospital Course: 72yo M with multiple cardiac risk factors presented with STEMI, found to have 3VD awaiting CABG, became HD unstable, coded > 1hr, brought back to cath lab and received four taxus stents to RCA. Patient was stabilized in the CCU on two pressors, intraortic balloon pump and transvenous pacer wire. These were all weened over the course of 4 days. Through discussions of risks and benefits with CT surgery, the patient's family, and primary cardiologist Dr. [Last Name (STitle) 73] it was decided to not undergo CABG for multivessel disease. The family decided on DNR/DNI code status at that time. With the patient stable off IABP and pressors he was extubated on [2118-9-9] however developed pulmonary edema and increased oxygen requirement. Was placed on BiPAP as temporizing measure. Further discussion with family confirmed DNR/DNI status, and they later decided to make the patient comfort measures only. Morphine drip was titrated for comfort and air hunger. The patient was pronounced dead at 11:25am on [2118-9-10]. Medications on Admission: Sotalol 80 PO TID Amlodipine 5mg daily Coumadin glyburide 2.5 PO twice daily fosamax zestril 5 lipitor 10 HCTZ 25 Tamsulosin 0.4 Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: ST elevation MI Discharge Condition: Pt Expired ICD9 Codes: 9971, 4275, 5070, 5849, 5859, 5990, 4019, 2724, 4439
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8486 }	Medical Text: Admission Date: [2188-4-28] Discharge Date: [2188-5-5] Date of Birth: [2188-4-28] Sex: F Service: Neonatology HISTORY: Baby Girl [Known lastname 56440] [Known lastname ] was the 1390 gram product of a 29 week gestation born to a 32-year-old G1, P0, now 1 female. Prenatal screens A+, antibody negative, RPR nonreactive, Rubella immune, Hepatitis B surface antigen negative, GBS unknown. Maternal history of hypothyroidism on Levoxyl. IUI, gonadotropin assisted pregnancy. Pregnancy complicated by HELLP syndrome. Treated with magnesium sulfate and betamethasone. Mother was transferred from [Name (NI) ] Hospital. Betamethasone complete. Worsening HELLP lead to induction. Vaginal delivery under epidural anesthesia. Apgars were 8 and 8. PHYSICAL EXAMINATION: On admission premature female with CPAP in place, intermittent apnea, anterior fontanel soft and flat. Non dysmorphic, intact palate. Eye ointment in. Red reflex not checked. Intermittent grunt, mild retractions, good aeration, clear breath sounds, no murmur. Normal pulses. Soft abdomen, three vessel cord, no hepatosplenomegaly. Normal female genitalia, patent anus. No hip click. No sacral dimple. Active, decreased tone. HOSPITAL COURSE: Respiratory: [Known lastname 56440] was initially placed on CPAP of 6 cm of water in room air for management of mild respiratory distress syndrome. She was weaned to nasal cannula on day of life four and weaned to room air within the same 24 hours. She is currently stable on room air with no further issues. She was empirically started on caffeine citrate on day of life four for management of mild apnea and bradycardia of maturity. She has had no documented episodes of spells in the last 48 hours. Cardiovascular. On admission required normal saline bolus times one for borderline blood pressures. Received Indomethacin times one course for empiric treatment for presumed patent ductus arteriosus. Echocardiogram performed on [5-1] had normal heart structure with no patent ductus arteriosus. Infant is currently cardiovascularly stable. Fluid/Electrolytes/Nutrition: Birth weight was 1390 grams. Discharge weight is 1345 grams. She was initially started on 80 cc's per kilo per day of D10-W. Enteral feedings were initiated on day of life three. She is currently on 150 cc's per kilo per day total fluids, 110 of which are breast milk 20 calories. She is advancing 15 mls per kilo q 12 hours. She was tolerating her feedings well. Her most recent set of electrolytes were on [2188-5-3], with a sodium of 137, potassium 4.5, chloride of 106, total CO2 18. Gastrointestinal: Peak bilirubin was on day of life two at 8.6/0.3. She was treated with phototherapy which was discontinued on [2188-5-4]. Rebound bili was 7.0/.3. Plan is to continue to follow clinically and recheck bilirubin as required. Hematology. Hematocrit on admission was 45. She has not required any blood transfusions. Infectious Disease: CBC and blood culture obtained on admission, CBC was benign. Antibiotics were initiated with Ampicillin and Gentamicin for a total of 48 hours at which time blood cultures remained negative and antibiotics were discontinued. Neurology: Due for head ultrasound on [2188-5-6]. Sensory: Audiology hearing screen has not been performed. Psychosocial: Involved family. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To Level II at [Hospital1 ]. NAME OF PRIMARY PEDIATRICIAN: Unidentified at this time. CARE AND RECOMMENDATIONS: Continue advancing feeds to maximum of 150 cc's per kilo per day of breast milk 20 and advance calories as needed. MEDICATIONS: Caffeine citrate 7 mg p.o. q day. Car seat position screening has not been performed. State newborn screens have been sent per protocol and have been within normal limits. Infant has not received any immunizations to date. DISCHARGE DIAGNOSIS: 1. Former preterm female born at 29 weeks, corrected to 30 weeks gestational age. 2. Status post mild respiratory distress syndrome. 3. Status post rule out sepsis. 4. Presumed patent ductus arteriosus, treated, resolved. 5. Mild apnea and bradycardia of prematurity on caffeine. 6. Hyperbilirubinemia, treated. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 54936] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2188-5-5] 15:37:37 T: [2188-5-5] 20:23:51 Job#: [Job Number ] ICD9 Codes: 769, 7742, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8487 }	Medical Text: Admission Date: [2129-10-16] Discharge Date: [2129-11-17] Date of Birth: [2069-5-18] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Cipro / Penicillins / Gluten / Ativan Attending:[First Name3 (LF) 30] Chief Complaint: Diarrhea, failure to thrive Major Surgical or Invasive Procedure: Pleuroscopy/Pleurodesis Bronchoscopy on [11-15] History of Present Illness: HPI: 60 F with h/o celiac disease, partial colectomy, presents for continued weight loss, albumin 1.1, anorexia, further eval of celiac disease by Dr. [Last Name (STitle) ] [Last Name (NamePattern4) 1356], GI [Hospital1 18]. Patient has had diarrhea and GI discomfort for the past 25 yrs per pt, and was diagnosed with celiac disease in [2124] during a colectomy at [Hospital1 2025]. . Over the past 2-3 months, the patient feels that she has progressively deteriorated. Over this time, the patient has had progressively more diarrhea, runny, brown, no blood, no mucus, but she has progressively not been able to control the diarrhea and has had increasing bouts of stool incontinence, for which she now requires a diaper at all times. She has never seen blood in her stool and has only seen black stool when taking iron. She has diffuse abdominal pain intermittently with eating too much, or with 3rd spacing in abdominal area. Her PO intake of food and fluid has not been decreasing dramatically, but she has been losing weight. Her legs, arms, buttock areas, backs of her legs, and abdomen have become more swollen with fluid. . Patient was on TPN at OSH through RIJ. RIJ line was inserted on [10-4] (dressing was changed on [10-16]). Patient briefly received prednisone, but this was for a rash from presumptive OsCal allergy. . Patient was admitted to [Hospital3 1443] Hospital on [10-2] with N/V/SOB/CP, was diagnosed with pna and UTI, placed on ceftriaxone, improved. Ruled out for MI by enzymes, EKG had TWI inferiorly. . Patient has been admitted for further assessment of her celiac disease by Dr. [First Name (STitle) 1356]. Concern at OSH has been for celiac disease vs. malignancy vs. anorexia (psych) vs amyloid. Had screening mammogram and abd CT as outpatient that were normal. Patient was seen by Dr. [Last Name (STitle) 8671] (GI consult at LMH) but has yet to have had endoscopy (upper or lower). LMH does not have push enteroscopy capabilities so as to obtain a SB sample as they were hoping for to r/o lymphoma. They were planning on colonoscopy (r/o malignancy) and rectal bx (r/o amyloid), when patient requested coming to a tertiary center to have extensive work-up. . ROS: +cough, +sore throat, +CP, +SOB, +weight loss, +pna, +urinary burning, +urinary incontinence, +abdominal pain, +LE swelling and pain. Past Medical History: PMH: HTN Cystocele Celiac disease - dxed [2124] Mitral regurgitation Left upper lobe lung nodule Hematuria Failure to thrive 20 lb weight loss since [3-1] after OSH admission, is s/p admission from [Date range (1) 101225] for uterine prolapse. Osteoporosis . PSH: Partial colectomy in [2124] at [Hospital1 2025] - dxed with celiac disease at this time Cholecystectomy in [7-1] at [Hospital3 1443] Hospital Social History: Patient was living alone, but daughter is now moving in with her in her single family house. She is disabled from day care work since her admission [Date range (1) 101225] with significant deconditioning and weight loss. No EtOH, smoked for 2 yrs in her 20s, no IVDU. She has a daughter and son, and a grandson she takes care of. Family History: No family history of celiac disease. Other than daughter and grandson, no history of autoimmune disease. Daughter - Crohn's disease Grandson - Type I diabetes mellitus Father - died 61 of renal failure, had stroke at 57 Maternal aunt - breast cancer Maternal aunt - ovarian cancer Physical Exam: Vs: 98.3 / 128/82 / 100 / 28 / 96% 2L nc Gen: Breathing fast, lying in bed, irritable, cachectic, looks tired HEENT: No JVD, RIJ line appears clean and nonerythematous, no LAD, oropharynx clear, moist mm, PERRL, anicteric sclerae, clear nasal turbinates Lungs: Dull to region 2 bilaterally, crackles and rhonchi that clear with coughing; pain on palpation of costochondral junctions Heart: Regular but tachy, no m/r/g, PMI non-displaced Abdomen: Shiny skin, 3rd spacing all over abdomen esp in dependent areas, tenderness diffusely to palpation Back: No CVA tenderness, no spinal tenderness Extr: No cyanosis or clubbing, but 3+ pitting edema in LE, proximal UE Skin: No rashes, but shiny stretched skin over abdomen, legs, arms, buttocks, backs of legs Neuro: [3-31] motor UE, [1-29] motor LE due to pain upon movement, sensation decreased in LE (per pt due to edema) Pertinent Results: [2129-10-9] from OSH: Na 140, K 4.3, Cl 115 (high), CO2 21 (high) Ca 6.6 (low), Phos 2.8, Mg 1.6 (low) . [Last Name (un) ] stim: 18 at 60 min . TG 112, Tot Prot 4.1, Phos 2.0, ALBUMIN 1.1 TB 0.1, AP 160, ALT 34, AST 39, . CXR [2129-10-9] from OSH: Continuing bilateral pleural effusions and/or infiltrates. WBC 9.2 . [2129-10-16] 05:50PM BLOOD WBC-6.7 RBC-2.84* Hgb-8.1* Hct-24.0* MCV-84 MCH-28.7 MCHC-34.0 RDW-17.6* Plt Ct-272 [2129-10-19] 06:36PM BLOOD WBC-11.1* RBC-3.86* Hgb-12.0 Hct-33.5* MCV-87 MCH-31.0 MCHC-35.8* RDW-17.3* Plt Ct-379 [2129-10-20] 04:31AM BLOOD WBC-9.1 RBC-3.44* Hgb-10.2* Hct-29.6* MCV-86 MCH-29.6 MCHC-34.5 RDW-16.5* Plt Ct-368 [2129-10-24] 04:30AM BLOOD WBC-11.2* RBC-3.23* Hgb-9.6* Hct-27.8* MCV-86 MCH-29.6 MCHC-34.4 RDW-15.9* Plt Ct-516* [2129-10-26] 03:35AM BLOOD WBC-10.5 RBC-3.13* Hgb-9.2* Hct-27.3* MCV-87 MCH-29.4 MCHC-33.9 RDW-15.7* Plt Ct-537* [2129-10-27] 04:46AM BLOOD WBC-14.6* RBC-3.24* Hgb-9.6* Hct-27.9* MCV-86 MCH-29.7 MCHC-34.5 RDW-15.5 Plt Ct-510* [2129-11-1] 06:06AM BLOOD WBC-12.0* RBC-3.41* Hgb-10.1* Hct-30.4* MCV-89 MCH-29.5 MCHC-33.1 RDW-15.4 Plt Ct-558* [2129-11-2] 06:15AM BLOOD WBC-10.2 RBC-3.22* Hgb-9.8* Hct-28.3* MCV-88 MCH-30.4 MCHC-34.6 RDW-16.4* Plt Ct-564* [2129-11-3] 04:09AM BLOOD WBC-33.7# RBC-3.33 Hgb-9.9* Hct-29.5* MCV-89 MCH-29.7 MCHC-33.5 RDW-15.1 Plt Ct-618* [2129-11-4] 03:55AM BLOOD WBC-25.0* RBC-3.22* Hgb-9.6* Hct-28.9* MCV-90 MCH-29.9 MCHC-33.3 RDW-16.6* Plt Ct-684* [2129-11-5] 04:54AM BLOOD WBC-13.5* RBC-3.21* Hgb-9.2* Hct-28.8* MCV-90 MCH-28.5 MCHC-31.7 RDW-15.2 Plt Ct-632* [2129-11-7] 04:13AM BLOOD WBC-12.2* RBC-3.94# Hgb-11.2# Hct-36.1# MCV-92 MCH-28.5 MCHC-31.1 RDW-15.2 Plt Ct-818* [2129-11-8] 05:20AM BLOOD WBC-15.4* RBC-3.11* Hgb-8.7* Hct-27.5* MCV-88 MCH-27.9 MCHC-31.6 RDW-15.5 Plt Ct-633* [2129-11-15] 05:00AM BLOOD WBC-14.9* RBC-3.59* Hgb-10.2* Hct-31.6* MCV-88 MCH-28.4 MCHC-32.3 RDW-15.7* Plt Ct-531* [2129-11-16] 11:27AM BLOOD WBC-14.2* RBC-3.52* Hgb-10.1* Hct-31.1* MCV-88 MCH-28.6 MCHC-32.4 RDW-15.9* Plt Ct-504* [2129-11-17] 04:45AM BLOOD WBC-10.6 RBC-3.31* Hgb-9.5* Hct-29.2* MCV-88 MCH-28.7 MCHC-32.5 RDW-16.0* Plt Ct-454* [2129-11-16] 11:27AM BLOOD Neuts-71.0* Lymphs-19.3 Monos-9.1 Eos-0.3 Baso-0.4 [2129-11-10] 04:58AM BLOOD PT-13.1 PTT-31.5 INR(PT)-1.2 [2129-11-4] 03:55AM BLOOD D-Dimer-2614* [2129-11-17] 04:45AM BLOOD Glucose-114* UreaN-17 Creat-0.3* Na-136 K-4.0 Cl-108 HCO3-23 AnGap-9 [2129-11-16] 05:22AM BLOOD Glucose-112* UreaN-18 Creat-0.3* Na-140 K-4.3 Cl-110* HCO3-21* AnGap-13 [2129-10-16] 05:50PM BLOOD Glucose-141* UreaN-6 Creat-0.5 Na-139 K-3.7 Cl-102 HCO3-31 AnGap-10 [2129-11-17] 04:45AM BLOOD Calcium-8.0* Phos-4.1 Mg-1.7 [2129-11-9] 11:27AM BLOOD Hapto-411* [2129-10-18] 06:34AM BLOOD VitB12-770 [2129-10-16] 05:50PM BLOOD calTIBC-105* Ferritn-550* TRF-81* [2129-11-15] 05:00AM BLOOD Triglyc-156* [2129-10-19] 05:04AM BLOOD Triglyc-76 [2129-10-16] 05:50PM BLOOD TSH-2.1 [2129-11-1] 06:06AM BLOOD IgG-1478 IgA-420* [2129-10-18] 06:34AM BLOOD PEP-ABNORMAL B IgG-991 IgA-371 IgM-77 IFE-BAND OF MO [2129-10-19] 06:36PM BLOOD HIV Ab-NEGATIVE [2129-11-9] 04:56PM BLOOD Type-ART pO2-74* pCO2-41 pH-7.47* calHCO3-31* Base XS-5 Comment-NASAL [Last Name (un) 154] [2129-11-7] 10:33PM BLOOD Type-ART O2 Flow-5 pO2-101 pCO2-45 pH-7.37 calHCO3-27 Base XS-0 Comment-NASAL [Last Name (un) 154] [2129-11-2] 07:17PM BLOOD Type-ART Rates-/30 FiO2-94 pO2-76* pCO2-38 pH-7.45 calHCO3-27 Base XS-2 AADO2-566 REQ O2-92 Intubat-NOT INTUBA [2129-11-3] 12:42AM BLOOD Type-ART pO2-103 pCO2-37 pH-7.44 calHCO3-26 Base XS-0 [2129-11-4] 01:18AM BLOOD Lactate-1.1 K-4.4 [2129-11-3] 12:42AM BLOOD Glucose-217* Lactate-1.8 Na-134* K-3.0* Cl-102 calHCO3-25. . CXR [10-16]: CHEST: A single portable semi-upright view at 4:00 p.m. shows bilateral pleural effusions with bibasilar atelectasis. There is vascular engorgement, indicating mild CHF. The evaluation of both lower lungs is limited due to pleural effusions and compressive atelectasis and concomitant pneumonia cannot be excluded. A right IJ central venous catheter is noted with the tip in SVC. . CT abd [10-17]: IMPRESSION: Bilateral pleural effusions, anasarca, and small amount of ascites. This patient will return for an IV contrast enhanced CT scan. . PICC placed [10-17] . Pleural fluid11/23: NEGATIVE FOR MALIGNANT CELLS. Histiocytes, mesothelial cells and small lymphocytes. CD 20 and CD 3 stains were performed on cytospins. Scattered T cells are noted. B-cell (CD 20) stain is negative. . EGD biopsy [10-26]: chronic active inflammation, no tumor . Colonoscopy [2129-10-26]: Strictures of the duodenum and jejunum Small hiatal hernia Abnormal mucosa in the duodenum and jejunum There was dilated jejunum with pooled bilious fluid suggestive of stasis. Erythema and congestion in the gastroesophageal junction Ulcers in the distal duodenum and visualized jejunum . Chest CT [2129-10-25]: 1. Mediastinal adenopathy, a nonspecific finding. 2. Left upper lobe nodule. Per given history, this was present and stable for fifteen years. Recommend direct comparison to prior studies to confirm stability. 3. Bilateral lower lobe atelectasis and mucoid impaction, occlusive on the right. 4. Bilateral pleural effusion, moderate left and small right, decreased in size from the prior study, consistent with interval thoracentesis. . CXR [11-13]:CHEST: PA and lateral views are compared to previous examination of [2129-11-9]. There are bilateral pleural effusions. The right pleural effusion has slightly decreased since the previous exam. The left hydropneumothorax is smaller on the current exam. Again seen is bibasilar atelectasis with probable pneumonia in the right lower lung. The left suprahilar pulmonary nodule remains stable. A right PICC line is seen with the tip in distal SVC. . Pleural biopsy [11-2]:Fragments of reactive mesothelium with acute and chronic inflammation, granulation tissue, and blood; no malignancy identified. . ucx [11-23]: no growth . bcx [11-7], [11-3], [10-26]:NGTD . stool cx [11-2]: c.diff + . CMV viral load negative . sputum cx [10-20]: sparse growth MRSA, pseudomonas Brief Hospital Course: Hospital Course: 60 F with h/o celiac disease, partial colectomy, presented for continued weight loss, albumin 1.1, anorexia, further eval of celiac disease. . Anorexia: Patient is a 60 F with an extremely complicated PMHx notable for celiac disease, partial colectomy, who initially presented on [2129-10-16] for continued weight loss, albumin 1.1,anorexia and diarrhea further eval of celiac disease by Dr. [First Name (STitle) 1356]. Given her [Known lastname ] standing history of celiac disease and non-compliance with gluten free diet, exacerbation of celiac disease was thought to be likely cause, though an underlying malignant process has not been completely ruled out. EGD on [10-26] showed strictures in duodenum and jejunum c/w celiac dx. No evidence of malignancy seen on biopsy. Patient was kept on a strict gluten free diet and diarrhea resolved. Appetite improved on megace and remeron and TPN was started because of weight loss and failure to thrive and was continued throught her admission. SPEP was done and found to have MGUS likely c/w autoantibodies from celiac disease. A severe Vitamin D deficiency was noted. At d/c will start Vit D [Numeric Identifier 1871] units qd x one one week, then qweek after that. Levels will need to be checked in one month. Will continue TPN as an outpatient. . SOB/PNA/Pleural effusions: Pt was found to have PNA at OSH prior to transfer with improvement on ceftriaxone. She was initially continued on Ceftriaxone for PNA and UTI found at OSH. At admission CXR showed bilateral pleural effusions and bibasilar atelectasis with mild CHF. She was diuresed with lasix during the beginning of her admission until she was euvolemic for volume overload and edema. Sputum cultures were obtained here that showed sparse growth of MRSA and pseudomonas. Chest CT was done on [10-25] for w/u of possible malignancy and showed right occlusive mucoid impaction. She was not immediately started on abx b/c she was thought to be colonized with the bacteria. However, she had some increasing SOB, chest pain and fevers so she was started on Vanc and Ceftaz on [10-26] with improvement in fevers. She completed a 14 day course of these medications. At that time her SOB was thought to be multifactorial secondary to pleural effusions, possible PNA, anxiety, CHF and possible pericardial effusion. Echo was done and showed only trivial pericardial effusion with EF >75%. In terms of her bilateral pleural effusions, her L sided effusion was tapped on [10-19], c/w transudate with 1500cc removed. Re-tapped on [10-31] and was c/w exudate with significant amount of bloody drainage. Because of the exudative effusion and some atypical cells (T cells) noted in prior pleural fluid she was sent for pleuroscopy and pleurodesis for her L sided effusion on [11-1]. Pleural space had inflammatory changes but pleural fluid was negative for malignancy. She had a chest tube placed at that time and this caused her a significant amount of pain. Patient was tachypneic to 40s-50s although satted well on 5L NC O2(could have tolerated less O2 but did not want to be weaned down). Pain controlled with morphine. Was briefly sent to the intensive care unit because of her tachypnea, but serial ABGs were stable and she was observed with no intervention.Chest tubes were removed and patient started to improve. During the entire course she was on MRSA precautions, scheduled atrovent nebs, PRN albuterol and chest PT. On [2129-11-15] she had a bronchoscopy to further evaluate for malignancy and retrieve tissue from an enlarged subcarinal LN seen on chest CT. One biopsy specimen was obtained but the procedure was terminated secondary to the patient desatting during the procedure. Had two episodes of desaturation during this admission, once on 5L NC thought to be secondary to mucous plugging, and once after walking with PT. Currently she is stable on 1.5 L NC O2 and O2 may likley be weaned down, but patient is anxious when attempt to wean O2 down. Will need to f/u on biopsy results from bronchoscopy. . LE edema: Patient had significant amount of lower extremity edema at admission with mild CHF on exam and bilateral pleural effusions. Much of this was thought to be d/t hypoalbuminemia since albumin was 1.1. She was aggressively diuresed early in her admission and nutritional status was increased with TPN and appetite stimulation and edema resolved. . C.diff colitis: Had diarrhea at admission which was thought to be secondary to noncompliance with gluten free diet. Her c.diff toxin assay was negative at that time and diarrhea improved on gluten free diet. On [11-3] WBC jumped to 33 and patient's stool was found to be positive for c. diff. She was treated with 2 weeks of flagyl and diarrhea improved and WBC trended down. . Lung nodule: Patient has had stable lung nodule in left upper lobe for past 15 years. This nodule was again seen on chest CT here, but no intervention was done and likely not malignancy since it has been stable for many years. . h/o Recurrent UTI: Patient had UTI at admission and was on ceftriaxone. She was continued on it initially at admission. She had a foley placed during her admission b/c of need for aggressive diuresis and urinary incontinence. Subsequent urine cultures were free of bacteria but were positive for yeast. She was treated with 5 days of diflucan. Foley was dc'd prior to discharge. . Chest pain: Patient had reproducible left sided chest pain during her admission with no new EKG changes. Was thought to be secondary to PNA, chostochondritis or possible pericardial effusion. Echo showed trivial pericardial effusion and pain improved after . Anemia: Patient has history of guiac positive stools and required several blood transfusions over the course of her admission. Likely was secondary to GI source as she was noted to have some ulceration in her duodenum during colonoscopy. Hct stable at d/c. . Anxiety: Patient very anxious throughout admission. Got confused on ativan. Did not want to try clonazepam. Tried zyprexa and stated it made her sleepy and did not want to take. . Outpatient follow-up: Will need to f/u with Dr. [First Name (STitle) ] in [Hospital 191] clinic in one month. Phone number is [Telephone/Fax (1) 250]. Prior to doing this, she will need to change her PCP at [Name9 (PRE) ] Health to Dr. [First Name (STitle) ]. Medications on Admission: Meds: Remeron 15 mg PO QHS (has not started yet) FeSO4 Welchol for diarrhea MVI Albuterol nebs prn Oxycodone prn for LE edema pain Discharge Medications: 1. Acetaminophen 160 mg/5 mL Solution Sig: One (1) tablet PO Q6H (every 6 hours). 2. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed). 3. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical PRN (as needed). 4. Megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day): until patient ambulating. 6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb neb Inhalation Q6H (every 6 hours). 10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for throat pain. 12. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 13. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 14. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a day for 7 days: 1st week. 15. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week for 3 weeks: for 3 weeks after loading for 1 week. 16. Vitamin D 400 unit Capsule Sig: Two (2) Capsule PO once a day: after 1 month of loading. 17. TPN at night, see attached for current formulation Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Recurrent pleural effusions. Pneumonia. Mediastinal lymphadenopathy. C. Difficile infection. Malnutrition. MGUS Celiac Sprue Anemia Discharge Condition: Fair Discharge Instructions: Continue all discharge meds at [Hospital1 ] as well as TPN. Follow up as below. If, after going home from [Hospital1 ], you experience fevers, chills, SOB, other concerning symptoms, you should call your PCP or go to the ER. Followup Instructions: F/u with 1. Dr. [First Name8 (NamePattern2) 6665] [Name (STitle) 1356], in gastroenterology at [Telephone/Fax (1) 7091]. 2. You have to call Masshealth to change your primary care site to [Hospital1 ] before we can make you an appointment. After doing that, you should make an appointment with Dr. [First Name8 (NamePattern2) ] [Name (STitle) ]. YOu can do that by calling ([Telephone/Fax (1) 1300]. ICD9 Codes: 4280, 5119, 2761, 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8488 }	Medical Text: Admission Date: [2171-8-6] Discharge Date: [2171-8-8] Date of Birth: [2106-10-9] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2901] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Left heart catheterization History of Present Illness: 64M with history of HTN and strong FH of CAD presenting with chest tightness that began around midnight while he was watching TV. Pt says he had no other symptoms and did not feel nauseous. He says he has never had these symptoms before. . In the ED, initial vitals were 97 82 159/97 16 100%. Initial EKG with anterior STE in V1-V2, I and aVL with recipricol STD in II, III, aVF, V4-6. Code STEMI initiated. Given 325mg ASA, 600mg plavix, 4000U heparin, and 3 SL NTG, metoprolol tartrate 5mg in ED and taken emergently to cath lab. In the cath lab patient was given bivalirudin 250mg, midazolam 2mg, fentanyl citrate 100 mcg, diltiazam 50mg . On arrival to the floor, patient is in no acute distress. Past Medical History: 1. CARDIAC RISK FACTORS: Hypertension on nifedical XL 30mg [Hospital1 ] 2. OTHER PAST MEDICAL HISTORY: borderline DM, not on any medications Social History: Tobacco history: none -ETOH: occasional -Illicit drugs: none Born in [Country 16225]. Works as a manager of a restaurant Family History: CAD: sister with [Name2 (NI) 28750] at age 38 then passed away at 38, 2 brothers with CAD and s/p [Name2 (NI) 28750] Physical Exam: Admission exam: VS: T 97.3 HR 76 BP 151/83 RR20 100%RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 7 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 1+ diastolic murmer at apex No r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. TR band on right wrist SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Discharge exam: VS: 98 97.5 124/83 (120s/70s-90s) 64 (60s) 18 100% RA No I/O recorded 63 --> 64.1 kg GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 7 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 1+ diastolic murmer at apex No r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. TR band on right wrist SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: DP 2+ bl Pertinent Results: [2171-8-8] 07:40AM BLOOD WBC-9.5 RBC-4.98 Hgb-11.1* Hct-37.2* MCV-75* MCH-22.2* MCHC-29.7* RDW-19.9* Plt Ct-278 [2171-8-6] 02:00AM BLOOD WBC-8.7 RBC-5.09 Hgb-11.5* Hct-38.0* MCV-75* MCH-22.6* MCHC-30.3* RDW-19.5* Plt Ct-287 [2171-8-6] 02:00AM BLOOD Plt Ct-287 [2171-8-6] 05:01AM BLOOD PT-44.1* PTT-146.2* INR(PT)-4.3* [2171-8-6] 05:01AM BLOOD Plt Ct-318 [2171-8-6] 12:18PM BLOOD PT-11.7 PTT-33.0 INR(PT)-1.1 [2171-8-6] 02:00AM BLOOD Glucose-143* UreaN-24* Creat-1.2 Na-143 K-3.4 Cl-107 HCO3-28 AnGap-11 [2171-8-8] 07:40AM BLOOD Glucose-95 UreaN-17 Creat-1.1 Na-143 K-4.2 Cl-108 HCO3-27 AnGap-12 [2171-8-6] 05:01AM BLOOD ALT-30 AST-171* CK(CPK)-2253* AlkPhos-58 TotBili-0.4 [2171-8-6] 02:00AM BLOOD CK(CPK)-221 [2171-8-7] 05:19AM BLOOD CK-MB-53* MB Indx-3.9 [2171-8-6] 02:00AM BLOOD CK-MB-3 cTropnT-<0.01 [2171-8-6] 05:01AM BLOOD CK-MB-213* MB Indx-9.5* cTropnT-4.45* [2171-8-6] 05:01AM BLOOD Triglyc-130 HDL-52 CHOL/HD-3.6 LDLcalc-109 [2171-8-6] 05:01AM BLOOD %HbA1c-6.0* eAG-126* [2171-8-6] 05:01AM BLOOD Albumin-4.3 Calcium-8.0* Phos-1.7* Mg-2.3 Cholest-187 [2171-8-8] 07:40AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.2 Brief Hospital Course: 64 year old man with a history of hypertension and strong family history of coronary artery disease here with an ST segment elevation myocardial infarction in anterior leads s/p cath lab found to have occlusion of LAD s/p DES in proximal LAD. . # CORONARIES: The patient was taken to the cath lab after being seen in the emergency department and diagnosed with an anterior STEMI. His first troponin was negative but a second returned at 4.45. He was admitted to the CCU from the cath lab, where he received left heart catheterization. LHC showed a 90% occlusion in proximal LAD for which a drug-eluting stent was placed and an occlusion of the mid LAD. The patient's RCA was normal with right to left collaterals. On arrival to the CCU, he was hemodynamically stable. His home nifedipine was stopped and he was started on Atorvastatin 80, Metoprolol 12.5 [Hospital1 ], Lisinopril 5, Plavix 75, ASA 325. His CK-MB was followed. His CK-MB peaked at 219 on [8-6] and had come down to 53 on [8-7]. Of note, his HbA1c was 6.0. He remained stable without any clinically significant arrhythmic activity and was transferred to the floor, where he continued to do well. He was seen by physical therapy and deemed safe to go home without services on [2171-8-8]. . # PUMP: The patient's left ventricular ejection fraction was found to be 40-45% on cardiac catheterization. . # Coagulation: INR on [8-6] was 1.0 with a second value later in the morning of 4.43. Vitamin K was given and the patient's INR returned to 1.1. No obvious cause was found. His ALT was 30 and his AST 173 in the setting of an albumin of 4.3, a normal alkaline phosphatase, and a normal total bilirubin. Transitional issues: # Coronaries: patient will need to be continued on Plavix/Aspirin for a minimum of 6 months to one year now that he has had a drug-eluting stent placed. He should receive regular follow-up with his primary care physician with referral to a cardiologist as required. His medications will need to be monitored as well now that he has been started on a full post-MI regimen. Medications on Admission: nifedical XL 30mg [Hospital1 ] Discharge Medications: 1. Aspirin EC 325 mg PO DAILY RX aspirin 325 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 2. Atorvastatin 80 mg PO DAILY RX atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 3. Clopidogrel 75 mg PO DAILY RX clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 4. Metoprolol Succinate XL 50 mg PO DAILY hold for SBP < 90, HR < 50 RX metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 5. Nitroglycerin SL 0.3 mg SL PRN chest pain RX Nitrostat 0.3 mg 1 tab sublingually as needed for chest pain Disp #30 Tablet Refills:3 6. Lisinopril 10 mg PO DAILY please hold for SBP<100 RX lisinopril 10 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 Discharge Disposition: Home Discharge Diagnosis: primary diagnosis: heart attack Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], It was a pleasure taking care of you while you were hospitalized at the [Hospital1 ] Hospital. As you know, you were admitted because of chest pain found to be caused by blockage of the blood vessels that supply your heart. A catheter was advanced into your blood vessels that showed a 90 % blockage of an artery called the proximal left anterior descending artery. A stent that has drugs in it was placed to help keep this narrowing open. There was a total blockage of that artery further along its course. It was noted that your heart pumped forcefully enough to not require drugs to augment its output. You were started on several new medications that are extremely important to take after you have had a heart attack. Please see the attached medication sheet. Do not miss [First Name (Titles) 691] [Last Name (Titles) 4319]. Followup Instructions: Please call the [Hospital1 ] 'find a doctor' line at [Telephone/Fax (1) 5867] on the day of your discharge. Please ask the receptionist to find you an appointment with a primary care physician within one week. You need to be seen by a physician shortly after discharge because of your heart attack. If you change your mind and would like to keep your current primary care physician, [Name10 (NameIs) ] call his office at the number below and tell him that you have been hospitalized for a heart attack and require a follow-up visit within one week. Name: [Last Name (LF) ],[First Name3 (LF) ] H. Location: AMERICAN [Hospital ] MEDICAL CENTER, PC Address: [State ] [Apartment Address(1) 6850], [Location (un) ],[Numeric Identifier 588] Phone: [Telephone/Fax (1) 30384] [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8489 }	Medical Text: Admission Date: [2179-2-11] Discharge Date: [2179-2-21] Date of Birth: [2115-5-24] Sex: F Service: SURGERY Allergies: Penicillins / Meperidine / Codeine / Percocet Attending:[First Name3 (LF) 148] Chief Complaint: melena, hypotension Major Surgical or Invasive Procedure: paracentesis [2179-2-11] central line placement [2179-2-11] ERCP, stent removal [2179-2-12] endotracheal intubation [2179-2-12] exploratory laparotomy, Roux-en-Y hepaticojejunostomy, duodenostomy, G and J tube placement, cholecystectomy [2179-2-13] History of Present Illness: 63yo F with prior diagnosis of pancreatic cancer that was unresectable and is s/p chemo/XRT. A CBD stent had been placed in [5-7] to relieve biliary obstruction. Pt was recently receiving chemotherapy whose treatment was halted due to progressive fatigue/weakness. 2d prior to [Hospital1 18] admission she presented to [Hospital3 ] hospital for hematemesis where an EGD demonstrated the CBD stent had slipped distally into the duodenum and was causing erosion against the duodenal wall. She was transfused 2u PRBC, hemodynamically stable, and transferred for [Hospital1 18] for further management and resumption of her prior care that was performed here. Past Medical History: pancreatic carcinoma, locally advanced, s/p chemo and XRT renal cell carcinoma ulcerative colitis hypercholesterolemia depression diverticulosis Social History: no Tob or EtOH lives on [Hospital3 635], married, many close children Family History: Mother died of cholangiocarcinoma at 80yo Maternal aunt died of pancreatic carcinoma at 60's yo Maternal grandfather died of pancreatic carcinoma Physical Exam: on presentation to the [Hospital Unit Name 153]: 100.5, HR 148, BP 130/67, R 23, sat 98% on 4L NC lethargic but oriented x3 and responsive dry mucous membranes supple tachy, regular, no M/R/G CTAB soft, NT, slightly distended. fluid wave no c/c/e, 2+ pulses, WWP moves all extremities x4, CN 2-12 intact Pertinent Results: [2179-2-11] 08:30PM BLOOD WBC-2.6* RBC-4.03* Hgb-12.6 Hct-37.5 MCV-93 MCH-31.3 MCHC-33.6 RDW-18.0* Plt Ct-263 [2179-2-12] 04:17AM BLOOD WBC-23.6# RBC-3.71 Hgb-11.5* Hct-33.3* MCV-90 MCH-30.9 MCHC-34.4 RDW-18.1* Plt Ct-134* [2179-2-12] 04:17AM BLOOD Neuts-91* Bands-2 Lymphs-2* Monos-3 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 [2179-2-12] 03:08PM BLOOD WBC-46.3# RBC-4.41 Hgb-13.4 Hct-39.7 MCV-90 MCH-30.5 MCHC-33.8 RDW-17.3 Plt Ct-166 [2179-2-11] 08:30PM BLOOD Plt Ct-263 [2179-2-11] 08:30PM BLOOD PT-14.7* PTT-25.5 INR(PT)-1.3* [2179-2-11] 08:30PM BLOOD Glucose-58* UreaN-20 Creat-0.7 Na-138 K-4.5 Cl-108 HCO3-18* AnGap-17 [2179-2-12] 04:17AM BLOOD Glucose-82 UreaN-19 Creat-0.7 Na-140 K-3.2* Cl-111* HCO3-16* AnGap-16 [2179-2-11] 08:30PM BLOOD ALT-23 AST-50* LD(LDH)-212 AlkPhos-387* Amylase-15 TotBili-1.1 [2179-2-11] 08:30PM BLOOD Albumin-2.6* Calcium-9.0 Phos-2.8 Mg-1.6 [2179-2-20] 12:36PM BLOOD Hapto-<20* TRF-<10* [2179-2-11] 09:07PM BLOOD Type-ART Temp-38.9 pO2-187* pCO2-24* pH-7.48* calHCO3-18* Base XS--2 Intubat-NOT INTUBA Comment-INTERPRET [2179-2-11] 09:07PM BLOOD Lactate-3.5* [2179-2-21] 01:22AM BLOOD Lactate-6.3* [2179-2-11] 11:35PM ASCITES WBC-89* RBC-124* Polys-4* Lymphs-13* Monos-23* Mesothe-3* Macroph-32* Other-25* [2179-2-11] 11:35PM ASCITES TotPro-0.3 Glucose-83 LD(LDH)-39 Albumin-<1.0 Blood CX [2-11]: EColi, pan-sensitive. Klebsiella, pan-sensitive. Blood Cx [2-11]: EColi, same sensitivities. Strep Milleri, [Last Name (un) 36] to PCN, Vanco. Brief Hospital Course: Pt was initially admitted to the floor but subsequently had an episode of large melena associated with hypotension and non-responsiveness. 2L IVF were bolused and she was transferred to the [Hospital Unit Name 153]. CVL lines placed and paracentesis performed for ascites, transfused 2u PRBC, and begun empiric antibiotics. GI consulted and ERCP performed the following morning, finding the CBD stent in the duodenal lumen which was removed. That afternoon, respiratory distress ensued with hypoxia, and the patient was intubated in the ERCP-PACU. The abdomen was distended and tympanitic, a KUB was concerning for localized air but no free air. Surgical consult from Dr. [Last Name (STitle) ] and the Gold (hepatobiliary) service was obtained and, after extensive discussion with the family, decision was reached for exploratory laparotomy for duodenal perforatoin from wall stent erosion, which was performed on [3-22] with a biliary bypass, repair of duodenal perforation. She continued to require aggressive IVF resuscitation in SICU on the [Hospital Ward Name 517] but overall was hemodynamically improved on moderate dose levophed. The evening of POD 1 ([2-14]) was notable for an acute desaturation into the 30's associated with hypotension into the 50's. Max'd pressors with large-scale IVF resuscitation. ABG showed worsening acidosis. SVT into 200's ensued which converted into sinus tachycardia in 120's. A swan-ganz catheter was utilized to guide management. Clinical picture highly suspicious and consistent with massive pulmonary embolus, but was too unstable for radiographic confirmation. Heparin drip was begun empirically. No further events ensued that evening as pressors remained at high levels, broad-spectrum antibiotics were continued, and net positive IVF resuscitation was required. cc per cc replacement of high JP (ascites) output commenced. Over the next few days, ventilatory pressures were high and vent changed to pressure-control ventilation. Thrombocytopenia ensued, a HIT was negative and heparin maintained throughout. Hematocrits were stable. An echocardiogram on [2-15] demonstrated no pericardial effusion. With results from admission cultures, antibiotics were adjusted. Trophic tube feeds begun. With rising bilirubin, ultrasound revealed complete thrombosis of the portal vein. A family meeting was held on POD 5 and she was made DNR. With worsening thrombocytopenia to 7, a hematology consult was obtained, and she was transfused platelets. On the morning on POD 9, she became hypotensive with falling hematocrit and worsening pressor and IVF requirement. Some mucosal bleeding was noted. After a lengthy discussion with the family, decision was reached to move to CMO care. Morphine gtt was titrated, pressors withdrawn, and eventually she was extubated and passed away in the presence of her family. Medications on Admission: ritalin [5-12] [Hospital1 ] prn avastin, last dose 2/6 procrit qMon zofran prn prevacid 20qday compazine 10 prn wellbutrin 200mg [Hospital1 ] xanax prn Discharge Disposition: Expired Discharge Diagnosis: advanced pancreatic carcinoma duodenal perforation d/t displaced CBD stent pulmonary embolus portal vein thrombosis Discharge Condition: expired ICD9 Codes: 0389, 5789, 2762, 311, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8490 }	Medical Text: Admission Date: [2150-3-24] Discharge Date: [2150-3-27] Date of Birth: [2092-8-31] Sex: F Service: MEDICINE Allergies: Diphenhydramine Attending:[Last Name (NamePattern4) 290] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: thoracentesis History of Present Illness: Pt is a 57 year old female with relapsed stage II C, grade II papillary serous ovarian cancer on Phase I trial (SNS 032) presenting with hypoxia, worsening [Last Name (NamePattern4) ]. . Pt has known history of lung parenchymal disease from her ovarian cancer as well as bilateral pleural effusions. She was started on phbase 1 trial of Sunesis on [3-23]. Has developed progressive SOB, [Month/Year (2) ], hypoxia with low grade fever (in the ED) over this time. Wears oxygen at baseline and has been having increasing requirement from 2L up to 5L oxygen. At baseline, patient is able to walk around her house, but unable to walk short distances without becoming SOB. She denies fevers at home, sick contacts, productive [Name2 (NI) ], hemoptysis, chest pressure, pleuritic chest pain, or lightheadedness on standing. Patient was intiially found in the ED to have O2sats to 85% on RA, up to 94% on NRB, with HR 100-130s. CTA negative for PE. Patient was found to have increased bilateral pleural effusions from prior. Patient admitted to ICU for hypoxia. . ROS: Recently has noted some N/V. Also mild constipation. Also complaining of significant fatigue. Patient denies significant abdominal pain, headache, chills, weight loss, bruising or bleeding. . Onc History: Dx'd [8-/2140] with Stage IIC ovarian cancer. Pathology showed serous papillary adenocarcinoma. She underwent TAH, Rt SPO and cytoreduction which did not remove all lesions. She was then treated with six cycles of carboplatin and Taxol until [2140-12-16]. She relapsed in [2146-1-9] in the form of a mass in the left hemipelvis. She underwent a second cytoreductive surgery on [2146-1-18] followed by four cycles of carboplatin and Taxol until [2146-4-9], which was discontinued because of disease progression. She was then treated with topotecan 1.25 mg/m2 x5 days IV every three weeks for four cycles from [Month (only) 547] [2146] until [2146-7-10] that was discontinued because of a rise in her CA-125. She was treated with Doxil 40 mg per meter squared for two cycles on [2146-8-30] and [2146-9-30], which was discontinued because of disease progression based on a CA-125 that was rising. She also developed a rash, mucositis, and hand-foot syndrome. She has been on weekly Taxol and Arimidex from [2146-11-9] to [2148-12-10] and this was discontinued because of disease progression. She received three cycles of gemcitabine but had significant disease progression. She was then on Navelbine in [Month (only) 958] but discontinued this in [2149-7-10] due to disease progression. She was treated with Xeloda but progressed on this therapy. She was started on oral etoposide in [2149-11-9] but discontinued it in [12-15] [3-13] GI side effects and fatigue. . Currently on started phase 1 trial on [3-23] with Sunesis. Past Medical History: - IBS - Anxiety - metastatic ovarian ca as above. Social History: She has been married for over 30 years. She has 2 kids and 1 grandchild. No alcohol or tobacco use. She lives at home with her husband. Family History: Mother and sister with breast cancer Physical Exam: T 100.4 BP 120/88 HR 120s RR 93% O2sat on NRB. RR 33. Gen: Awake, increased WOB. Coughing throughout interview. HEENT: PERRL, EOMI, clear OP, anicteric, mucous membranes dry. Neck: No LAD, JVD. +Supraclavicular lymph node 1 cm rubbery. Lymph: Right supraclavicular LN. Left axillary LN. No cervical or inguinal LAD. Lungs: Decreased BS throught left lung. Dullness to percussion over left lung, and base of right lung. No wheezing, rales, or rhonchi. Heart: Tachycardic. Abd: Soft, NT, ND +BS. Purplish subcutaneous 3 cm nodule to left of umbilicus, representing metastatic disease. Ext: No edema, 2+ DP/PT. Neuro: A&O times 3, no focal deficits Pertinent Results: . Labs/studies: 138 100 16 / 107 AGap=13 ------------ 3.8 29 0.6 \ Ca: 7.9 Mg: 2.0 P: 3.9 ALT: 28 AP: Tbili: 0.3 AST: 26 UricA:2.6 85 6.8 D \ 14.5 / 440 -------- 43.0 N:74.3 Band:7.9 L:6.9 M:8.9 E:0 Bas:0 Atyps: 2.0 . CXR- As best can be compared across modalities, there is a markedly stable radiograph with bilateral pleural effusions, left much greater than right. The left effusion has loculated components with a large intrafissural subcomponent as well. . CTA Chest: 1. No pulmonary embolism. No aortic dissection. 2. Interval worsening of large left loculated pleural effusion and small right pleural effusion. 3. Similar appearance of right lower lobe total consolidation due to aspiration. 4. Interval slight worsening of thoracic metastatic disease. Brief Hospital Course: This is a 57 yo female with relapsing ovarian cancer with metastatic disease to the lymph nodes, lungs, pleural effusions presents with worsening dyspnea. . 1. [Name (NI) 1621] Pt. with known bilateral pleural effusions secondary to malignant effusions from ovarian cancer. She just started a phase 1 chemotherapy trial with SNS03 on [3-23] and presented to [Hospital1 ] with SOB. There was no evidence of PE on CTA but the CT did show worsening of the loculated bilateral pleural effusions, which was the most likely etiology of her dyspnea. She also had low grade fevers and was immunosupressed from chemotherapy. Therefore, she was started on levofloxacin for possible underlying pneumonia. The patient was oxygen dependent was being treated with standing nebulizer treatments. Additionally, we performed a therapeutic thoracentesis under ultrasound guidance. Overtime the shortness of breath did not improve, despite these measures. The patient continued to deteriorate. A family meeting was called to discuss further options for intervention and goals of care. After extensive conversation with the attending and the family and patient, the following was decided upon: no further chemotherapy, no further interventions. The patients code status was made DNR/DNI and the focus of her care became comfort measures. The patient expired on [2150-3-27] at 3:20pm with her family at her bedside. 2. Ovarian Cancer- Unfortunately the patient had relapsed disease and failed multiple chemo regimens. On presentation to [Hospital1 ] she was on a phase 1 trial drug, sunesis. The decision was made to stop chemotherapy. Medications on Admission: - Paxil 20 mg daily - Centrum Silver multivitamin 1 tablet daily (start unknown) - Warfarin 1mg daily - Lorazepam 1 mg prn - Ambien 10mg qpm - Albuterol Nebulizer PRN (approx 3 times a week) - Chemotherapy regimen Sunesis Cycle 1/Day 2 - Prednisone (recently completed course - ?for breathing) Discharge Medications: deceased Discharge Disposition: Expired Discharge Diagnosis: ovarian cancer Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2150-3-27] ICD9 Codes: 486
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8491 }	Medical Text: Admission Date: [2141-5-19] Discharge Date: [2141-5-25] Date of Birth: [2083-10-25] Sex: M Service: [Doctor Last Name 1181] CHIEF COMPLAINT: The patient was referred from outside hospital for further management of hypoglycemia, acute on chronic renal failure, and fever of unknown origin. HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old man who presents to the [Hospital ] Hospital on [2141-5-18] after being found unresponsive by his wife. By report, the patient awoke feeling poorly and had one episode of emesis on the date of admission. His temperature at that time was 102 degrees (of note the patient has had a long history of fever of unknown origin with an extensive workup including fluoroscopic lung [Year (4 digits) ]). The patient was found by his wife unresponsive after she left the house to run errands and returned approximately 90 minutes later, he was diaphoretic as well. When the EMS arrived in his home, he had one further episode of emesis, was cyanotic, and had good pulses. His fingerstick blood glucose was 17. He received one ampule of dextrose 50. The patient was intubated upon arrival to [Hospital ] Hospital, and was still unresponsive despite fingerstick blood glucose of 170. Computed tomography of the head was unrevealing at that time. He was admitted to the Intensive Care Unit and was extubated. He was restless, complained of abdominal pain (but had a benign examination), and had a desaturation of a pulse oxygen to 88% on 100% nonrebreather face mask, and he was reintubated. The patient received stress dose of steroids as he is on chronic prednisone for his transplant. His BNP was found to be markedly elevated, and he was given a dose of intravenous furosemide. He was started on Unasyn for aspiration pneumonia and had blood and urine cultures attained as well. He was started on Heparin intravenously for a deep venous thrombosis of his leg as his INR was found to be subtherapeutic. PAST MEDICAL HISTORY: 1. Type 1 diabetes complicated by triopathy. 2. End-stage renal disease status post transplant from a living related donor in [2130] complicated by rejection and transient dialysis for two months. He is now currently off dialysis. His baseline creatinine is approximately 5.0. 3. Coronary artery disease status post myocardial infarction. He has a stent in the left anterior descending artery placed in [2139-10-10]. 4. Congestive heart failure with a diastolic dysfunction and an ejection fraction of 45%. 5. History of empyema status post VATS. 6. Recurrent pneumonias. 7. History of Clostridium difficile colitis. 8. Multiple myeloma. 9. Blindness OD. 10. History of FEO with extensive workup. 11. Obstructive-sleep apnea, wears CPAP at night. 12. History of deep venous thrombosis of the left thigh currently on warfarin. 13. History of Barrett's esophagus. 14. History of bacteremia and septic emboli with Staphylococcus aureus. ALLERGIES: Dicloxacillin causes nausea and vomiting. Compazine causes hallucinations. MEDICATIONS ON TRANSFER: 1. Unasyn 1.5 grams every 24 hours. 2. Protonix 40 mg IV every 24 hours. 3. Erythropoietin 20,000 units twice weekly. 4. Niferex 150 mg [Hospital1 ]. 5. Aspirin 325 mg daily. 6. Heparin intravenously. 7. Versed and Fentanyl sedation. 8. Decadron 2 mg IV every eight hours. 9. Metoprolol 25 mg every six hours. 10. Insulin glargine and regular insulin-sliding scale. EXAMINATION: Temperature 96.0, heart rate 72, blood pressure 136/50, respiratory rate 16, and oxygen saturation of 96%. Fingerstick glucose 233. Generally, opening eyes following commands with encouragement. Neck: No jugular venous distention. Heart: Normal S1, S2, 1/6 systolic murmur, no S3, S4. Lungs are clear to auscultation bilaterally. Abdomen: Normal bowel sounds, soft, nontender, nondistended, slightly obese. Extremities: No rash, no clubbing, cyanosis, or edema, +2 dorsalis pedis pulses. Neurologic: Essentially unresponsive, he opens his eyes briefly and moves all extremities on command. LABORATORY VALUES ON PRESENTATION: White blood cell count 7.1, hematocrit 29, platelets 149. Chemistry panel is significant for increase in BUN to 113 and creatinine to 6.5. INR was 1.5. LABORATORY EVALUATION AT THE OUTSIDE HOSPITAL: He had a computed tomograph of the head which was not revealing in terms of acute hemorrhage and a chest x-ray on [5-18] showing fluffy alveolar and interstitial markings consistent with congestive heart failure. He had an abdominal computer tomograph on [5-18] as well, which showed multiple nonspecific pretracheal and mediastinal lymph nodes, extensive consolidation throughout both lung fields. Nodular lesions were also seen in the right upper lobe, cardiomegaly, large dilated gallbladder, and a density in the right transplanted kidney, hematoma versus cyst was on the differential. HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit. We were following 1.5 days. The patient self extubated (i.e., the patient pulled the orotracheal tube himself. He complained of some throat pain on several days following extubation. His palate elevated symmetrically. Computed tomography of the neck did not reveal a hematoma or airway narrowing). He underwent minor changes to his insulin scale specifically increasing his glargine dose in the evenings as his fingerstick blood glucose in the hospital ran as high as 300. There was no evidence of ketoacidosis. Pneumonia was treated initially with levofloxacin and metronidazole. However, a sputum culture revealed methicillin-resistant Staphylococcus aureus. Levofloxacin was discontinued, Vancomycin intravenously was administered (dose was 750 mg intravenously every 48 hours). The patient's oxygen requirement decreased such that he was able to breathe and maintain oxygen saturation on room air. He was evaluated by the Physical Therapy service and deemed safe to go home. Patient's renal function stabilized with a creatinine ranging between 5.2 and 5.6. Placement of the peritoneal dialysis catheter was deferred until later date, given that the patient was not oliguric at this point. A midline catheter was placed in his arm for completion of his Vancomycin course. DISCHARGE DIAGNOSES: 1. Aspiration pneumonia. 2. Type 1 diabetes mellitus complicated by hypoglycemic coma. Type 1 diabetes complicated by triopathy. 3. End-stage renal disease status post transplant from a living related donor in [2130] complicated by rejection and transient dialysis for two months. He is now currently off dialysis. His baseline creatinine is approximately 5.0. 4. Coronary artery disease status post myocardial infarction. He has a stent in the left anterior descending artery placed in [2139-10-10]. 5. Congestive heart failure with a diastolic dysfunction and an ejection fraction of 45%. 6. History of empyema status post VATS. 7. Recurrent pneumonias. 8. History of Clostridium difficile colitis. 9. Multiple myeloma. 10. Blindness OD. 11. History of FEO with extensive workup. 12. Obstructive-sleep apnea, wears CPAP at night. 13. History of deep venous thrombosis of the left thigh currently on warfarin. 14. History of Barrett's esophagus. 15. History of bacteremia and septic emboli with Staphylococcus aureus. DISCHARGE MEDICATIONS: 1. Metronidazole 500 mg po tid x10 days. 2. Levofloxacin 250 mg po q4-8h x10 days starting on [2141-5-25]. 3. Vancomycin 750 mg IV q4-8 for seven days starting on [2141-5-25]. 4. Niferex 150 mg po bid. 5. Warfarin 2.5 mg po q day. 6. Calcium carbonate 500 mg po tid. 7. Furosemide 40 mg po q am and 60 mg po q pm. 8. Prednisone 5 mg daily. 9. Atenolol 175 mg daily. 10. Midodrine 5 mg po tid. 11. Pravastatin 40 mg po q day. 12. Sodium bicarbonate 1.3 grams po tid. 13. Nitroglycerin 0.3 mg po q5 minutes if needed. 14. Multivitamin one capsule po daily. 15. Isosorbide mononitrate sustained release 30 mg po q24h. 16. Gabapentin 300 mg po tid. 17. Amlodipine 5 mg po q24h. 18. Aspirin 325 mg po daily. 19. Pantoprazole 40 mg po q24h. 20. Erythropoietin 20,000 units q Monday and Thursday. DISPOSITION: The patient was discharged home to complete a seven day course of Vancomycin, specifically received doses on [5-27] and [2141-5-29]. He should have his INR checked weekly as well as his BUN and creatinine. Heparin flushes should be administered in his midline. [Name6 (MD) 251] [Last Name (NamePattern4) 11865], M.D. [MD Number(1) 11866] Dictated By:[Name8 (MD) 7102] MEDQUIST36 D: [2141-5-25] 17:05 T: [2141-5-26] 07:19 JOB#: [Job Number 20631] ICD9 Codes: 5070, 5849, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8492 }	Medical Text: Admission Date: [2163-11-3] Discharge Date: [2163-11-22] Date of Birth: [2091-4-25] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 618] Chief Complaint: ICH (transferred from OSH) Right sided weakness Major Surgical or Invasive Procedure: intubation (extubated [11-7]) History of Present Illness: 72 yo left handed woman with parkinsonism and labile BP who was in her USOH at a book club meeting on the night of admission, when she went to the BR and felt her right side "gave way" and slid down the wall. Per the husband, she did not lose conciousness. She yelled for help and she was taken to [Hospital1 9191]. There, her vitals were (at 2040): 217/121, 74, 16, 98% RA. She was A&Ox3, noted to have headache and dizziness, with right face droop, right arm weakness and slurred speech. Left pupil 2->1, right pupil 3- >1. FS 105. NCHCT was done and she was found to have an intracerebral hemorrhage - 7 slices approx 2x4 cm with lateral ventricle extension. She was given 1 gram of dilantin and lifeflighted here. En route she was given 20mg IV labetolol. Upon arrival, vitals were 98.1, 66, 117/108, 18, 98%RA. She was found to be "verbalizing but not following commands" and was felt she could not protect her airway, thus she was intubated (lido, vec, etom, succ, and versed as needed for sedation). Her BP fell to 97/52, then later rose to 197/92 (very labile). Repeat head CT here shows worse bleed, left sided, on 8 slices, 2x6 cm with extension to the lateral and 3rd ventricles and mass effect on the lateral ventricle without overt shift left to right. Neurosurgery was consulted who did not recommend any intervention at this time. I called the family who confirmed full code status. No preceeding illnesses, very active. Fevers, chills, headaches, weakness, numbness. Naps frequently, not unusual. Past Medical History: Parkinsonism - Followed at [Hospital1 2025] Labile BP - no meds, "white coat syndrome" Social History: She lives with her husband, has 2 kids, no tob, etoh, drugs. Clinical social worker, retired. From Southshore. FULL CODE. Family History: There are no hemorrhages, aneurysms, and no cancers in the family. Physical Exam: PE: Vitals: 98.1, 66, 197/92, 19, 98% intubated GEN: elderly thin woman intubated in the ED on stretcher HEENT: NC/AT, anicteric sclera, EET obscuring view NECK: supple, no LAD or bruits CHEST: CTA bilat CV: RRR without mur ABD: soft, NT/ND, +BS, no HSM EXTREM: no edema, warm and well perfused NEURO: MENTAL STATUS: not opening eyes to sternal rub or following commands CRANIAL NERVES: Pupil exam: right 3->2.5, left 2.5->2 EOM exam: + dolls Fundo: could not see disc, but no hemorrhages in the fundus. Corneal reflex: + corneal reflex bilaterally Facial symmetry: obscured by ETT Gag reflex: not done at this time although patient is actively trying to pull ETT with her left hand MOTOR: vigorously moving the left side purposefully, trying to extubate self. Right side is very hypertonic (tone is increased throughout but right>> left) with right arm at her side extensor posturing SENSORY: purposefully withdrawls on the left, extensor postures and triple flexion on the right REFLEXES: a brisk 3 throughout with upgoing toes bilaterally Pertinent Results: [2163-11-2] 11:40PM WBC-5.1 RBC-3.94* HGB-13.5 HCT-38.2 MCV-97 MCH-34.3* MCHC-35.4* RDW-12.6 [2163-11-2] 11:40PM NEUTS-80.6* LYMPHS-13.8* MONOS-3.7 EOS-1.3 BASOS-0.7 [2163-11-2] 11:40PM PLT COUNT-142* [2163-11-2] 11:40PM CK(CPK)-106 [2163-11-2] 11:40PM CK-MB-3 cTropnT-<0.01 [2163-11-2] 11:40PM GLUCOSE-175* UREA N-13 CREAT-0.5 SODIUM-143 POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-27 ANION GAP-14 [2163-11-3] 12:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [2163-11-3] 12:10AM PT-13.3 PTT-24.8 INR(PT)-1.2 [2163-11-3] 04:00AM PLT COUNT-162 [2163-11-3] 04:00AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2163-11-3] 04:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2163-11-3] 04:00AM TSH-4.3* [2163-11-3] 04:00AM TRIGLYCER-89 HDL CHOL-57 CHOL/HDL-2.3 LDL(CALC)-56 [2163-11-3] 04:00AM %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE [2163-11-3] 04:00AM CALCIUM-8.7 PHOSPHATE-1.9* MAGNESIUM-1.5* CHOLEST-131 [2163-11-3] 04:00AM ALT(SGPT)-45* AST(SGOT)-46* CK(CPK)-185* TOT BILI-1.1 [2163-11-3] 04:20AM LACTATE-2.5* [2163-11-3] 04:20AM TYPE-ART PO2-446* PCO2-30* PH-7.54* TOTAL CO2-26 BASE XS-4 CXR: AP UPRIGHT PORTABLE CHEST X-RAY: The endotracheal tube is seen with the tip at the level of the clavicles. A nasogastric tube descends below the diaphragm with the tip not visualized. The cardiac silhouette is upper limits of normal, with left ventricular prominence. The mediastinal and hilar contours are normal. The pulmonary vasculature is normal. Both lungs are clear without consolidations or effusions. The surrounding soft tissue and osseous structures demonstrate several right posterior rib fractures. IMPRESSION: No acute cardiopulmonary process. [11-1] Head CT NONCONTRAST HEAD CT: There is a large intraparenchymal hemorrhage extending through the white matter of the left insula and the left thalamus, irregularly shaped, but measuring up to 6.0 cm in transverse dimension. Hemorrhage extends into the left lateral ventricle and into the third ventricle superiorly. The degree of hemorrhage has worsened since the study of [Hospital1 9191]. The hemorrhage is impressing and narrowing the left lateral ventricle, with mild midline shift to the right. No extra-axial fluid collections are noted. The [Doctor Last Name 352]-white differentiation remains preserved. The visualized paranasal sinuses and mastoid air cells are clear. Osseous and soft tissue structures are unremarkable. IMPRESSION: Large intraparenchymal hemorrhage of the white matter of the left frontal lobe and thalamus has increased since the outside hospital study. There is mild midline shift to the right. Head CT [11-2]: Increase in the volume of intracerebral hemorrhage, accompanied by slight increase in mass effect, left to right midline shift, and blood within the left lateral ventricle. There is a small amount of hypodensity surrounding the hemorrhage, compatible with an extruded serum. Head CT [11-3], [11-4]: Similar appearance of large cerebral and intraventricular hemorrhage. No new hemorrhage identified. Head CT [11-13]: Interval decrease in hemorrhage within the left frontal/temporal lobes and left thalamus with resolution of the intraventricular blood within the left lateral ventricle. Stable minimal shift of rightward structures. Ventricles are stable in configuration. [11-15] Chest/Abd/Pelvis CT - Circumferential bowel wall thickening seen in the cecum. Differential for this includes infection and ischemia. Inflammatory changes are considered less likely. - Micronodule or tree-in-[Male First Name (un) 239] type appearance at both lung bases, right greater than left. These may represent early atypical infection. If required, a chest CT could be obtained for further evaluation. - Two large ovarian cysts, the first measuring 4.1 x 4.2 cm, and the second measuring 2.4 x 3.3 cm. The right ovary is not visualized. No free fluid or lymphadenopathy is seen in the pelvis. Given the patient's age, a pelvic ultrasound is recommended for further evaluation. Brief Hospital Course: This is a 72 yo LH woman with h/o labile BP and parkinsonism on a daily baby aspirin who presents from OSH with large left sided intraparenchymal hemorrhage. The bleed is subcortical and extending to the lateral and third ventricle. DDx on the etiology for this hemorrhage includes: hypertensive bleed (esp given location), trauma (less likely by history), AVM/aneurysm, toxic, amyloid (less likely given subcortical location), tumor, sinus thrombosis (also less likely given location, unilateral). Neuro - Untreated hypertension is the most likely etiology of Pt's hemorrhage. Serial head CTs displayed mild worsening in hemorrhage and mass effect with worsening of mental status, requiring intubation. Loaded with Dilantin d/t concern for seizure, but not continued (other factors more likely causing decline in level of alertness). Head CT stable since [11-3]. Continued Sinemet. Exam remains notable for intermittent somnolence, at times very difficult to arouse, requiring sternal rub. Pt does not always readily appear to be awake, but will follow commands with eyes closed. Flaccid paralysis in R upper extremity. Plegic R lower extremity worse proximally, withdraws to noxious stim. Increased tone in R lower extremity. Limited speech output, but comprehension intact. CV - Ruled out for MI on admission. Hypertension initially controlled with Nicardipine gtt. Now on regimen of Captopril and Metoprolol. Lipids wnl Chol 131 TG 89 HDL 57 LDL 56. Resp - Extubated on [11-6]. Non-specific nodules noted on upper part of [11-15] abdominal CT, outpatient chest CT scheduled for follow up. Currently stable on small O2 requirement. FEN/GI - Tolerating tube feeds without difficulty at goal. PEG placed on [11-17]. Had increase in LFTs on [11-15] (max ALT 291, AST 112) likely d/t Levofloxacin, which was d/c'd, LFTs now improving. No liver pathology identified on [11-15] abdominal CT. ID - Treated from [11-7] to [11-12] with Ciprol for E.coli UTI, changed to Levofloxacin on [11-12] in the setting of fever, incr WBC, sputum Cx + MSSA. Levofloxacin d/c'd d/t incr in LFTs. Afebrile with nl WBC at the time of discharge. Nystatin for thrush. Endo - HbA1C 5.6, TSH 4.3 Gyn - L ovarian cysts identified on [11-15] pelvis CT, which are unusual for Pt's age. Plan for follow-up pelvic ultrasound after discharge from rehab. Prophylaxis - Heparin SC, bowel regimen, AFOs bilaterally FULL CODE - confirmed with family, husband [Telephone/Fax (1) 64599], daughter [Name (NI) 803] [Telephone/Fax (1) 64600] Discharged to acute rehab on [2163-11-22] in stable condition. Medications on Admission: sinemet 25/100 1.5 am, 1.5 pm, 1 qhs vitamins ASA 81 daily Discharge Medications: 1. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 2. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). 3. Carbidopa-Levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 4. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain, fever. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 9. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): Hold for SBP<120. 10. Insulin Regular Human 100 unit/mL Solution Sig: per scale Injection ASDIR (AS DIRECTED). 11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6-8H (every 6 to 8 hours) as needed for titrate to one soft bowel mvmt per day, may hold for loose stools or abdominal pain. 13. Captopril 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 14. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Left intraparenchymal hemorrhage Discharge Condition: Stable. Discharge Instructions: Seek medical attention for somnolence, new weakness, numbness, sudden change in vision or hearing, headache, or for other concerns. Continue all new medications as prescribed. Followup Instructions: Follow up with your primary physician after discharge from rehab. Pelvic ultrasound, RADIOLOGY, [Hospital Ward Name 23] Building, [Location (un) ], [Telephone/Fax (1) 327]. Date/Time:[2163-12-22] 10:15am. Please go to appt with a full bladder. Chest CT SCAN, RADIOLOGY, [Hospital Ward Name 23] Building, [Location (un) ], [Telephone/Fax (1) 327] Date/Time:[2163-12-22] 11:30am. Neurology, [Name6 (MD) ] [Name8 (MD) ], M.D., [Hospital Ward Name 23] Building, [Location (un) ], [Telephone/Fax (1) 2574]. Date/Time:[2164-1-3] 2:30 [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] Completed by:[2163-11-22] ICD9 Codes: 431, 5990, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8493 }	Medical Text: Admission Date: [2167-6-8] Discharge Date: [2167-6-25] Date of Birth: [2098-12-22] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2569] Chief Complaint: Left sided weakness Major Surgical or Invasive Procedure: [6-10] craniotomy with evacuation of hematoma [6-17] bilateral cerebral angiogram [6-18] PEG placement History of Present Illness: 68 yo man h/o DM2, [Hospital ] transferred from OSH after presenting with sudden onset of headache, left sided weakness and decreased verbal output. History obtained from family and OSH records. Patient went to his usual volunteer work at an animal shelter and returned home around 9am where he reported not feeling well and having a sudden onset of a headache. He proceeded to become nonverbal and develop left sided weakness around 10am which prompted his family to call 911. Upon arrival to OSH ED, BP 156/102 HR 69. NCHCT showed ICH, "centrally in the frontal region, there is an acute 6 x 4 cm intraparenchymal bleed. On the posterior margin, there is a somewhat enhancing rim which raises the question as to whether there is a meningioma in this area which has bled. There is mild anterior midline shift to the left and the ventricles are normal size." At OSH, rec'd reglan, zofran and 1g dilantin IV. Transferred to [Hospital1 18] ED for further management. Noted to by dry heaving en route. ROS: Denies head trauma, weight loss, prior h/o cancer, blood clotting disorder. Past Medical History: DM2 HTN gout [Hospital1 3390] [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7568], [Location (un) 5503], MA Social History: Lives with wife [Name (NI) 47532] [Telephone/Fax (1) 78608] (home), [Telephone/Fax (1) 78609] (cell), two daughters also nearby. No tob, ~2 drinks/wk, no drugs. Retired delivery truck driver. Family History: NC Physical Exam: T- 97.5 BP- 157/79 HR- 74 RR- 16 100 O2Sat RA Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: supple, no carotid or vertebral bruit CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Neurologic examination: MS: asleep requiring constant stimulus to stay awake. does not answer questions but then says "ouch" with noxious stim. follows commands with right hand, squeeze hand, shows two fingers and wiggles thumb. CN: I: not tested II,III: blinks to threat bilaterally, PERRL 3mm to 2mm III,IV,V: EOMI with OCM, no ptosis V: unable VII: left facial droop VIII: unable IX,X: palate elevates symmetrically, uvula midline [Doctor First Name 81]: SCM/trapezeii [6-1] bilaterally XII: tongue protrudes midline, no dysarthria Motor: Normal bulk. Decr'd tone on left side; no tremor, asterixis or myoclonus. Right arm full [6-1] to resistance and purposeful. Left arm flaccid no movement to noxious stim. Legs w/d to noxious stim only R>L. Reflex: No clonus, 2+ brisker on the left arm>leg and 2+ on the right. Right toe downgoing, left upgoing. Coordination/Gait/Romberg: Negative Pertinent Results: [6-8] MRI OF THE BRAIN: There is a large mixed-density hematoma centered within the corpus callosum and extending superiorly into the right interhemispheric cistern and along the right medial frontal lobe. There is inferior displacement of the septum pellucidum and mass effect on the ventricles which are mildly dilated and increased compared to prior CT. Hemorrhage has also increased within the ventricles. There is no definite underlying mass or arteriovenous malformation. Restricted diffusion within the hematoma is expected. There are additional areas of restricted diffusion to suggest infarction. MRA OF THE CIRCLE OF [Location (un) ]: The MRA is somewhat suboptimal due to motion. The right A1 is hypoplastic and the right A2 arises from the anterior communicating artery. There is a right-sided fetal PCA. No flow-limiting stenosis, aneurysm or AV malformation is identified. IMPRESSION: 1. Large corpus callosal and right intraparenchymal hematoma with mixed- density blood products and no definite underlying mass or arteriovenous malformation. A repeat MRI could be performed in six weeks to better assess for an underlying abnormality such as a mass, aneurysm or undetected small AVM. 2. Increased size of hemorrhage and intraventricular extension, with increased hydrocephalus. CT/CTA [6-9] NON-CONTRAST HEAD CT: There has been interval expansion of the large intraparenchymal hemorrhage located in the right medial frontal lobe and corpus callosum. The hematoma in greatest dimension measures 6.8 x 4.8 cm, previously 6.3 x 4 cm. The component in the corpus callosum is also expanded, and there is inferior displacement of the septum pellucidum. The hematoma is of mixed density with clotted blood centrally. There is markedly increased intraventricular extension, which layers in the occipital horns, as well as interval increase in ventricular size and prominence of the temporal horns. There are also new foci of subarachnoid hemorrhage within the bilateral parietal sulci and interpeduncular cistern. No evidence of acute infarct. CTA OF THE CIRCLE OF [Location (un) ]: As noted on recent MRA, there are hypoplastic right A1 and the right A2 derived from the anterior communicating artery. There is a fetal right PCA, a normal variant. No flow-limiting stenosis or aneurysm is seen within the circle of [Location (un) 431]. IMPRESSION: Interval increase in right frontal/corpus callosal hemorrhage with increasing intraventricular extension of hemorrhage and hydrocephalus. No definite underlying mass, aneurysm, or AVM is detected, though followup imaging is recommended to evaluate for underlying abnormality. There are also new foci of subarachnoid hemorrhage. POST-OP CT [6-10] Patient is status post right frontal craniotomy and right frontal intraparenchymal hemorrhage evacuation. There is a small amount of residual blood within the right frontal lobe. There is no appreciable extra-axial collection. There is hyperdensity seen along the left medial frontal lobe, probably related to artifact rather than new hemorrhage. Bilateral parietal subarachnoid hemorrhages are again noted with of more apparent frontal subarachnoid involvement, which was previously present, overall of similar extent. The intraventricular blood layering within the occipital horns is similar. There is no hydrocephalus, and the ventricles are similar in size. IMPRESSION: Expected postoperative changes following right frontal intraparenchymal hemorrhage evacuation. MRI [6-13] (done for persistent fever, to r/o post-surgical abscess) The patient is status post right frontal craniotomy and evacuation of right frontal intra-axial hemorrhage. In comparison with the prior MRI, there is evidence of residual blood products and vasogenic edema at the level of the corpus callosum and interhemispheric cistern as well as along the right medial frontal lobes. There is persistent inferior displacement of the septum pellucidum and narrowing of the right frontal ventricular [Doctor Last Name 534]. The amount of intraventricular hemorrhage has decreased in the interim. Restricted diffusion is again visualized surrounding the surgical cavity and extending to the convexity and also involving partially the left medial cerebral hemisphere, which are also hyperintense on the T1 pre-contrast sequence, likely related with blood products, contiguous followup is recommended to rule out ischemic changes in these areas. Diffuse hyperintensity signal is noted in the convexity sulci, likely consistent with post-surgical subarachnoid hemorrhage. After the administration of gadolinium contrast, no significant enhancement is visualized to suggest abscess formation. Soft tissue swelling is identified in the right frontal region and related with the recent surgical procedure. The orbits, the paranasal sinuses appear within normal limits. Minimal patchy opacities are noted in the mastoid air cells. IMPRESSION: 1. Status post right frontal craniotomy and evacuation of right frontal hemorrhage. Persistent areas of restricted diffusion, surrounding the surgical bed, worrisome for ischemic changes, new areas of hyperintensity signal are demonstrated on the T1-weighted sequence, likely consistent with blood products, contiguous followup is recommended to rule out new ischemic changes. Residual diffuse subarachnoid hemorrhage likely post-surgical in nature. Decrease in the amount of the intraventricular hemorrhage as described above. No significant enhancement is visualized or evidence of abscess. ANGIOGRAM [6-17] Written informed consent was obtained after explaining the risks, indications, and alternative management of the procedure. Risks explained included stroke, loss of vision and speech whether temporary or permanent, with possible treatment with stent and coils if needed. After obtaining informed consent, the patient was brought to the interventional neuroradiology suite and placed on the biplane table in the supine position. Both groins were prepped and draped in the usual sterile fashion. Access to the right common femoral artery was obtained using a 19- gauge single wall needle under local anesthesia with 1% lidocaine. Through the needle, a 0.035 [Last Name (un) 7648] wire was introduced and the needle was taken out. Over the wire, a 5 French vascular sheath was placed and connected to a saline infusion (mixed with heparin 500 units in 500 cc of saline) with a continuous drip. Through the sheath, a 4 French Berenstein catheter was introduced and connected to a continuous saline infusion (with heparin mixture: 1000 units of heparin in 1000 cc of saline). The following vessels were selectively catheterized and arteriograms were performed from these locations: 1. Left internal carotid artery. 2. Left common carotid artery. 3. Left vertebral artery. 4. Right common carotid artery. 5. Right external carotid artery. 6. Right internal carotid artery. 7. Right vertebral artery. After review of the film, it was determined that there was mild vasospasm of the right distal MCA branches and nonvisualization of the right anterior cerebral artery. At this point, 5 mg of Verapamil were administered through the right internal carotid artery. The films were reviewed and at this point the sheath and catheter were withdrawn and pressure was applied on the groin until hemostasis was obtained. The procedure was uneventful and the patient tolerated the procedure well. FINDINGS: Upon arteriogram of the right internal carotid artery, there is decreased perfusion over the right anterior cerebral artery territory without visualization of the right anterior cerebral artery. The finding could be due to severe vasospasm or perhaps due to the obstruction due to the hemorrhage in this region or an infarct. However, there is normal appearance of the right M1 and M2 segments but there is mild vasospasm in the distal right in M3 branches. The visualized distal right internal carotid artery is unremarkable. The right and left vertebral arteries demonstrated no high-grade stenosis or occlusion. The posterior and anterior inferior cerebellar arteries are within normal limits. The basilar artery shows no high-grade stenosis or occlusion. There is normal flow into the posterior cerebral arteries. Evaluation of the right and left external carotid artery demonstrate normal course in the appearance of the external carotid artery and its major branches. Arteriogram of the left internal carotid artery demonstrate normal flow into the anterior and middle cerebral arteries on the left. There is only mild cross filling into the branches of the right ACA. IMPRESSION: Cerebral angiogram demonstrated decreased perfusion along the right anterior cerebral artery territory. Nonvisualization of the right anterior cerebral artery. There is mild vasospasm of the distal branches of the right middle cerebral artery. 5 mg of Verapamil were administered into the right internal carotid artery. PATH [6-10] clot: SPECIMEN SUBMITTED: Subdural clot, dura, superficial clot ?mass, deep ? clot?mass, deep margins. Procedure date Tissue received Report Date Diagnosed by [2167-6-9] [2167-6-10] [2167-6-22] DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/lo?????? DIAGNOSIS: I. Subdural clot, removal (A): A. Organizing hemorrhage. B. No malignancy identified (Cytokeratin cocktail, LCA and HMB45 reviewed). II. Dura (B-C): Fragments of dura and unremarkable bone. III. Superficial clot of mass (D): A. Numerous vessels with thickened walls and mural deposition of eosinophilic material (See part V for further description). B. Organizing hemorrhage. IV. Deep clot mass (E): A. Numerous vessels with thickened walls and mural deposition of eosinophilic material (See part V for further description). B. Organizing hemorrhage. V. Deep margin (F-J): A. Amyloid angiopathy (see note). B. Organizing hemorrhage. C. Cortical [Doctor Last Name 352] matter with amyloid plaques (early Alzhiemer's type neurodegenerative change) D. Iron stain shows iron deposition within brain tissue suggestive of remote hemorrhage (see slide I). Note: Several arteries show evidence of chronic injury including mural thickening, adventitial fibrosis, and reduplication of the internal elastic lamina (trichrome and elastic stain evaluated). There is marked deposition of beta-amyloid (immunohistochemistry) within several leptomeningeal and penetrating vessels and as plaques within the [Doctor Last Name 352] matter brain tissue confirming the diagnosis of amyloid angiopathy and indicating some early neurodegenerative changes often found in Alzhiemer's disease. GFAP immunohistochemistry was also performed and showed a mild gliosis. Brief Hospital Course: 68 yo man h/o DM2, [Hospital ] transferred from OSH after presenting with sudden onset of headaches which progressed to left-sided weakness and decreased verbal output. Initial exam: blinks to threat, PERRL, EOMs intact, mild left facial droop, keeps his eyes closed; brisk reflexes on the left, left toe upgoing; does not follow any commands; L hemiparesis; akinetic mutism. CT at OSH showed 6.4 cm intraparenchymal bleed with compression of lateral ventricles, blood seems to cross in the corpus callosum. The differential diagnosis of this hemorrhagic lesion includes an underlying mass such as a glioblastoma multiforme that suddenly bled. Alternatively, there could be a vascular malformation (e.g., aneurysm of the pericallosal artery, AVM, cavernoma). An amyloid hemorrhage is less likely and a hemorrhagic metastasis is also less likely considering the location. Less typical for hypertensive bleed; family denies preceding trauma. NEURO: -intial CTA did not show evidence of vasc malformation -deterioration in neurological status on [6-9], started on Mannitol and Decadron, required intubation, and emergency craniotomy for evacuation of the IPH [6-10] and biopsy. -Post-op course complicated by MRI/MRA brain w/ and w/o contrast repeated [6-14] acute R ACA infarct, likely due to sacrificing of vessel intraop. -Prelim path did not show evidence of tumor, possibly vascular malformation (ectatic veins, beta-amyloid staining pending) -Thus he underwent a conventional [Hospital1 ]-hemispheric cerebral angio [6-17], which did not show evidence of vascular malformation, though if there had been one it could have been removed during surgery given that there was no longer a R ACA present. -He was on dilantin which was discontinued [6-15] after EEG showed mild encephalopathy: diffuse slowing 7 Hz esp bifrontal R > L, no epileptiform discharges. -He developed a fluid collection under his craniotomy site which neurosurg evaluated and thought was just CSF leak, not requiring intervention. -Exam improved: much more alert, still non-verbal, intermittently shows 2 fingers with R hand on command, dense L-plegia, LLE ext rotated, bilat upgoing plantars -Full code status CVS: -HTN was somewhat difficult to control (goal was MAP < 130, SBP <160), though some discrepancy between art line and cuff BPs, meds increased as follows: Valsartan 80 daily, Metoprolol 75 TID and Amlodipine 10 daily. -on one occasion he was switched to Labetalol and had a hypotensive episode [6-19] requiring a few hours on Neosyneph RESP: extubated [6-11], he slowly weaned off shovel mask O2 FLUIDS/METABOLICS: -ALT/AST normal on admission and then repeated on [6-16] to look for evidence of acalculous cholecystitis given fever NOS, and found to be trending upwards with ALT 123 & AST 53 -His Simvastatin 80 daily was held; he was receiving regular Acetaminophen due to fever and so this was discontinued in favor of Ibuprofen. -Liver U/S [6-17] showed mild liver echogenicity c/w non-specific fatty liver. -He underwent PEG tube insertion [6-18] -His insulin was held on multiple occasions due to being NPO for PEG tube so his glycemic control has been poor. -hypernatremia resolved with free H20, also persistently elevated BUN around 30 HEME: Hct stable post-PEG ID: persistent leucocytosis since admission, recurrent fevers for many days with negative cultures, LP was considered but then found to have E.Coli UTI [6-15] so started on Cipro until [6-23] and CoNS grew at 48 hrs from CVL tip removed [6-15] so started on Vanco. He subsequently defervesced. BRIEF FLOOR COURSE [6-20] - [6-25] Elevated LFTs as above, maximum values ALT 539 AST 251. Hepatology was consulted. Extensive hepatitis A, B, C panel, NH3, CMV, EBV, [Doctor First Name ] and anti-SMA, Fe, Ferritin, TIBC all negative, although the latter revealed some anemia of chronic illness. U/S (including Doppler) of RUQ on [6-17] and repeat on [6-23] negative. D/C'd acetaminophen, phenytoin, vancomycin, statin, motrin, cefazolin, started to trend down spontaneously. Last values on [6-25] were ALT 249 AST 53, consistently trending down for four days. Most likely Dx is medication induced transaminitis. There we no further issues on the floor. His exam remained very poor, opening eyes to voice, not regarding, fixing or following, not following commands. Dense plegia on the L, no response to noxious stimulation. Grasping reflex on R, likely representing a frontal release sign. Medications on Admission: Valsartan 40mg QD Simvastatin 80mg QD Glipizide 5mg [Hospital1 ] ALL: NKDA Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) 10 mL PO BID (2 times a day). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constip. 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000 units Injection TID (3 times a day). 5. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Insulin Insulin schedule: NPH 40 Q12 hrs, plus SLIDING SCALE. 8. Labetalol 100 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 9. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for skin irritation. Discharge Disposition: Extended Care Facility: [Hospital ] Hospital of [Location (un) ] & Islands - [Location (un) 6251] Discharge Diagnosis: 1 Large R frontal intracranial hemorrhage 2 R anterior cerebral artery infarction 3 Medication induced transaminitis 4 E Coli urinary tract infection 5 PEG placement [6-18] 6 CNS Line sepsis Discharge Condition: Stable. For details please see [Hospital ] hospital course' inthe D/C summary. Monitor LFTs. Discharge Instructions: You have been admitted with a R frontal bleed, which eventually needed urgent evacuation. The surgery was complicated by a stroke. Please take all your medications excactly as directed and please attend all your follow-up appointments. Please report to the nearest ER or call 911 or your [Hospital 3390] immediately when you experience recurrence of weakness, numbness, tingling, problems with vision, speech, language, walking, thinking, headache, or difficulties arousing, or any other signs or symptoms of concern. Followup Instructions: Please call [Telephone/Fax (1) 78610] for a follow-up appointment with Stroke Service if the rehabilitation doctors [Name5 (PTitle) ] your [Name5 (PTitle) 3390] find it indicated as well as feasible. [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575] Completed by:[2167-6-25] ICD9 Codes: 2875, 4019, 0389, 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8494 }	Medical Text: Admission Date: [2109-1-25] Discharge Date: [2109-1-31] Date of Birth: [2032-11-24] Sex: F Service: MEDICINE Allergies: Aspirin / Lipitor Attending:[First Name3 (LF) 613] Chief Complaint: Bright red blood per rectum. Major Surgical or Invasive Procedure: 1. Upper endoscopy. 2. Colonoscopy. History of Present Illness: Ms. [Known lastname 1968] is a 76F with CAD s/p CABG on plavix, chronic angina (unstable, sometimes with rest), DM presents following 3 episodes of BRBPR at home, filling toilet bowl. Also had abdominal discomfort and mild nausea, no vomiting. Has had CP for past few months, unchanged. Denies recent NSAID use. No F/C. Has had a lower GI bleed previously in [2107], with colonoscopy showing melanosis coli and grade 2 hemorrhoids. A previous upper endoscopy performed for dyspepsia in [2106] was unrevealing. . In the ED, vitals were 96.7 103 207/84 16 100%RA. Had a clotty red BM in the ED. 1st set of enzymes negative. CXR showed mild congestion. She was given 2 SL nitroglycerin, 4 IV morphine, and zofran. Her CP resolved after morphine and nitro x2, however she became hypotensive to 80's 30 minutes following nitroglycerin. Her BP subsequently responded to IVF. CT-A abdomen showed patent vasculature no acute process. HCT at baseline (29.2). Ordered for 2 units pRBCs in ED, got 1 of them in the ED. Access obtained with 2 18-gauge peripherals. Most recent vitals 96.5 73 113/49 16 100% 3L. Past Medical History: Prior GIB while on aspirin CAD s/p CABG [15]+ years ago -- cardiac cath [11-17] showed patent LIMA and one SVG, with one occluded SVG, diffuse disease of native vessels--> no intervention Hypertension Dyslipidemia Diabetes Moderate Mitral Regurgitation Moderate to severe tricuspid regurgitation [10-15]-Right Rotator Cuff Surgery GERD Spinal Stenosis Hysterectomy Prior back surgery Anemia s/p cataract surgery Social History: She lives with her daughter. She denies use of tobacco or alcohol,but smoked > 40 years ago. She is a retired [Company 2676] technician. She is divorced with 5 children. She walks unassisted. Family History: Denies any history of cancer, dm, htn. Physical Exam: T 96.5, BP 126/52, HR 83, RR 23, 100%3L General: comfortable, no distress HEENT: PERRL, EOMI Neck No JVD Pulm: Bibasilar crackles CV: RRR, III/VI SEM Abd +BS, soft, non-distended, mild tenderness LLQ. No rebound/guarding Extrem: no edema Pertinent Results: [2109-1-25] 09:30AM PT-13.8* PTT-34.0 INR(PT)-1.2* [2109-1-25] 09:30AM PLT COUNT-243 [2109-1-25] 09:30AM NEUTS-64.7 LYMPHS-29.6 MONOS-4.0 EOS-1.6 BASOS-0.1 [2109-1-25] 09:30AM WBC-6.4 RBC-3.40* HGB-9.9* HCT-29.2* MCV-86 MCH-29.2 MCHC-34.0 RDW-14.1 [2109-1-25] 09:30AM CK-MB-NotDone cTropnT-<0.01 [2109-1-25] 09:30AM CK(CPK)-43 [2109-1-25] 09:30AM estGFR-Using this [2109-1-25] 09:30AM GLUCOSE-190* UREA N-27* CREAT-1.0 SODIUM-139 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14 [2109-1-25] 09:54AM LACTATE-1.3 [2109-1-25] 01:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 [2109-1-25] 01:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2109-1-25] 01:00PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.045* [2109-1-25] 01:00PM URINE GR HOLD-HOLD [2109-1-25] 01:00PM URINE HOURS-RANDOM . CXR ([1-25]): mild pulm edema, slightly improved from prior . CTA abdomen ([1-25]): 1. No acute process in the abdomen or pelvis; specifically, no evidence of mesenteric ischemia. 2. Stable hypodense lesion within the pancreatic body likely represents a lipoma or interposed fat as this lesion is stable from [2106-12-3] exam. If there is strong clinical concern, an MRCP may be obtained. 3. Left renal hypodense cyst. 4. Colonic diverticulosis, without evidence of diverticulitis. 5. Calcific density at the pelvic floor, stable from [2106], likely represents a stone within a urethral diverticulum. . Colonoscopy ([1-28]): Small internal hemorrhoids were noted. A single diverticulum with small opening was seen in the sigmoid colon. Diverticulosis appeared to be of mild severity. No old or fresh blood was seen in the colon. Impression: Internal hemorrhoids. Diverticulum in the sigmoid colon. No old or fresh blood was seen in the colon. Otherwise normal colonoscopy to cecum. . EGD ([1-29]): Duodenum: Normal duodenum. jejunum: Normal jejunum. ileum: Not examined. Impression: Polyps in the pylorus. Otherwise normal small bowel enteroscopy to proximal jejunum. Brief Hospital Course: Ms. [Known lastname 1968] is a 76F with DM, CAD, and h/o GIB who presents with GIB and CP. She was admitted to the MICU for monitoring. Hospital course is discussed below by problem: . 1. Gastrointestinal bleed. The history of BRBPR was more suggestive of a lower source. A brisk upper bleed seemed less likely. Her baseline hct is 30, and during this admission, it dropped to as low as 23.9. She had small amounts of bright red blood in her stool, although nothing to explain the 6 point hematocrit drop. A central line was placed and she was transfused a total of 9 units PRBCs during her six-day course in the unit. GI was consulted and performed both upper endoscopy and colonoscopy, although no source of active bleeding or old blood could be identified. The full reports are provided above. She was started on IV proton-pump inhibitor and her hematocrit stabilized in the low thirties on the fifth hospital day, and remained stable with stable vital signs. She was transferred to the floors on hospital day 6, and her hematocrit followed twice daily. After transfer, she had no more bloody bowel movements. Her Plavix has been held, and her antihypertensives have also been held. She will follow-up in [Hospital ] clinic with Dr. [First Name (STitle) 1356] in one week. . 2. Chest pain, coronary artery disease, history of CABG. She has chronic chest pain, and is on 2 anti-anginal medications. During this admission, she reported intermittent episodes of angina. EKGs did not show acute changes and cardiac enzymes were cycled and negative. Her ranolazine was continued but her Imdur and SL nitros held for concern of precipitating hypotension. She was transfused a total of 9 units PRBCs to keep her hct above 25. As above, we have held her Plavix and cardiovascular medicines at time of discharge given the recent GI bleed. Her blood pressure has been well-controlled, despite being off meds, with ranges in the 120s-140s/60-70s. She will follow-up with her primary care where decision can be made regarding resumption of her Plavix and CV meds. . 3. Diabetes mellitus II. We held her oral hypoglycemics and kept her on sliding scale humalog insulin. She will resume her oral hypoglycemics after discharge. . 4. Hypertension. As above, her metoprolol, Cozaar, Imdur and triamterene/HCTZ were stopped in the setting of GI bleed. These can be resumed as outpatient if her blood pressure warrants additional meds, although during this admission her pressures have been relatively well-controlled without. . 5. Hyperlipidemia. We continued her outpatient simvastatin. . Her diet was progressed as tolerated to diabetic, heart-healthy diet. Pneumoboots were used for venous thrombosis prophylaxis. Her code status is full code. Medications on Admission: Razolazine 500 [Hospital1 ] Plavix 75 daily Omeprazole 20 daily Simvastatin 20 daily Triamterene/HCTZ 37.5/25 daily Diltiazem ER 90mg [Hospital1 ] Metoprolol succinate 25 daily Isosorbide mononitrate 120 daily Losartan 100 daily Glipizide 10 daily Actos 30 daily Insulin Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Ranolazine 500 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO BID (2 times a day). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 4. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 5. Pioglitazone 30 mg Tablet Sig: One (1) Tablet PO once a day. 6. Insulin Glargine 100 unit/mL Cartridge Subcutaneous Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Gastrointestinal bleed of undetermined origin Acute blood loss anemia . Secondary Diagnoses Coronary artery disease Diabetes mellitus type II, uncontrolled with complications Hypertension Dyslipidemia Gastroesophageal reflux Discharge Condition: Vital signs stable. Afebrile. Hematocrit stable. Discharge Instructions: You were hospitalized for treatment of gastrointestinal bleed. You received nine transfusions of red blood cells. You also underwent colonoscopy and upper endoscopy and we could not find the source of the bleeding. Your red cell count has been stable now for three days. . We have made the following changes to your medications: 1. We have held the Plavix. 2. We have held the triamterene/hydrochlorthiazide. 3. We have held the diltiazem. 4. We have held the metoprolol. 5. We have held the isosorbide mononitrate. 6. We have held the losartan. Please do not restart these medicines until you follow-up with your primary care provider. . Please note your follow-up appointments below: we have scheduled appointments in [Hospital ] clinic and primary care clinic. . Please call your doctor or return to the emergency room if you notice any more bleeding, if you feel lightheaded or dizzy, or if you develop any other symptoms that are concerning to you. Followup Instructions: 1. Please schedule with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10273], NP on next Wednesday, [2-6] at 1:30PM at [Hospital3 4262] Group. . 2. Please follow-up in [Hospital ] clinic: Tuesday, [2-5] at 9:30 with Dr. [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) 1356] at [Last Name (NamePattern1) 439] on the [Location (un) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 1983] Date/Time:[2109-2-5] 9:30 . 3. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2109-2-18] 11:00 [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2109-1-31] ICD9 Codes: 4111, 4240, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8495 }	Medical Text: Admission Date: [2156-1-27] Discharge Date: [2156-2-2] Date of Birth: [2156-1-27] Sex: M Service: NEONATOLOGY HISTORY: Baby [Name (NI) ] [Known lastname 1968] was born at 36-5/7 weeks gestation to a 29-year-old, G3, P2, now 3, mother whose pregnancy was complicated by gestational diabetes requiring insulin; otherwise, pregnancy was uncomplicated. Infant was born by spontaneous vaginal delivery with Apgars of 8 and 9 at 1 and 5 minutes. The infant did well initially, but was noted to have a blood sugar of 24 shortly after birth, which required admission to the NICU for management of hypoglycemia. Mother's prenatal screen is blood type O positive, antibody negative, HBSAG negative, rubella immune, RPR nonreactive, GBS negative. PHYSICAL EXAM ON ADMISSION: Pink, active and nondysmorphic,well-perfused with oxygen saturation stable in room air. Skin without lesions. HEENT within normal limits. CARDIAC: Normal S1, S2, grade I-II blowing musical murmur at mid left sternal border radiating to the base. Abdomen benign. Neuro exam nonfocal and age-appropriate, moving all extremities. Skeletal normal. Patent anus. Hips normal. Normal male genitalia. Birthweight 2285 grams which is 75th to 90th percentile, length 47 cm which is 25th to 50th percentile, head circumference 33 cm which is 50th percentile. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: The infant presented with some grunting, flaring and retracting on admission to the NICU, which resolved shortly after admission. Infant remained on room air and has not required any oxygen therapy or any other respiratory therapies. Respiratory rate and rhythm stabilized after the initial tachypnea. O2 saturations have remained within normal limits. CARDIOVASCULAR: The infant has remained hemodynamically stable with a rare intermittent murmur. Blood pressure and heart rate are both within normal limits. Pink and well- perfused. Has required no cardiac intervention or further monitoring. FLUIDS, ELECTROLYTES AND NUTRITION: IV fluids were initiated on admission due to hypoglycemia. The infant received a total of 3 D10W boluses to maintain a normal blood sugar and was started on enteral feedings on the newborn day. The infant continued to require IV fluid infusion for hypoglycemia through to day of life 3, which is [2156-1-30], and at that time the infant was able to maintain normal glycemia with enteral feedings alone. At this time, the infant has been p.o. ad lib feeding Enfamil 20 with iron q. [3-13] h. with D-stick stable in the 60s or greater a.c. Most recent set of electrolytes was on [2156-1-31]: Sodium 136, K 5.1, chloride 100, CO2 25. Most recent weight _____. GI: Baby has had hyperbilirubinemia with a peak bilirubin level of 13.3. His most recent bilirubin level of 10.1/0.4 wa s on [2156-2-2]. HEMATOLOGY: The crit on admission was 50.3. No blood typing has been done on this infant. That is the most recent hematocrit, and the infant has required no blood product transfusions. INFECTIOUS DISEASE: CBC and blood culture were screened on admission. The CBC remained within normal limits, and the blood culture remained negative. The infant was never started on antibiotics. NEUROLOGIC: The infant has maintained a normal neurologic exam for gestational age. SENSORY: Hearing screen was done on PSYCHOSOCIAL: There have been no psychosocial issues with this family, but if there are any concerns, a [Hospital1 18] social worker can be reached at [Telephone/Fax (1) 8717]. CONDITION AT DISCHARGE: Good. DISCHARGE DISPOSITION: NAME OF PRIMARY CARE PEDIATRICIAN: Infant will be seen at [Hospital 65207] Health Center, telephone number [Telephone/Fax (1) 65208]. CARE RECOMMENDATIONS: 1. Ad lib p.o. feedings Enfamil 20 with iron. 2. Infant is on no medications. 3. State screen was sent on day 3 of life, results are pending. 4. Immunizations received: 5. Immunizations recommended: 1) 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 gestation, 2) Born between 32 and 35 weeks gestation with 2 of the following: daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school- aged siblings, 3) Chronic lung disease. 2) Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. 6. Follow-up appointment is scheduled for _____. DISCHARGE DIAGNOSES: A 36-week gestation infant, insulin dependent diabetes mellitus, hyperbilirubinemia, hypoglycemia, resolved respiratory distress. DR.[Last Name (STitle) 37692],[First Name3 (LF) 37693] 50-454 Dictated By:[Name8 (MD) 62299] MEDQUIST36 D: [2156-1-31] 21:22:04 T: [2156-1-31] 22:08:47 Job#: [Job Number 65209] ICD9 Codes: 7742, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8496 }	Medical Text: Admission Date: [2151-6-24] Discharge Date: [2151-7-9] Date of Birth: [2151-6-24] Sex: F Service: Neonatology. HISTORY OF PRESENT ILLNESS: This is a 33 and [3-15] week gestation, twin #2, delivered preterm, due to preterm labor. Mother is a 40 year old, Gravida II, Para 1, now 2 mother. Prenatal screens: 0 positive, antibody negative. RPR nonreactive. Rubella immune. Hepatitis B surface antigen negative. GBS unknown. History notable for previous delivery at 32 weeks (baby treated in the Neonatal Intensive Care Unit at [Hospital1 69]). This pregnancy was conceived on Clomid. Di/di twin gestation. Pregnancy complicated by preterm labor, treated with a complete course of steroids, tocolysis, including magnesium sulfate and bed rest in the hospital for one week. Mother also treated with Terbutaline. Mother presented on day of delivery four cms dilated, delivered by repeat cesarean section. Rupture of membranes at delivery. No maternal fever. Twin emerged with spontaneous cry, requiring only blow-by oxygen in the delivery room. Apgars were eight and nine at one and five minutes. Infant was transferred to the Neonatal Intensive Care Unit for further evaluation and management of prematurity. PHYSICAL EXAMINATION: On admission, birth weight was 1,890 grams (45th percentile); length 42.5 cms (25th percentile); head circumference 31 cms (40th percentile). Overall appearance was consistent with known gestational age. Anterior fontanel was open and flat. Red reflex present bilaterally. Palate intact. No increased work of breathing. Breath sounds clear and equal. Regular rate and rhythm without murmur. Abdomen benign. Skin pink and well perfused. Alert and responsive with normal tone and activity. HOSPITAL COURSE: Respiratory: Infant has remained in room air throughout this hospitalization with oxygen saturation of 97 to 100%. Respiratory rate 40 to 60. Infant has not had any apnea or bradycardia this hospitalization. Cardiovascular: Infant has remained hemodynamically stable this hospitalization. No murmur. Heart rate 150 to 170. Mean blood pressures have been 47 to 62. Fluids, electrolytes and nutrition: Infant was started on enteral feedings on day of delivery, taking in approximately 60 cc per kg per day of premature Enfamil of 20 calories per ounce p.o. and gavage. Infant was advanced to total volume of 150 cc per kg per day by day of life six. Calories were advanced to breast milk or premature Enfamil 24 calories per ounce by day of life seven. Infant tolerated feeding advancement without difficulty. Infant is currently taking 150 cc per kg per day of breast milk, 24 calories per ounce with Enfamil powder mixed in the breast milk p.o. ad lib. Most recent weight is 2165 grams. Most recent length is 43 cms. Head circumference 31 cms. Gastrointestinal: Infant did not receive phototherapy this hospitalization. The most recent bilirubin level on day of life four showed a total of 5.5 with a direct of 0.2. Hematology: The most recent hematocrit on day of delivery was 47.4%. The infant has not received any blood transfusions this hospitalization. Infectious disease: CBC, differential and blood culture were sent on admission due to preterm labor. The white blood cell count was 16.6; hematocrit was 47.4%; platelets 257,000; 27 polys, 27 neutrophils, 2 bands. Antibiotics were not started and the blood culture has remained negative to date. Neurology: No issues. Sensory: Hearing screening was performed with automated auditory brain stem responses. Infant passed both ears. Ophthalmology: Infant did not meet criteria for eye examination. Psychosocial: Parents involved with infants. [Hospital1 346] social work involved with the family. The contact social worker can be reached at [Telephone/Fax (1) 8717]. Condition at discharge: Former 33 and [3-15] week gestation, now 35 and 4/7 weeks corrected; stable in room air. DISCHARGE DISPOSITION: Home with parents. NAME OF PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], phone number [Telephone/Fax (1) 51546]; fax number [Telephone/Fax (1) 38715]. CARE RECOMMENDATIONS: Feedings at discharge: 150 cc per kg per day of breast milk, 24 calories per ounce, p.o. breast milk 20 calories per ounce, mixed with four calories per ounce of Enfamil powder. Medications: Ferrous sulfate 25 mg per cc, 0.15 cc p.o. q. day. Car seat position screening. State newborn screens were sent on [6-28] and [7-8]. Results are pending. Immunizations: Infant received hepatitis B vaccine on [7-6]. Follow-up appointments: Follow-up with primary pediatrician, recommended on [2151-7-12]. Visiting nurses association. DISCHARGE DIAGNOSES: Prematurity, 33 and [3-15] week, twin gestation. Status post rule out sepsis. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ],m.d.50-aad Dictated By:[Last Name (NamePattern1) 37196] MEDQUIST36 D: [2151-7-8] 02:21 T: [2151-7-8] 15:00 JOB#: [Job Number 51649] ICD9 Codes: V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8497 }	Medical Text: Admission Date: [2124-10-18] Discharge Date:[2124-10-12] Service: HISTORY OF PRESENT ILLNESS: This is an 89 year-old white male with the history of coronary artery disease, status post PTCA times three, hypertension, spinal stenosis, osteoarthritis who presents with lower gastrointestinal bleed times three hours. Patient was in his usual state of health until approximately 9 P.M. last night when he noted the onset of diarrhea. He describes stool as bright red but with a formed element, i.e. not pure blood. He had five such episodes overnight. He says that he contact[Name (NI) ] his granddaughter who recommended to try to get some rest. The diarrhea persisted and during the episode the patient go up to use the bathroom and felt faint. It is unclear whether he lost consciousness at this time. He had several more episodes of bloody diarrhea, the last of which was pure blood per the patient. He called 911 and was brought to the [Hospital1 1444] Emergency Room at 2 A.M. on the morning of admission. He denies abdominal pain although he describes some discomfort located in his suprapubic region. This discomfort is not new. He denies nausea, vomiting, melena, cramping, fevers, chills. He has not eaten anything unusual. He has had no sick contacts. [Name (NI) ] has not had any fatigue and describes the weight loss as occurring during the last six months with wife's illness and death which was in [2124-3-23]. He presents for evaluation and work up of lower gastrointestinal bleeding. The patient does have a remote history of diverticulosis that improved when he stopped eating nuts and taking the skin off his apples. PAST MEDICAL HISTORY: Coronary artery disease. He is status post PTCA times three, hypertension, spinal stenosis, status post laminectomy, osteoarthritis, possible history of diverticulitis, hypothyroidism. MEDICATIONS: Lopressor 50 mg p.o. b.i.d., Lasix 50 mg p.o. q. day, Norvasc 10 mg p.o. q. day, Cardura 2 mg p.o. b.i.., Niacin 250 mg p.o. q. day, Levoxil 250 mcg p.o. q. day. He has allergy to benzodiazepines. SOCIAL HISTORY: Lives at Brick House in [Location (un) ]. No alcohol use. He has a remote history of smoking less than ten pack years. FAMILY HISTORY: His father had cancer. PHYSICAL EXAMINATION: On admission vital signs temperature 98.1, blood pressure 138/44, pulse 76, respirations 12, oxygen saturation 99% on room air. In general this is a minimally obese elderly white male lying in bed in the Emergency Room in no acute distress. Head, eyes, ears, nose and throat normocephalic, atraumatic. Pupils equal, round and reactive to light and accomodation. Extraocular eye movements intact. Oropharynx was clear. Pulmonary clear to auscultation bilaterally, no wheezes, or rhonchi. Cardiology: distant heart sound, regular rate and rhythm, normal S1, S2, no murmurs or gallop. Abdomen soft and obese, nontender, no hepatosplenomegaly, no ecchymosis, no rebound or guarding, normal active bowel sounds. Extremities: 1+ pulses in lower extremities, no clubbing, cyanosis or edema, good capillary refill. Neurologic grossly intact. LABORATORY DATA: White blood cell count 9.4, hemoglobin 7.3, hematocrit 22.5, platelets 252, neutrophils 89%, lymphocytes 9%, monocytes 2%, no eosinophils or basophils. PT 12.9, INR 1.1. PTT 23.4. Sodium 140, potassium 4.8, chloride 106, bicarb 22, BUN 56, creatinine 1.8 and glucose 229. Electrocardiogram showed sinus rhythm with right bundle branch block, no acute changes compared with electrocardiogram from [Month (only) 1096] of 2,000. HOSPITAL COURSE: The patient was admitted for evaluation of lower gastrointestinal bleed, however, was noted to have a stool with bright red blood clots and was transferred to the Medical Intensive Care Unit the day after admission on the [4-18]. Gastrointestinal: Once the patient was transferred for evaluation to the Medical Intensive Care Unit he was given a bowel prep of Go-Lytely and sent for colonoscopy. On colonoscopy it was found that the patient had diverticulosis of the hepatic flexure, transverse colon and descending colon and sigmoid colon. Otherwise the colonoscopy was normal to the cecum. On the following day the patient had an esophagogastroduodenoscopy which only showed duodenitis and no other source for bleeding. The patient did not have any further episodes of diarrhea or bright red blood per rectum or melena throughout his course in the Medical Intensive Care Unit and once his hematocrit was stabilized with transfusions continued to do very well from gastrointestinal standpoint. The patient was started on Protonix 40 mg p.o. q. day on hospitalization to protect against further irritation of his stomach lining. This dose was increased to 40 mg p.o. b.i.d. during the hospital stay and was sent home with a prescription for Protonix 40 mg p.o. b.i.d. Hematology: The patient was transfused a total of eight units of packed red blood cells during his stay in the Medical Intensive Care Unit. His hematocrit responded initially inadequately to the transfusions, however, then responded adequately and was stable for 48 hours after his transfusions in the range of 33 to 37. The patient's coagulations were normal and his hematocrit was stable on discharge. Cardiology: The patient has a history of coronary artery disease, status post PTCA times [2121]. He had no episodes of chest pain during his hospital course. His hypertensive medication was held during his Medical Intensive Care Unit stay. On transfer to the floor he was restarted on his regular dose of Cardura and Norvasc and Lopressor was titrated back to his usual 58 mg b.i.d. dose. Endocrine: The patient has a history of hyperthyroidism and was maintained on Levoxil 250 mg p.o. q. day dosing. Pulmonary: The patient had no evidence for congestive heart failure after his transfusions. His O2 saturations were stable. Renal: The patient's creatinine was initially elevated on admission at 1.8. However, with hydration this dropped to a baseline of 1.2. Prophylaxis: The patient had pneumoboots while in the Medical Intensive Care Unit when he was not ambulating. These were discontinued once he started ambulating. He was also maintained on Protonix as described above. DISCHARGE DIAGNOSIS: Lower gastrointestinal bleed, likely secondary to bleeding diverticulosis. DISCHARGE CONDITION: Good and improving. Patient was evaluated by Physical Therapy and was able to ambulate very well before discharge. He was also tolerating p.o. without any nausea, vomiting or pain. Physical Therapy determined that the patient was functioning at a very high level and could return home with his cane. DISCHARGE MEDICATIONS: Protonix 40 mg p.o. b.i.d., Cardura 2 mg p.o. b.i.d., Lopressor 50 mg p.o. b.i.d. and Lasix 50 mg q. day, Norvasc 10 mg p.o. q. day, niacin 250 mg p.o. q. day, Levoxil 250 mg p.o. q. day, Levoxil 250 mcg p.o. q. day. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1207], M.D. [MD Number(1) 1208] Dictated By:[Last Name (NamePattern1) 7896] MEDQUIST36 D: [2124-10-22] 13:03 T: [2124-10-22] 13:10 JOB#: [Job Number ] ICD9 Codes: 4280, 2449, 4019, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8498 }	Medical Text: Admission Date: [2154-2-27] Discharge Date: [2154-3-4] Date of Birth: [2117-5-22] Sex: M Service: Trauma Surgery HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old male who fell down the stairs at home and had a knife in his rear pocket. The knife stabbed him in the left flank. He presented to an outside hospital where a CT scan was done. The patient was hypotensive at this outside hospital to 88/38 and his hypotensive was responsive to fluid. A CT scan demonstrated a left hematoma around his kidney as well as a renal laceration and small splenic laceration. Among this, the patient was transferred to [Hospital1 188] for trauma care. PAST MEDICAL HISTORY: Status post exploratory laparotomy for stab wound. MEDICATIONS: He is currently on no medications. ALLERGIES: He has no allergies. SOCIAL HISTORY: Is a pack per day smoker with heavy alcohol use history. PHYSICAL EXAM ON ADMISSION: The patient's temperature was 98.7, blood pressure 140/palpable to 124/73, pulse 90, respiratory rate 18, and saturating 96% on room air. Head and neck examination showed equal, round, and reactive pupils. Supple neck with midline trachea. No head trauma. The patient's neck was nontender to palpation. Chest and lungs were clear to auscultation bilaterally. Cardiac was regular rate, no murmurs, rubs, or gallops. His back was without step-off, deformity, or tenderness. On abdominal examination, the patient had an approximately 3 cm stab wound to his left flank which was draining copious amounts of fluid. A Foley was placed which was draining bloody urine. Rectal examination showed normal tone, it was heme negative. Trauma laboratory values demonstrate a sodium of 138. Blood gas: 7.38, 37, 75, 23, and -2, and lactate of 1.4. The patient had a white count of 16.4 and hematocrit of 36 which decreased to 33.5. Repeat CT scan was done in the Emergency Room which demonstrated again, a left perinephric hematoma with a renal laceration. No evidence of vascular or ureteral injury. There is also no evidence of contrast extravasation from the bowel. Additionally, there is no free air in the abdomen. HOSPITAL COURSE: From the Emergency Room, the patient was admitted to the Trauma Intensive Care Unit, where he was observed with serial abdominal examinations and hematocrit checks overnight. Throughout hospital day one, the patient's hematocrit was followed, was noted to be slightly decreasing in value from 36 and to 33 to 29, then to 28 by 4:30 pm on hospital day one. Urology consult was obtained, who thought the patient had a grade [2-26] left renal penetrating injury. A creatinine was sent from the fluid, which the patient had from his stab wound, which is not consistent with urine leaking at that time. Throughout hospital day one, the patient continued to ooze serosanguinous fluid from his stab wound. Additionally his hematocrit continued to fall further. Given this, it was decided on hospital day one to take the patient to the operating room for exploratory laparotomy and questionable renal repair. On [2154-2-27] in the evening, Mr. [Known lastname ] was taken to the operating room by Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) 770] of Urology. Exploratory laparotomy excision was made. At that time, a left renorrhaphy had a 3 cm laceration of the kidney was performed as well as a splenorrhaphy was performed for a small renal laceration which was present. Findings at that time showed a grade 3 renal laceration. The patient tolerated the procedure well. A Hemovac drain was left posterior to the kidney, pancreas, and spleen for drainage of fluid postoperatively. Intraoperatively, the patient received approximately 8,000 cc of crystalloid and 5 units of packed red blood cells for an estimated blood loss of approximately 2500 cc. Postoperatively, the patient was transferred from the operating room back to the Trauma Intensive Care Unit for continued abdominal examination, monitoring of his wound output overnight from postoperative day 0 to postoperative day one, the patient did well. His hematocrit postoperatively was noted to be 38. This remained relatively stable overnight from postoperative day 0 to postoperative day one. JP output was high on postoperative day one. This drain putting out approximately 1,000 cc. Initially on postoperative day one, it was decided to transfer the patient from the Trauma Intensive Care Unit to the regular floor. The patient was maintained on Kefzol from postoperative days one through four until his JP drain was discontinued. On postoperative day two, the patient's drain continued to have a high amount of output, there was a question whether or not the patient had a kyllous leak. At this time, a PICC line was obtained via the IV service at the hospital, and TPN was started given the patient might be unable to eat should this be a kyllous leak. Workup for a kyllous leak revealed a JP fluid triglyceride count of 22, amylase of 36, and a creatinine of 0.6, so this is probably not felt to be kyllous. The patient was started back on a regular diet on postoperative day three. On postoperative day three, the patient tolerated a regular diet well. Additionally, the patient was seen by the Physical Therapy service for mobilization. They felt that he would be good for discharge home and has good rehabilitation potential. On hospital day five, postoperative day four, the patient was doing well. He continued to tolerate a regular diet, and was able to ambulate on postoperative four, the patient's Foley was discontinued. He was able to urinate without any difficulty. Postoperative day five, that is [2154-3-4], the patient was doing well, tolerating regular diet, JP output on the previous day had only been 260 cc. Because of this, it was decided to discontinue the JP drain and antibiotics at this time. On [2154-3-4] on postoperative day five again, the patient tolerated regular diet, ambulating, and with his Foley and JP drain removed, it was decided to discharge the patient to home. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Stab wound left flank. 2. Status post exploratory laparotomy. 3. Renorrhaphy. 4. Splenorrhaphy. DISCHARGE MEDICATIONS: 1. Percocet 1-2 tablets po q4-6h prn pain. 2. Colace 100 mg po bid prn constipation. FOLLOW-UP INSTRUCTIONS: The patient should follow up with the Trauma Clinic within 7-10 days for discontinuation of staples. The patient is instructed to return to his primary care physician within the next two weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2213], M.D. [MD Number(1) 2214] Dictated By:[Name8 (MD) 16207] MEDQUIST36 D: [2154-3-4] 11:55 T: [2154-3-5] 06:41 JOB#: [Job Number 47307] ICD9 Codes: 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8499 }	Medical Text: Admission Date: [2173-11-28] Discharge Date: [2173-12-3] Date of Birth: [2111-5-12] Sex: F Service: MEDICINE Allergies: Macrodantin / Zosyn Attending:[First Name3 (LF) 2485] Chief Complaint: FEVER Major Surgical or Invasive Procedure: PICC line placement Foley Catheter Right Internal Jugular Venous [Last Name (un) ] Bronchoscopy History of Present Illness: 62 yo woman with MS (non-verbal), chronic vent [Hospital 105385] transferred from rehab ([Hospital3 672]) with potassium of 7.2. She was given kayexelate and calcium gluconate 2 amps then transferred here. Potassium here 3.9. She was found to be febrile to 101.2. Of note she had a midline placed yesterday. Per her daughters this was to treat a urinary tract infection, which she gets frequently. At baseline her daughters report she interacts with them by nodding yes or no. She does this about 80% of the time when she is at her best. .ROS: Per her daughters she has been more drowsy the past few days, and may have had fever yesterday. They deny any diarrhea, change in vent secretions, known change in sacral decubs, or recent epidemics at her facility. She was noted to be in a room with a patient colonized with VRE so had to be moved. . Review of reocrds from [Hospital 106167] Hospital: Urine Cx [11-18]: Proteus sensitive to amikacin, aztreonam, ceftaz, cefepime, cefoxitin, cefuroxime, cefotetan, imipenem, zosyn; pseudomonas sensitive to amikacin, ceftaz, cefepime, defotetan, imipenem, zosyn. Urine Cx [11-24]: Proteus, same sensitvity panel except resistance to aztreonam. Respiratory culture [11-25]: GNR's: pseudomonas, 2 other colonies, GPR's. WBC 10.3 [11-28], 76% PMN's, potassium 7.2 (not hemolyzed) MD orders: [11-14]: cefuroxime 500mg [Hospital1 ] x14 days, [11-15]: cefuroxime d/c'd, bactrim DS started Notes: Desat to 70's [11-27], suctioned, switched from SIMV to AC, FIO2 increased, sats to 98. . In the ED, VS: T on arrival: 101.2 T at transfer: 99.8 HR 78 BP 129/74 RR 15 Sat 100% on AC 500/15/5/35%. She was given vancomycin 1gm iv, cefepime 2gm iv, tylenol and 1L NS. Blood cultures and urine culture were sent. Past Medical History: Nephrolithiasis: Staghorn Calculi, urosepsis, stent placement [10-7] MS: vent dependent x7 years, s/p G-tube Chronic decubitus ulcers COPD Hypertension Anemia Gallstones DM Social History: In NH/rehab for many years. No history of smoking or etoh use. Family History: Mother with breast CA, sister with ovarian CA, multiple family members with DM, HTN, CVA. Physical Exam: VS: T: 98 HR: 78 BP: 101/57 RR: 19 Sat: 97% on 500/10(13)/5/35% Gen: Elderly woman in NAD HEENT: NC/AT, sclera white, conjunctiva pink, disconjugate gaze (baseline per daughter), [Name (NI) 2994] 3->2mm, unable to assess OP Neck: No LAD, unable to assess JVP 2/2 habiuts CV: RRR, S1, S2 present, no murmurs/rubs/gallops, 2+ DP pulses bilaterally Resp: Bilat rhochi R>L, no wheezes, rales, rhonchi Abdomen: Soft, NT, ND, +BS, no masses or organomegally, G-tube site intact, midline lower abdominal scar, well-healed (thought [2-5] C-section) Ext: trace edema UE/LE bilaterally, chronic contractures Neuro: Moves head, eyelids, does not respond to commands, no movement of torso/extremities Skin: Sacral decubitus ulcer and left hip ulcer: sacral probes beyond view, hip probes to friable, necrotic looking tissue, unclear if either go to bone, no other rashes Pertinent Results: Admission Labs: [2173-11-28] 02:40PM WBC-9.2 RBC-3.79* HGB-10.3* HCT-30.5* MCV-81* MCH-27.1 MCHC-33.7 RDW-15.5 [2173-11-28] 02:40PM NEUTS-80.9* LYMPHS-12.2* MONOS-5.9 EOS-0.6 BASOS-0.5 [2173-11-28] 02:40PM PLT COUNT-324 [2173-11-28] 02:40PM PT-13.6* PTT-33.5 INR(PT)-1.2* [2173-11-28] 02:40PM ALT(SGPT)-39 AST(SGOT)-29 ALK PHOS-109 AMYLASE-65 [2173-11-28] 02:40PM GLUCOSE-114* UREA N-26* CREAT-0.6 SODIUM-139 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-22 ANION GAP-17 [2173-11-28] 03:30PM URINE 3PHOSPHAT-RARE [2173-11-28] 03:30PM URINE RBC-21-50* WBC-21-50* BACTERIA-MOD YEAST-NONE EPI-0 [2173-11-28] 03:30PM URINE BLOOD-LG NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-MOD [2173-11-28] 04:10PM LACTATE-2.8* CXR [12-3] - In comparison with the study of [12-2], the right IJ catheter has been removed and replaced with a right subclavian line that extends to the lowest portion of the superior vena cava. Again, the cardiac silhouette is displaced to the right. Some increased opacification at the right base is consistent with partial collapse. Tracheostomy tube remains in place . Renal US - [11-29] - Multiple renal stones bilaterally. No evidence of gross hydronephrosis. Bladder is poorly visualized. . [2173-11-28] 3:30 pm URINE CLEAN CATCH. FINAL REPORT [2173-12-1] URINE CULTURE (Final [2173-12-1]): PROTEUS MIRABILIS. PRESUMPTIVE IDENTIFICATION. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 I CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 4 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- 32 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R . [2173-11-30] 5:36 pm BRONCHOALVEOLAR LAVAGE Site: ENDOTRACHEAL FINAL REPORT [2173-12-4] GRAM STAIN (Final [2173-11-30]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [2173-12-4]): 10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML.. OF TWO COLONIAL MORPHOLOGIES. GRAM NEGATIVE ROD #3. 10,000-100,000 ORGANISMS/ML.. PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. 2ND STRAIN. PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. GRAM NEGATIVE ROD(S). ~6OOO/ML. 6TH TYPE. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. GRAM NEGATIVE ROD(S). ~3000/ML. 7TH TYPE. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| PSEUDOMONAS AERUGINOSA \| \| CEFEPIME-------------- 4 S <=1 S CEFTAZIDIME----------- 4 S <=1 S CIPROFLOXACIN--------- 2 I =>4 R GENTAMICIN------------ <=1 S <=1 S IMIPENEM-------------- <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN---------- 8 S <=4 S PIPERACILLIN/TAZO----- 8 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S Brief Hospital Course: 62 yo woman with MS who presented from [Hospital ] rehab with hyperkalemia, now with fever, elevated lactate. . # Fever: Multiple possible sources, given elevated lactate concerning for sepsis though BP relatively stable, not tachycardic, normal WBC. Urine culture from OSH positive for Proteus and Serratia, cefepime sensitive UTI although the patient has a chronic indwelling foley difficult so this could be colonization. CXR significant for RRL collapse, likely complicated by a PNA. Underwent Bronchoscopy on [11-30] and had thick secretions suctioned. The following day her CXR showed mild improvement, with better visualization of her right heart border. Sputum from OSH positive for Pseudomonas with sensitivies pending. Plastics saw her decubs, felt that they were chronic and not contributing to her fevers. Has staghorn calculi bilaterally by KUB - urology consulted and did not feel that these were contributing to her acute picture and could be followed as an outpatient. The patient was placed on cefepime and will continue a 15 day course. . # Hyperkalemia/Hypokalemia: Unclear etiology, after treatment with kayexelate improved to 3.9. She then became hypokalemic the following day, requiring potassium supplementation. Cr was in normal range but may be elevated for her given chronic immobility. Consider obstructing stone with hydronephrosis vs. hemolysis. No concerning changes on ECG. Urology was consulted for lithotripsy - did not recommend inpatient procedure, outpatient appointment scheduled for [Month (only) 404] with Dr. [Last Name (STitle) 724] at [Hospital1 2177]. . # Sacral decubitus and left hip ulcers: Plastics feels they are chronic as above no acute intervention was felt to be warranted. The patient was given a kinair bedand wound care reccomendations were followed. . # Staghorn calculi: Likely infected (proteus). She was continued on cefepime. Proteus not sensitive to cipro per OSH cultures. Urology consult reccommended no intervention at this time. She has an outpatient appointment scheduled for [Month (only) 404] with Dr. [Last Name (STitle) 724] at [Hospital1 2177]. . # Chronic respiratory failure: She remained stable and wa maintained on her current vent settings. . # Hypertension: On metoprolol, captopril at baseline. Unknown if she has autonomic dysregulation with MS. [First Name (Titles) ] [Last Name (Titles) 106168] were held and restarted at discharge. . # COPD: Her atrovent/albuterol was continued. . # Anemia: Unknown baseline hct, microcytic. Continued iron supplementation and monitored for acute blood loss. . # DM: Continued home regimen of lantus and SSRI, monitored BG, well-controlled on current regimen . # FEN: Tube feeds per Nutrition consult. Monitored and repleted lytes prn. Medications on Admission: Milk of magnesia 30mL q4 prn dulcolax pr daily vitamin C 500mg PO bid tylenol 650mg po q4 prn zinc 220mg po daily theragram daily metoprolol 50mg [Hospital1 ] atrovent neb q6hr prn novolin slikding scale q12 lantus 22u QHS feosol 325mg po bid nexium 40mg po daily vitamin D 400u qd lovenox 40mg daily colace liquid 100mg [Hospital1 ] captopril 12.5mg q8 combivent 4 puffs qid albuterol q6h prn Discharge Disposition: Extended Care Facility: [Hospital3 672] Hospital Discharge Diagnosis: Hyperkalemia Urinary Tract Infection Pneumonia Discharge Condition: Improved Discharge Instructions: You were admitted for hyperkalemia. You were treated for this electrolyte disorder and your levels of potassium are now low normal. You have a fever and cultures from you urine and lungs showed evidence of infections for which you have been prescribed a course of antibiotics. If you should experience any return of your fevers, increased difficulty breathing, hypotension or any symptoms that are new, worse or of concern to you or your care provider please call your physician or return to the hospital. Followup Instructions: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 724], Urology, [Hospital6 ], [2174-1-27] at 10am. ICD9 Codes: 5990, 5180, 2767, 4019, 496, 2859

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