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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8600
} | Medical Text: Admission Date: [**2159-7-26**] Discharge Date: [**2159-8-5**]
Date of Birth: [**2159-7-26**] Sex: M
Service: NB
DISCHARGE DIAGNOSES:
1. Premature male infant at 35 and 1/7 weeks gestation.
2. Status post respiratory distress.
3. Status post hyperbilirubinemia.
4. Status post immature feeding.
HISTORY OF PRESENT ILLNESS: [**Known firstname 58533**] is the former 35 and [**12-20**]
week infant born weighing 2.170 kilograms to a 33-year-old
gravida 2, para 1 (now 2) B positive female who prenatal
screens were noncontributory. Group B strep status was
unknown.
The pregnancy was notable for a twin gestation with one fetus
suffering an in utero demise at 20 weeks gestation. The
mother was followed serially via ultrasound as there were
concerns over the overall growth of this infant. On the day
of delivery, the images revealed decreasing fetal growth
which prompted delivery.
The delivery was by repeat cesarean section. No sepsis risk
factors. The infant was delivered with Apgar scores of 8 and
8. The infant was admitted to the Newborn Intensive Care
Unit at [**Hospital1 69**] with mild
respiratory distress.
PHYSICAL EXAMINATION ON PRESENTATION: On admission, the
infant weighed 2.170 kilograms, length was 44 cm, and head
circumference was 30 cm; all appropriate for gestational age.
SUMMARY OF HOSPITAL COURSE: Problems during hospital stay
included.
1. RESPIRATORY: The infant remained on nasal cannula from
[**7-26**] through [**7-31**]. An x-ray done at four days
of life revealed some mild hypoinflation. No evidence of
hyaline membrane disease. The infant remained on room air
thereafter with no episodes of apnea or bradycardia.
1. CARDIAC: There were no cardiac issues.
1. FEEDING AND NUTRITION: At the time of discharge, the
infant weighed 2.015 kilograms. He initially had not been
able to feed all by mouth. At the time of discharge, the
infant was feeding a minimum of 130 cc per kilogram per
day of expressed mother's milk - made up to 24 calories
per ounce on Similac 24. The infant initially was kept at
130 cc per kilogram because of frequent spitting and
eventually increased to 140 cc/kg.
1. INFECTIOUS DISEASE: The initial complete blood count was
benign. No antibiotics were initiated. The infant was
delivered for intrauterine growth restriction.
1. HEMATOLOGIC: The mother was B positive. The infant had
an initial hematocrit of 44.2, and a peak bilirubin of
14.8, with a direct bilirubin of 0.4 - for which he
underwent several days of phototherapy. On [**8-2**] -
with a bilirubin of 8.4/0.3 - phototherapy was
discontinued. On [**8-3**], a rebound bilirubin was
drawn and was 7.4/0.3.
1. GENITOURINARY: There was initially some question as to
whether the infant had some hypospadius; however, several
of us did examine the infant. The foreskin looked
complete. The parents were not interested in
circumcision.
1. AUDIOLOGY: A hearing screen performed prior to discharge.
1. IMMUNIZATIONS: Hepatitis B immunization number 1 was
given on [**8-1**].
1. NEUROLOGIC: A screening head ultrasound was done on
[**7-30**] because of the intrauterine fetal demise at 20
weeks of the twin. The head ultrasound was normal.
DISCHARGE STATUS: At the time of discharge, the infant was
sent home feeding Similac 24 calories per ounce or expressed
mother's milk made up to 24 calories.
DISCHARGE FOLLOWUP: Upon discharge, the infant will be
followed at [**Hospital1 **] [**Location (un) 1468**] Center by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]. The infant shall be seen within five days of
discharge. As the patient's speak little English, I have
been conversing with the paternal aunt [**Name (NI) **]. [**First Name8 (NamePattern2) 58534**] [**Last Name (Titles) **]), and
she has been relaying information to the parents. There has
been one family meeting with interpreters present.
DR,[**Doctor Last Name **],[**Doctor Last Name **] 50-398
Dictated By:[**Last Name (NamePattern1) 56049**]
MEDQUIST36
D: [**2159-8-2**] 12:06:20
T: [**2159-8-2**] 12:32:01
Job#: [**Job Number 58535**]
ICD9 Codes: 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8601
} | Medical Text: Admission Date: [**2104-1-8**] Discharge Date: [**2104-1-10**]
Date of Birth: [**2026-5-18**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
abnormal stress test
Major Surgical or Invasive Procedure:
s/p cardiac cathterization with stent on [**2104-1-8**]
History of Present Illness:
77 year old female with DM, COPD, CAD s/p CABG [**2101**], angina and
abnormal stress test at OSH with worsening EF on [**1-3**] presents
for cardiac catheterization. Patient's cardiac history includes
a silent MI about 15 yrs ago, CP and dyspnea with MI in [**2101**],
s/p CABGx4 by Dr. [**Last Name (STitle) 5296**]. Patient was diagnosed with DM 2 days
prior to admission with blood sugar 300. Pt was admitted to OSH
last week with CHF. She was admitted again on [**1-7**] with CHF, BNP
1760, ruled out for MI. At OSH patient noted to have worsening
EF and she was admitted to [**Hospital1 18**] for cath. Patient states she
had CP at rest 5 days prior for 10 minutes and overnight that
night woke up short of breath without CP. Patient denies
orthopnea. She has had increasing lower extremity swelling in
the past 4 days and does get short of breath with activity (she
has had PFTs at [**Location (un) **] in past).
During catheterization patient had an episode of CP,
increased PCWP and hypotension when balloon was inflated, but
this resolved when balloon was deflated. A small vessel was
perforated and Echo performed but no effusion seen.
Past Medical History:
HTN
hypercholesterolemia
newly diagnosed DM
ischemic CM
silent MI [**2088**]'s
CAD s/p MI and CABG [**2101**] (LIMA-LAD; VG-diag; VG2-OMs)
known LBBB
s/p cataract surgery
osteo
right CEA
Social History:
Soc Hx: widowed, 1.5 ppd tobacco x 50 yrs.
Family History:
Non-contributory
Physical Exam:
afebrile 101 128/66 19 97%/2L n.c.
Gen: AOX3, pleasant, NAD, speaking in full sentences
HEENT: MMM, small amount dried blood on lip
Neck: supple
CV: Distant S1, S2, RRR, no murmurs appreciated
Pulm: CTA-anteriorly
Abd: Normoactive BS, soft, ND/NT
Ext: wwp, 1+ pitting edema b/l, 1+ DP b/l. Right groin without
hematoma.
Pertinent Results:
[**2104-1-8**] 05:09PM TYPE-ART PO2-85 PCO2-52* PH-7.40 TOTAL
CO2-33* BASE XS-5 INTUBATED-NOT INTUBA
[**2104-1-8**] 05:09PM O2 SAT-96
.
[**2104-1-8**] 10:24PM BLOOD CK(CPK)-75 CK-MB-3
[**2104-1-9**] 04:05AM BLOOD CK(CPK)-77 CK-MB-4
.
[**2104-1-8**] CARDIAC Catheterization
FINAL DIAGNOSIS:
1. Two vessel native coronary artery disease. Patent SVG-OM3.
Occluded
proximal SVG-D1-OM2 with patent D1-OM2 jump segment. Atretic
LIMA-LAD.
2. Mild biventricular diastolic dysfunction.
3. PCI of LAD with DES.
COMMENTS: 1. Selective coronary angiography demonstrated native
two
vessel coronary artery disease in this right dominant
circulation. The
LMCA had mild disease without flow limitation. The LAD was
heavily
calcified proximally with serial 80% and 90% stenoses in the mid
and
distal vessel. The diagonal had a jump segment of vein graft
that filled
an occluded OM. The LCX had a 50% proximal stenosis. The OM1 was
without
flow limiting disease. The OM2 and OM3 were totally occluded.
The OM2
filled via the jump segment from the diagonal. The OM3 filled
via a
patent vein graft. The RCA had mild luminal irregularities
without flow
limiting disease.
2. Graft angiography demonstrated the SVG-OM3 to be widely
patent. The
SVG-D1-OM2 was totally occluded in the proximal graft with a
patent jump
segment supplying the OM2 via the native diagonal.
3. Arterial conduit angiography demonstrated an atretic LIMA-LAD
with
minimal flow into the LAD.
4. Resting hemodynamics from right and left heart
catheterization
demonstrated elevated right and left filling pressures
(RVEDP=15mmHg,
PCWP=20mmHg, LVEDP=20mmHg). Cardiac output and index were
preserved at
4.9 L/min and 2.8 L/min/m2. Mild pulmonary arterial hypertension
was
present.
5. Left ventriculography was not performed to reduce contrast
load.
6. PCI of LAD with DES.
.
Echocardiogram [**2104-1-9**]:
EF 20%. The left atrium is elongated. Left ventricular wall
thicknesses and cavity size are normal. There is severe regional
left ventricular systolic dysfunction with relative preservation
of the basal lateral and distal lateral walls and near akinesis
of remaining segments. No masses or thrombi are seen in the left
ventricle. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Extensive regional left ventricular systolic
dysfunction c/w multivessel CAD or other diffuse process.
Moderate pulmonary artery systolic hypertension. Mild mitral
regurgitation. No pericardial effusion.
.
Day of discharge Labs [**2104-1-10**]:
[**2104-1-10**] 05:15AM BLOOD WBC-9.4 RBC-3.30* Hgb-10.4* Hct-30.3*
MCV-92 MCH-31.6 MCHC-34.5 RDW-13.2 Plt Ct-341
[**2104-1-10**] 05:15AM BLOOD Glucose-111* UreaN-28* Creat-1.3* Na-143
K-4.1 Cl-103 HCO3-34* AnGap-10
Brief Hospital Course:
A/P: 77 yo F with DM, COPD, CAD s/p CABG '[**01**], recent angina and
abnormal stress test at OSH w/ worsening EF on [**1-3**] presents
for cardiac catheterization.
.
1. CV:
Ischemia: s/p LAD stents. Continue ASA, Plavix,
beta-blocker, statin. Not on ACEI given history of ?renal
failure. Started Captopril, creatinine stable at 1.3 and
transitioned to lisinopril 5 on day of discharge. Creatinine to
be followed by outpatient PCP and cardiologist.
Pump: Continued lasix and titrate to goal even to 500 cc
negative. Rechecked Echo on 1/0/06, EF 20%, mod PA systolic
HTN, no pericardial effusion (results above). Started Digoxin
0.125.
Rhythm: NSR, monitor on Telemetry. Monitor EKGs.
.
2. DM: newly diagnosed and not on any medications. Will check
finger sticks and regular insulin sliding scale for now.
Patient required very little insulin, blood sugars 100-170.
Patient to follow with [**Last Name (un) **] at [**Location (un) **]. She is to follow-up
with PCP 5 days after discharge and to schedule an appointment
at the [**Last Name (un) **] in the next week. She was given a glucometer and
was instructed to test her blood sugars at least once daily and
call her PCP if blood sugars > 300.
.
3. Pulm: Patient with COPD, not currently wheezing. Continue
advair.
.
4. FEN: low salt/heart healthy/diabetic diet. Monitor
electrolytes and repleted prn.
.
5. Proph: ambulate, PT to see pt prior to discharge.
.
6. Dispo: Patient to receive VNA at home for Diabetes teaching.
She is to test blood sugars at least once daily. She has
follow-up scheduled next week with both her PCP and her
cardiologist.
Medications on Admission:
Toprol xl 200 qam, 100 qpm
Pravachol 80 po qhs
Plavix
Norvasc 10 po qday
lasix 40 po qday
ecASA 325 qday
zetia 10 po qday
Fosamax qweek
folate 1 po qday
advair [**Hospital1 **]
ambivent
?metazalone (new), ?recently started on digoxin
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 30 days.
Disp:*30 Tablet(s)* Refills:*1*
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO twice a day.
Disp:*120 Tablet Sustained Release 24HR(s)* Refills:*2*
4. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
coronary artery disease s/p cardiac catheterization on [**2104-1-8**]
systolic congestive heart failure
diabetes mellitus
Discharge Condition:
stable
Discharge Instructions:
Please call your physician or return to the hospital if you
experience chest pain, shortness of breath, increased leg
swelling or other concerning symptoms.
Followup Instructions:
You have a follow-up appointment scheduled with your
cardiologist, Dr. [**Last Name (STitle) 11493**] on [**1-16**] at 9:45 a.m.
You have a follow-up appointment scheduled with Dr. [**Last Name (STitle) 27772**] on
Tuesday, [**2104-1-15**] at 9:45 a.m.
Please call [**Telephone/Fax (1) 27773**] to schedule an appointment with the
[**Hospital **] clinic at [**Location (un) **] in the next week.
Completed by:[**2104-1-10**]
ICD9 Codes: 4280, 496, 2720, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8602
} | Medical Text: Admission Date: [**2136-8-7**] Discharge Date: [**2136-8-13**]
Date of Birth: [**2057-10-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Naprosyn / Lamisil At / Naftin
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2136-8-7**] - Aortic Valve Replacement( 19mm Magna Pericardial Tissue
Valve)
History of Present Illness:
This 78 year-old female with a
history of congestive heart failure and hypertension who for
the past 2 years had had progressive symptoms which included
dyspnea on exertion. These symptoms have progressively
increased, especially over the past 2 months. The
echocardiogram showed an ejection fraction of 65 to 70% with
an aortic valve area of 0.51. Coronary catheterization
revealed no evidence of coronary artery disease. Based on
this findings the patient agreed to proceed with surgery. The
risks, benefits and possible alternatives were discussed with
the patient, including but not limited to bleeding,
infection, myocardial infarction, cerebrovascular accident,
death, renal and pulmonary insufficiency as well as future
operations for her heart valves and she agreed to proceed. We
specifically discussed the possibility of all these
complications. We also discussed the valve choices and the
patient agreed and would like to have a tissue valve to avoid
the use of Coumadin. All questions were answered prior to
proceeding to the surgery to the patient's satisfaction.
Past Medical History:
Heart Failure
Aortic Stenosis
Obesity
Hypertension
Bilateral wrist fractures
s/p ceasarian section
s/p cholecystectomy - 20 years ago
Social History:
Homemaker
Lives alone
Tobacco: denies
Alcohol: denies
Family History:
Noncontributory
Physical Exam:
Preop:
Vitals: Blood pressure 140/70, Heart Rate 76, Respiratory Rate
24, weight 204 pounds
General: well developed female in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD, Carotid murmur bilaterally
Heart: regular rate, normal s1s2, murmur
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds, red rash ?
yeast over lower abdomen, bilateral groins, and perineum
Ext: warm, no edema, no varicosities
Pulses: 1+ distally, radial +2
Neuro: nonfocal
Discharge:
VS: T 98.2 HR 66SR BP 108/55 RR20 O2Sat 93%RA
Gen-NAD
Neuro-A&O, non focal exam
Pulm- CTA bilat
CV- RRR, sternum stable, incision CDI
Abdm soft, NT/ND/NABS
Ext- warm well perfused, 2+ edema bilat
Pertinent Results:
[**2136-8-13**] 04:51AM BLOOD Hct-26.4* Plt Ct-78*
[**2136-8-13**] 04:51AM BLOOD UreaN-31* Creat-0.8 K-3.2*
[**2136-8-12**] CXR:
Again seen is moderately enlarged heart but it is similar in
size compared to the prior study. The mediastinal contour is
also unchanged. Again seen is a right IJ line with tip in the
right atrium and scarring or volume loss at both bases. There
are small bilateral pleural effusions that have increased
compared to the film from three days ago.
[**2136-8-7**] ECHO
Conclusions:
PRE-BYPASS:
1. The left atrium is markedly dilated. No atrial septal defect
is seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic arch. There are
complex (>4mm)
atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis. Mild (1+) aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
7. There is a trivial/physiologic pericardial effusion.
POST-BYPASS: Pt is being AV paced and is receiving an infusion
of
Phenylephrine
1. A bioprosthesis is well seated in the Aortic position. Trace
wash in jets and trace central AI are noted. A peak gradient of
40-45 mm of Hg was noted and an epicardial scan was also
performed confirming the findings. All 3 leaflets move well.
2. Aorta appears intact
3. Other changes are unchanged.
Brief Hospital Course:
Patient admitted directly to operating room on [**2136-8-7**] for
scheduled aortic valve replacement. At that time she had an AVR
with #19 [**Last Name (un) 3843**]-[**Doctor Last Name **] Magna pericardial tissue valve. Her
bypass time was 111 minutes, crossclamp time was 87 minutes. She
tolerated the operation well and was transferred from the OR to
ICU on Neosynephrine and Propofol infusions. Please see OR
report for details.
The pt did well in the immediate post-op period, anesthesia was
reversed, sedation was weaned off and she was sucessfully
extubated. On POD1 shw was weaned from her Neo infusion,
remained hemodynamically stable and was transferred to the step
down floor for continued post-op care.
Once on the floor the patient had an uneventful post-op course,
on POD2 her chest tubes were removed, on POD 5 here epicardial
wires were removed. Her activity level was advanced with the
assistance of nursing and PT.
On POD 6 it was decided the patient was stable and ready to be
discharged to rehabilitation.
Medications on Admission:
Lisinopril 20mg daily
Lasix 40mg daily
Amoxicillin prn dental
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO Q12H (every
12 hours): 60mg [**Hospital1 **] x 7days then 40mg QD .
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q4H (every 4 hours) as needed.
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO Q12H (every 12 hours):
[**Hospital1 **] x 7 days then QD.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **]
Discharge Diagnosis:
s/p AVR (#19 CE Magna pericardial)
CHF
Obesity
HTN
s/p CCY
s/p C-section
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) No driving for 1 month.
4) No lotions creams or powders to wound until it has healed.
You may shower and wash incision. No swimming or bathing until
wound has healed.
5) Take all medication as prescribed
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1290**] (cardiac surgeon) in 4 weeks. ([**Telephone/Fax (1) 4044**]
Follow-up with cardiologist Dr. [**Last Name (STitle) 32255**] in [**1-6**] weeks.
Follow-up with primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8162**] in [**1-6**] weeks.
([**Telephone/Fax (1) 69501**]
Call all providers for appointments.
Completed by:[**2136-8-13**]
ICD9 Codes: 4241, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8603
} | Medical Text: Admission Date: [**2189-11-29**] Discharge Date: [**2189-11-29**]
Date of Birth: Sex: M
Service: NEURO ICU
HISTORY OF PRESENT ILLNESS: The patient is a 56 year-old man
with a history of a recent stroke at the end of [**Month (only) **]
causing a left sided weakness due to a right frontal stroke.
He also has a history of an old thalamic stroke in [**2179**]. The
patient had also been on Coumadin secondary to hip fractures
and had been in his nursing home since discharge from the
hospital. He was well last night and woke up this morning
and initially felt well and then began to call for help with
new onset left sided weakness. When the staff arrived they
found him leaning to the right with slurred speech. The
patient quickly became less alert and was sent immediately to
[**Hospital1 69**] via ambulance. On
arrival initially he was able to indicate answers to yes or
no questions, but soon became completely unresponsive.
PAST MEDICAL HISTORY:
1. Right thalamic stroke in [**2179**].
2. Right frontal stroke several weeks ago.
3. Gunshot wound in [**2155**].
4. Hip fracture [**9-2**].
5. Hypertension.
6. Hepatitis C.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Baclofen.
2. Procardia.
3. Elavil.
4. Neurontin.
5. Coumadin 5 mg q day.
6. Percocet prn.
SOCIAL HISTORY: Smokes a pack a day. No alcohol or
intravenous drug use for years. Lives in a group home.
PHYSICAL EXAMINATION ON ADMISSION: He was afebrile. His
blood pressure was 200s/100s with a pulse in the 130s.
Generally he was a diaphoretic unresponsive to voice. He was
quickly intubated. He did not open his eyes to command or to
sternal rub. His pupils were 5 mm bilaterally and
nonreactive with no response to visual threat. He had no
response to oculocephalic or ocular vestibular maneuvers. He
had no gag. He had no corneal reflexes. His motor
examination although initially he withdrew his left arm from
pain and had extensor posturing from the right arm, quickly
progressed to no movement to any stimulation in any of his
lower extremities with no spontaneous movements. His
reflexes were trace to absent throughout.
His head CT showed a large left basal ganglia hemorrhage with
blood throughout the ventricular system and with significant
shift and mass effect as well as some edema.
HOSPITAL COURSE: The patient was admitted to the
Neurological Intensive Care Unit with a large left basal
ganglia bleed. He received fresh frozen platelets to reverse
his INR of 3, although no factor 9 complex was available from
the pharmacy on admission. Neurosurgery was consulted, but
was unable to place a drain with his INR at 3. His blood
pressure was controlled with Nipride and Labetalol drips.
His family came into the hospital and another head CT was
performed with increase in bleeding as well as edema and
continued shift. His examination remained without brain stem
reflexes and with no evidence of cortical function. After
prolonged discussion with his family members the family
decided to make the patient CMO and to extubate him. He was
extubated around 7:00 on the [**8-30**] and the patient
expired soon after. The patient was declared at 9:00 p.m.
He had no carotid pulse, no respirations and no heart beat.
The cause of death immediately was respiratory failure. The
other main cause of death was intracranial hemorrhage. The
family was not interested in an autopsy. They were informed
of his death.
DISCHARGE DIAGNOSIS:
Large left basal ganglia hemorrhage with shift in edema.
DISCHARGE STATUS: Expired.
DR [**Last Name (STitle) **] [**Name (STitle) 4267**] 13.282
Dictated By:[**Last Name (NamePattern1) 1203**]
MEDQUIST36
D: [**2189-11-29**] 10:22
T: [**2189-11-30**] 07:12
JOB#: [**Job Number 93316**]
ICD9 Codes: 431, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8604
} | Medical Text: Admission Date: [**2176-3-5**] Discharge Date: [**2176-3-13**]
Date of Birth: [**2124-6-21**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
fevers, hypotension, afib with RVR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 51 year-old female with a history of fistulizing
crohn's, pAfib, who presents with diarrhea, BRBPR, fevers, and
dizziness to the ED. States that since Thursday, her symptoms
have been worsening, c/w previous Crohn's flareups but this is
not as bad as she's had before. She is not on steroids as an
outpt. She has been having worsening LLQ pain, nausea, and
occasional non-bloody emesis. She has been having fevers at home
to 102. She has taken tylenol for fevers at home. She has not
been able to keep much POs down.
In the ED, she was initially afebrile, BP 142/89, HR 105, 99%RA.
While prepping for abd CT, the patient became tachycardic to
150s, ECG with afib. She was given dilt 10 mg IV x 2, with
decreased SBP to 90s and HR in 110s. AT this time, she also
spiked fever to 101. She received 3.5 L of IVFs but SBP
persistently in 80s-90s. Due to the persistent hypotension and
tachycardia, a RIJ was placed, and the patient was started on
levophed, but prior to that she was transiently on dopamine. Her
SBP came up to 120s on levophed, but HR remained in the 120s. A
CT abd was done which was fairly unremarkable except for some
bowel wall thickening, and given her hypotension/tachycardia,
she was given vanco/zosyn in the ED. Levophed was weaned off,
but her HR currently in 140s with plan to give dilt again for
rate control. Lactate was 2.4 in the ED. CXR was without
infiltrate. UA/Uculture not sent yet, but will be prior to
transfer to MICU. Patient is being transferred to MICU for
hypotension and tachycardia thought to be secondary to sepsis.
ROS: As above. Otherwise the patient denies any melena, chest
pain, shortness of breath, orthopnea, PND, lower extremity
oedema, cough, urinary frequency, urgency, dysuria,
lightheadedness, gait unsteadiness, focal weakness, vision
changes, headache, rash or skin changes.
Past Medical History:
Crohn's disease (diagnosed in [**2167**])
Pre-diabetes
Hyperlipidemia
Benign multinodular goiter (followed by Dr. [**Last Name (STitle) **]
Cervical cancer
GERD
Paraspinal cyst (followed by Dr. [**Last Name (STitle) 575**]
Atrial fibrillation
s/p L tib/fib fixation
Surgical History:
[**2167**] - Temporary colostomy
[**2168**] - reversal of colostomy
[**2169**] - reconstruction of fistulas
[**2172**] - bowel resection
[**2173**] - repair of ventral hernia with allograft
[**2174**] - patient reports 7 operations, to fix hernias, had a
abscess under her allograft
Social History:
Lives with her husband. Nicotine: Denies smoking (smoked for 4
years a college student a few cigarettes a day) EtOH: Denies
drinking. Denies use of any recreational drugs
Family History:
Her father has ulcerative colitis. On her father's side, she has
an aunt who was diagnosed at 70 with Crohn's, and a cousin who
was diagnosed at 14 with IBD. There might be more; she says that
her family is very private and likely wouldn't share about their
condition. Her father had esophageal cancer, her maternal
grandfather liver cancer and her maternal grandmother lung
cancer. A paternal aunt had breast cancer and her mother had
basal and squamous cell carcinoma.
Physical Exam:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: tachycardiac, irregular, no M/G/R, normal S1 S2, radial
pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, well healed surgical scars; tenderness in LLQ with
voluntary guarding. +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2176-3-6**] 04:32AM BLOOD WBC-5.9 RBC-3.20* Hgb-10.0* Hct-28.7*
MCV-90 MCH-31.3 MCHC-34.9 RDW-14.2 Plt Ct-183
[**2176-3-5**] 04:12AM BLOOD WBC-5.7 RBC-3.36* Hgb-10.3* Hct-29.8*
MCV-89 MCH-30.7 MCHC-34.7 RDW-14.3 Plt Ct-216
[**2176-3-4**] 02:00PM BLOOD WBC-7.8 RBC-3.99* Hgb-12.5 Hct-35.0*
MCV-88# MCH-31.3 MCHC-35.7*# RDW-14.1 Plt Ct-279
[**2176-3-4**] 02:00PM BLOOD Neuts-88.5* Lymphs-9.8* Monos-1.3*
Eos-0.2 Baso-0.2
[**2176-3-6**] 04:32AM BLOOD Plt Ct-183
[**2176-3-6**] 04:32AM BLOOD PT-16.6* PTT-31.6 INR(PT)-1.5*
[**2176-3-5**] 04:12AM BLOOD PT-15.6* PTT-32.0 INR(PT)-1.4*
[**2176-3-6**] 04:32AM BLOOD Glucose-90 UreaN-10 Creat-0.7 Na-136
K-3.5 Cl-104 HCO3-25 AnGap-11
[**2176-3-4**] 05:10PM BLOOD Creat-1.6*
[**2176-3-4**] 02:00PM BLOOD Glucose-100 UreaN-33* Creat-1.8* Na-133
K-3.2* Cl-92* HCO3-29 AnGap-15
[**2176-3-4**] 02:00PM BLOOD ALT-48* AST-101* AlkPhos-61 TotBili-0.5
[**2176-3-6**] 04:32AM BLOOD Calcium-7.2* Phos-2.3* Mg-1.6
[**2176-3-4**] 06:33PM BLOOD Lactate-2.4*
[**2176-3-5**] 04:20AM BLOOD Lactate-1.1
[**2176-3-6**] 04:32AM BLOOD CRP-207.1*
ABDOMINAL AND PELVIS CT W/O CONTRAST
1. Concentric thickening of the rectum and sigmoid colon to a
greater extent
than prior study, with minimal surrounding stranding suggesting
acute mild
flare of inflammatory bowel disease. No evidence of abscess or
fistula
formation.
2. Ventral hernia as before.
3. Fatty infiltration of the liver.
<br>
[**2176-3-6**] Flex-Sig:
Findings:
Mucosa: Segmental continuous granularity, erythema, friability,
congestion and exudate with deep linear ulcerations with contact
bleeding were noted in the rectum, proximal sigmoid colon and
descending colon. The mucosa was edematous causing luminal
narrowing in the sigmoid and descending colon. These findings
are compatible with Crohn's disease. Cold forceps biopsies were
performed for histology at the descending colon. Cold forceps
biopsies were performed for histology at the sigmoid colon. Cold
forceps biopsies were performed for histology at the rectum.
Impression: Ulceration, granularity, erythema, friability,
congestion and exudate in the rectum, proximal sigmoid colon and
descending colon compatible with Crohn's disease (biopsy,
biopsy, biopsy)
Otherwise normal sigmoidoscopy to descending colon
Recommendations: Follow-up biopsy results, specifically
evaluating for CMV.
Continue ciprofloxacin and flagyl.
Hold humira and steroids for now.
Monitor abdominal exam.
<br>
Brief Hospital Course:
This is a 51 year-old female with a history of fistulizing
crohn's (with multiple ab surgies in past) and pAFib who
presents with hypotension, fevers, diarrhea, and afib with RVR
also with acute renal failure. Pt overall presenting with
crohn's flare with sig volume depletion with hypotension -
initially not responsive to IVF - required brief period of
levophed in ED - but off once admitted to [**Hospital Unit Name 153**]. Pt of note has
failed 6mp, humira, prednisone, remicade tx in past - being
currently tx with cipro/flagyl (initially vanc/zosyn in ED -
changed to cipro/flagyl in [**Hospital Unit Name 153**]). CT a/p done without evid of
abscess, flex-sig done [**3-6**] showing sig crohn's dz - bxs taken
to eval for CMV. Pt currently with treatment with abx, pain
control, GI following with rec for colorectal [**Doctor First Name **] eval - staff
recs currently pending for further intervention - though plan
for future surgery - currently assessing pre-op nutritional
status. Planning on getting more certain recs following
weekend, in addition pt not convinced would like immediate
surgery now vs soon electively. Pt also of note developed
a-fib with rvr earlier in [**Hospital Unit Name 153**] (had h/o of a-fib prior) - tx
with bb and also dilt gtt started - off since [**3-6**] am - being
treated with po scheduled metoprolol and dilt as described below
- noted pt has been ASx in respect to a-fib. Issues of
bradycardia earlier while on floor [**3-11**] more to pain medication -
reduced and pt again doing well with good rate control. Pt as
of [**2176-3-10**] first time with some possible clinical improvement
with decreased BMs, though tx only with cipro/flagyl now - on
low residue diet now tolerating well. Disposition pending
tomorrow for final staff GI and surgical recommendations
tomorrow as discussed with services today. Also per surgery -
needing further cardiac eval - noted brief periods of NSVT on
tele - last echo [**11-13**] - getting echo for tomorrow to eval for
impaired systolic dysfunction.
<br>
# Crohn's Dz with active flare and fevers - failed 6mp, humera,
prednisone, remicade tx in past, had flex-sig [**3-6**] - bxs taken
to eval for CMV, currently pending. Mild improvements - pt will
need surgery - decision of timing of this is pending. Pt is
refusing steriods, being tx conservatively as below. She was
continued on mesalamine and antibiotics. She was evaluated by
the GI and surgical service. Plan was for her to continue Humira
and follow-up with surgery as an outpatient for consideration of
surgical therapy. Her diarrhea improved prior to discharge.
# A-fib with RVR/CHADS1: likely in the setting of underlying
infxn and hypovolemia. Has had pAF in the past, not on
anticoagulation as outpt just rate control with BB (lower [**Country **]
plus ongoing GI blood losses from crohn's). Initially tx with BB
and then dilt gtt in unit. Patient had brief episodes or
aysmptomatic bradycardia, and had one run of NSVT. No evidence
of ischemia. Her beta blocker was uptitrated and diltiazem was
increased during the admission. She was discharged prior to
repeat TTE and recommended to follow-up with her outpatient
cardiologist.
# Acute Renal Failure: Creatinine to 1.8 on arrival to ED. This
is likely prerenal in the setting of diarrhea and hypotension.
Transiently SBP in the 80s in the ED prior to pressors.
Currently Cr back to baseline, resolved.
# Lymphedema - +L LE edema - noted prior surgical history -
however pt here in ICU immobile, high inflammatory state.
- Left LE US done on [**3-7**] - NO DVT
# Anemia, Chronic Blood losses - H/H near baseline - and
remained stable.
# HTN, benign - cont metoprolol and dilt; with addition of dilt,
ace-i held, and was restarted prior to discharge
# GERD - cont ppi
Medications on Admission:
Asacol 2400 mg [**Hospital1 **]
Metoprolol 50 mg QAM and 100 mg QPM
Lisinopril 20 mg qam
Adalat 30 mg QPM
Vitamin B12 1000 mcg daily
Folic Acid
Humira
ASA 325 mg daily
Discharge Medications:
1. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Six (6)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Oxycodone-Acetaminophen 10-325 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain for 15 doses.
Disp:*15 Tablet(s)* Refills:*0*
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Adalimumab 40 mg/0.8 mL Pen Injector Kit Sig: One (1) ML
Subcutaneous once a week.
9. Diltiazem HCl 180 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO once a day.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
11. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
#Crohn's disease
#Atiral fibrillaion
#Hypertension
#Gastrointestinal Reflux Disease
#Suspected sleep apnea
Discharge Condition:
stable
Discharge Instructions:
You came in primarily due to your crohn's disease which
complicated your prior condition of a-fib. We adjusted your
heart medications as noted and also note we have held your prior
lisinopril as your blood pressure is now controlled with all
your medications for your a-fib.
<br>
As for your Crohn's disease, your gastroenterologist's final
recommenations were to restart Humira. You should take your dose
at home this Friday. Please call your doctor or return to the
hospital if you develop fevers, chills, worsening diarrhea or
abdominal pain.
Followup Instructions:
1) [**2176-3-18**] 2pm with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 2233**]
2)Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2176-4-16**] 1:00
3)ULTRASOUND Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2176-7-23**] 11:00
** You should also call your primary care doctor and your
cardiologist to schedule follow-up appointments**
ICD9 Codes: 5849, 4271, 4589, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8605
} | Medical Text: Admission Date: [**2107-1-23**] Discharge Date: [**2107-2-1**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
MS change
.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 88 M w/ presented to OSH after having fallen while
carrying groceries from his car. Wife thinks it was a
mechanical fall. No head trauma. No LOC. He was noted to have
an acute MS change within 30 minutes. T=101.8 upon arriving to
OSH ED. Electively intubated for airway protection and
transferred to [**Hospital1 18**].
.
ED COURSE:
-- U/A - 11-20 WBCs, occasional bacteria
-- WBCs - 28.9 w/ 91% lymphs
-- UCx and BCx sent
-- ceftriaxone and vancomycin started
-- CXR - Abnormal opacity involving both lungs. The finding
represents both airspace and interstitial disease. Diagnostic
considerations include pulmonary edema in the setting of chronic
interstitial changes. Bilateral pleural effusions are present as
well.
-- CT CHEST - Severe emphysema and moderate pulmonary edema.
Left lower lobe consolidation could represent pneumonia,
aspiration or atelectasis. Mild stranding in left upper quadrant
around the splenic flexure of uncertain etiology.
-- CT HEAD - negative
-- EKG - sinus tachycardia, PVCs, nl axis, nl intervals, no
significant ST interval or T wave changes.
.
Past Medical History:
PMH:
-- PAF
-- htn
-- dyslipidemia
-- Transitional Cell bladder CA -- BCG tx
-- Lung mass (seen on staging CT [**7-/2106**]) -- left lower lobe
4x4x3cm, concerning for malignancy. pt has to present refused
intervention.
-- TTE ([**7-18**]) - NL LV size and function, EF=60-65%.
-- glaucoma
-- osteoporosis
.
Social History:
lives with wife.
.
Family History:
non-contributory
.
Physical Exam:
VENT: Vt=550, Pressure=10, PEEP=5, FiO2=50, RR=20
T=100.2
BP=120/70
HR=90
RR=20
O2sat=97%
GEN: lying in bed intubated, sedated
HEENT: no lad
CV: rrr
PULMO: ctab anteriorly
ABD: bs+, nt, nd
EXT: warm, no c/c/e
NEURO: pinpoint pupils, reactive, b/l. reactive to painful
stimuli. moving all extremities, but not to command. toes are
neither upgoing or downgoing.
.
Pertinent Results:
MRI [**2107-1-24**]:IMPRESSION:
1. Multiple punctate foci of increased diffusion signal are
suggestive of multiple watershed infarcts in the cortex between
the MCA/ACA distribution and MCA/PCA distribution. This could
be secondary to an episode of global hypotension and/or hypoxia.
2. No evidence of intracranial mass.
3. Left choroid plexus xanthogranuloma.
4. Fluid layering in the nasopharynx, possibly secondary to
patient
unresponsive state or intubation.
.
[**2107-1-23**] 07:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2107-1-23**] 07:45PM URINE RBC-[**2-14**]* WBC-[**11-1**]* BACTERIA-OCC
YEAST-NONE EPI-<1
[**2107-1-23**] 07:38PM LACTATE-2.2*
[**2107-1-23**] 07:28PM TYPE-ART PO2-303* PCO2-48* PH-7.38 TOTAL
CO2-29 BASE XS-2
[**2107-1-23**] 06:24PM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2107-1-23**] 06:10PM GLUCOSE-141* UREA N-16 CREAT-0.8 SODIUM-137
POTASSIUM-3.3 CHLORIDE-99 TOTAL CO2-27 ANION GAP-14
[**2107-1-23**] 06:10PM CK(CPK)-170
[**2107-1-23**] 06:10PM CK-MB-18* MB INDX-10.6* cTropnT-.78*
[**2107-1-23**] 06:10PM CALCIUM-9.9 PHOSPHATE-2.9 MAGNESIUM-2.0
[**2107-1-23**] 06:10PM WBC-28.9* RBC-5.27 HGB-16.0 HCT-49.2 MCV-93
MCH-30.3 MCHC-32.5 RDW-14.9
[**2107-1-23**] 06:10PM NEUTS-91.1* BANDS-0 LYMPHS-3.9* MONOS-4.4
EOS-0.1 BASOS-0.6
[**2107-1-23**] 06:10PM PT-27.9* PTT-29.8 INR(PT)-2.9*
Brief Hospital Course:
A/P: 88 M w/ presented from OSH intubated after having fallen.
.
The patient was admitted from an OSH intubated to the MICU. He
was noted to have had a fall complicated by altered mental
status. Non-contrast head CT was negative for intracranial
bleed. There was high concern for an infectious process due to a
leukocytosis. CT torso revealed no focal inectious etiology.
The patient was noted to have a positive UA and a question of a
pneumonia. The patient was initiated on ceftriaxone and vanco at
meningeal dosing. LP was not done due to elevated INR and
minimal clinical indications. MRI/A of the head on the day of
admission revealed numerous watershed infarcts. These were felt
to be consistent with either an episode of hypotension (which
the patient was not known to have had) or embolic phenomena. The
patient was known to have A. Fib but TTE did not reveal any
intra-cardiac thrombi. The patient was already fully
anticoagulated on admission and heparin gtt was initaited at the
time of infarct discovery. It is possible that the patient is
hypercoaguable secondary to malignancy. Repeat MRI/A on hospital
day 4 revealed progression of the patient's infarcted area. He
was successfully weaned from the ventilator. After discussion
with the family regarding the patient's poor prognosis, he was
advanced to comfort measures only and transferred to the
medicine floor service. On the medicine service he received
ativan, morphine and scopolamine as needed for comfort. The
patient expired at 09:55AM on [**2107-2-1**] when he was found to have
no pulse, no spontaneous breaths and no pupillary reflex. The
patient's family was contact[**Name (NI) **]. They declined an autopsy.
Medications on Admission:
MEDS:
--aspirin 81 mg daily
--terazosin 2 mg [**Hospital1 **]
--oxybutynin 5 mg HS
--tylenol prn
--atenolol 50 mg daily
--coumadin 5 mg M, W, F
--coumadin 2.5 mg T, Th, Sat, Sun
--alendronate 40 mg every Mon
--simvastatin 5 mg HS
--brimonidine 0.2 1 drop in each eye daily
--travoprost 0.004% 1 drop each eye daily
--calcium, mvi
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Cerebrovascular accident
Discharge Condition:
None
Discharge Instructions:
None
Followup Instructions:
None
ICD9 Codes: 5990, 486, 496, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8606
} | Medical Text: Admission Date: [**2115-12-29**] Discharge Date: [**2116-1-4**]
Service: MICU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is an 82-year-old male
admitted to the Medical Intensive Care Unit for
gastrointestinal bleed, hypotension. This gentlemen was
recently admitted one month ago for chronic obstructive
pulmonary disease flare, deep vein thrombosis and pulmonary
embolus and was discharged to [**Hospital3 7**] where he was
noted today on the day of admission to have 300 cc of bright
red blood per rectum and hypotension systolic in the 80s. He
had been started on Lovenox in the hospital and on Coumadin
prior to being discharged for his venous thromboembolic
disease. His last documented INR was 2.6 two days prior to
admission. Patient denied any fevers, abdominal pain, nausea
or vomiting, chest pain, shortness of breath, dizziness or
lightheadedness. He has never had gastrointestinal bleeds in
the past.
PAST MEDICAL HISTORY:
1. Recent deep vein thrombosis/PE and discharged for same
condition on [**2115-12-23**]. He also has a remote deep
vein thrombosis several years ago.
2. Chronic obstructive pulmonary disease on two liters of
home 02 at night. Never intubated, and not on chronic
steroids, however, is frequently on steroid tapers. He is
also status post blood resection.
3. Hypertension.
4. Prior CVA with right-sided weakness.
5. Benign prostatic hypertrophy.
6. Osteoporosis.
7. A neuropathy.
8. Status post appendectomy.
9. Ventricular ectopy and nonsustained ventricular
tachycardia and he did have an echocardiogram in [**2115-3-21**]
showing an ejection fraction of 50%.
10. Right upper lobe mass seen on CT on the most recent
admission and also noticed on chest x-ray of this admission
whose cause is unknown, but is most likely felt to be
malignant in nature.
MEDICATIONS:
1. Prednisone 20 mg q.d. on taper.
2. Lansoprazole.
3. Aspirin.
4. Zestril.
5. Finasteride.
6. Senna.
7. Coumadin.
8. Fosamax.
9. Lasix.
10. Albuterol.
11. Atrovent MDIs.
12. Flovent.
ALLERGIES: Patient denies any medical allergies.
SOCIAL HISTORY: He lives with his wife of 40 years and he
quit smoking 30 years ago after an extensive pack year
history. He is a retired lawyer in the area.
HOSPITAL COURSE: In the Emergency Room, the patient was
hypotensive in the 80s systolic range. A femoral groin line
was placed and he was resuscitated with normal saline 4 units
of fresh frozen plasma and four units of packed red blood
cells. Nasogastric lavage revealed small amount of coffee
ground material and a small bright red clot which cleared
with less than 500 cc normal saline. In the Emergency
Department, he also received treatment for hypercalcemia in
the setting of his ectopy seen on monitor.
Echocardiogram was obtained which showed ST depressions in
the lateral segments and a chest x-ray revealed no pulmonary
edema, persistence of the right upper lobe mass and flattened
diaphragm. Chest x-ray was repeated after fluid
resuscitation and remained unchanged.
Upon Medical Intensive Care Unit evaluation, physical
examination showed a temperature of 97. Heart rate of 120
with frequent premature ventricular contractions. Blood
pressure 170/87. Respiratory rate of 24. Oxygen saturation
100% on three liters per minute. Generally, she was
tachypneic with retractions and using accessory muscles with
copious upper airway secretions. Head, eyes, ears, nose and
throat: Significant for conjunctival pallor. Pupils equal,
round and reactive to light. Extraocular movements intact.
Neck was supple without any lymphadenopathy and difficult to
assess the jugular venous pressure due to the retractions.
There was no thyromegaly. Cardiovascular was tachycardic
without murmurs, rubs or gallops. Lungs were extraordinarily
decreased breath sounds with expiratory wheezing, no crackles
were noted. Abdomen was soft, nontender, with hyperactive
bowel sounds and no hepatosplenomegaly. The rectal exam was
deferred secondary to the perfuse amounts of maroon stool
seen in his exam. His extremities were without edema, warm
and without palpable pulses in the feet.
LABORATORY VALUES: Significant for a hematocrit of 41, which
subsequently decreased to 21 after intravenous fluid
resuscitation and a white blood cell count of 21.7.
Potassium is 6.4. Coags were unable to be obtained secondary
to a laboratory error on the sample of blood prior to fresh
frozen plasma being administered.
HOSPITAL COURSE: An abdominal CT was performed revealing
only a slightly dilated head of the pancreas consistent with
IPMT. The remainder of his abdominal laboratories were
normal. Patient was taken to Interventional Radiology that
night for angiography which revealed a small blush in the
duodenum which was coiled at that time by Interventional
Radiology. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter was also placed in the IVC by
Interventional Radiology at the same time. >......<cells in
the Emergency Department and he was admitted to the Intensive
Care Unit for observation and had a
esophagogastroduodenoscopy the following morning which
revealed only small superficial erosions and no frank
ulcerations in the duodenum. His hematocrit remained stable
and he was transferred to the floor.
On the floor he had a left IJ placed and his femoral line was
removed. About the same time, he was noted to have
approximately a liter of maroon stools and also an expanding
groin hematoma at the site of the line removal. Emergent
ultrasound of the right groin revealed a heterogenous flow in
the >.....<however, no direct fistula was seen. Patient was
found to have had a hematocrit drop of 10 points, so he was
transferred back to the Intensive Care Unit and received
another three units of packed red blood cells. He had a
repeat esophagogastroduodenoscopy which again showed only
superficial mucosal erosions and no blood. He was kept NPO
and observed and colonoscopy was performed by
Gastrointestinal in the Intensive Care Unit, which revealed
diverticula, however, no evidence of bleeding.
On hospital day seven, he has had clear rectal affluent from
his GoLYTELY prep. His diet has been advanced to clears and
his hematocrit has remained stable at 34 and he is called out
to the floor.
FINAL DIAGNOSIS/PROBLEM LIST:
1. [**Name2 (NI) **]l bleed. Unclear source given the
positive angiographic findings and lack of findings on
esophagogastroduodenoscopy times two and negative
colonoscopy. His second visit to the Intensive Care Unit
regarding his decreased hematocrit may have been related to
his groin hematoma as opposed to a new gastrointestinal
bleed. If he re-bleeds again, he should have a bleeding scan
obtained promptly and Gastrointestinal should be
re-consulted. Otherwise, he will continue to be on Protonix
and his diet should be advanced soon to full as he has been
without nutrition for seven days.
2. Right thigh hematoma: A repeat ultrasound demonstrated a
CFV at a CFA fistula. This will need to be followed over
time. There was no discrete aneurysm or pseudoaneurysms seen
and there was no flow seen in the hematoma indicating a
stable lesion. It is likely that the triple lumen catheter
passed through the artery and then was cannulated in the
vein. Vascular Surgery is following this patient for this
problem.
3. Venous thromboembolic disease: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter was
placed as the patient is not a candidate for anticoagulation
at this point.
4. Intermittent atrial fibrillation while in the Intensive
Care Unit: The patient has multiple premature ventricular
contractions and ectopy and also has atrial fibrillation,
however, again, we will not anticoagulate given his ongoing
gastrointestinal bleeding issues.
5. Chronic obstructive pulmonary disease: The patient has
severe lung disease and he will continue using a steroid
taper. He will continue to receive his inhaled steroids
Ipratropium and albuterol.
6. Right upper lobe mass: Most likely being malignancy
given his extensive smoking history and the persistence of
this mass over a one month time. His wife is aware of this
as is his primary pulmonologist Dr. [**Last Name (STitle) 1632**]. The wife and
Dr. [**Last Name (STitle) 1632**] have decided that it is not in the patient's
best interest to discuss it with him at this time in the
setting of this acute illness, however, it should be
addressed with him at some point in the future. It is likely
given his poor underlying pulmonary status, that he will die
with this lesion as a result from it.
7. Thrombocytopenia: Prior to this admission, the patient
had been noted to have platelets in the 250,000 range,
however, on this admission, the patient had platelets in the
100,000s and drifting down to 80 and 70,000 range. All of
his heparin was stopped including it in his flushes and a hit
antibody was sent. The first hit antibody was negative,
however, a repeat hit is pending. Until this comes back, the
patient should be off all heparin.
8. Leukocytosis: Most likely related to his prednisone and
may also be related to his likely pulmonary malignancy.
9. Prophylaxis: He is on pneumatic boots and proton pump
inhibitors and no heparin should be used at this time.
10. Access: He has a triple lumen catheter in his left IJ.
11. Code status: He is "Do Not Resuscitate/Do Not Intubate,"
however, but after long discussion with the patient and his
wife, and with Dr. [**Last Name (STitle) 1632**], who will act as his primary
care physician during this admission, he may be cardioverted
once should he have an episode of VTVF, which is not an
unreasonable condition given the frequency of the ectopy
which he demonstrates on the cardiac monitor.
[**Last Name (LF) **], [**First Name3 (LF) **] 11.575
Dictated By:[**Last Name (NamePattern1) 4791**]
MEDQUIST36
D: [**2116-1-4**] 02:36
T: [**2116-1-5**] 14:34
JOB#: [**Job Number 21435**]
ICD9 Codes: 2875, 2851, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8607
} | Medical Text: Admission Date: [**2159-11-26**] Discharge Date: [**2159-12-5**]
Date of Birth: [**2085-6-2**] Sex: M
Service: NEUROLOGY
Allergies:
Shellfish
Attending:[**First Name3 (LF) 5868**]
Chief Complaint:
Acute Stroke, s/p IV t-PA
Major Surgical or Invasive Procedure:
IV TPA
History of Present Illness:
74 year old man with hx of CAD (s/p MI, s/p CABG), HTN, Right
carotid stenosis (s/p carotid stent [**10-5**]), and arthritis who
presented to the ED on [**11-25**] complaining of left sided weakness.
A code stroke was called and the stroke
fellow assessed the patient immediately (Please see Dr.[**Name (NI) 105059**]
note [**11-25**] for details of initial assessment). He was initially
found to have an NIHSS of 9. CT/CTA was done and was negative
for early signs of infarction, but did show a paucity of vessels
in the right MCA territory. IV tPA was administered by Dr.
[**Last Name (STitle) **] at 8:53am.
I arrived at 9:00AM and obtained the following history. Pt was
feeling well when he went to bed last night, [**11-24**]. He awoke in
his USOH on the morning of admission at 5am, watched the news,
then started to read a book. At that time, he was able to use
both hands to hold the book and had no difficulty turning the
pages. Around 6-6:30am, he got out of bed to go to the
bathroom. His left leg "gave out" and he slid to the floor. He
thought that there might be something wrong with his heart so he
reached for his nitroglycerine tablets. He noticed that he was
unable to grip the bottle with his left hand. He crawled back
into bed and called EMS. He was brought to the ED where he
arrived shortly after 8AM. He was noted to have a left visual
field cut, dysarthria, left sided inattention, left facial
droop, left hemiplegia (arm>leg) and left hemisensory deficit.
He was given IV-tPA. NIHSS=8 (see exam below).
He denies fever/chills, CP, SOB, palpitations, nausea/vomiting,
or dysuria. He denies having similar symptoms in the past.
Past Medical History:
1. CAD- s/p MI and CABG [**63**] yrs ago with subsequent coronary
stenting
2. COPD
3. HTN
4. High cholesterol
5. PVD-s/p right leg stenting
6. Osteoarthritis
Social History:
Divorced, lives alone. Used to work appraising properties for
the government. 60 pk yr smoking hx, quit 2 yrs ago. Drinks
once per week. No drugs.
Family History:
Brother - stroke
[**Name2 (NI) 6419**] parents had heart disease in their 60s.
Physical Exam:
T-96.6 BP-155/103 HR-72 RR-20 O2Sat-100
Gen: Lying in bed, NAD
HEENT: NC/AT, facial rubor, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, no carotid bruits
CV: RRR, Nl S1 and S2, [**2-4**] HSM
Lung: Decreased breath sounds throughout
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. He is attentive,
says [**Doctor Last Name 1841**] backwards. Speech is fluent with normal comprehension
and repetition; naming intact. Moderate dysarthria. [**Location (un) **]
intact. Registers [**2-1**], recalls [**2-1**] in 5 minutes. No right left
confusion. He has left sided inattention, but does look at
examiner on the left.
Cranial Nerves:
I: not tested
II: Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. No visual field cut, +extinction to visual DSS
III, IV, VI: Right gaze preference, but extraocular movements
full bilaterally, no nystagmus.
V: Sensation decreased to LT and pin on left V1-V3
VII: Left lower facial palsy, also some weakness of orbicularis
occuli on the left-though forehead moves symmetrically.
VIII: Hearing intact to finger rub bilaterally
IX, X: Palate elevation symmetrical
[**Doctor First Name 81**]: Sternocleidomastoid normal bilaterally.
XII: Tongue midline (when facial droop corrected), movements
intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
Left drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 4+
L 5- 5 5 3 2 1 2 5- 5 5 5 5 5 4+
Sensation: Intact to light touch, pinprick on right, decreased
by (?50%) on left. Vibration and proprioception diminished to
shin/ankle bilaterally. Decreased proprioception in left
fingers (intact on right). +agraphesthesia on left. +
extinction to DSS on left.
Reflexes:
+2 and symmetric throughout.
Toes upgoing bilaterally
Coordination: finger-nose-finger normal on left-ataxia in
proportion to weakness on left, heel to shin normal, Unable to
do RAMs on left.
Gait/Romberg: Unable to assess
Pertinent Results:
7.1>37.8<197 73N 17L 5E
Na 143 K 4.0 Cl 106 CO2 25 BUN 20 Cr 1.1 Glu 112
Ca 9.4 Mg 1.7 Ph 3.6
Lip 43
PT 12.8 PTT 23.3 INR 1.1
A1C 5.2
Chol 155 TG 110 HDL 69 LDL 64
U/A neg
Head CT [**11-25**] - Abrupt cut-off of the anterior division of the
right middle cerebral artery (M3), consistent with acute
occlusive thrombus or embolus. No intracranial hemorrhage or
mass effect.
Head CT [**11-26**] and [**12-3**] - Stable head CT with evidence of evolving
right middle cerebral artery territory infarct, without definite
hemorrhage.
MRI head [**11-25**] - Large area of restricted diffusion in the right
middle cerebral artery territory in the right frontal and
temporal lobes, consistent with acute infarct. MR [**First Name (Titles) 4058**] [**Last Name (Titles) 4579**]s significantly decreased flow in the right mid
cerebral artery branches
Transthoracic Echocardiogram [**11-26**] - Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%).
Carotid ultrasound [**11-28**] - Minimal plaque on the right with a
less than 40% carotid stenosis. On the left, there is moderate
plaque with a 40-59% stenosis.
Neck MRA [**11-27**] - Patent right internal carotid artery stent but
with apparent slow flow. Signal irregularity and apparent
diminutive flow through the stent could be secondary to magnetic
susceptibility from the stent, intimal hyperplasia, or a small
amount of thrombus.
Preliminarily transesophageal echocardiogram: simple atheroma
in descending aorta
Brief Hospital Course:
74 year old man with hx of CAD, HTN, high cholesterol, smoking,
s/p recent right carotid stent, and family hx of stroke who
presents with acute onset of left sided weakness. He is s/p IV
tPA 2.5hrs after symptom onset. Initial exam notable for left
sided inattention, dysarthria, left facial, left sided weakness
(primarily in arm with cortical hand), left sided sensory
deficit to all modalities, left sided cortical sensory loss.
Deficits localize to the right fronto-parietal region. He was
admitted to the neuro ICU after receiving tPA; MRI/A showed M2
or M3 occlusion, no recannulization.
Neuro - Stroke was most likely related to embolism from stent
thrombus. Serial head CTs stable, but more dense weakness
beginning on HD#2. Pt was continued on aspirin and plavix for
stent. Patient was started on low dose coumadin 2.5 mg a day
with no load given that he is already on two antiplatelets. The
target is for low INR around 2. Plan for Coumadin for 3 months,
re-image stent, if patent, discontinue Coumadin. Exam remains
most notable for dysarthria, L hemiplegia and L extinction to
double simultaneous stimulation.
CV - Ruled out for MI upon admission. Blood pressure was
initially allowed to autoregulate. HTN now controlled on
Metoprolol. No events on telemetry. TEE performed on [**12-5**] prelim
read: simple atheroma in descending aorta, moderately thick
aortic valve, no ASD or PFO (final report pending). Should
follow up with his outpatient Cardiologist, Dr. [**Last Name (STitle) 2912**],
[**Telephone/Fax (1) 25832**] after discharge from rehab. Should continue Plavix
for at least 6 months after stent placement; duration of therapy
to be guided directly by Pt's cardiologist.
FEN/GI - Pt failed initial swallow evaluations, requiring tube
feeds through [**12-3**]. Cleared by video swallow evaluation for soft
solids and thin liquids on [**12-4**].
Heme - Should start Coumadin 2.5mg QHS on [**12-5**], goal INR ~2 (low
therapeutic goal as Pt will also be on Aspirin and Plavix and
would be at high risk for bleeding with higher INR). Check INR
twice weekly.
ID - Being treated with Nitrofurantoin for UTI, course to be
complete on [**12-7**].
Tox - For significant alcohol history, Pt was started on
Thiamine, Folate.
Discharged to rehab on [**2159-12-5**] in stable condition.
Medications on Admission:
Plavix
ASA 325
Lipitor
NTG
Fluticasone
Atneolol
Lisinopril
Folate
Elavil
Pletal
Folate
Temazepam
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Right MCA stroke
Discharge Condition:
Stable
Discharge Instructions:
Please do not load with coumadin, just start coumadin gently and
allow inr to trend slowing to goal INR of 2.
Seek medical attention for worsened weakness, numbness,
difficulty speaking, sudden change in vision/hearing, severe
headache, seizure, or for other concerns.
Take all medications (including new ones) as prescribed.
Followup Instructions:
1. If you do not receive a call from Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office
(Neurology) in [**12-3**] weeks, please call her office at [**Telephone/Fax (1) 105060**]
for an appointment
2. Follow up with your primary care physician after discharge
from rehab.
ICD9 Codes: 5990, 4240, 4019, 4439, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8608
} | Medical Text: Admission Date: [**2117-5-29**] Discharge Date: [**2117-6-3**]
Date of Birth: [**2052-3-29**] Sex: F
Service: NEUROSURGY
HISTORY OF PRESENT ILLNESS: The patient is a 65 year old
woman on Coumadin for past medical history of right superior
MCA stroke presumably embolic with residual left hemiparesis.
Is now admitted with subacute right subdural hematoma. The
patient fell three weeks ago. Had negative head CT at that
time. Today presents to an outside hospital with left leg
focal motor seizure and facial droop. The patient was
transferred to [**Hospital1 69**] with head
CT that showed right subdural hematoma.
PAST MEDICAL HISTORY: Right MCA CVA.
MEDICATIONS: Coumadin, Lipitor.
ALLERGIES: No known allergies.
LABORATORY DATA: On admission white count was 9.4,
hematocrit 37.4, platelet count 236. Sodium 142, K 4.4,
chloride 105, CO2 24, BUN 15, creatinine 0.6, glucose 99.
Coagulation studies were 22.3, 34.6, INR 3.3. The patient
was given FFP.
PHYSICAL EXAMINATION: On physical exam vitals on admission
were T-max of 97.6, heart rate 72, blood pressure 158/58,
respiratory rate 15, sat 99%. The patient was keeping eyes
closed, awake, alert and oriented times three. Pupils were
equal, round and reactive to light 4 down to 2 mm. EOMs
full. Strength 3/5 in the right upper extremity and right
lower extremity, [**4-8**] to 5/5 strength in the left upper
extremity and [**5-8**] in the left lower extremity. Chest clear
to auscultation. Cardiac regular rate and rhythm. Abdomen
soft, nontender, nondistended. Extremities warm, no edema.
Neurologically the patient was stable.
HOSPITAL COURSE: The patient was monitored in the surgical
intensive care unit and neurologically was stable and
transferred to the regular floor on [**2117-5-31**]. On [**2117-6-1**] the
patient had MRA and head CT which showed the presence of the
subdural hematoma which had not changed since admission. The
patient was observed times 24 hours and then discharged to
home with followup head CT and followup appointment with
Dr. [**First Name (STitle) **] in two weeks' time. Neurologically the patient's
status was unchanged.
She was seen by physical therapy and occupational therapy and
given a prescription for outpatient therapy at the time of
discharge.
DISCHARGE MEDICATIONS:
1. Dilantin 200 mg p.o. q.h.s.
2. Percocet one to two tabs p.o. q.four hours p.r.n. pain.
The patient will follow up with Dr. [**First Name (STitle) **] for head CT in two
weeks.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2117-6-3**] 12:39
T: [**2117-6-5**] 12:39
JOB#: [**Job Number 46882**]
ICD9 Codes: 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8609
} | Medical Text: Admission Date: [**2153-9-21**] Discharge Date: [**2153-10-12**]
Date of Birth: [**2122-12-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
mitral valve methicillin resistent staph aureus endocarditis
Major Surgical or Invasive Procedure:
Mini thoracotomy, Tricuspid valve replacement (31 St. [**Male First Name (un) 923**]
tissue), Patent foramen ovale closure [**2153-10-5**]
History of Present Illness:
Ms. [**Known lastname **] is a 30 year old woman who is a current intravenous
drug user, with a history of Hepatitis B and C, who was
transferred from [**Hospital1 498**] on [**9-21**] for persistent fevers and
tachycardia while being treated for methicillin resistent staph
aureus tricuspid endocarditis, pulmonary emboli, and cardiogenic
shock. She originally presented to another outside hospital with
two weeks of fevers, malaise, and nausea and vomitting. She was
treated with a Z-pack prior to that presentation due to a cough.
She was septic with temperature of 94.5, SBP in 90s and HR in
120s, was given 1g Vancomycin and 2g ceftriaxone and 750mg
levofloxacin, and transferred to [**Hospital1 498**] on [**2153-8-9**].
At [**Hospital1 498**], a chest CT was positive for pulmonary embolism and
multiple bilateral cavitary pulmonary nodules, most likely
septic emboli. An echocardiogram showed an ejection fraction of
70%, tricuspid valve with possible anterior flail leaflet with
large highly mobile vegetation, severe tricuspid regurgitation.
During her hospital stay, she developed a pulmonary embolism and
cardiogenic shock. On the medicine floor, she continued to be
febrile in the 100 to 101 range despite vancomycin. A heparin
infusion for pulmonary emboli was discontinued when she
developed anemia and there was concern for bleeding. Multiple
picc lines were placed and pulled as they could be possible
sources of infection. She was febrile during her entire hosp
stay to 100-101 degrees. She remained tachycardic with a heart
rate in the 110's at rest up to 150's with activity during the
entire hospitalization. Most recent cultures were negative. She
was kept on intravenous ativan and valium. She had a right
psoas abscess, with a pigtail drain placed by interventional
radiology.
On presentation to [**Hospital1 18**], she denied any pain but did say she
could not move her right leg but said this had been the case for
the past month. She denied any fevers, chills, chest pain,
shortness of breath or nausea or vomitting. Her last menstrual
period was in [**2150**] (mirena IUD).
Past Medical History:
-ADHD
-Hepatitis C
-Hepatitis B
-Intravenous drug use
Social History:
Ms. [**Known lastname **] is married and has two children. She lives at home
and is currently unemployed. Her family is unaware of her
intravenous drug use and she does not want it mentioned in their
presence. She was a smoker as a teenager, and denies alcohol
use. She has a history of intravenous heroine use as a teenager
and then subsequent sobriety for many years. About six months
ago she began crushing suboxone in tap water and injecting it.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T=96.5 BP=107/71 HR=100s RR=18...O2 sat=96-98%RA
GENERAL: Somnolent female in NAD. AAO*3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no significant JVP.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Tachycardic Loud S2. without m/r/g. No thrills, lifts
appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Poor inspiratory
effort. bibasilar crackles appreciated. no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
BACK: drain in lower right hip draining minimal serosanguinous
fluid.
EXTREMITIES: 1+ non pitting edema on right leg. No femoral
bruits. R knee somewhat warmer than L to touch, slightly
swollen.
SKIN: Small erythematous macules on buttocks. Several possible
pustules noted under clear drain dressing. No stasis dermatitis,
ulcers, scars, or xanthomas. No splinter hemorrhages, no
[**Last Name (un) **] lesions or osler nodes.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
NEURO: AAOx3, CN2-12 grossly intact, motor strength and
sensation grossly intact b/l, except R hip flexor not assessed
as pt said had difficult moving LEG
Pertinent Results:
MICROBIOLOGY:
-Hep B viral load [**9-21**]: HBV DNA not detected.
-Hep C viral load [**9-21**]: HCV-RNA NOT DETECTED.
-[**9-23**] MRI head: FINDINGS: Within the right posterior temporal
region is a subcentimeter curvilinear area of elevated T2 signal
that appears to exhibit corresponding contrast enhancement. The
etiology for this finding is uncertain, but in light of the
known systemic infection, an inflammatory process (meningeal
based) could be considered, as opposed to a small vascular
malformation. A CT or MR angiogram may be of some diagnostic
benefit, in this regard. There is no baseline T1 hyperintensity
to suggest locally thrombosed vessel or hemorrhage, although in
the acute phase, T1 hyperintensity may not be present in the
setting of either hemorrhage or thrombosis (as in the setting of
a mycotic aneurysm). There is a punctate area of elevated T2
signal, without enhancement in the left corona radiata. There is
no restricted diffusion or abnormal susceptibility,
hydrocephalus, or shift of normally midline structures.
The principal vascular flow patterns are identified. There is a
subcentimeter, likely retention cyst arising from the floor of
the left
maxillary sinus.
CONCLUSION: Focal areas of abnormal signal and isolated area of
pathological enhancement, as noted above. Please see the above
report for details and recommended potential followup studies,
in order to exclude a mycotic aneurysm.
.
-[**9-24**] CTA Head: IMPRESSION:
1. No evidence of acute infarct or intracranial hemorrhage.
2. No evidence of focal flow-limiting stenosis, occlusion or
aneurysm greater than 3 mm in the arteries of anterior and
posterior circulation of head.
3. The small enhancing focus noted in the right temporal lobe on
the previous MRI is not seen on the present study. However, CTA
can be less sensitive in the detection of very tiny aneurysms or
mycotic aneurysms. As the lesion was seen on MR study, consider
close folow up with MR [**Name13 (STitle) 430**] without and with contrast to assess
stability / progression and if necessary INR consult.
.
-[**10-1**] MRI Head:
IMPRESSION: Interval appearance of at least one, though probably
several foci of slow diffusion with associated enhancement, most
compatible with foci of septic emboli within the left frontal
lobe. Interval [**Doctor Last Name 688**] of previously noted abnormality within the
right temporal lobe may also support septic embolization as the
etiology.
.
[**10-3**] TEE: No spontaneous echo contrast or thrombus is seen in
the body of the left atrium or left atrial appendage. A patent
foramen ovale is present with leftward bowing of the interatrial
septum and right-to-left shunt at rest. The ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaque to 32 cm from the incisors.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No masses or vegetations are seen on the
aortic valve. No aortic valve abscess is seen. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. No mass or vegetation
is seen on the mitral valve. The tricuspid valve has a large
vegetation and associated partial flail leaflet. Severe [4+]
tricuspid regurgitation is seen directed towards the interatrial
septum. No vegetation/mass is seen on the pulmonic valve. There
is a trivial/physiologic pericardial effusion.
IMPRESSION: Large vegetation and associated partial flail
tricuspid leaflet. Severe tricuspid regurgitation with flow
directed towards a patent foramen ovale and a likely substantial
right to left shunt at rest.
.
Intra-op TEE [**2153-10-5**]
Conclusions
PRE-BYPASS: The left atrium is normal in size. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. The right atrium is moderately
dilated. A left-to-right shunt across the interatrial septum is
seen at rest. A small secundum atrial septal defect is present.
Left ventricular wall thicknesses and cavity size are normal.
The right ventricular free wall thickness is normal. The right
ventricular cavity is moderately dilated with borderline normal
free wall function. The ascending, transverse and descending
thoracic aorta are normal in diameter and free of
atherosclerotic plaque to XX cm from the incisors. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are
moderately thickened. There is partial flail of a tricuspid
valve leaflet. There is a probable vegetation on the tricuspid
valve. There is a large vegetation on the tricuspid valve. There
is no abscess of the tricuspid valve. Severe [4+] tricuspid
regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
.
[**2153-10-12**] 05:45AM BLOOD WBC-4.5 RBC-3.15* Hgb-8.5* Hct-26.3*
MCV-84 MCH-27.0 MCHC-32.3 RDW-15.5 Plt Ct-221
[**2153-10-10**] 07:51AM BLOOD WBC-4.8 RBC-3.46* Hgb-8.8* Hct-28.2*
MCV-82 MCH-25.6* MCHC-31.4 RDW-15.2 Plt Ct-201
[**2153-10-12**] 05:45AM BLOOD Glucose-91 UreaN-14 Creat-0.7 Na-139
K-4.3 Cl-104 HCO3-28 AnGap-11
[**2153-10-10**] 07:51AM BLOOD Glucose-114* UreaN-13 Creat-0.6 Na-138
K-4.1 Cl-101 HCO3-28 AnGap-13
[**2153-10-12**] 05:45AM BLOOD Calcium-8.7 Phos-4.8* Mg-1.9
[**2153-10-10**] 07:51AM BLOOD Calcium-8.8 Phos-4.2 Mg-1.8
Brief Hospital Course:
Ms. [**Known lastname **] is a 30 y.o. woman with a h/o IVDU, Hep B and C,
transferred from [**Hospital1 498**] on [**9-21**] for cardiac surgery evaluation
due to persistent fevers and tachycardia while on vancomycin for
MRSA tricuspid endocarditis. OSH stay was c/b septic emboli to
lungs, R psoas abscess, and cardiogenic shock. In brief, at
[**Hospital1 18**] she remained afebrile on Vancomycin, but head imaging was
concerning for septic emboli suggestive of left-sided disease.
TEE [**10-3**] demonstrated a large vegetation and associated partial
flail tricuspid leaflet, along with severe tricuspid
regurgitation with flow directed towards a patent foramen ovale
and a likely substantial right to left shunt at rest. She was
taken for valve repair surgery on [**10-5**].
.
ACTIVE ISSUES:
.
# INFECTIOUS ENDOCARDITIS WITH MRSA: OSH Echo showed a large
vegetation on tricuspid valve and blood Cx's were positive for
MRSA. TTE from [**Hospital1 18**] on [**2153-9-22**] redemonstrated the tricuspid
vegetation. OSH course was c/b persistent fevers despite >1 mo
vancomycin IV therapy. Pt has been afebrile since [**9-22**] and CT
Surgery evaluated the patient on [**9-26**] and recommended
proceeding with operation after 6 weeks of vancomycin after the
first negative blood culture (on [**9-11**] at OSH), unless new
sequelae developed or she became unstable. We continued her IV
vancomycin at 1250mg IV q12h with a trough goal of ~20 per
recommendation by ID. HIV Ab test, Hep B/C viral loads were all
negative.
Head imaging (MRI head and CTA head) initially could not r/o a
small mycotic aneurysm. Repeat MRI head one week later on [**10-1**]
was concerning for septic emboli suggestive of left-sided
disease. TEE [**10-3**] demonstrated a large vegetation and
associated partial flail tricuspid leaflet, along with severe
tricuspid regurgitation with flow directed towards a patent
foramen ovale and a likely substantial right to left shunt at
rest.
She was taken for valve repair surgery on [**10-5**]- SEE
POST-OPERATIVE Course below
.
# PE: Dx with PE at OSH likely secondary to septic emboli on
[**2153-8-9**]. Last CTA at OSH on [**2153-9-11**] showed intraluminal emboli
with signs of pulmonary infarct. We continued to hold heparin
due to recent history of septic emboli. At [**Hospital1 18**], CT Torso
showed pleural effusions, and IP placed a chest tube on [**9-24**]
which was removed several days later. Pleural fluid analysis
showed 1675 WBCs and 5600 RBCs; prot 4.5, LDH 184, cholest 73,
c/w exudative process. The pt maintained good O2 sats on RA
throughout admission.
.
# R PSOAS ABSCESS: Reported psoas abscess was likely secondary
to her bacteremia. Ortho tapped the hip joint at the OSH and
joint aspirate was not concerning for septic arthritis. She had
a drain in her right hip that was placed by IR at the OSH for
possible absess, and was removed by [**Hospital1 18**] surgery on [**9-25**] given
minimal output and lack of communication with the abscess on CT.
She continued to remain afebrile throughout admission on the
cardiology floor at [**Hospital1 18**].
.
# R leg weakness and pain: The pt had difficulty moving her
right leg upon admission to [**Hospital1 18**], due to pain primarily in the
knee. Lumbar MRI, knee plain films, and R leg CT were all
negative for acute process. Neurology was consulted, and their
examination showed "significant weakness of right hip flexion
and knee extension with possible weakness of right hip flexion
although this could be related to right knee pain. Her sensory
exam shows decreased sensation to pin as well as allodynia in
the distribution of the right femoral nerve. Additionally she
has an absent reflex in the right knee which points to a lower
motor neuron dysfunction, and the pattern of weakness and
sensory loss most likely suggest femoral nerve dysfunction. This
is most likely due to inflammatory changes induced by the psoas
abscess which could also cause femoral nerve dysfunction by
local compression. Given that this is a peripheral nerve
dysfunction, with time, this will improve as the nerve
regenerates and she has experienced this already. The
characteristic of the pain is also consistent with neuropathic
pain." Gabapentin was started (300 mg at night and escalated by
300 mg every 3-5 days as tolerated, with a target daily dose of
[**Telephone/Fax (1) 90968**] mg daily). Lidocaine patches were occasionally applied
to the knee as needed. Physical therapy was initiated, and the
pt demonstrated improvement in strength and pain control with
the gabapentin and increased activity.
.
# SOMNOLENCE: On [**9-22**] pt was noted to have increased somnolence
and some waxing and [**Doctor Last Name 688**] of alertness and consciousness but
was always arousable. Psychiatry saw patient on [**9-22**] and
attributed this somnolence to hypoactive delirium rather than
depression and recommended a switch from diazepam to lorazepam.
The pt's mental status improved on [**9-24**] and continued to
improve throughout her hospitilization; the pt remained AAOx3,
alert, and interactive throughout the remainder of admission.
.
# IVDU: At OSH she was treated for suboxone withdrawal with
fentanyl IV and then later a transdermal fentanyl patch; per OSH
report was using suboxone daily for 6 months PTA. After
admission, her pain regimen was decreased to the following:
fentanyl patch was decreased to 12.5, PRN Oxycodone was
decreased to 5-10mg q6hrs, and prn lorazepam was discontinued.
She showed no Si/Sx of opioid withdrawal.
.
# ANEMIA: Hct 30.9 this am which is stable from [**9-26**] which was
31.8 on [**9-25**] (admission 34.0). Fe studies were consistent with
anemia of chronic disease. Hct remained stable in low 30's
throughout admission.
.
TRANSITIONAL ISSUES:
.
- Abx treatment course for MRSA endocarditis: Pt is currently on
Vancomycin 1000mg IV q12hrs. First negative blood Cx at OSH was
[**2153-9-11**], so last day of six weeks of treatment will be [**2153-10-23**].
.
- Psoas abscess: R psoas abscess drain was pulled on [**9-24**]; pt
has had no fevers thereafter. If pt's R leg function
deteriorates or fever returns, re-imaging for psoas abscess can
be considered.
On [**10-5**] Mrs.[**Known lastname **] was taken to the operating room and
underwent a Minimally invasive tricuspid valve replacement with
size 31 St. [**Male First Name (un) 923**] tissue valve and patent foramen ovale closure
with Dr.[**First Name8 (NamePattern2) **] [**Name (STitle) **]. Please see operative report for further
details. She tolerated the procedure well and was transferred to
the CVICU intubated and sedated. She awoke neurologically intact
and was weaned to extubate without incident. ID continued to
follow her postoperatively for antibiotic recommendations. Daily
surveillance cultures were monitored which had no growth
postoperatively. A PICC line was placed for likely 6 weeks from
Op date of Vancomycin, along with weekly surveillance labs per
ID. On POD#1 she was transferred to the step down unit for
further monitoring. She was started on aspirin and diuresis. She
was in an accelerated junctional rhythm and Betablockers were
not intiated. Her rate was stable and she was trialed on a low
dose betablocker (lopressor 12.5 [**Hospital1 **]) and developed complete
heart block. Betablockers were d/c'd and the EP service was
consulted: "She has stable narrow complex junctional escape
rhythm and does not need pacemaker at this point. However, we
nned to carefully
monitor her recovery and re-assess the need for a pacemaker over
the next week." The patient will be discharged to rehab on
telemetry and follow-up with EP 2 weeks following discharge.
Beta blockers/nodal agents will not be given due to her complete
heart block.
Physical Therapy was consulted for evaluation of strength and
mobility and rehab was recommended. On POD 7 she was cleared for
discharge to [**Hospital1 **], [**Location (un) 86**]. All follow up appointments were
advised.
Medications on Admission:
Home meds (as per [**Hospital1 498**] admit note [**2153-8-9**])
Adderall PRN
Mirena IUD.
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Medications
No AV nodal blocking agents due to AV dissociation
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Please
apply for 12 hours and then remove for 12 hours
.
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
15. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed for constipation.
16. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*0*
17. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
18. 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.
19. Outpatient Lab Work
Weekly CBC with Diff, BUN/Cr, Vanc trough
fax to [**Hospital **] clinic: [**Telephone/Fax (1) 57729**]
20. vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
every twelve (12) hours for 5 weeks: Through [**2153-11-16**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
MRSA Tricuspid endocarditis
Hepatitis B and C
Discharge Condition:
Alert and oriented x3 nonfocal
Deconditioned
Incisional pain managed with oral and transdermal analgesia
Incisions:
Right Anterior Chest wall incision - healing well, no erythema
or drainage
No edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 5 pounds for 2 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
**For any issues related to cardiac rhythm, please contact
cardiology/EP: Dr. [**Last Name (STitle) 90969**] office [**Telephone/Fax (1) 62**] - if off hours
will be placed in contact with cardiology fellow**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2153-11-12**] at 1:15pm in the [**Hospital **] medical office
building [**Hospital Unit Name **]
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2153-10-26**] 3:00
ID: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2153-10-30**] 9:00
ID: Dr. [**Last Name (STitle) **] [**Name (STitle) **], [**2153-11-13**], 10:30am
Cardiologist:Please have your PCP refer [**Name Initial (PRE) **] local Cardiologist to
you for follow up
Please call to schedule appointments with your:
Primary Care Dr.[**First Name4 (NamePattern1) 26772**] [**Last Name (NamePattern1) 90970**] in [**3-20**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2153-10-30**] 9:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2153-10-12**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8610
} | Medical Text: Admission Date: [**2126-11-16**] Discharge Date: [**2126-11-28**]
Date of Birth: [**2056-1-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
pancreatitis, fever, change in mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70 yo F w/h/o CVA, Dementia, HTN, hypothyroidism presented to
OSH from NH for fevers, increasing somnolence, abdominal pain,
N/V x1. Pt was admitted to NWH on [**2126-11-13**] w/initial VS 100.3 BP
179/98 HR 91 RR 14 97%RA. Fever w/u included CXR-unremarkable,
labs notable for amylase/lipase 1078/457 respectively. Abdominal
U/S w/multiple gall stones. Abd CT w/moderate inflammatory
changes of RUQ>LUQ areas, minimal peripancreatic inflammation
around head/body of pancrease. Abd CT c/b 25cc Contrast
extravasation into L arm. Conservative management of
pancreatitis, surgery consulted and aggreed to continue
conservative management of pancreatitis w/IVF resuscitation, NPO
and pain control. Contrast extravasation also managed
conservatively with elevation and Ice placement, followed by
plastics-no surgical intervention. On [**2126-11-16**] pt found to be
less responsive, febrile 102 w/tachypnea RR 36 using accessory
muscles ABG on 3.5LNC 7.45/32/88. ICU evaluation at NWH, however
no MICU beds available. Transferred to [**Hospital1 18**] MICU for closer
monitoring.
Past Medical History:
Dementia--baseline A&0 x1 self, does not do own ADLs, had been
ambulating w/walker
-HTN
-CVA
-s/p Fall [**12/2125**]
-s/p ORIF L intertrochanteric fxr
-Osteoporosis
-Depression
-Hypoparathyroidism
Social History:
Lives in Sunshine NH in [**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) **]. Brother=HCP. At
baseline does not to own ADLs. Retired nurse.
-No TOB or ETOH use.
Family History:
unknown
Physical Exam:
VS: 103.4 Rectally, 182/89 110 24 100%2LNC
GEN: Arousable, not interactive
HEENT: PERRL, Anicteric sclera, Dry MM, cracked tongue, no
cervical LAD
RESP: CTA b/l antly, no wheezing
CV: Reg Nml S1, S2, no M/R/G
ABD: Soft ND/NT, significantly diminished BS, guarding, no
rebound
EXT: No peripheral edema, warm, 2+DP pulses b/l
NEURO: Arousable, does not follow commands, normal reflexes,
downgoing toes b/l
Pertinent Results:
IMAGING:
OSH:
CXR--No PNA/PTX/CHF
ABD U/S--Limited study due to motion; multiple stones in GB
ABD CT--Moderate inflammatory changes RUQ>LUQ; Minimal
peripancreatic inflammation around head/body of pancreas
.
LABS:
OSH
[**11-14**]: Amylase 1078; lipase 457 Tbili 1.0, Dbili0.3; Tn-I<0.01
WBC 24.5 HCT 43.0 PLT 209
[**11-15**]: Amylase 482; lipase 156
WBC 18.7, HCT 38.6 PLT 168
ABG 7.43/27/85 4LNC
[**11-16**]: WBC 19.5 HCT 39.8 PLT 180; Ca 6.3 Ph 1.2
ABG 7.45/32/88 3.5LNC
MICRO Data [**11-14**] Blood--NGT; Urine--E. Coli pan sensitive
Transfer to [**Hospital1 18**] labs:
[**2126-11-16**] 10:31PM BLOOD WBC-19.7* RBC-4.00* Hgb-13.5 Hct-39.7
MCV-99* MCH-33.8* MCHC-34.0 RDW-13.1 Plt Ct-233
[**2126-11-16**] 10:31PM BLOOD PT-15.2* PTT-26.5 INR(PT)-1.4*
[**2126-11-16**] 10:31PM BLOOD Glucose-173* UreaN-10 Creat-0.8 Na-135
K-3.7 Cl-99 HCO3-24 AnGap-16
[**2126-11-16**] 10:31PM BLOOD ALT-48* AST-57* LD(LDH)-878* AlkPhos-140*
Amylase-219* TotBili-1.2
[**2126-11-16**] 10:31PM BLOOD Lipase-114*
[**2126-11-17**] 05:10AM BLOOD Lipase-109*
[**2126-11-18**] 03:00AM BLOOD Lipase-72*
[**2126-11-16**] 10:31PM BLOOD Albumin-3.1* Calcium-7.8* Phos-2.3*
Mg-1.7
[**2126-11-18**] 06:24AM BLOOD Type-ART Temp-38 O2 Flow-4 pO2-101
pCO2-30* pH-7.48* calTCO2-23 Base XS-0 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2126-11-16**] 10:53PM BLOOD Lactate-2.4*
.
IMAGING: [**11-16**] CXR: There are no old films available for
comparison. The heart is mildly enlarged. There is ill-defined
pulmonary vasculature redistribution. The hemidiaphragms are
poorly visualized suggesting bilateral pleural effusions. There
is bilateral lower lobe volume loss. A focal infiltrate cannot
be totally excluded. Some mildly dilated loops of bowel are
seen in the abdomen. IMPRESSION:
1. Fluid overload with bilateral pleural effusions and vascular
plethora.
.
[**11-16**] RIGHT UPPER QUADRANT ULTRASOUND: Limited views of the
liver demonstrate no focal or textural abnormalities. Small
stones and sludge are seen within a nondistended gallbladder.
There is no gallbladder wall edema or adjacent pericholecystic
fluid to indicate acute cholecystitis. Common bile duct
measures 4 mm and is not dilated. There is no son[**Name (NI) 493**]
[**Name2 (NI) 515**] sign. No ascites is seen in the right upper quadrant.
Limited views of the right kidney demonstrate no hydronephrosis
or calculi. IMPRESSION: Limited study. Cholelithiasis and
sludge without evidence of acute cholecystitis. No biliary
ductal dilatation.
.
[**11-20**] HEAD CT: 1. No evidence of acute intracranial pathology,
including no sign of hemorrhage. Chronic small vessel
infarction as described above. 2. Bilateral prominence of the
lateral ventricles out of proportion to the degree of brain
atrophy. Question is raised of communicating hydrocephalus,
which should be correlated clinically.
.
Chest/Abd/Pelvis CT: 1. Overall limited examination; however,
no definite evidence of pulmonary embolus to the segmental
level.
2. Extensive severe pancreatitis with no definite evidence of
pancreatic necrosis. No comparison exams are available at our
institution limiting assessment for change. Due to extensive
inflammatory changes, the patient is at risk for sequela of
severe pancreatitis including necrosis and vascular
complications.
3. Bilateral pleural effusions and compression atelectasis with
no definite evidence of pneumonia.
.
Echo: 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. Overall left
ventricular systolic function is probably normal (LVEF 50-60%)
(The inferior wall appears hypokinetic on some views, but not
all). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion. IMPRESSION: Overall low normal LVEF. Cannot exclude a
regioanl wall motion abnormality due to technical limitations.
Brief Hospital Course:
.
#. Fevers: Fevers to 103.2 on presentation raised concern for
SIRS vs. biliary sepsis in the setting of pancreatitis and
E-coli UTI, elevated lactate, and leukocytosis. She was
initially treated with meropeneum empirically for biliary
infection possibility. Upon improvement of pancreatitis,
meropenem changed to cipro for pansensitive e. coli UTI on
[**2126-11-9**].=, however, she developed another positive UA on this
regimen and began spiking fevers again, therefore this was
changed to ceftazadime on [**2126-11-22**]. Blood cultures from the OSH
and [**Hospital1 18**] were all negative. A CT chest showed b/l pulm
infiltrates, but no PNA. She defervesced around [**11-24**]. All
antibiotics were stopped around [**11-24**].(Pnemovac and Flu vaccine
given [**11-14**] at OSH)
.
#. Pancreatitis: Most likely due to gall stones noted on abd u/s
at OSH. Surgery was consulted and did not feel that the patient
was a surgical candidate given her multiple other active medical
issues. She was treated conservatively with IVF, NPO and pain
control. A post pyloric daubhoff was placed by [**Doctor First Name **] for tube
feeding. A repeat CT showed extensive and severe pancreatitis,
but no sign of necrosis. She was started on sips with modified
diet per speech and swallow on [**11-25**] and was tolerating thin
liquids and ground diet on [**11-27**].
.
#. Delta MS/Dementia: Multifactorial in setting of infectious
process, resolved with improvement of acute issues. Baseline MS
per report by patients brother is [**Name (NI) 70299**] to self only, not
independent in ADL's. A head CT was done to rule out acute
intracranial processes; it revealed atrophy along with
enlargement of the ventricals out of proportion to the degree of
atrophy. After transfer to the floor, her mental status
stabilized and her brother felt that she returned to her
baseline on [**11-24**].
.
#. Tachypnea: The patient required supplemental O2 throughout
her stay. She was noted to have worsening pulmonary edema by
CXR despite diuresis at the OSH. She was diuresised with Lasix
40 IV PRN with good response. The patient's PCP was [**Name (NI) 653**];
the patient has no documented history of CHF (though no recent
echo and on standing lasix as outpatient). Bilateral pleural
effusions were noted on Chest CT (negative for PNA or PE). A
TTE was performed to assess for CHF which showed low normal EF.
She was also treated symptomatically with nebs. She remained
stable on room air since transfer to the floor
.
#. HTN: Pt's HTN managed with metoprolol; this was initially
held due to her tenuous original status w/SIRS. Restarted as
blood pressure increased.
.
#. CODE: Full, confirmed w/Brother=HCP [**Name (NI) **] [**Known lastname 14164**]
[**Telephone/Fax (1) 70300**]
.
#. Contact: Brother as noted above and [**Name (NI) **] [**Telephone/Fax (1) 70301**];
Sunrise NH [**Telephone/Fax (1) 70302**]
Medications on Admission:
AT HOME)
-Tylenol 1000mg TID
-Actonel 35mg
-Namenda 10mg [**Hospital1 **]
-Emabolex 7.5mg daily
-Toprol Xl 50mg daily
-Lasix 40mg daily
.
(On Transfer)
-Lovenox 40mg SC daily
-Synthroid 60mcg IV daiy
-Pantoprazole 40mg IV daily
-Lasix 20mg IV daily (received x1day)
-Lopressor 5mg IV Q6hours x3 days
-Aspirin 81 mg PO daily
-Colace
-Senna
-Zosyn 3.375mg IV q8hrs (day1=[**11-14**] received for 3 days total)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever.
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 5176**]
Discharge Diagnosis:
pancreatitis
pulmonary edema
hypertension
hypothyroidism
fever
Discharge Condition:
Stable. Patient is tolerating thin liquids and ground foods and
her medications in applesauce.
Discharge Instructions:
please take your medication as directed
please call your physician if you develop fever, chills, nausea,
vomiting, abdominal pain or diarrhea as these may suggest a
serious condition.
Followup Instructions:
Please follow-up with your surgeon [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD on [**2126-12-9**]
8:15. His phone number is [**Telephone/Fax (1) 476**].
.
Please call for follow-up appointment with your primary care
physician [**Last Name (NamePattern4) **] [**1-4**] weeks after your discharge from the extended
care facility.
ICD9 Codes: 5990, 4280, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8611
} | Medical Text: Admission Date: [**2108-5-15**] Discharge Date: [**2108-5-18**]
Date of Birth: [**2047-9-9**] Sex: M
Service: MEDICINE
Allergies:
Compazine / Codeine / Atenolol
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
hypertensive emergency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 60 y.o.m. with HTN, anxiety, depression,
personality disorder, PTSD, COPD, h/o PE with multiple
admissions for malignant hypertension who is admitted to the ICU
for hyertensive emergency. He was seen in [**Company 191**] today for chest
pain during a regular routine f/u appt. Has had CP for 3 days on
left side, radiating down left arm, unchanged with rest or
exertion. Pressure is constant. Also with 10/10 HA and vision
blurriness as well as photophobia and ataxia/difficulty with
gait. BP was elevated to 210/110 at [**Company 191**], equal in both arms.
Sent to ED for evaluation.
In the ED vitals were 99.3, 66, 192/103, 16, 98%2L. Given
aspirin 325 mg daily, nitro 0.4 mg SL with no relief. Received
one percocet for pain. Head CT negative. Neuro consult did not
find any deficits but inadequate exam because he was
uncooperative and therefore an MRI was recommended which was
negative. EKG without ischemic changes. CTA chest without PE or
aortic dissection. Started on nitro gtt for goal SBP 180 and he
was admitted to the ICU for titration of BP.
Currently the patient is minimially communicative but endorses
chest pain, HA, vision blurriness, and ataxia as above. Also
states that he is anxious and hasn't gotten his clonopin for the
day. Also endorsed nausea, emesis, abdominal discomfort, and
SOB, but unable to elaborate on any of these symptoms. After
this examiner left the room, he voiced a stream of thoughts to
the nurse that included stating he has not had a solid meal
since his girlfriend died a couple of months ago and that he has
been taking his meds intermittently and the reason he showed up
at clinic today was to get meds refilled as he had run out
Past Medical History:
- Multiple admission for malignant HTN after drug abuse and not
taking medications. Normal P-MIBI [**6-28**], normal EF on echo [**3-29**].
MRI of Kidneys were negative for RAS. TSH was normal. No
stigmata of Cushings Disease and random AM cortisol normal.
- PE: s/p IVC filter, recent admit for PE [**11/2107**], on lovenox SC
x 4 weeks.
- Heroin abuse: methadone maintenance clinic Habit Management;
per pt, quit 20 yrs ago
- Hepatitis B previous infection, now sAg negative
- Hepatitis C, undetectable HCV RNA [**3-29**]
- COPD
- Gastroesophageal reflux disease
- PTSD
- Anxiety / Depression
- Antisocial personality disorder
- Microcytic Anemia baseline 27
- Vit B12 deficiency
Social History:
Past heroin abuse, now on methadone. No recent illicits. Denies
current smoking (but found to have sig history in past). Denies
alcohol.
Military history ([**Country **] veteran), Homeless, living with a
friend. Girlfriend of many years died 2 weeks ago while having
CABG (per his report, due to undisclosed clonidine abuse).
Former chemical salesman, currently on disability.
Family History:
Father died of MI, mother of pancreatic CA.
Physical Exam:
HR: 64 (64 - 64) bpm
BP: 187/109(127) {187/109(127) - 187/109(127)} mmHg
RR: 7 (7 - 7) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 94.1 kg (admission): 94.1 kg
Height: 67 Inch
General Appearance: Well nourished, No acute distress, Anxious
Eyes / Conjunctiva: PERRL, no scleral icterus
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: RRR. no M/R/G. nl S1,S2
Respiratory / Chest: CTA Bilaterally
Abdominal: Soft, Bowel sounds present, Tender: in all 4
guadrants, nonspecific, no rebound or guarding, no HSM
Extremities: 2+ DP pulses. no edema
Skin: Warm no rash
Neurologic: A/O x 3. no SI/HI
Pertinent Results:
[**2108-5-15**] MRI/MRA BRAIN:
FINDINGS: BRAIN MRI:
There is no evidence of acute infarct seen. There is mild
periventricular hyperintensities due to minimal changes of small
vessel disease. There is no midline shift or hydrocephalus.
IMPRESSION: No evidence of acute infarct.
MRA OF THE HEAD:
The head MRA demonstrates normal flow signal within the arteries
of anterior and posterior circulation. The distal left vertebral
artery ends in posterior inferior cerebellar artery, a normal
variation. There is no vascular occlusion or stenosis seen.
There is no evidence of an aneurysm greater than 3 mm in size.
IMPRESSION: Normal MRA of the head.
[**2108-5-15**] CTA CHEST:
IMPRESSION: No evidence of pulmonary embolism or thoracic aortic
dissection.
[**2108-5-15**] CT HEAD:
IMPRESSION: No evidence of acute intracranial hemorrhage.
[**2108-5-15**] CXR:
IMPRESSION: No acute cardiopulmonary disease.
Brief Hospital Course:
The patient is a 60 y.o.m. with HTN and multiple admissions for
malignant hypertension, anxiety, depression, PTSD, COPD who
presents with hypertensive emergency with signs of end organ
damage.
# Malignant Hypertension ?????? Etiology mednoncompliance. Workup in
the past has been negative to identify causes other than
essential hypertension. No evidence of intracerebral hemorrhage
or infarcts. [**Month (only) 116**] have hypertensive encephalopathy which is
characterized by HA, nausea, and vomiting, but the brain MRI did
not show any evidence of edema. Other neurologic symptoms such
as vision blurriness and ataxia, as well as cardiac symtpoms of
chest pain and [**Last Name (un) **] are likely the result of hypertension and end
organ damage. He was started on nitro gtt with goal SBP<160.
He was then switched to metoprolol, amlodipine, and clondine PO.
He has a history of non-compliance, and clondine can cause
rebound hypertension. His BP was well controlled on discharge.
Patient instructed in importance of taking his meds faithfully.
# Chest pain - Patient with risk factors including hypertension
and h/o tobacco in the past as well as family history. No
hypercholesteremia or diabetes. EKG and story not c/w ACS. CTA
without PE or aortic dissection. Reproducible on exam. Likely
due to costrochondritis as well as hypertensive emergency. 3
sets of cardiac enzymes were negative. Patient was continued on
aspirin and b-blocker.
# [**Last Name (un) **] - Cr mildly elevated at 1.3, likely due to malignant
hypertension. Was elevated to 1.6 during last admission with
similar presentation.
# COPD - Currently stable.
- Continue tiatroprium and fluticasone
# H/O PE - Treated with lovenox. IVC filter in place. No
evidence of recurrent PE.
# Psych - Ah/o depression, anxiety, PTSD, personality disorder.
Also homeless. Psych consult recommended current psych meds, no
evidence of active suicidal ideation.
# Substance Abuse - Tox screen negative.
- Continue methadone at outpatient dose (per last discharge in
[**Month (only) **], dose confirmed)
Medications on Admission:
Methadone 135 mg daily (rx by methadone clinic)
Clonazepam 1mg TID prn
Duloxetine 60 mg daily
Aspirin 325mg daily
Tiatroprium daily
Pantoprazole daily
Fluticasone 2 puffs [**Hospital1 **]
Seroquel 150 mg QHS
Amlodipine 10 mg daily
Metoprolol 25 mg [**Hospital1 **]
Clonidine 0.6 patch Qtues
Discharge Medications:
1. Methadone 10 mg/mL Concentrate Sig: One [**Age over 90 10973**]y Five
(135) mg PO DAILY (Daily).
2. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
7. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day) as needed for constipation.
8. Quetiapine 50 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
Disp:*90 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
10. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
11. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Clonazepam 2 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive Emergency
Chest Pain
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return to ED if having vision changes, severe headache,
prolonged nausea and vomiting.
Followup Instructions:
Patient to f/u with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5717**].
ICD9 Codes: 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8612
} | Medical Text: Admission Date: [**2195-4-8**] Discharge Date: [**2195-4-17**]
Date of Birth: [**2117-9-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Zocor
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
known CAD with unstable angina and severe 3 vessel disease
Major Surgical or Invasive Procedure:
s/p CABGx3 [**4-10**]
LIMA-LAD, SVG-OM, SVG-PDA
History of Present Illness:
Mr. [**Known lastname 9817**] is a 77 yo with known CAD who had previously refused
surgery but had been experiencing increasing episodes of
unstable angina. He was refered to Dr. [**Last Name (STitle) **] for operative
management
Past Medical History:
CAD
prostate CA with metastatic bone disease
OA gout
hypercholesterolemiaHTN
cataracts
Pertinent Results:
[**2195-4-17**] 06:25AM BLOOD WBC-4.6 RBC-3.65* Hgb-11.3* Hct-33.2*
MCV-91 MCH-30.9 MCHC-34.0 RDW-15.8* Plt Ct-139*
[**2195-4-17**] 06:25AM BLOOD Plt Ct-139*
[**2195-4-17**] 06:25AM BLOOD UreaN-13 Creat-0.8 K-3.7
Brief Hospital Course:
Mr. [**Known lastname 9817**] was admitted from Dr.[**Name (NI) 3502**] office on [**2195-4-8**] with
c/o worsening unstable angina. He was taken to surgery with Dr.
[**Last Name (STitle) **] on [**4-10**] and underwend CABGx3, LIMA-LAD, SVG-OM, SVG-PDA.
He tollerated the procedure well and was transfered to the
intensive care unit. Post operatively he was noted to have high
chest tube outputs. The decision was made to take the patient
back to the operating room for exploration for bleeding. Please
see operative notes for full details. He was transfered bact to
the intensive care unit in stable conditionOn POD1 he was noted
to have collapse of his RUL on CXR and underwent a bronchoscopy
to remove secretions. After the procedure, he was weaned and
extubated from mechanical ventillation without difficulty. Post
operatively, he had mild confusion which slowly resolved and on
POD#3, he was transfered from the intensive care unit to the
regular floor. His confusion fully cleared by POD#5 and by POD#7
he was cleared by physical therapy and was hemodynamically
stable and discharged to home.
Medications on Admission:
Norvasc 10mg qd
atenolol 50mg qd
plavix 75mgqd
ketoconazole 200mg [**Hospital1 **]
hydrocortisone 20mg [**Hospital1 **]
nitroglycerin prn
percocet prn
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Ketoconazole 200 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Community VNA of [**Location (un) 6981**]
Discharge Diagnosis:
CAD
s/p CABGx3
post op confusion-resolved
prostate CA w/metastatic bone disease
hypercholesterolemia
HTN
Discharge Condition:
good
Discharge Instructions:
you may wash your incisions with mild soap and water
do not swim or take a bath for 1 month
do not drive for 1 month
do not apply lotions, creams, ointments or powders to your
incisions
do not lift anything heavier than 5 pounds for 3 months
Followup Instructions:
follow up with Dr. [**First Name (STitle) **] in [**1-25**] weeks
follow up with Dr. [**Last Name (STitle) 174**] in [**1-25**] weeks
follow up with Dr. [**Last Name (STitle) **] in [**3-27**] weeks
Completed by:[**2195-4-17**]
ICD9 Codes: 4111, 5180, 4280, 4019, 2720, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8613
} | Medical Text: Admission Date: [**2193-4-26**] Discharge Date: [**2193-4-29**]
Date of Birth: [**2114-9-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
transfer for c. cath/STEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization with drug-eluting stent placed in the
left anterior descending artery
History of Present Illness:
79-year-old male with history of CAD and prior PCI with DES to
OM2 at [**Hospital1 2025**] ([**10-7**]) that presented to the ER at OSH with [**2192-2-8**]
chest pain. The night prior to presentation he experienced
indigestion. He then awoke with a "rope-like" non-radiating
chest discomfort with no associated symptoms except perhaps
chills that resolving except the portion "over the heart." He
continued to have this discomfort. His wife called his PCP and
told him to report to the nearest ER. EKG on presentation showed
ST elevation in leads V3,4, and 5. Troponin was 12.483.
He was given 81 mg ASA x 4, 4500 units heparin bolus with drip
at 1800 units/hr and 5 mg IV lopressor. He was given plavix 600
mg PO x 1 prior to transfer to [**Hospital1 18**] for c. cath. He was chest
pain free prior to transfer. Vitals at transfer were BP 145/87
HR 63 SR pOx 100 % on 3 L O2 and RR 20.
He was taken to the c. cath lab showing subtotally occluded LAD
with successful PTCA/stenting with 2.5 x 18 promus stent. LCx
and RCA were patent.
On the floor, patient in NAD without any complaints.
Of note, he was recently hospitalized at [**Name (NI) 75328**] [**Hospital 18806**] Medical
[**Name2 (NI) **] in early [**Name (NI) 547**] for sepsis from a urinary source secondary
to BPH. He completed a course of levofloxacin, was placed on
flomax, and is scheduled to follow-up with urology.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies exertional buttock or calf pain.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for dyspnea on exertion,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope. + palpitations two days before the event
.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, +Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
CAD s/p prior PCI
- PERCUTANEOUS CORONARY INTERVENTIONS:
[**Hospital1 2025**] ([**2185**]): Has stent placed to OM2 with ? MI in setting of
shoulder pain. At that time, he was placed on ASA/plavix.
3. OTHER PAST MEDICAL HISTORY:
- BPH with urinary retention
- History of HL
- History of UTI
- Esophageal Dilitation
Social History:
He lives with his wife.
- Tobacco history: none
- ETOH: [**1-6**] glasses of wine/week
- Illicit drugs: none
Family History:
- Brother died of MI at age 60 (sudden death) while shoveling
snow.
- Mother: unknown cancer at age [**Age over 90 **]
- Father: COPD at age 85
Physical Exam:
Tmax: 35.9 ??????C (96.6 ??????F)
Tcurrent: 35.9 ??????C (96.6 ??????F)
HR: 69 (69 - 69) bpm
BP: 125/73(82) {125/73(82) - 125/73(82)} mmHg
RR: 21 (21 - 21) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): AAOx2 (not to date fully), Movement:
Not assessed, Tone: Not assessed
Pertinent Results:
I. Cardiology
A. Cath ([**2193-4-26**]) ** PRELIM REPORT **
BRIEF HISTORY: 78 M presented to OSH with chest pain and [**Hospital **]
transferred to [**Hospital1 18**] for emergent cardiac catheterization.
INDICATIONS FOR CATHETERIZATION:
Coronary artery disease, STEMI transfer
PROCEDURE:
Coronary angiography
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
**PTCA RESULTS
LAD
PTCA COMMENTS: Initial angiography reveald a mid LAD 95%
subacute
thrombus. We planned to treat this thrombus with aspiration
thrombectomy/PTCA/stenting and heparin/integrilin given
prophylactically. An XB LAD 4.0 guiding catheter provided good
support
for the procedure and a Prowater wire was advanced into the
distal LAD
with moderate difficulty. We then proceed with an Export AP
aspiration
thrombectomy but unable to deliver device distal to subacute
thrombus.
We then predilated the mid LAD thrombus with an Apex OTW 2.0x8
mm
balloon inflated at 8 atm. We then noted an acute cut-off in the
distal
LAD after flow was re-established and proceeded with cautious
dotting of
the cut-off area with the balloon and distal delivery of NTG via
balloon
with minimal improvement of distal LAD flow. We then stented the
mid LAD
with a Promus Rx 2.5x18 mm drug-eluting stent (DES) post-dilated
with an
NC Quantum Apex MR 2.75x12 mm balloon inflated at 20 atm for 20
sec.
Final angiography revealed normal TIMI 3 flow in the vessel, no
angiographically apparent dissection and 0% residual stenosis in
the
newly deployed stent but acute cut-off in distal LAD showed
diffusely
diseased small apical vesswel that remained unchanged despite
mechanical
dottering and distal NTG delivery via balloon. The R 6Fr femoral
artery
sheath was removed post limited groin angiography and an
Angioseal
closure device was deployed without complications with distal
pulses
confirmed post deployment. The patient left the cath lab
angina-free and
in hemodynamically stable condition.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 59 minutes.
Arterial time = 56 minutes.
Fluoro time = 15.2 minutes.
IRP dose = 733 mGy.
Contrast injected:
Omnipaque 175 cc total contrast during procedure
Anesthesia:
1% Lidocaine SC, fentanyl 25 mcg IV, versed 0.5 mg IV
total
Anticoagulation:
Heparin [**2182**] units, integrilin bolus and infusion
COMMENTS:
1. Emergent coronary angiography revealed a right dominant
systemt. The
LMCA, LCx and RCA were all patent. The LAD revealed a mid 95%
occlusion
with thrombus.
2. Limited resting hemodynamics revealed a SBP of 142 mmHg and a
DBP of
80 mmHg.
3. Successful aspiration thrombectomy/PTCA/stenting of the mid
LAD with
a Promus Rx 2.5x18 mm [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]-dilated with an NC 2.75 mm
balloon. Final
angiography revealed normal TIMI 3 flow, no angiographically
apparent
dissection and 0% residual stenosis in the newly deployed stent
with an
abrupt cut-off in the distal LAD unchagned despite mechanical
balloon
dottering and distal NTG delivery via balloon. (see PTCA
comments)
4. R 6Fr femoral artery Angioseal closure device deployed
without
complicatons (see PTCA comments)
FINAL DIAGNOSIS:
1. Severe coronary artery disease with subtotally occluded mid
LAD: see
comments section.
2. Successful aspiration thrombectomy/PTCA/stenting of the mid
LAD with
a Promus Rx 2.5x18 mm [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]-dilated with an NC 2.75 mm
balloon. (see
PTCA comments)
3. R 6Fr femoral artery Angioseal closure device deployed
without
complications (see PTCA comments)
4. ASA indefinitely; plavix (clopidogrel) 75 mg daily for at
least 12
months for DES
5. Integrilin gtt for 18 hours post PCI for thrombus and abrupt
cut-off
of distal small vessel apical LAD unchanged despite mechanical
balloon
dottering and distal NTG delivery via balloon
B. TTE ([**2193-4-26**])
Conclusions
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is mild to moderate regional left ventricular systolic
dysfunction with basal to mid lateral hypokinesis and distal
septal/distal anterior and apical septal hypokinesis. No masses
or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
C. ECG
No prior ECG available for comparison.
OSH ECG dated [**2193-4-26**] at 9:01 showing ?ectopic atrial rhythm,
NI, leftward axis. STE in V3, V4, and V5.
II. Labs
A. Admission
[**2193-4-26**] 03:15PM BLOOD WBC-7.5 RBC-4.21* Hgb-13.6* Hct-38.9*
MCV-92 MCH-32.3* MCHC-34.9 RDW-12.7 Plt Ct-253
[**2193-4-26**] 03:15PM BLOOD PT-13.4 PTT-27.0 INR(PT)-1.1
[**2193-4-26**] 03:15PM BLOOD Glucose-130* UreaN-15 Creat-1.1 Na-139
K-4.2 Cl-103 HCO3-28 AnGap-12
[**2193-4-26**] 03:15PM BLOOD Calcium-9.4 Phos-3.0 Mg-2.1 Cholest-204*
B. Cardiac
[**2193-4-27**] 05:57AM BLOOD CK(CPK)-426*
[**2193-4-26**] 11:13PM BLOOD CK(CPK)-675*
[**2193-4-27**] 05:57AM BLOOD CK-MB-22* MB Indx-5.2 cTropnT-1.36*
[**2193-4-26**] 11:13PM BLOOD CK-MB-41* MB Indx-6.1*
[**2193-4-26**] 03:15PM BLOOD CK-MB-96* MB Indx-9.2* cTropnT-3.21*
C. Misc
[**2193-4-26**] 03:15PM BLOOD %HbA1c-6.0* eAG-126*
[**2193-4-26**] 03:15PM BLOOD Triglyc-135 HDL-44 CHOL/HD-4.6
LDLcalc-133*
D. Discharge
WBC 4.5 Hgb 11.2 Plt 181 INR 1.2 Na 141 K 4.4 Cl 108 HCO3 29 BUN
20 Cr 1.4 Ca 9.1 Ph 3.2 Mg 2.1
Brief Hospital Course:
79-year-old male with history of CAD and prior PCI with DES to
OM2 at [**Hospital1 2025**] ([**10-7**]) that presented to the ER at OSH with [**Hospital **]
transferred to [**Hospital1 18**], and now s/p successful PTCA/stenting with
DES for LAD lesion.
# STEMI
Patient has known history of CAD given prior stent placement in
OM2. It is uncertain why the patient is not on any cardiac
medications for risk reduction. He presented with chest
discomfort. OSH ECG notable for ectopic atrial rhythm and ST
elevations in V3, V4, and V5 and initial troponin 12.483
(unknown if I or T) and CK-MB 68.5. Cardiac biomarkers indicated
CK-MB 22 and cTrop 1.36. He was transferred to [**Hospital1 18**] for c. cath
with successful PTCA/stenting with DES for 95 % subacute mid-LAD
thrombus. Final angiography revealed normal TIMI 3 flow and no
angiographically apparent dissection. See cardiac cath report
for full details. Cardiac biomarkers indicated CK-MB 22 and
cTrop 1.36. Post-MI ECHO indicated LVEF 35-40 % withmild to
moderate regional left ventricular systolic dysfunction with
basal to mid lateral hypokinesis and distal septal/distal
anterior and apical septal hypokinesis. This may be suggestive
of another MI given that these wall motion abnormalities do not
necessarily correspond to his LAD lesion.
He was continued on an integrilin infusion for 18 hours post PCI
for thrombus and abrupt cut-off of distal small vessel apical
LAD unchanged despite mechanical balloon dottering and distal
NTG delivery via balloon.
He was placed on aspirin 325 mg PO qD indefinitely, clopidogrel
75 PO qD for at least 12 months for DES. He was started on
crestor given concern for myalgias. He was also started on
metoprolol and lisinopril.
# Hyperlipidemia
Patient was not on lipid-lowering therapy on admission.
Cholesterol panel showing total cholesterol 204, TG 135, HDL 44,
and LDL 133. He was started on statin as above and advised to
initiate lifestyle modifications.
A1c was 6 suggestive of pre-diabetic state.
# RHYTHM: Patient remained in NSR during hospitalization with
telemetry showing bradycardia to low 40s during sleep.
# BPH with urinary retention
Patient was recently hospitalized at [**Name (NI) 75328**] Brothers in the
state of [**Name (NI) 531**] for sepsis from a urinary source in the
setting of urinary retention per provided records from family.
He was continued on flomax during hospitalization and will
follow-up with urology after hospitalization.
CODE: Full
COMM: patient, wife [**Name (NI) **] [**Telephone/Fax (1) 88873**] (H) [**Telephone/Fax (1) 88874**] (C)
Medications on Admission:
- flomax 0.4 mg PO qD
- Multivitamin
Discharge Medications:
1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
6. Outpatient Lab Work
Please check Chem-7 and CBC on [**4-1**] at Dr.[**Name (NI) **] office.
7. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
Disp:*25 tablets* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
ST elevation myocardial infarction
Coronary Artery Disease
Acute Kidney Injury
.
Secondary Diagnosis:
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 26762**],
It was a pleasure taking part in your care at [**Hospital1 18**]. You were
transferred here after it was determined that you had suffered a
heart attack prior to arriving at hospital. You underwent a
cardiac catheterization procedure where a drug eluting stent was
placed in one your heart arteries and you did very well after
this.
You will need to take a number of medications to keep your heart
healthy and make sure the stent stays open.
We have made the following changes to your medications:
START taking aspirin 325 mg and Plavix daily. These medicines
work together to prevent the stent from clotting off. YOu will
need to take these medicines daily for the next year and
possibly longer. Do not stop taking aspirin and Plavix unless
Dr. [**Last Name (STitle) **] says that it is OK.
START taking Rosuvastatin (Crestor) to lower your cholesterol.
YOu will need to have your liver function tested with blood
tests on a regular hasis on this medicine. If you develop muscle
cramps on this medicine, please call Dr. [**Last Name (STitle) **].
START taking Lisinopril to lower your blood pressure and help
your heart recover from the heart attack.
START taking Metoprolol to lower your heart rate and help your
heart recover from the heart attack.
START taking nitroglycerin if you have chest pain at home. Take
one tablet under your tongue, sit down and wait 5 minutes. You
can take another tablet if you still have chest pain but please
call Dr. [**Last Name (STitle) **] if you take any nitroglycerin.
Continue to take Flomax as before.
Followup Instructions:
D'[**Last Name (LF) **],[**First Name3 (LF) **] D. [**Telephone/Fax (1) 22235**]
Appointment already made on [**2193-5-2**] at 11:00 AM
.
Name: [**Last Name (LF) 7526**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] BLDG
Address: 131 ORNAC, [**Apartment Address(1) 88875**], [**Location (un) **],[**Numeric Identifier 17125**]
Phone: [**Telephone/Fax (1) 88876**]
Appt: [**5-16**] at 3:30pm
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
ICD9 Codes: 5849, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8614
} | Medical Text: Admission Date: [**2176-1-21**] Discharge Date: [**2176-3-20**]
Date of Birth: [**2124-9-13**] Sex: M
HISTORY OF PRESENT ILLNESS: Briefly, this is a 51-year-old
male who was recently discharged in [**Month (only) 404**] for diabetic
ketoacidosis who had a known history of cirrhosis with
multiple episodes of spontaneous bacterial peritonitis and
He had been admitted multiple times, and at this time was
being admitted for his high [**Month (only) **] sugars. He presented with
nausea, vomiting, and a sour taste in his stomach and started
vomiting. He denied any [**Last Name (LF) **], [**First Name3 (LF) 691**] diffuse abdominal pain,
or changes in bowels.
significant for)
1. Hepatitis C and alcohol abuse with cirrhosis (he was a
Child class C).
2. He had portal gastropathy.
3. Grade II varices.
4. Ascites.
5. Multiple episodes of spontaneous bacterial peritonitis.
6. He had multiple episodes of encephalopathy.
7. Type 1 diabetes.
8. Gastroparesis.
9. Chronic renal insufficiency.
10. Osteoporosis.
11. Diverticulitis.
12. Status post hemicolectomy.
MEDICATIONS ON ADMISSION: (His medications on admission
were)
1. NPH insulin 32 units subcutaneously q.a.m.
2. Humalog sliding-scale.
3. Folate.
4. Protonix 40 mg p.o. q.d.
5. Spironolactone 100 mg p.o. q.d.
6. Lasix 80 mg p.o. q.d.
7. Thiamine 100 mg p.o. q.d.
8. Lactulose 30 cc p.o. q.i.d.
9. Reglan 10 mg p.o. q.i.d.
10. Neutra-Phos four times per day.
11. Multivitamin one tablet p.o. q.d.
12. Colace.
ALLERGIES:
SOCIAL HISTORY: He lives with his wife and two sons. [**Name (NI) **]
quit alcohol 13 years ago. He also had been a bartender.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, he was afebrile. His vital signs were stable.
He was alert and oriented times three and appeared
comfortable. His pupils were equally round and reactive to
light. Extraocular muscles were intact. He had icterus and
generalized jaundice. His neck was supple. His lungs had
crackles at the bases but were otherwise clear. His heart
was regular in rate and rhythm with a 2/6 systolic ejection
murmur. His abdomen was distended, diffusely tender (left
greater than right), with ascites, and with rebound. His
extremities had bilateral edema. His neurologic examination
was nonfocal.
PERTINENT LABORATORY VALUES ON PRESENTATION: His
laboratories upon admission evaluated he had a white [**Name (NI) **]
cell count of 6.3, hematocrit was 29.7, and platelet count
was 89. Chemistries revealed sodium was 125, potassium was
5.3, chloride was 98, bicarbonate was 18, [**Name (NI) **] urea nitrogen
was 91, creatinine was 1.8, and [**Name (NI) **] glucose was 142. His
prothrombin time was 15, partial thromboplastin time was
32.3, and his INR was 1.5. His ALT was 70, AST was 110,
alkaline phosphatase was 247, total bilirubin was 2.4,
albumin was 3.2, amylase of 52, and lipase was 44.
HOSPITAL COURSE: He was admitted to the Medicine Service at
that time for a question of spontaneous bacterial peritonitis
versus gastritis and was managed at that time. He stayed in
the hospital with great difficulty managing his sugars as
well as a question per bacterial peritonitis.
On [**2176-1-29**], the patient received a cadaveric liver
transplant with a primary end to end bile duct anastomosis with
no T- tube. The patient was transferred to the Intensive Care
Unit postoperatively where he stayed through postoperative day
15.
At this time, he continued to be afebrile throughout his
Intensive Care Unit course. His [**Year (4 digits) **] pressure was good. He
was started on oral food on postoperative day six as well as
continued on intravenous fluids. He was also started on tube
feeds on postoperative day 12. His urine output continued to
improve, and after postoperative day one he required no more
[**Year (4 digits) **] transfusions. His urine output was excellent
throughout his Intensive Care Unit stay, and his
[**Location (un) 1661**]-[**Location (un) 1662**] output slowly decreased. His left
[**Location (un) 1661**]-[**Location (un) 1662**] drain was discontinued on postoperative day 10.
His laboratories revealed his white [**Location (un) **] cell count stayed
normal. His hematocrit was stable after an original
transfusion, and his platelet count stayed less than 100
(which required multiple platelet transfusions). His
chemistries were within normal limits. His creatinine, which
rose to a high of 3, slowly began to return to normal at that
time. His liver function tests slowly reduced to normal, and
he continued to improve. His bilirubin, which rose to a high
of 19, returned slowly back down to his normal range of
approximately 2.6, and his INR slowly corrected. The patient
did well from that standpoint. His liver ultrasound was
normal, and he was continued on MMF Solu-Medrol which was
slowly tapered, and prednisone, and cyclosporin.
The patient had OK T3 until the end of his Intensive Care
Unit course and was only started on CSA on postoperative day
seven. The patient did well from a transplant point of view,
and he was transferred to the floor.
It was noted during his hospital stay that his left knee had
become swollen, and Orthopaedics consulted on postoperative
day 18. He was taken to the operating room for a left knee
washout which he tolerated well. At that time, the joint
fluid showed 53,000 white [**Location (un) **] cells, with many polys, with
4+ white [**Location (un) **] cells, and no organisms on Gram stain. His
cultures ultimately did not growth anything; however, he did
have the washout for a septic joint.
On postoperative day 16, an endoscopic retrograde
cholangiopancreatography was done which showed no bile leak.
The [**Location (un) 1661**]-[**Location (un) 1662**] drain in the bile was approximately 1.9.
Chest x-rays continued to show small pleural effusions which
slowly improved over time. The patient continued to improve
on the floor postoperatively from his washout as well as from
his liver transplant. His white [**Location (un) **] cell count continued
to remain normal. His chemistries were all within normal
limits, and his creatinine slowly dropped to within normal
limits. His alkaline phosphatase and liver enzymes were
slightly elevated postoperatively, and he continued to
fluctuate (upwards of 800).
A biopsy was done on postoperative day 22 which showed no
evidence of acute rejection. His ultrasound also showed
patent vessels with good flow. He was continued on his MMF,
his prednisone, and his CSA. His levels were all within
normal limits (around 300).
He continued to do well. His total bilirubin continued to
normalize, and his Foley was removed on postoperative day 25.
On postoperative day 26, a magnetic resonance imaging of the
brain was done for episodes of confusion and showed no focal
lesions with generalized atrophy (no more than expected for
his age). His immunosuppressants were continued at that time
at the same doses. His oxycodone was stopped at that time
for his confusion.
His [**Location (un) **] sugars, which continued to fluctuate throughout his
course, required an insulin drip occasionally as well as
management by the [**Hospital **] [**Hospital 982**] Clinic. He had multiple
episodes in which his [**Hospital **] sugars were upwards of 400 and
also dropped very low down to the 30s.
He continued to have excellent urine output and was given
minor diuresis. Due to his positive vancomycin-resistant
enterococcus cultures, and other bacterial cultures from his
knee washout, he was started linezolid, levofloxacin, and
meropenem, as well as the regular antibiotics as Bactrim,
fluconazole, and Valcyte for his graft.
On postoperative day 29, another biopsy was done which showed
cholestasis, but no evidence of acute rejection. It also
showed some mononuclear infiltrations around his portal vein.
A repeat endoscopic retrograde cholangiopancreatography was
done the next day which showed a small bile leak which was
stented at that time. A computed tomography scan of the
abdomen showed an increasing right pleural effusion, but no
focal collections. His ascites was drained at that time for
2.4 liters. Vicodin was restarted after the paracentesis for
pain control. Due to a rise in his bilirubin, a repeat
endoscopic retrograde cholangiopancreatography was done which
showed a continued leak as well as obstruction of the stent
which had been placed. A new stent was placed at that time,
and meropenem was started.
Two days later, on postoperative day 35, his bilirubin
continued to rise. Therefore, another endoscopic retrograde
cholangiopancreatography was performed which again showed a
leak as well as pus around the major papilla and a question
of a right hepatic duct abscess, and the stent again being
occluded. The stent was replaced. A computed tomography
angiogram of the liver was done which showed no intrahepatic
collections, with good flow in the right hepatic artery.
The next day a HIDA scan was performed which was normal with
no leak and normal bile transit. Due to his increased
pleural effusions, which had been noted from before, a
pleural tap was done on postoperative day 37.
On postoperative day 42, another repeat endoscopic retrograde
cholangiopancreatography was done, and the stent was
replaced. An ultrasound at that time was also normal for
liver flow. His bilirubin, which had reached a maximum of
8.1, slowly began to decrease at that time.
At the time of the last endoscopic retrograde
cholangiopancreatography, on postoperative day 42, a Dobbhoff
tube was placed. That tube required Interventional Radiology
for placement into the postpyloric into the duodenum; after
which time, tube feeds (which had been stopped due to the
bile leak) were restarted at a goal of 50 cc per hour of
Nepro.
After the final endoscopic retrograde
cholangiopancreatography on postoperative day 42, the
patient's bilirubin returned to [**Location 213**]. It was noted that
the patient had some slight abdominal pain on postoperative
day 41, and a computed tomography scan was done which showed
fluid collection in the abdomen. The fluid collection
throughout the abdomen were drained and were found to be
frankly bilious. Therefore, a repeat endoscopic retrograde
cholangiopancreatography on postoperative day 42 was done,
and a new stent was placed. At that time, the drain output
of the abdominal drain slowly decreased and also changed in
character from bilious to more ascitic.
The patient's abdominal drain was removed and antibiotics
were stopped. First the meropenem was stopped, and then the
levofloxacin. Linezolid was also stopped. The drain site
was stitched, and the patient was doing well. His was at
goal tube feeds as well as taking oral intake. He was making
adequate urine, and his white [**Location **] cell count was normal.
His cyclosporin levels were stabilized, and he was planned to
be discharged to a rehabilitation facility with taking Neoral
at approximately 150 mg p.o. b.i.d.
MEDICATIONS ON DISCHARGE: (The patient's discharge
medications at that time included)
1. Neoral 150 mg p.o. b.i.d.
2. Insulin sliding-scale as well as a fixed dose. He was
to receive 18 units of NPH in the morning and 18 units of NPH
at night.
3. Lasix 40 mg p.o. b.i.d.
4. Prednisone 50 mg p.o. q.d.
5. MMF 1000 mg p.o. b.i.d.
6. Nystatin swish-and-swallow 5 mg p.o. q.i.d.
7. Vicodin one to two tablets p.o. q.4h. as needed.
8. Fluconazole 400 mg p.o. q.d.
9. Trazodone 7.5 mg p.o. q.h.s.
10. Actigall 300 mg p.o. t.i.d.
11. Valcyte 450 mg p.o. q.d.
12. Protonix 40 mg p.o. q.d.
13. Bactrim one tablet p.o. q.d.
DISCHARGE DISPOSITION: Upon discharge, the patient's
creatinine had normalized. His liver function tests were all
within normal limits, and his white [**Location **] cell count had
stabilized, and his hematocrit had hovered approximately at
30 throughout his hospital course after his initial
transfusion.
DISCHARGE STATUS: The patient was discharged to a
rehabilitation facility on [**2176-3-20**].
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with Dr. [**Last Name (STitle) 497**] in one week.
2. The patient was also to follow up with the [**Hospital 1326**]
Clinic in one week.
3. His levels and [**Hospital **] tests were to be done twice per week
and reported back to Dr. [**Last Name (STitle) 497**] as well as the [**Hospital 1326**]
Clinic for modifications.
4. The patient was discharged with tube feeds (Nepro 50 cc
per hour continuous through a Dobbhoff tube). He was also
instructed to continue that until such time as it is deemed
that he is able to take enough adequate oral intake in order
to discontinue the Dobbhoff.
DISCHARGE DIAGNOSES:
1. Hepatitis C alcoholic cirrhosis.
2. Status post orthotopic liver transplant.
3. Insulin-dependent diabetes mellitus.
4. Chronic renal insufficiency.
5. Gastroparesis.
6. Diverticulitis.
7. Status post colectomy.
8. Spontaneous bacterial peritonitis on multiple occasions.
9. Grade II varies.
10. Status post left knee washout for a septic joint.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Name8 (MD) 105899**]
MEDQUIST36
D: [**2176-3-19**] 21:44
T: [**2176-3-20**] 01:35
JOB#: [**Job Number 105900**]
ICD9 Codes: 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8615
} | Medical Text: Admission Date: [**2114-2-21**] Discharge Date: [**2114-3-21**]
Date of Birth: [**2036-5-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Abdominal pain and distension
Major Surgical or Invasive Procedure:
[**2113-2-21**] exploratory laparotomy, appendectomy, and needle
decompression of large bowel
.
[**3-17**]: intubation
History of Present Illness:
77 M last discharged from [**Hospital1 18**] on [**2114-2-3**] with the diagnosis of
pneumonia and CHF exacerbation presents with progressive
abdominal pain fo rthe last week, denies flatus or bowel
movements for 3 weeks. Patient denies fever, chills, nausea or
vomitting. Patient never had a colonoscopy in the past.
Past Medical History:
* COPD: no PFTs on record, on home O2 3L/m for past 2 weeks
* Interstitial lung disease
* atrial fibrillation (formerly on coumadin; stopped during last
admission)
* CHF: last echo [**12-31**] with LVEF >55%, 2+ MR, 3+ TR, mild AV
stenosis, severe pulm art HTN
* severe pulm art HTN by echo
* DM type II
* CRI: baseline creat 1.6
* BPH
* known bladder mass since [**2108**]
* ? lung mass
* anemia
Social History:
lives with his wife in a 2 story house but is now at a [**Hospital1 1501**] since
recent hospitalization; smoked 150 pack-years, quit 7 years ago;
formerly worked in a battery factory and may have been exposed
to hazardous chemicals during this time; has a h/o asbestos
exposure; no alcohol or illicit drug use. One daughter lives
down the street.
Family History:
Father with CAD.
Physical Exam:
Admission Examination:
T=97.5 HR=87 BP=109/63 RR=31 95% RA
Chest: wheezes B/L
Heart: RRR
ABD: very distended, no rebound tenderness
Ext: no edema
Rectal: no blood or masses, profuse diarrhea provoked by exam
Pertinent Results:
Admission Labs
[**2114-2-21**] 01:55AM PT-12.2 PTT-24.9 INR(PT)-1.0
[**2114-2-21**] 01:55AM NEUTS-90.0* BANDS-0 LYMPHS-4.1* MONOS-4.6
EOS-1.1 BASOS-0.1
[**2114-2-21**] 01:55AM WBC-12.9* RBC-3.11* HGB-9.5* HCT-27.7* MCV-89
MCH-30.4 MCHC-34.1 RDW-19.7*
[**2114-2-21**] 01:55AM ALBUMIN-3.4 CALCIUM-9.2 PHOSPHATE-3.8
MAGNESIUM-2.3
[**2114-2-21**] 01:55AM LIPASE-26
[**2114-2-21**] 01:55AM ALT(SGPT)-20 AST(SGOT)-18 LD(LDH)-314* ALK
PHOS-113 AMYLASE-71 TOT BILI-0.8
[**2114-2-21**] 01:55AM GLUCOSE-126* UREA N-65* CREAT-1.9*
SODIUM-129* POTASSIUM-4.2 CHLORIDE-88* TOTAL CO2-30 ANION GAP-15
[**2-21**] KUB: large bowel obstruction
[**2-21**] CT ABD/PELVIS:
IMPRESSION:
1. Dilated fluid-filled distal appendix with periappendiceal
stranding concerning for tip appendicitis in the proper clinical
setting.
2. Ill-defined nodular opacities in the right lower lobe
consistent with infectious process.
3. Small bilateral pleural effusions.
4. Calcified pleural plaques consistent with asbestosis
exposure.
5. Dilated large bowel without evidence of obstruction. These
findings are consistent with [**Last Name (un) **] syndrome.
6. Fat-containing right inguinal hernia.
[**2-27**] CT ABD/PELVIS/ CHEST CTA:
IMPRESSION:
1. Compared to [**2114-2-21**], there is improvement in the
previously described multifocal patchy opacities in the
bilateral lungs. There remains mild ground glass opacities
within the lung apices.
2. There is diffuse colonic wall thickening with mural
enhancement, concerning for infectious colitis; however, in the
setting of recent abdominal surgery, ischemia cannot be totally
excluded. There is no other finding suggestive of ischemia such
as portal venous air or pneumatosis.
3. Small bilateral pleural effusions.
4. Diverticulosis without evidence of diverticulitis.
5. Soft tissue mass adjacent to the Foley catheter in the
bladder, for which further evaluation with ultrasound with full
bladder is recommended. This may represent asymmetric
hypertrophy of the prosatate gland, however a neoplasm of the
bladder is included in the differential diagnosis.
6. Small amount of ascites.
7. No evidence of pulmonary embolus or thoracic aortic
dissection.
[**3-1**] Renal Ultrasound: no hydronephrosis
[**3-6**] ABD 2 views:
There are gas-filled loops of prominent transverse colon
overlying the mid abdomen with slight thickening of haustral
folds. Though nonspecific, this may be seen due to infectious
etiology such as C. diff colitis. There is no gross evidence for
free air or signs specific for obstruction. Pleural
calcifications are evident in the visualized portions of the
lower chest as better demonstrated on a recent chest CT.
________
MICU:
Echocardiogram:
Conclusions: Overall left ventricular systolic function is low
normal (LVEF 50%). There is no ventricular septal defect. The
right ventricular free wall is hypertrophied. The right
ventricular cavity is dilated. Right ventricular systolic
function appears depressed. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (area 1.2-1.9cm2). No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. The supporting structures of the tricuspid
valve are thickened/fibrotic. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery
systolic hypertension. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade. Echocardiographic signs
of tamponade may be absent in the presence of elevated right
sided pressures. Compared with the findings of the prior study
(images reviewed) of [**2114-1-16**], multiple major
abnormalities as noted above persist without significant
change.
[**2114-3-21**] 02:47AM BUN: 96* Creatinine: 4.0*
Brief Hospital Course:
Patient was admitted to surgery under Dr. [**Last Name (STitle) **]. Patient was
brought directly to the OR for exploratory laparotomy,
appendectomy and decompression of the large bowel. There were
no complications and the patient was transferred to the SICU
intubated. The patient received peri-op Kefzol and Flagyl.
Cardiology was consulted and recommended beta blockage to keep
HR<110, and to keep Hct>30%. On POD1, patient was manually
decompressed, extubated, and received 1u PRBCs. On POD3, patient
remained hemodynamically stable, still a-fib, afebrile, had
formed stools, and soft, non-tender abdomen. Patient was
transferred to the floor, NGT was d/c'ed. Patient was kept NPO
for minor abdominal distention. On POD3, patient had hematuria
and a continuous bladder irrigation was started. Urology was
consulted and recommended CBI (titrate to light pink. Patient
remained on IV hydrocortisone to cover his chronic prednisone
therpay. A steroid taper was started. On POD4, stool was found
to be positive for C. Diff. The patient was continued on IV
Flagyl and oral vancomycin was started. On the evening of POD5,
patient complained of severe chest and back pain. EKG, cardiac
enzymes, and CTA chest were all negative. Pain was not relieved
on SL nitroglycerin. Arterial blood gas showed an O2 of 81.
The patient was tranferred back to the SCIU for hemodynamic
monitoring. Cardiology was reconsulted. Cycled cardiac enzymes
were negative. He remained stable in the ICU with a mild O2
requirement (3L). Amylase and lipase were noted to be elevated
the morning following this event and he was diagnosed with
pancreatitis. He remained NPO for 2days however never had a
recurrence of pain and his amylase and lipase trended to normal
over the next 4 days. TPN was initiated given his prolonged
status without significant oral intake. This was continued and
calorie counts are currently being recorded to assess his
caloric intake. His creatinine was noted to rise significantly
on POD7-10 accompanied by an abrupt decline in urine output.
This has currently peaked and his urine as well as creatinine
have improved. Renal was consulted during this time and felt
that contrast nephropathy vs ATN from other etiologies was the
cause. He remains up approximately 10kg and is now successfully
being diuresed on high doses of lasix. He currently has 3+
peripheral edema as well as mild plural edema. His FSBG began
to increase requiring an insulin gtt on POD11. Insulin was
increased in his TPN to 40units (dex 300). On POD13 his TPN was
cut in half due to moderate oral intake and he was noted to wean
off of the insulin gtt overnight.
.
S/p MICU transfer [**3-6**] for management of multiple post-operative
complications.
.
***MICU Course***
.
Mr. [**Known lastname 4427**] was transferred to the Medical ICU in the setting of
worsening renal function, anemia, respiratory decline. His
respiratory status continued to decline, with acute worsening on
[**3-17**] requiring intubation, likely secondary to persistant
and significant pulmonary edema. Though diuresis was attempted
during MICU stay, it has to be discontinued in the setting of
worsening renal function and hypotension. Discussions were held
with nephrology and the patient's family regarding the role of
hemodialysis to remove excess fluid; the patient had explicitly
stated to family previously that he would not want to be on
hemodialysis. His renal function continued to decline, and the
patient's family chose to make Mr. [**Known lastname 4427**] [**Last Name (Titles) **] measures only.
He was extubated on [**3-21**] and expired within one hour of
extubation from respiratory arrest.
.
# Hypercarbic respiratory failure - initially felt secondary to
increased work of breathing in setting of volume overload.
Nosocomial pneumonia also potential contributor. On [**3-17**],
required intubation for obtundation and acidemia in setting of
hypercarbia, as he did not seem to be responding to NIPPV.
Bilateral pleural effusions may be contributing to respiratory
difficulties
- treated with zosyn and vancomycin for possible nosocomial
pneumonia without improvement
-unable to diurese given diminished U/O, ARF
-per family, no HD at patient's wishes
-per family no thoracentesis
-extubated [**3-21**] and ceased spontaneous respiration within
one hour.
.
# Acute renal failure: Creatinine has increased from 1.3 to 3 in
the setting of hypotension. Pre-renal and likely now a component
of intrinsic renal failure. [**Month (only) 116**] be obstructive component with
hematuria and decreased urine output, but no evidence of this on
ultrasound or CT.
- followed by renal service throughout MICU course
-given worsening pulmonary edema and renal failure, discussed
role of HD with family and renal service, however in accordance
with patient's wishes, HD declined by family.
.
# Hypotension: felt secondary to CHF or sepsis. No improvement
with antiboitics or hydrocortisone. Likely component of
decreased cardiac output in setting of volume overload from
renal failure, but unable to diurese as discussed above.
.
# anemia: Likely combination of GI and GU losses, and possibly
decreased production secondary to poor nutritional status. GI
recommends conservative management at present, as endoscopy
would be moderate risk procedure given patient's recent surgery
and comorbidities. CT obtained - no RP bleed, likely hematoma in
bladder.
- treated with [**Hospital1 **] pantoprazole and transfused to maintain
hematocrit > 25
.
# ID - Increasing leukocytosis and hypotension as above. Wound
culture demonstrating ESBL Klebsiella and Enterococcus. Previous
cultures showed VRE. Also with LUE cellulitis and C. difficile
positive on [**2114-2-25**].
- Linezolid -Started [**2114-3-11**] for rash; d/c [**3-19**] given
improvement in rash
- pip-tazo started [**2114-3-17**] for broad-spectrum coverage of
possible pna - to complete 8 day course
-started vancomycin [**3-19**] for potential nosocomial pna for 8 day
course.
- PO Vanco and metronidazole continued during administration of
antibiotics for C. difficile.
.
# Rapid afib: intially with HR in the 120s; has independently
become more bradycardic. Held metoprolol in setting of
hypotension and digoxin as spontaneously rate decreased
- no anticoagulation given active hematuria and GI bleed, and
anemia
.
# DM: Initially difficult to control during this
hospitalization, currently stable on current regimen of NPH AM
and PM. Treated with standing NPH and sliding scale insulin in
ED.
.
# CHF: Clearly total body volume overloaded but unable to
diurese as discussed above. No HD per family
.
# Rash on trunk: Initially felt to be due to irritation from
lying on trunk as was only on dependent areas of body, but
became more diffuse. Initially seemed to improved w/ linezolid
which was continued for approximately 1 week course. No temporal
relation to new medications.
.
# [**Last Name (un) **] syndrome: s/p decompression [**2-21**] as discussed in
surgerical course above.
.
#Urologic: Known history of bladder mass, with prolonged course
of hematuria. Evaluated by urology service who performed
cystoscopy, revealing large hematoma within the bladder, but no
active bleeding; the removed large portions of the clot during
the cystoscopy. Despite this intervention and continuous bladder
irrigation for most of his MICU course, hematuria persisted.
Eventually urine output declined as renal function worsened.
.
# FEN: initially on TPN, then transition to tube feeds.
Medications on Admission:
Ipratropium
Senna/Colace
Levalbuterol
Prednisone 20mg until [**1-27**]
Furosemide 40mg qMWF
ASA 325 mg qd
Lisinopril 2.5 mg qd
Diltiazem 240 qd
Tamulosin 0.4 mg qhs
Insulin SS
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Congestive Heart Failure
Respiratory Failure
Pulmonary Edema
Renal Failure
[**Last Name (un) 3696**] Syndrome
Atrial Fibrillation
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Completed by:[**2114-3-29**]
ICD9 Codes: 4280, 5845, 496, 486, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8616
} | Medical Text: Admission Date: [**2164-11-29**] Discharge Date: [**2165-1-19**]
Service: SURGERY
Allergies:
Tramadol / Advil / Nsaids / Hydrocodone
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Gi bleeding
Major Surgical or Invasive Procedure:
EGD on [**11-29**] and [**11-30**]
Angiography on [**2164-11-30**]
IVC Filter placement
[**11-30**] ex-lap, duodenotomy, oversowing of ulcer, J-tube placement
and liver biopsy
History of Present Illness:
This is an 86 year old gentleman with multiple medical problems
who was found unresponsive at his nursing home and surrounded by
bloody stools. he had recently been discharged on coumadin
status-post a right hip repair. He has a history of black tarry
stools in [**2164-8-13**] diagnosed as peptic ulcer disease.
Past Medical History:
1. Hypertension
2. Chronic obstructive pulmonary disease
3. Osteoarthritis
4. Osteopenia
5. Dementia
6. Depression
7. Status post bilateral inguinal hernia repair
8. Status post bilateral cataract surgery
9. Status post right total hip replacement
Social History:
1. No smoking
2. Occasional alcohol
3. No drug use
Family History:
non contributory
Physical Exam:
vital signs: BP 80/50 at [**Last Name (LF) **] , [**First Name3 (LF) **] 110-137/48-53. HR 96.
Gen: responds to stimuli, non-conversant, not awake or alert
HEENT: head NC/AT, pale conjunctivae
CV: sinus tachycardia
Pulm: CTAB
Abd: soft, non-distended
Rectal: guaic positive, bloody output
Extr: pale
Pertinent Results:
[**2164-11-29**] 09:00AM BLOOD WBC-13.1*# RBC-1.66*# Hgb-4.6*#
Hct-14.7*# MCV-89 MCH-27.9 MCHC-31.4 RDW-16.5* Plt Ct-530*#
[**2164-12-3**] 04:14AM BLOOD WBC-9.5 RBC-2.82* Hgb-9.0* Hct-24.8*
MCV-88 MCH-31.8 MCHC-36.2* RDW-15.7* Plt Ct-130*
[**2164-12-8**] 01:56PM BLOOD WBC-12.1* RBC-3.37* Hgb-10.5* Hct-31.7*
MCV-94 MCH-31.1 MCHC-33.0 RDW-14.9 Plt Ct-386
[**2164-12-25**] 05:30AM BLOOD WBC-10.8 RBC-2.94* Hgb-8.5* Hct-26.2*
MCV-89 MCH-29.0 MCHC-32.5 RDW-16.6* Plt Ct-493*
[**2165-1-9**] 06:30AM BLOOD WBC-8.5 RBC-3.03* Hgb-8.6* Hct-25.7*
MCV-85 MCH-28.4 MCHC-33.4 RDW-17.7* Plt Ct-455*
[**2164-11-29**] 09:00AM BLOOD Neuts-79.7* Bands-0 Lymphs-16.0*
Monos-3.9 Eos-0.2 Baso-0.2
[**2165-1-8**] 03:30PM BLOOD Neuts-76.8* Lymphs-15.1* Monos-5.7
Eos-1.8 Baso-0.6
[**2164-11-29**] 09:00AM BLOOD PT-30.3* PTT-36.2* INR(PT)-6.9
[**2164-11-29**] 11:15AM BLOOD PT-16.8* PTT-30.7 INR(PT)-2.0
[**2164-11-29**] 03:06PM BLOOD PT-15.3* PTT-29.2 INR(PT)-1.6
[**2164-11-30**] 09:15AM BLOOD PT-16.1* PTT-42.5* INR(PT)-1.8
[**2164-12-3**] 04:14AM BLOOD PT-13.5* PTT-28.2 INR(PT)-1.2
[**2165-1-9**] 06:30AM BLOOD Plt Ct-455*
[**2164-11-30**] 09:15AM BLOOD Fibrino-181
[**2164-11-29**] 09:00AM BLOOD Glucose-229* UreaN-38* Creat-1.1 Na-143
K-5.1 Cl-110* HCO3-21* AnGap-17
[**2164-11-30**] 01:46AM BLOOD Glucose-126* UreaN-23* Creat-0.8 Na-147*
K-3.8 Cl-118* HCO3-23 AnGap-10
[**2165-1-10**] 09:30AM BLOOD Glucose-97 UreaN-23* Creat-0.7 Na-140
K-4.6 Cl-103 HCO3-26 AnGap-16
[**2164-11-29**] 09:00AM BLOOD CK(CPK)-20*
[**2164-12-1**] 02:55AM BLOOD ALT-34 AST-46* CK(CPK)-148 AlkPhos-48
TotBili-0.7
[**2164-12-18**] 04:00PM BLOOD ALT-29 AST-32 LD(LDH)-280* AlkPhos-206*
Amylase-63 TotBili-0.5
[**2164-11-29**] 07:02PM BLOOD CK-MB-28* MB Indx-12.1* cTropnT-0.63*
[**2164-11-30**] 05:13AM BLOOD CK-MB-10 MB Indx-7.9* cTropnT-0.70*
[**2164-12-1**] 02:55AM BLOOD CK-MB-4 cTropnT-0.49*
[**2164-12-13**] 01:24AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2164-11-30**] 01:46AM BLOOD Calcium-6.4* Phos-3.3# Mg-1.6
[**2164-12-1**] 02:55AM BLOOD Albumin-2.1* Calcium-7.1* Phos-2.9 Mg-1.8
[**2164-12-18**] 04:00PM BLOOD Albumin-2.5*
[**2165-1-7**] 10:50AM BLOOD Albumin-2.5* Iron-8*
[**2165-1-7**] 10:50AM BLOOD calTIBC-187* Ferritn-434* TRF-144*
[**2164-12-18**] 04:00PM BLOOD Ammonia-29
[**2164-12-18**] 04:00PM BLOOD TSH-1.2
Microbiology:
[**11-19**] urine cx: negative
[**12-4**] sputum cx: MRSA
[**12-10**] rectal swab: VRE
[**12-24**] blood cx: pseudomonas
[**12-24**] urine cx: pseudomonas and serratia
[**1-6**] blood cx: negative
[**1-6**] urine cx: negative
[**1-8**] peri-j-tube swab: MRSA
[**1-14**] stool: negative for c. diff
RADIOLOGY:
[**11-30**] Angiography:The procedure is performed by Drs. [**Last Name (STitle) **] and
[**Doctor Last Name **] the attending physician, [**Name10 (NameIs) 1023**] was present and supervising
throughout. Informed
consent was obtained with the patient's sons. The patient was
placed supine on the angiography table and his right groin was
prepped and draped in standard sterile fashion. After infusion
of 1% lidocaine, the right common femoral artery was accessed
with a 19-gauge needle. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire was advanced into the
abdominal aorta and the puncture needle was exchanged for a
5-French sheath which was attached to a continuous flush
throughout the procedure. Using a C2 Cobra Glide catheter,
selective access into the superior mesenteric artery was
obtained and arteriogram was performed. This demonstrated a
patent superior mesenteric. There was equivocal extravasation
of contrast from the region of the gastroduodenal artery;
however, this determination was difficult due to the overlying
transverse colon.
Next, selective access into the common hepatic artery was
obtained with a C2 Cobra Glide catheter and angled Glidewire.
Hepatic arteriogram demonstrated active extravasation of
contrast from the region of the gastroduodenal- gastroepiploic
junction as well as a branch of the superior
pancreaticoduodenal artery. Superselective access was obtained
into the gastroduodenal artery. Arteriogram performed at this
position demonstrated active extravasation. Superselective
access was obtained into the gastroepiploic artery. Arteriogram
performed at this position demonstrated a patent gastroepiploic
and confirmed that the catheter was distal to the site of
extravasation in ideal location for snadwich technique of
exclusion of the beeding source. Based on the diagnostic
arteriograms, it was decided that the patient was a good
candidate for and would benefit from embolization. With gradual
withdrawal of the catheter four 3 mm x 5 cm coils were deployed
across the area of active extravasation in the gastroduodenal-
gastroepiploic junction. Superselective arteriogram of the
proximal gastroduodenal artery demonstrated cessation of flow
through this vessel. However, continued active extravasation
was observed from a proximal branch of the superior
pancreaticoduodenal artery. Superselective catheter access was
obtained into the superior pancreaticoduodenal artery towards
the superior mesenteric artery and an arteriogram was done. It
showed patent vessel and good catheter position distal to the
bleeding site. Three coils were deployed in the superior
pancreaticoduodenal artery with gradual withdrawal of the
catheter. A small amount of residual flow was observed on post-
embolization arteriogram from the gastroduodenal artery.
Subsequently, three additional 3 mm x 5 cm coils were deployed
across the proximal gastroduodenal artery. Post- coiling
arteriogram from the common hepatic artery demonstrated
cessation of flow through the gastroduodenal artery and its
branches including the gastroepiploic and superior
pancreaticoduodenal. No further extravasation of contrast was
observed. The catheter was subsequently removed. The sheath was
secured with 0 silk suture. The patient was taken back to the
intensive care unit in stable condition. There were no
immediate post-procedure complications.
IMPRESSION:
1. Active extravasation into the duodenum from the
gastroduodenal-
gastroepiploic junction and a branch of the superior
pancreaticoduodenal
artery.
2. Successful coiling of the gastroepiploic, gastroduodenal, and
superior
pancreaticoduodenal arteries. Post-embolization arteriogram
demonstrated no further evidence of active extravasation
[**1-6**] Abdominal CT: 1. Wedge-shaped low density spleen lesion,
somewhat improved since the last examination, representing an
infarct.
2. Low density lesion in the adrenal gland. A non-contrast CT
scan of this region should be obtained on a nonemergent basis to
ensure its benignity.
3. Otherwise, no significant interval change.
[**1-10**] Video Swallow Eval: Weak oral phase with delayed swallow.
Silent aspiration of thin liquids, nectar thickened liquids, and
purees. Pharyngeal residue seen within the valleculae.
[**12-24**] Chest CT: 1. Wedge-shaped low-density area in the spleen,
probably representing infarction. No evidence of abscess
formation.
2. Status post coiling of gastroduodenal arteries, with
nonspecific fat
stranding surrounding the coils. 3. Small left pleural
effusion.
4. Gallstone.
[**12-24**] IVC placement: Successful placement of a recovery IVC
filter in the inferior vena cava. A retrievable filter had to be
used since teh patient is potentially infected and
superinfection of the filter without ability to remove it may
have serious consequences.
[**12-22**] CTA Chest: No pulmonary embolus. Bibasilar atelectasis and
small bilateral pleural effusions.
[**12-12**] Heat CT: No evidence of intracranial hemorrhage or mass
effect. Please note that MRI is more sensitive than CT in the
detection of acute ischemia if this is the clinical concern. See
above report for additional findings.
ENDOSCOPY:
[**11-29**] EGD: Small hiatal hernia
There was no evidence of blood in the stomach. There was
stigmata of NG trauma.
There was no evidence of post bulbar bleeding. Ulcer in the
distal bulb
Otherwise normal egd to second part of the duodenum
[**11-30**] EGD: A large blood clot starting in the distal portion of
the duodenal bulb and extending past the duodenal sweep was
noted. There was active oozing around the clot. Despite multiple
washings and use of polypectomy snare the clot could not be
fully dislodged to visualize the source of bleeding. Bright red
blood was noted distal to the clot site. Epinephrine was not
used due to lack of visualization and ongoing myocardial
infarction.
Cardiology
[**1-9**] Transthoracic Echo: The left atrium is elongated. The
right atrium is moderately dilated. The left ventricular cavity
size is normal. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve is not well seen. There is a minimally increased
gradient consistent with minimal aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
No vegetation seen (cannot exclude).
Brief Hospital Course:
This is an 86 year old gentleman who presented as a transfer
from his nursing home with bloody stools. He had a prolonged
hospital course as summarized below:
GI: The patient was admitted with hematemesis. His hematocrit
was 14 in the ER on presentation and NGT was bloody; he was
intubated for aspiration precautions and immediately transfused
with blood and FFP. Endoscopy was performed with findings of
bleeding duodenal ulcerations. This could not be controlled
endoscopically and the patient was taken for angiography with
embolization on the day after admission, with resolution of his
bleeding. After further bleeding on [**11-30**] he was taken to the
operating room and underwent exp lap, duodenotomy, oversewn
ulcer, j-tube placement and biopsy of liver mass. He was
continued on a proton pump inhibitor. He failed various swallow
evaluations and was fed through his J-tube. He had some diarrhea
which improved with elemental formula.
Pulm: The patient remained intubated in the intensive care unit
for several days. During this time he was found to have MRSA
positive sputum which was treated. He was successfully extubated
and had normal pulmonary functions through the majority of his
hospital course. He had some CHF that was effectively treated
with daily Lasix diuresis.
Neurology: During the [**Hospital 228**] hospital course he demonstrated
periods of aphasia and dysarthria/dysphagia. He was evaluated by
neurology and it was felt that this was consistent with his
baseline dementia, with some component of overlying delirium. He
remained stable throughout his hospital course and workup with
Head CT and EEG was consistent with encephalopathy but no acute
process.
Heme: The patient was found to have superficial femoral vein
clots. Given the patient's need for anticoagulation from his
prior hip surgery, and his risk for further GI bleeding, an IVC
filter was placed for prophylaxis. His coagulation studies
remained normal throughout his hospital course after reversal
upon his admission. He was started on iron and folate
supplementation for anemia.
ID: During the patient's prolonged ICU and hospital course, he
developed several infectious processes which were treated. He
had pseudomonas in his urine and blood which was treated with a
course of Zosyn and follow-up studies were negative. He
developed profound fevers during mid-late [**Month (only) 1096**] which were
evaluated with serial cultures and echo studies with no positive
cultures; these fevers eventually resolved. Please see the
listing of his culture date under "Results" section.
Ortho: The patient worked with physical therapy but was
essentially bed-ridden given his recent right hip surgery and
dementia.
Dispo: Per consultation with the patient's family and social
work services, a rehabiliation bed was found for the patient. He
was discharged with planned interval follow-up with Dr. [**Last Name (STitle) 519**].
Discharge Medications:
1. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Oxycodone 5 mg/5 mL Solution Sig: Two (2) ml PO Q8H (every 8
hours) as needed.
4. Fluconazole 150 mg Tablet Sig: One (1) Tablet PO QWEEK ().
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection [**Hospital1 **] (2 times a day).
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-14**] Sprays Nasal
TID (3 times a day).
9. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One
(1) Spray Nasal [**Hospital1 **] (2 times a day).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) suspension PO BID (2 times a day).
13. Albuterol Sulfate 0.083 % Solution Sig: One (1) INH
Inhalation Q6H (every 6 hours) as needed.
14. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical PRN (as needed).
15. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
16. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Loperamide 1 mg/5 mL Liquid Sig: Two (2) mg PO QID (4 times
a day).
Tubefeeding: Probalance Full strength; Additives: Banana flakes,
3 packets per day
Starting rate: 75 ml/hr; Do not advance rate Goal rate: 75 ml/hr
Residual Check: q4h Hold feeding for residual >= : 100 ml
Flush w/ 30 ml water Before and after each feeding
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary: Duodenal Ulcer Bleed
Secondary: Dementia, Pneumonia, Urinary Tract infections,
tube-feeding dependence, COPD, hypertension, depression, s/p R
total hip replacement
Discharge Condition:
stable
Discharge Instructions:
Please take medications as prescribed and read warning labels
carefully. Please follow intructions as previously discussed by
Dr. [**Last Name (STitle) 519**].
If symptoms worsen, such as bloody vomitus, bloody or black
stool, or fainting, please call or go to the emergency room.
Followup Instructions:
Please Follow up with Dr. [**Last Name (STitle) 519**] within 1-2 weeks. Please call
ahead of time to confirm appointment. ([**Telephone/Fax (1) 2007**].
Please follow-up with Dr. [**Last Name (STitle) **] in orthopaedics at [**Telephone/Fax (1) 9118**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2165-1-15**]
ICD9 Codes: 4280, 496, 5990, 7907, 4019, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8617
} | Medical Text: Admission Date: [**2164-8-5**] Discharge Date: [**2164-8-16**]
Date of Birth: [**2083-12-13**] Sex: M
Service: MEDICINE
Allergies:
Levaquin
Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
lightheadedness, s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
.
HPI: Mr. [**Known lastname 103005**] is an 80 year old male with extensive medical
history, pertinently including chronic anemia, CAD s/p MI,
recently discharged from [**Hospital1 18**] on [**2164-7-16**] with pacer placement
for AFib with slow ventricular response. He presented to the ER
s/p fall in his bathroom. He had been feeling lightheaded all
day, was reaching for something in his bathroom, was dizzy and
fell over. He did not syncopize, feel palpitations, have
evidence of seizures. ROS was entirely negative.
.
On arrival to the ED his T was 100.1, HR 78, BP 84/40, RR 22,
96% on RA. His temp later rose to 102.8. Labs were notable for
lactate 3.7. Code Sepsis was called and he had a central line
placed, received 5 L NS, and was given Ceftriaxone, flagyl. His
SBP improved to 100-110 with fluids. He had a stat abdominal US
which was negative for free fluid. Labs were only otherwise
notable for a hct of 26.8, down from 31 on [**7-27**]. In the setting
of aggressive fluid resuscitation in the [**Hospital Unit Name 153**], Hct dropped to
21.1, up to 28 after 3 units of PRBCs. A TTE was obtained at
this point in the setting of some CHF, and revealed 4+ MR (TTE
one month prior showed [**12-11**]+ MR). Subsequent TEE showed a 2mm
vegetation, although ruptured chordae could not be definitively
ruled out. Initial blood cultures were negative and there were
no peripheral stigmata of endocarditis, and the patient had
defervesced. He was started on vancomycin and transferred to
the floor in stable condition.
Past Medical History:
- CAD s/p MI in [**2135**] - cath [**6-12**] showing 100% proximal RCA, 40%
proximal LAD, 60% intermedius
- s/p pacemaker placement
- Afib- on coumadin
- Bradycardia in the setting of propanolol
- anemia
- thrombosis of the popliteal artery aneurysm - Fem-[**Doctor Last Name **] bypass
[**2164-5-3**]
- Admission for PNA with hypertensive emergency in [**1-14**]
- AAA repair in [**2145**]
- Guaiac + stool with gastric erosions per EGD [**1-14**]
- Vit B12 deficiency
- Diverticulitis s/p colectomy
- HTN
- CRI with baseline creat 1.2-1.6, h/o pre-renal ARF
- Hyperchol
- Detached retina in [**2141**]
- Gout
- Glaucoma
- h/o EtOH abuse
Social History:
Lives with niece and brother-in-law.
150 pk-yr smoker, but quit 20 yrs ago.
No EtOH for 15 yrs
Family History:
FAMILY HX: He has a strong family history of CAD. His sister had
an MI at 55. Both of his parents had MIs, however he is not sure
how old they were. His father died at 77, mother at 73. His
father had DM. His other sister died of a cerebral hemorrhage
Physical Exam:
Vitals T 98.7, Tmax 99.8 70 121-152/41-52 15-19 97% RA.
Gen NAD, AOX3.
Neuro CN 2-12 intact. Legally blind L eye.
HEENT EOMI. NCAT. OP clear. Surgical IOL on L. No conjunctival
hemorrhages.
Neck no JVP appreciated. No bruits.
Chest Crackles bilaterally R>L, dullness at R base, otherwise
clear.
CV RRR, nl S1, physiologic S2, [**2-12**] holosystolic at apex->RLSB.
Abd Mod obese, S, NT, ND, well healed midline scar.
Ext Intact pulses, no edema. No peripheral stigmata of
endocarditis.
Pertinent Results:
[**2164-8-6**] 12:00AM GLUCOSE-120* UREA N-28* CREAT-1.6* SODIUM-140
POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-20* ANION GAP-15
[**2164-8-6**] 12:00AM HAPTOGLOB-203*
[**2164-8-6**] 12:00AM WBC-3.6* RBC-2.21* HGB-7.0* HCT-21.1* MCV-95
MCH-31.8 MCHC-33.4 RDW-16.5*
[**2164-8-6**] 12:00AM NEUTS-72.3* LYMPHS-21.2 MONOS-5.0 EOS-1.3
BASOS-0.1
[**2164-8-5**] 07:50PM CK(CPK)-71
[**2164-8-5**] 07:50PM CK-MB-NotDone cTropnT-0.02*
Blood cultures 8/30 (on therapy) grew GP cocci (no speciation as
of yet). All other blood cultures NGTD [**Date range (1) 81908**].
CRP 76
-CXR: cephalization, generous PA's, ?infiltrate R hilar region
-EKG: AFib, V-paced at 70
-TEE: Small 2.5 mm vegetation posterior mitral valve leaflet vs.
ruptured chordae tendinae, preserved EF, [**2-10**]+ MR (which is new
compared to study performed [**2164-7-9**])
Brief Hospital Course:
80 year old male with h/o chronic anemia, CAD s/p MI, recently
discharged on [**2164-7-16**] s/p pacer placement, admitted to [**Hospital Unit Name 153**] s/p
fall in his bathroom, febrile, hypotensive, on sepsis protocol.
.
#ID: Infectious disease consultation was obtained to weigh in
on whether the findings on TEE represented endocarditis (along
with fever, elevated CRP, and positive blood culture). It was
felt that this would be an unusual presentation for endocarditis
given mainly negative blood cultures, that the one positive
culture may have been central line-related, but that it was
reasonable to discontinue vancomycin therapy and follow
clinically for any signs of infection with fevers and if he
starts to spike, to re-culture and re-echo for change in
possible vegetation. No other source of infection was
identified over the hospital stay.
.
#Hypotension: Unclear source of fever and hypotension on
admission. It is unlikely to have been secondary to a
bacteremia - as blood cultures have been negative. One possible
sequence of events is that a primary chordae tendinae rupture
(due to myxomatous degeneration) may have caused a primary mixed
cardiogenic and hypovolemic shock in the setting of acute mitral
regurgitation and a possible febrile infection, which caused him
to be hypotensive and fall. The patient was resuscitated
effectively with fluids during his [**Hospital Unit Name 153**] stay. Initial exam on
the floor and CXR was consistent with mild fluid overload, and
the patient was effectively diuresed with 40 mg po Lasix times
one. On the floor, metoprolol 12.5 mg po bid was initiated for
BP control and cardiovascular effects; he has been in the low
140s on this regimen and could likely be advanced to 25 mg po
bid as an outpatient if he tolerates this well.
.
#anemia: Patient with baseline anemia of unclear etiology (bone
marrow normal) requiring transfusions q 2weeks. Iron studies
most consistent with anemia of chronic inflammation (although
source of chronic inflammation somewhat unclear); pancytopenia
and history consistent with a dilutional component (heme
following patient, suggested role for outpatient Epo). Retic
count on discharge 1.8. No evidence of hemolysis with normal
hapto and LDH over hospital course. Trending crit - baseline of
31 -> 26.8 in ED -> 21.1 in the setting of aggressive fluid
resuscitation -> 30.2 on discharge after 3 units. Hematocrit
should be monitored at rehab and well and transfused
periodically for Hct<28.
.
#Renal - Patient's creatinine was 2.0 on admission. No RBC
casts suggesting GN [**1-11**] septic emboli. Urine lytes with FENa
not consistent with pure pre-renal ARF, but of note from last
admission the patient had been discharged on Lasix 40 mg po bid.
ARF thus likely to have at least a pre-renal component given
resolution with fluids. On discharge Cr down to 1.1.
.
Mitral regurgitation: newly progressed 4+MR from recent echo 3
weeks prior at last admission, unclear source as above and when
in unit after blood transfusions would have episodes of flash
pulmonary edema which is requirining lasix.
Medications on Admission:
. Aspirin 81 mg daily
2. Docusate Sodium 100 mg [**Hospital1 **]
3. Gabapentin 300 mg PO BID
4. Pantoprazole Sodium 40 mg PO Q24H
5. Allopurinol 300 mg PO DAILY
6. Amlodipine 5 mg PO DAILY
7. Isosorbide Mononitrate 120 mg Tablet Sustained Release 24HR
PO HS
8. Lactulose (30) ML PO Q8H PRN
9. Ascorbic Acid 500 mg PO BID
10. Timolol Maleate 0.25 % Drops 1 drop [**Hospital1 **]
11. Lisinopril 7.5 mg PO DAILY
12. Fluticasone-Salmeterol 100-50 mcg 1 INH [**Hospital1 **]
13. Furosemide 40 mg PO BID
14. Ferrous Sulfate 325 mg daily
15. Ipratropium Bromide 18 mcg 2 puffs QID
16. Albuterol 90 mcg 1-2 puffs Q6 PRN
17. Warfarin Sodium 2.5 mg PO 3X/WEEK (MO,WE,FR).
18. Warfarin Sodium 5 mg PO 4X/WEEK ([**Doctor First Name **],TU,TH,SA).
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Metronidazole 0.75 % Gel Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): Apply thin layer to face over areas affected by
flaking/"rash".
Disp:*qs 1* Refills:*0*
7. Selenium Sulfide 2.5 % Shampoo Sig: 5-10 MLs Topical once a
day for 1 months: Massage 5 to 10 ml into wet scalp. Allow to
remain on scalp 2 to 3 minutes, rinse thoroughly and repeat. .
Disp:*qs ML(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO
QSUTUTHSAT ().
12. Albuterol Sulfate 0.083 % Solution Sig: 1-2 puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
13. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
14. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disk
with Device(s)
15. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation.
17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
18. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
19. Zolpidem Tartrate 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed.
20. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
21. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4199**] Hospital TCU - [**Location (un) 2251**]
Discharge Diagnosis:
Primary:
1. Rule out endocarditis
2. Hypotension
3. Sepsis
Secondary:
1. Coronary artery disease, status post myocardial infarction
2. Hypertension
3. Hypercholesterolemia
4. Chronic renal insufficiency
5. Chronic anemia
6. Abdominal Aortic Aneurysm
7. Left Popliteal artery aneurysm, status post thrombosis,
status post bypass graft
8. Atrial fibrillation, status post pacemaker placement
Discharge Condition:
Vital signs stable; afebrile, blood cultures with no growth,
ambulating and taking po's.
Discharge Instructions:
Please take all medications as prescribed. Please note that we
made a few changes in your medications.
Please follow up as listed below.
Please continue to have your INR (coumadin level) monitored as
you did prior to the admission.
Please return to care if you notice chest pain, increasing
shortness of breath, fevers, other signs and symptoms of
infection, or neurological compromise.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) 1270**](call for appointment [**0-0-**]) upon discharge
from the rehab facility.
Please return to care if you notice chest pain, increasing
shortness of breath, fevers, other signs and symptoms of
infection, or neurological compromise.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2164-8-31**] 10:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 5566**] [**Name Initial (NameIs) **]. HEMATOLOGY/ONCOLOGY-CC9 Where: [**Hospital 4054**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2164-8-31**] 10:30
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2164-9-6**] 10:00
Completed by:[**2164-8-17**]
ICD9 Codes: 0389, 5849, 412, 2749, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8618
} | Medical Text: Admission Date: [**2126-5-5**] Discharge Date: [**2126-8-2**]
Date of Birth: [**2126-5-5**] Sex: F
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname 32348**] [**Known lastname 40930**],
twin number two was born at 24 and 5/7 weeks gestation to a
40 year-old gravida 3 para 1 now 3 woman. Her prenatal
screens were blood type A positive, antibody negative,
Rubella immune, RPR nonreactive, hepatitis surface antigen
obstetrical history is significant for a history of maternal
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 4585**]. The first pregnancy went to term without any
complications. The mother's past medical history is
remarkable for a congenital hip dysplasia, hypothyroidism and
hypercholesterolemia. This pregnancy was conceived with
Clomid. The mother was treated with cerclage placement at
eighteen weeks and then she presented at 22 weeks for
cervix and was placed on bed rest. A course of betamethasone
was given and completed on [**2126-5-1**]. Rupture of membranes
occurred 24 hours prior to delivery and then the mother had a
fever to 100 and labor progressed and so a cesarean birth was
performed. This infant emerged with good tone and activity,
spontaneous cry and respiratory effort. Apgars were 7 at one
minute and 8 at five minutes.
The infant's birth weight was 640 grams, 30% percentile,
birth length was 30.5 cm, 15% percentile and head
circumference 20.5 cm 10th percentile for gestational age.
ADMISSION PHYSICAL EXAMINATION: Revealed an extremely
preterm infant. Anterior fontanel soft and flat. Palette
intact. Nondysmorphic appearance. Breath sounds tight with
moderate retractions, a grade 2/6 systolic murmur at the left
upper sternal border. Pulses full. Three vessel umbilical
cord. No organomegaly. Immature female genitalia and age
appropriate tone and reflexes.
HOSPITAL COURSE: Respiratory status, the infant was
intubated at the time of delivery. She received three doses
of Surfactant. She successfully weaned to nasopharyngeal
continuous positive airway pressure on day of life 51 and
then weaned to nasal cannula oxygen on day of life 55. On [**7-29**],
day 85 she weaned to room air. At this stage she requires
approximately 75 cc/min flow with feeds. She was treated with
caffeine citrate for apnea of prematurity from day of life five
until day of life 70. Her apnea and bradycardia is very
infrequent at this stage. On examination she has comfortable
respirations and her lung sounds are clear and equal.
Cardiovascular status, she required Dopamine for blood
pressure support for the first 36 hours of life and has
remained normotensive since that time. She was treated with
Indocin for a clinical presentation of a patent ductus
arteriosus on day of life number one with resolution of the
symptoms. She does continue to have an intermittent grade
1/6 systolic murmur consistent with flow murmur without any
hemodynamic significance.
Fluid, electrolyte and nutrition status, enteral feeds were
begun on day of life number four, but she was made NPO on day
of life number nine with the onset of sepsis. She had
enteral feeds reinitiated on day of life number twenty four
and reached full volume feeds by day of life thirty and then
was advanced to 32 calories per ounce breast milk with added
ProMod. Enteral feeds were again stopped on day of life
number forty two with a clinical presentation of sepsis.
They were restarted again on day of life forty four and to
reach full volume feeds on day of life forty eight and then
advanced to the present feeding plan of 30 calories per ounce
breast milk with added ProMod. Total fluids are 150 cc per
kilogram per day and she is beginning to feed orally. Her
last laboratories on [**2126-7-22**] were sodium 141, potassium 5.4,
chloride 106, bicarbonate 27, BUN 17 and creatinine 0.2,
calcium 10, phosphorus 5.8, albumin 3.5, alkaline phosphatase
492. At the time of transfer her weight is 2475 grams,
length 43 cm and her head circumference 30.5 cm.
Gastrointestinal status, she was treated with phototherapy
for hyperbilirubinemia prematurity from day of life one until
day of life eleven. Her peak bilirubin occurred on day of
life number one and was total 3.4, direct 0.2. She has had
some intermittent dymotility with dilated loops of bowel
associated with her episodes of infection, but never any
evidence of necrotizing enterocolitis.
Hematological status, she was transfused a total of six times
of packed red blood cells. The last transfusion occurred on
[**2126-6-16**]. Her last hematocrit of [**2126-7-22**] was 28.5 with a
reticulocyte count of 7.7%. She is receiving supplemental
iron of 2 mg per kilogram per day in addition to her
feedings. Her blood type is A positive, her direct Coombs is
negative.
Infectious disease status, she was started on Ampicillin and
Gentamycin for sepsis risk factors at the time of neonatal
Intensive Care Unit admission. She completed seven days of
antibiotics for presumed sepsis. Her blood and cerebral
spinal fluid cultures did remain negative. On day of life
number nine she was started on Ampicillin, Gentamycin and
Cefotaxime for clinical presentation of E-coli sepsis. She
completed a fourteen day course of Gentamycin and Cefotaxime.
A renal ultrasound on [**2126-5-27**] was completely within normal
limits. She remained off antibiotics until day of life forty
two when she had a clinical decompensation and had
Pseudomonas and Acinetobacter diagnosed from her tracheal
aspirate. She completed a fourteen day course of Gentamycin
and Meropenem. Her blood and cerebral spinal fluid cultures
did remain negative. She has remained off of antibiotics
since that time.
Neurological status, head ultrasound on [**4-18**] and [**6-5**]
are all within normal limits. Her eyes were examined most
recently on [**2126-7-24**] revealing retinopathy of prematurity stage
one, six clock hours, zone two, O.U. A follow up examination
is recommended for one week from that time. Audiology,
hearing screen was performed with automated auditory brain
stem responses and the infant passed in both ears on [**2126-7-14**].
Psycho/social status, parents are married. They have been
very involved in the infant's NICU care throughout the
Neonatal Intensive Care Unit stay. [**Known lastname 40933**] sibling [**Doctor First Name 1453**]
died at one week of age. She had a diagnosis of trisomy 21.
Chromosomes were sent on [**Known lastname 32348**] and they were 46 XX.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The infant is being transferred to [**Hospital6 3622**] for continuing care.
Primary pediatric care will be provided by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2406**] of
[**Hospital **] Pediatrics.
FEEDINGS AT DISCHARGE: 30 calorie breast milk with added
ProMod, 4 calories per ounce of human milk fortifier, 4
calories per ounce of medium chain triglyceride, and 2
calories per ounce of Polycose. Total fluid of 150 cc per
kilogram per day with some by lavage and some orally.
MEDICATIONS: 1. Fer-in-[**Male First Name (un) **] 0.2 cc po pg q.d. 2. Vitamin
E 5 international units po pg q.d.
She has not yet had a car seat positioning screening test.
Her state newborn screens, the last three were sent on [**5-29**] and [**7-7**] and all were within normal limits. She has
received the hepatitis B vaccine on [**2126-7-6**], HIB [**2126-7-5**], IPV
[**2126-7-5**], DtaP [**2126-7-8**], Pneumococcal (Prevnar) [**2126-7-6**].
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Twin number two.
3. Status post [**Doctor Last Name **] membrane disease.
4. E-coli sepsis.
5. Pseudomonas pneumonia.
6. Presumed patent ductus arteriosus.
7. Apnea of prematurity.
8. Status post physiologic hyperbilirubinemia.
9. Anemia of prematurity.
10. Retinopathy of prematurity.
11. Chronic lung disease.
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Last Name (NamePattern1) 40934**]
MEDQUIST36
D: [**2126-7-26**] 05:11
T: [**2126-7-26**] 06:43
JOB#: [**Job Number 40935**]
ICD9 Codes: 769 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8619
} | Medical Text: Admission Date: [**2156-12-13**] Discharge Date: [**2156-12-18**]
Date of Birth: [**2099-9-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
s/p Ascending Aortic Replacement w/ 28mm gelweave graft/Aortic
Valve Replacement w/ 28mm CE pericardial tissue vavle- [**2156-12-13**]
History of Present Illness:
57 y/o male with h/o aortic stenosis and bicuspid aortic valve
followed by serial echocardiograms now with dyspnea on exertion
and worsening aortic stenosis. Echo on [**9-29**] revealed [**First Name8 (NamePattern2) **] [**Location (un) 109**] of
0.9 cm2 with a peak of 45 and mean of 31. Cath afterwards then
revealed a dilated ascending aorta with clean coronaries. Pt.
was then referred for surgical intervention.
Past Medical History:
Aortic Stenosis/Bicuspid Aortic Valve
Hypertension
s/p deviated septum repair 85
s/p ?facial repair 80
s/p inguinal hernia repair 04
s/p knee arthroscopy 99
Social History:
Remote tobacco use. Drinks [**12-28**] alcoholic beverages/day
Family History:
Daughter s/p AVR (for bicuspid AV)
Physical Exam:
VS: 76 18 132/78 130/74 6' 210#
General: Well-appearing 57 y/o male in NAD
Skin: Warm, dry -lesions
HEENT: EOMI, PERRL, NC/AT
Neck: Supple, FROM, -JVD, -Carotid Bruit
Chest: CTAB -w/r/r
Heart: RRR, +S1S2, -c/r/m/g
Abd: Soft, NT/ND, +BS
Ext: Warm, Well-perfused -c/c/e, -varicosities
Neuro: A&O x 3, MAE, non-focal
Brief Hospital Course:
Patient was a same day admit and on admit day, [**2156-12-13**], he was
brought to the operating room where he underwent an aortic valve
replacement and ascending aortic repair. Please see op note for
surgical details. Following the procedure he was brought to the
CSRU in stable condition on minimal Inotropic support. Later on
op day he was weaned from mechanical ventilation and sedation
and was neurologically intact. And then was extubated. On
post-operative day two he was weaned off of all Inotropes,
started on diuretics and b blockers, and transferred to the
telemetry floor. While on the tele floor the patient diuresed
well, worked with physical therapy and was generally doing well.
His blood pressure and heart rate were well controlled. He was
started on nebulizers treatments for some intermittent low
oxygen saturation. The patient was discharged to home with
services on post operative day four.
Medications on Admission:
Lisinopril 10mg qd
ASA 325mg qd
MVI
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
5. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*1*
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Ascending Aortic Aneurysm s/p Ascending Aortic Replacement
Aortic Stenosis/Bicuspid Aortic Valve s/p Aortic Valve
Replacement
Hypertension
Discharge Condition:
good
Discharge Instructions:
Keep wounds clean and dry. Can shower, no bathing or swimming.
Do not apply lotions, creams, ointments or powders to incisions.
Do not drive for 1 month.
Do not lift greater than 10 pounds for 2 months.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds.
[**Last Name (NamePattern4) 2138**]p Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr [**Last Name (STitle) **] in [**12-28**] weeks
Dr [**Last Name (STitle) 64572**] in [**1-29**] weeks
Dr [**Last Name (Prefixes) **] in 4 weeks
ICD9 Codes: 4241, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8620
} | Medical Text: Admission Date: [**2103-2-24**] Discharge Date: [**2103-4-20**]
Date of Birth: [**2103-2-24**] Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: This is a 33 [**2-23**] week infant
admitted for issues of prematurity. The infant was born to a
39 year old gravida 1, para 0 mother. Prenatal screens - A
positive, antibody negative, hepatitis B surface antigen
negative, Rubella immune, RPR nonreactive, Group B
Streptotoccus unknown. Prenatal course significant for
normal prenatal ultrasound on [**2102-11-8**], limited
survey due to maternal obesity. Maternal pregnancy-induced
hypertension with elevated blood pressure and proteinuria
noted at approximately 28 weeks gestation. Mother on bedrest
at home until she presented in preterm labor at approximately
31 1/2 weeks. Preterm labor at 31 1/2 weeks, received
betamethasone times two doses on [**2-12**] and [**2-13**],
received magnesium sulfate, remained in the hospital and on
day of delivery was noted to have labile elevated blood
pressure prompting induction.
Past maternal history - Asthma, anxiety (Prozac and prn
Ativan). Infant delivered by cesarean section on [**2-24**]
due to failed induction, increased fetal heartrate, baseline
160 to 170s and variables to 90 to 100. Infant emerged with
apnea and decreased tone, received positive pressure
ventilation for one to two minutes. Respiratory effort noted
approximately one minute of age, by two minutes positive
pressure ventilation stopped, blow-by oxygen for cyanosis and
then room air during transport to the Neonatal Intensive Care
Unit. Tone was decreased upon arrival to the Neonatal
Intensive Care Unit. Apgars were 7 at one minute and 8 at
five minutes.
PHYSICAL EXAMINATION: On admission, birthweight [**2065**] gm (25
to 50th percentile), length 44 cm (50th percentile), head
circumference 31.25 cm (approximately 60th percentile).
Anterior fontanelle open and flat, eyes appear small with
hypertelorism, swollen eyelid, frontal bossing, hematoma in
corner of right eye. Ears, normal appearance and set, light
micrognathia, palate intact. No murmur. Breath sounds clear.
Abdomen, soft, nontender, nondistended. Extremities well
perfused. Tone, initially significantly decreased throughout
but improved and symmetric. Spine intact. Anus patent.
HOSPITAL COURSE: Infant has remained in room air throughout
this hospitalization with oxygen saturation greater than 94%.
Respiratory rate was 40s to 60s. No apnea or bradycardia.
Infant did not receive methylxanthine therapy this
hospitalization.
Cardiovascular - The patient has remained hemodynamically
stable this hospitalization. A soft intermittent murmur was
noted on day of life #34. On day of life #35, a chest x-ray
was obtained which was normal, four extremity blood pressures
were within normal limits and a hyperoxia test was performed
revealing a pCO2 of greater than 320, on 100% FIO2. The
murmur is still intermittently present and is thought to be a
benign flow murmur. It should be investigate further if
persistent.
Fluids, electrolytes and nutrition - The infant initially ate
nothing by mouth, receiving 1 cc/kg/day of D10/W. Enteral
feedings were started on day of life #1 and were advanced to
full volume of 150 cc/kg/day by day of life #6. Maximum
caloric density of premature Enfamil 24 cal/oz was achieved
by day of life #7. The infant tolerated feeding without
difficulty. The most recent set of electrolytes on day of
life #2 showed a sodium of 139, chloride 104, potassium 6.4,
pCO2 22. At 39 weeks corrected gestation, (day of life #38)
the infant continued to receive gavage feeding and to have
difficulty with oral feeding. The feeding team at [**Hospital3 18242**] was consulted and they evaluated [**Known lastname **] on [**4-3**]
which was day of life #38 at 39 weeks corrected. The infant
was noted to have dyscoordination of suck/swallow. Their
recommendation was to continue to encourage oral feeding and
that the feeding team re-evaluate on [**4-9**]. They then
recommended a swallow study which was done at [**Hospital3 18242**] on [**4-11**] which was within normal limits,
revealing no aspiration.
Otorhinolaryngology was consulted due to stridor noted with
feeding. Dr. [**Last Name (STitle) 174**] recommended a bronchoscopy and
laryngoscopy which was done at [**Hospital3 1810**] on [**3-19**]
which revealed mild laryngomalacia. This does not appear
to have functional significance and requires only clinical
observation.
The infant was noted to be
taking in full volume feedings on day of life #55 and has been
orally feeding ad lib Enfamil 20 cal/oz and taking 150 to 180
cc/kg/day p.o. The most recent weight is 3495 gm, head
circumference 36 cm, length 50.5 cm.
Gastrointestinal - The infant received phototherapy from day
of life #4 to day of life #6, maximum bilirubin level was
12.8 with a direct of 0.4. The most recent bilirubin level
on day of life #8 was 8.6 with a direct of 0.3.
Heme - The infant did not receive any packed red blood cell
transfusions this hospitalization. The most recent
hematocrit on [**3-4**] was 51.8%.
Infectious disease - A complete blood count, differential and
blood culture were drawn on the day of delivery which showed
a white blood cell count of 13.5, hematocrit 56%, platelets
241,000, 29 polys, 0 bands. The infant received 48 hours of
Ampicillin and Gentamicin. Blood cultures were negative.
Neurology - Head ultrasound on day of life #38 ([**2103-4-3**]), revealed bilateral Grade 1 terminal matrix
hemorrhages. A follow up head ultrasound is recommended.
Due to poor oral feeding, Neurology was also consulted at 39
weeks corrected gestation. The neurological
examination was normal and he did not recommend any further
head imaging at that time.
Genetics - Due to poor oral feeding and mild dysmorphic
features, genetics was consulted (Dr. [**Last Name (STitle) 40698**]. Their
examination revealed mild frontal bossing and borderline
lowset ears, otherwise the examination was unremarkable, no
further workup was recommended at that time.
Hearing - Hearing screening was performed with automated
auditory brain stem responses, the infant passed both ears.
Psychosocial - Parents are involved with infant. Social work
is also involved with family. Contact social worker can be
reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Former 33 [**3-23**] week gestation female,
now 41 [**3-23**] week corrected, stable in room air.
DISCHARGE DISPOSITION: Home with parents. Name of primary
pediatrician, Dr. [**Last Name (STitle) 30207**], phone [**Telephone/Fax (1) 37875**].
CARE RECOMMENDATIONS:
1. Feedings at discharge - Enfamil 20 cal/oz p.o. ad lib.
2. Medications - Simethicone drops 0.3 cc every four hours p.o.
3. Carseat position screening - Performed and infant passed.
4. State newborn screens - Sent on [**2-27**], [**3-10**] and
[**4-5**], all were within normal range.
5. Immunizations - The infant received hepatitis B vaccine on
[**3-7**]. Infant received Synagis on [**3-10**] and
[**4-21**]. Two month immunizations are due on [**4-25**].
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.
FOLLOW UP APPOINTMENTS: Primary pediatrician, Dr. [**Last Name (STitle) 30207**].
[**Hospital1 **] Community Early Intervention Program, phone
[**Telephone/Fax (1) 46075**].
DISCHARGE DIAGNOSIS:
1. Prematurity 33 3/7 weeks gestation
2. Status post rule out sepsis
3. Status post hyperbilirubinemia
4. Mild laryngomalacia
Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**]
Dictated By:[**Last Name (NamePattern1) 43219**]
MEDQUIST36
D: [**2103-4-22**] 01:40
T: [**2103-4-22**] 06:24
JOB#: [**Job Number 46076**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8621
} | Medical Text: Admission Date: [**2195-12-9**] Discharge Date: [**2195-12-18**]
Date of Birth: [**2119-11-25**] Sex: M
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 53735**] is a 76 year-old
man who has a history of hypertension, gastroesophageal
reflux disease, Paget's disease, has had a few episodes of
chest pain over the past few weeks. Yesterday he was
exercising and had severe chest pain, which lasted two to
three hours. He woke up with dull chest pain this morning
and presented to his primary care physician's office where he
had electrocardiogram changes, which included inferior Q
waves, ST elevations and T wave inversions. He underwent
cardiac catheterization at [**Hospital6 3872**] on the
day of transfer, which revealed left main with a high grade
lesion, left anterior descending coronary artery with 80%
osteal and 80% mid lesion, left circumflex with an 90% osteal
and 80% osteal obtuse marginal one lesion and an 80% osteal
obtuse marginal two lesion. The right coronary artery was
subtotally occluded with an 80% [**Last Name (LF) 48199**], [**First Name3 (LF) **] was estimated at 40%
with inferior wall akinesis. He is transferred from [**Hospital3 6454**] to [**Hospital1 69**] for coronary
artery bypass grafting.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Paget's disease.
3. Degenerative joint disease.
4. Esophagitis.
5. Gastroesophageal reflux disease.
6. Status post transurethral resection of the prostate.
7. Status post left total knee replacement.
8. Status post right arm surgery.
9. Status post appendectomy.
PREOPERATIVE MEDICATIONS:
1. Terazosin 2 mg q.h.s.
2. Methyldopa 500 mg q.d.
3. Prilosec 20 mg q.d.
4. Ecotrin 325 q.d.
5. Fosamax 70 once a week.
6. Celebrex prn.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Positive for coronary artery disease.
SOCIAL HISTORY: Has forty pack year cigarette history. He
quit twenty years ago. Alcohol use is intermittent with two
drinks per evening. He lives with his wife who is disabled
and he cares for her.
PHYSICAL EXAMINATION: Vital signs heart rate 63. Blood
pressure 159/67. Respiratory rate 22. O2 sat 100% on room
air. General, elderly man in no acute distress. HEENT
pupils are equal, round and reactive to light. Extraocular
movements intact. Anicteric. Noninjected. Oropharynx is
benign. Neck is supple. No lymphadenopathy or thyromegaly.
Carotids are 2+ bilaterally without bruits. Lungs are clear
to auscultation. Cardiovascular regular rate and rhythm. S1
and S2 with no murmurs, rubs or gallops. Abdomen is soft,
nontender, nondistended. No masses or hepatosplenomegaly
with positive bowel sounds. Extremities warm and well
perfuse with no clubbing, cyanosis or edema. 2+ pulses
bilaterally. Neurological examination is nonfocal.
The patient underwent a transthoracic echocardiogram upon
arrival at [**Hospital1 69**]. TEE at that
time showed normal RV size and function, normal left
ventricular size with an EF of 35 to 40% with inferolateral
hypokinesis, mild mitral regurgitation, mild aortic
regurgitation, no pericardial effusion.
HOSPITAL COURSE: The following morning the patient was
brought to the Operating Room at which time he underwent
coronary artery bypass grafting. Please see the operative
report for full details. In summary the patient had coronary
artery bypass graft times five with a left internal mammary
coronary artery to the left anterior descending coronary
artery, saphenous vein graft to the PL and obtuse marginal
sequentially, saphenous vein graft to the posterior
descending coronary artery and saphenous vein graft to the
diagonal. The patient's bypass time was 139 minutes. His
cross clap time was 82 minutes. He tolerated the operation
well and was transferred from the Operating Room to the
Cardiothoracic Intensive Care Unit. At the time of transfer
the patient had a mean arterial pressure of 90. He was in
normal sinus rhythm. He had Amiodarone at 1 mg per minute,
Propofol at 20 micrograms per kilogram per minute and
nitroglycerin at 0.5 micrograms per minute. The patient did
well in the immediate postoperative period. Sedation was
reversed. He was weaned from the ventilator and successfully
extubated. He remained hemodynamically stable throughout the
day and night of surgery. On postoperative day one the
patient remained hemodynamically stable and his Amiodarone
was transitioned to oral medications. His Swan-Ganz catheter
was discontinued.
Additionally the patient was noted to be confused and
agitated following extubation striking out at nurses.
Therefore he remained in the Intensive Care Unit for further
hemodynamic as well as monitoring of his neurological status.
On postoperative day two the patient remained occasionally
disoriented, but easily reoriented. Hemodynamically the
patient remained stable. He was off all intravenous
medications and it was felt that he was ready to be
transferred to the floor, however, there were no floor beds
available and the patient therefore stayed in the Intensive
Care Unit. On postoperative day three the patient remained
hemodynamically stable. His neurological status had improved
and he only had rare episodes of confusion. There were still
no floor beds available and he stayed in the Intensive Care
Unit until postoperative day four when he was transferred to
the floor for continuing postoperative care and cardiac
rehabilitation. Following transfer to the floor the
patient's Foley catheter was removed. He failed his initial
voiding trial and the catheter was replaced at that time.
The patient was restarted on his Terazosin and it was also
noted that the patient was having episodes of atrial
fibrillation with a heart rate to 120. He remained
hemodynamically stable throughout these episodes. On
postoperative day six the patient's Foley was again
discontinued. He did initially void following removal of his
Foley catheter, however, he had an episode of greater then
twelve hours without voiding. A bladder scan done at that
time showed greater then 900 cc of urine in his bladder. His
Foley was then reinserted and urology was consulted.
On postoperative day seven the patient had reached an
adequate activity level to be considered safe and ready for
discharge to home and on postoperative day eight the patient
was discharged to home with visiting nurses services.
At the time of discharge the patient's physical examination
revealed vital signs temperature 99. Heart rate 69, sinus
rhythm. Blood pressure 134/62. Respirations 18. O2 sat 98%
on room air. Weight preoperatively a 74.4 kilograms, at
discharge is 82 kilograms. Neurologically alert and oriented
times three, moves all extremities, follows commands.
Respirations clear to auscultation bilaterally. Cardiac
regular rate and rhythm. S1 and S2 with no murmurs. Sternum
is stable. Incision with Steri-Strips open to air clean and
dry. Abdomen soft, nontender, nondistended with normoactive
bowel sounds. Extremities are warm and well perfuse with 1+
edema bilaterally. Saphenous vein graft site with
Steri-Strips covered with dry sterile dressing.
Laboratory data on discharge, hematocrit 26.2, sodium 135,
potassium 4.2, BUN 26, creatinine 1.1, glucose 101.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass grafting times five with left internal mammary
coronary artery to the left anterior descending coronary
artery, saphenous vein graft to the PL and obtuse marginal
sequentially, saphenous vein graft to the posterior
descending coronary artery, saphenous vein graft to the
diagonal.
2. Hypertension.
3. Paget's disease.
4. Degenerative joint disease.
5. Esophagitis.
6. Gastroesophageal reflux disease.
7. Status post transurethral resection of the prostate.
8. Status post left total knee replacement.
9. Status post right arm fracture.
10. Status post appendectomy.
11. Atrial fibrillation.
12. Status post transurethral resection of the prostate.
13. Urinary retention.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg q.d.
2. Prilosec 20 mg q.d.
3. Terazosin 3 mg q.h.s.
4. Metoprolol 50 mg b.i.d.
5. Lasix 20 mg q.d. times two weeks.
6. Potassium chloride 20 milliequivalents q.d. times two
weeks.
7. Vioxx 25 mg q.d. prn.
8. Fosamax 70 mg q week.
9. Amiodarone 400 mg q.d. times one week and then 200 mg
q.d. times one month.
FO[**Last Name (STitle) 996**]P: The patient is to have follow up in the wound
clinic in two weeks. Follow up with the urology resident
clinic in one to two weeks. The patient is to call with an
appointment. Follow up with Dr. [**Last Name (STitle) **] in three to four weeks
and follow up with Dr. [**Last Name (Prefixes) **] in four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Doctor Last Name 9076**]
MEDQUIST36
D: [**2195-12-18**] 11:22
T: [**2195-12-18**] 11:43
JOB#: [**Job Number 53736**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8622
} | Medical Text: Admission Date: [**2115-11-6**] Discharge Date: [**2115-11-9**]
Date of Birth: [**2077-4-24**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
esophogastroduodenoscopy
History of Present Illness:
38yo man s/p recent NSTEMI w/ bare-metal stent placement and
hypertension here with SOB on exertion and several days of
melanotic stools. The patient says that he had several days of
dark stools after starting Aspirin and Plavix. This improved
after he starting taking his medications with meals. However,
yesterday he again had several black stools, followed by crampy,
low abdominal discomfort. He slept poorly overnight, but this
morning still tried to go to work. On his way there he noticed
that his palms were very pale, he was very SOB with exertion,
and he began feeling dizzy and diaphoretic.
.
He went to urgent care where BP 103/75 HR 84, O2 sat 100%, pale,
lungs clear, cardiac exam unremarkable. He was apparently
complaining of diaphoresis and acute onset chest pain, though he
now says he has not had CP since his MI. EKG showed old infarct
in inferior q waves, j point elevation and LVH. Got IV fluids
and oxygen and was sent to the ED.
.
In the ED, initial vs were: 98.4 96 106/70 18 100% 2L Nasal
Cannula. Patient found to have Hct 17, though hemodynamically
stable. Hct 40 [**2115-10-10**] at [**Hospital3 7362**]. Two 18G IVs were
placed, pt started on pantoprazole gtt and transfused 1 unit
PRBC. Vitals prior to transfer were 86, 120/88, 18, 98% RA.
Speaks very little English.
.
The patient was admitted to [**Hospital3 7362**] [**2115-10-10**] with chest
pain. Cath showed an occluded RCA that was collateralized, w/ a
high-grade circumflex lesion requiring a bare-metal stent. He
was discharged [**10-12**] on Aspirin, Plavix, simvastatin, HCTZ and
Zestril.
.
In the MICU, pt had EGD, which showed non-bleeding ulcer. He was
placed on IV PPI [**Hospital1 **]. He was given 4 units PRBC's. Pt has
remained HD stable. He was advanced to clears today. He was also
restarted on metoprolol 25mg [**Hospital1 **] for now. Pt written for
captopril (in place of Lisinopril) while in MICU. He was not had
his ASA & Plavix yet restarted. Still waiting to hear back from
GI. H. pylori was sent and is still pending.
Past Medical History:
- CAD s/p NSTEMI with BMS to circumflex [**2115-10-10**]
- Hypertension since his 20's
- Chronic kidney disease with proteinuria, baseline Cr 1.3
- possible OSA, though has not had a sleep study
- 10 years ago had ? anoscopy for hemorrhoids, followed by
surgical repair.
Social History:
Moved here from [**Country 10181**] one year ago to work as a post-doc in
microbiology at [**University/College 5130**] Univ. Former smoker. No EtOH, no
drugs.
Family History:
Father has diabetes, mother with HTN. No family history of
premature MI.
Physical Exam:
On admission:General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, no thyromegaly
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur.
Abdomen: no scars, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
On Discharge: unchanged from admission
Pertinent Results:
Lab Results on Admission:
[**2115-11-6**] 12:00PM BLOOD WBC-9.0 RBC-1.93* Hgb-6.0* Hct-17.4*
MCV-90 MCH-30.9 MCHC-34.3 RDW-15.7* Plt Ct-237
[**2115-11-6**] 12:00PM BLOOD Neuts-77.4* Lymphs-17.5* Monos-3.9
Eos-0.6 Baso-0.5
[**2115-11-6**] 12:00PM BLOOD PT-12.6 PTT-22.5 INR(PT)-1.1
[**2115-11-6**] 12:00PM BLOOD Glucose-113* UreaN-59* Creat-1.3* Na-139
K-4.3 Cl-108 HCO3-23 AnGap-12
[**2115-11-6**] 12:00PM BLOOD ALT-28 AST-16 LD(LDH)-111 AlkPhos-59
TotBili-0.3
[**2115-11-6**] 12:00PM BLOOD Lipase-49
[**2115-11-6**] 12:00PM BLOOD cTropnT-<0.01
[**2115-11-6**] 12:00PM BLOOD Albumin-3.7 Calcium-8.0* Phos-2.1* Mg-2.1
Studies:
[**11-6**] ECG: Sinus rhythm. There is an initial small R wave in
leads III and aVF. Non-specific lateral ST segment changes. No
previous tracing available for comparison.
[**2115-11-6**] 12:40 pm SEROLOGY/BLOOD
CHM S# [**Serial Number 90750**]L H/PYLORI ADDED [**11-6**].
**FINAL REPORT [**2115-11-8**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2115-11-8**]):
NEGATIVE BY EIA.
(Reference Range-Negative).
Lab Results on Discharge:
[**2115-11-9**] 06:50AM BLOOD Hct-28.2*
[**2115-11-7**] 04:18AM BLOOD PT-12.3 PTT-22.5 INR(PT)-1.0
[**2115-11-8**] 05:15AM BLOOD Glucose-107* UreaN-21* Creat-1.3* Na-138
K-3.9 Cl-104 HCO3-23 AnGap-15
[**2115-11-8**] 05:15AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.3
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION: Patient is a 38yo man with
PMH of HTN and CAD 27 days s/p NSTEMI with bare-metal stent
placment who presented to the hospital with SOB on exertion and
about three weeks of melanotic stools. He was found to be
profoundly anemic to Hct 17 and received 4UpRBC. EGD showed
gastric ulcer with no active bleeding. He was given Protonix and
patient's aspirin and plavix were held. Serologic testing was
negative for H. pylori. His Hct remained stable at 28 on
discharge, and aspirin was decreased to 81mg daily and plavix
was held as patient was 1 month post-cath on discharge. He was
given follow-up appointments with his PCP and gastroenterology.
.
ACUTE CARE:
.
1. GI Bleed: Patient experienced about 3 weeks of dark stools
while on aspirin/plavix following cardiac stenting for NSTEMI.
He had DOE, fatigue and had Hct 17 on admisison. Patient was
found to have gastric ulcer on EGD however no intervention was
performed because there was no evidence of ongoing bleeding. He
reveived 4UpRBC, and aspirin and plavix were held, and PPI was
started. Home antihypertensives were held. He remained
hemodynamically stable and crits stabilized at 28. His home
plavix was restarted for two days but discontinued at discharge
because the one-month post-cath period was over for bare-metal
stent that he just revceived. He was continued PPI and home
antihypertensives were gradually restarted. Aspirin was
decreased to 81mg PO daily as patient has high lifetime risk for
CAD. H. pylori serologies were negative. He was discharged with
PCP and gastroenterology [**Name9 (PRE) 702**].
.
2. Recent MI: Patient BMS placed for NSTEMI 27 days prior to
admission. Simvastatin was continued but aspirin and plavix were
held for acute GI bleed. When Gi bleed resolved patient received
two further days of plavix which was stopped at discharge as one
month of treatment was completed. Patient's aspirin was
decreased to 81mg daily for risk of CAD and antihypertensives
that were held for GIB were re-started on discharge.
.
CHRONIC CARE:
1. Chronic Kidney Disease: Patient's creatinine was at baseline
for hospital stay and was trended in setting of volume status
changes.
.
2. Hypertension: Patient's home antihypertensive medications
were held during management of GI bleed and re-started before
discharge. His BP was stable at discharge.
.
TRANSITIONS IN CARE:
1. FOLLOW-UP: Patient has an appointment with his PCP and
Gastroenterologist following discharge.
2. MEDICATION CHANGES: Patient's clopidogrel was stopped and
aspirin was decreased to 81mg daily from 325 daily. Patient was
started on pantoprazole 40mg PO Q12H for treatment of PUD.
3. CODE STATUS: FULL
Medications on Admission:
- lisinopril 20mg daily
- Potassium Chloride ER 20 mEq daily
- simvastatin 20mg QHS
- aspirin 325mg daily
- clopidogrel 75mg daily
- HCTZ 12.5mg daily
- metoprolol succinate 50mg
Discharge Medications:
1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
6. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day.
7. aspirin, buffered 81 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. bleeding ulcer
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 during this admission. You
were admitted with feeling fatigued and found to have blood in
your stools. Your red blood cell level was very low and you were
admitted to the intensive care unit initially. You were given
red blood cells and your levels then remained stable. You had an
endosocopy in the ICU, and they found an ulcer. You were started
on a medication called pantoprazole for this. We tested you for
bacteria called H. pylori, but this was negative. You will need
to continue the Pantoprazole until you follow-up with the
gastroenterologists. You will also need a repeat endoscopy to
reassess the ulcer in ~8 weeks. We initially held your plavix
and gave you two further days of this medication when the
bleeding resolved. We are discharging you with a baby aspirin
and no further plavix.
The following medications were changed during this admission:
1. START Pantoprazole 40mg by mouth twice daily
2. Change Aspirin dose to 81mg by mouth daily
3. Discontinue Plavix
Please continue the other medications you were taking prior to
this admission.
Please keep all followup appointments.
Followup Instructions:
Please follow-up with the following appointments:
Name: [**Known lastname **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
Appointment: Monday [**2115-11-11**] 3:40pm
Name: [**Last Name (LF) 26390**], [**First Name7 (NamePattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 641**]
Department: Gastroenterology
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
Appointment: Thursday [**2115-11-21**] 3:00pm
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
ICD9 Codes: 2851, 5859, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8623
} | Medical Text: Admission Date: [**2155-9-1**] Discharge Date: [**2155-10-22**]
Date of Birth: [**2088-9-6**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 14689**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
ORIF
Pericaridal Window
Endotrachial Intubation and mechanical ventilation
PEG tube placement
History of Present Illness:
66 year old male with hypopharyngeal mass diagnosed in [**2155-7-4**]
who was in his usual state of health until this morning. He
suffered a mechanical fall this morning while intoxicated
complicated by left humerus and hip fracture. He was evaluated
at an OSH and transferred to [**Hospital1 18**] due to shortness of breath
and his known tumor.
At [**Hospital1 18**] ED, his initial vitals were : 98.8 103 125/57 22 97%
2LNC. He was noted to have increased work of breathing though
without stridor and satting well on room air. He reports he has
had increasing difficulty swallowing for the past several weeks
worsening over the last several days, but is tolerating liquids.
He reports significant weight loss in the past month. He is
having more difficulty breathing. He reports his tumor was found
during a procedure for skin cancer in which there was difficulty
during intubation.
CT scan showed 2-cm exophytic mass in L piriform sinus. Large
submucosal hypopharyngeal/postcricoid/esophageal mass measuring
5 cm TV x 2 cm AP x 8.5 cm SI with focal airway narrowing down
to 1.3 x 0.7 cm, bilateral hyoid and thyroid cartilage invasion.
Bilateral enlarged/necrotic LN. ENT performed laryngoscopy
which showed left exophytic portion of mass clearly viewed on
fiberoptic exam, while right and posterior portion appreciated
as obliteration of right pyriform and post-cricoid space. He was
given Decadron 5 mg IV and transferred to MICU for monitoring.
Orthotrauma was consulted who would like ENT/Anesthesia involved
prior to taking him to the OR.
In the MICU, he had no other complaints. He reports history of
withdrawal seizures but no intubation. He also reports being
anxious about his upcoming operation.
Past Medical History:
Basal cell cancer
Hypothyroidism
Pneumonia
Anemia
ETOH abuse
Hyperlipidemia
Hypopharyngeal mass
Social History:
denies smoking, prior to admission pt reportedly had several
drinks of ETOH daily
Family History:
no history of head and neck cancer
Physical Exam:
Admission Exam
102.1 98 127/65 98%humidified face tent
General: Alert, oriented. Moderate respiratory distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: large anterior cervical mass
CV: Difficult to hear over his upper airway sounds
Lungs: Prominent upper airway sounds. No wheezing
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: Internally rotated left hip and externally rotated left
forearm.
Neuro: CNII-XII intact, 5/5 strength deferred on LUE and LLE due
to pain.
Discharge Exam
VS: 97.7, 130/90, 79, 18, 97%RA
GEN: Cachectic. Awake, NAD
HEENT: Pupils equal. Poor dentition
PULM: CTAB anteriorly, no wheezing, rales, rhonchi
CV: RRR. No murmurs appreciated.
ABD: BS+. Soft. NT. Distended. G-tube bandage C/D/I. No rebound
or guarding.
EXT: Left arm swelling from hand to above left elbow, 2+ DP/PT
pulses bilaterally. No lower extrem edema bilaterally. Left
second metatarsal appears swollen with some erythema around toe.
Neuro: AxOx3
Pertinent Results:
Admission Labs
[**2155-8-31**] 10:50PM BLOOD WBC-16.1* RBC-2.92* Hgb-9.2* Hct-27.5*
MCV-94 MCH-31.4 MCHC-33.5 RDW-14.0 Plt Ct-269
[**2155-8-31**] 10:50PM BLOOD Neuts-93.7* Lymphs-3.2* Monos-2.9 Eos-0.1
Baso-0.2
[**2155-8-31**] 10:50PM BLOOD PT-13.2* PTT-30.2 INR(PT)-1.2*
[**2155-8-31**] 10:50PM BLOOD Glucose-121* UreaN-12 Creat-0.8 Na-130*
K-4.3 Cl-93* HCO3-28 AnGap-13
[**2155-9-1**] 04:13AM BLOOD Calcium-8.4 Phos-4.2 Mg-1.6
Discharge labs:
[**2155-10-22**] 05:44AM BLOOD WBC-2.3* RBC-2.58* Hgb-8.0* Hct-23.7*
MCV-92 MCH-31.2 MCHC-33.9 RDW-15.1 Plt Ct-185
[**2155-10-21**] 06:28AM BLOOD WBC-2.4* RBC-2.63* Hgb-8.4* Hct-24.4*
MCV-93 MCH-31.8 MCHC-34.3 RDW-15.2 Plt Ct-201
[**2155-10-9**] 03:27AM BLOOD Neuts-56.5 Lymphs-28.9 Monos-6.3 Eos-7.4*
Baso-0.9
[**2155-10-22**] 05:44AM BLOOD Gran Ct-1170*
[**2155-10-22**] 05:44AM BLOOD Glucose-106* UreaN-21* Creat-0.6 Na-134
K-4.6 Cl-97 HCO3-32 AnGap-10
[**2155-10-15**] 06:13AM BLOOD LD(LDH)-150 TotBili-0.2
[**2155-10-22**] 05:44AM BLOOD Mg-1.7
CT Neck: 2-cm exophytic mass in L piriform sinus.
Large submucosal hypopharyngeal/postcricoid/esophageal mass
measuring 5 cm TV x 2 cm AP x 8.5 cm SI with focal airway
narrowing down to 1.3 x 0.7 cm,
bilateral hyoid and thyroid cartilage invasion.
Bilateral enlarged/necrotic LN.
CT Pelvis ...
IMPRESSION:
1. Comminuted left intertrochanteric femur fracture with varus
angulation of the distal fracture fragment.
2. Diffusely severely osteopenic bones as described above. The
possibility of an underlying lytic lesion would be difficult to
exclude in this setting.
3. Loss of height of the L5 vertebral body, though no findings
suggestive of acute compression fracture.
4. Degenerative changes noted.
5. Bladder distended, but trabeculated, which may be secondary
to outlet
obstruction or cystitis, correlate clinically.
LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT IN O.R. [**2155-9-1**]
FINDINGS: Multiple fluoroscopic images of the left hip in the
operating room demonstrate interval placement of a dynamic
compression screw with associated fracture plates and screws
fixating an intertrochanteric fracture of the left proximal
femur. The total intraservice fluoroscopic time was 74.9
seconds. There is improved anatomic alignment of the fracture
with no signs of hardware-related complications.
CHEST (PORTABLE AP) [**2155-9-1**]
The ET tube tip is 5 cm above the carina. Cardiomegaly is
unchanged.
Mediastinal silhouette is stable. There is progression of the
left lower lobe consolidation concerning for interval
progression of infectious process. Mild edema is present.
Right basal consolidation has slightly progressed as well.
CHEST (PORTABLE AP) Study Date of [**2155-9-2**]
The ET tube tip is impinging the left tracheal wall and should
be
repositioned, currently 4.5 cm above the carina. Additional
substantial
progression of left lower lung consolidation is noted as well as
of the right lower lobe. No frank edema is seen, although mild
degree of congestion cannot be excluded. Left pleural effusion
is most likely present. No pneumothorax is seen.
CHEST (PA & LAT) Study Date of [**2155-9-3**]
The patient was extubated in the meantime interval. There is
slight interval improvement in the left lower lobe consolidation
consistent with resolution of potentially infectious process or
aspiration. Right lower lobe opacity appears to be unchanged.
There is no appreciable pneumothorax or increase in pleural
effusion demonstrated.
FDG TUMOR IMAGING (PET-CT) [**2155-9-4**]
IMPRESSION: 1. Large FDG avid hypopharyngeal mass inseparable
from esophagus and causing significant narrowing of the airway.
2. FDG avid level II lymph nodes bilaterally and right level
II/III node.
3. Left lower lobe pneumonia.
4. Mediastinal FDG avid lymph node could be reactive to
pneumonia.
5. Small to moderate pericardial effusion.
6. Recent left humerus and femur fractures, as previously seen.
7. Persistent CT contrast in renal collecting system and
bladder from
examination three days prior suggesting delayed clearance.
CHEST (SINGLE VIEW) [**2155-9-4**]
Heart size and mediastinum are grossly similar in appearance.
Left lower lobe consolidation continues to be present,
concerning for infectious process. The major change since the
prior radiograph is interval development of interstitial
pulmonary edema within the last less than 5 hours. No
pneumothorax is seen. Small bilateral pleural effusion cannot
be excluded.
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 112384**],[**Known firstname **] [**2088-9-6**] 66 Male [**-1/3374**] [**Numeric Identifier 112385**]
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/rate
SPECIMEN SUBMITTED: hypopharyngeal tumor, Left Femoral Neck
Reamings.
Procedure date Tissue received Report Date Diagnosed
by
[**2155-9-1**] [**2155-9-1**] [**2155-9-4**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 1431**]/mn????????????
DIAGNOSIS:
I. Hypopharyngeal tumor biopsy (A-B):
Squamous cell carcinoma, invasive, poorly differentiated,
extending to tissue edges.
II. Left femoral neck reamings (C):
Bone and skeletal muscle with recent hemorrhage consistent with
fracture.
Clinical: Left hip fracture.
Gross: The specimen is received in two parts each labeled with
the patient's name "[**Known lastname 4427**], [**Known firstname 449**]" and the medical record
number.
Part 1 is additionally labeled "hypopharyngeal tumor biopsy".
It was received from the OR and consists of multiple fragments
of tan tissue measuring 1 x 0.5 x 0.5 cm in aggregate. The
specimen was partially submitted for frozen section examination
and the frozen section diagnosis by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10940**] is: "Positive
for carcinoma, favor squamous cell". The specimen is entirely
submitted as follows: A=frozen section remnant; B=remainder of
tissue.
Part 2 is additionally labeled "left femoral neck reamings". It
consists of multiple red/tan tissue fragments that measure 2.1 x
2 x 1 cm in aggregate. The specimen is entirely submitted in
cassette C.
CXR [**2155-9-9**]
Moderate right pleural effusion has increased. Severe bibasilar
consolidation
is unchanged. In addition to persistence of severe gaseous
distention of the
colon in the upper abdomen, there is new definition of the outer
wall of the
bowel, raising serious concern for pneumoperitoneum. This
examination claims
to have been performed with the patient upright. That needs to
be confirmed.
I have paged Dr.[**Last Name (STitle) 112386**] to discuss this.
Heart size is normal. Right PIC line has been withdrawn to the
brachiocephalic vein, several centimeters proximal to its
junction with the
left.
CXR [**2155-9-9**]
FINDINGS: Single AP view of the chest was obtained with the
patient in
semi-upright position. Pulmonary congestion and pleural
effusion is again
seen, unchanged, left greater than right. The pulmonary
vasculature does not
show signs of congestion. The PICC line has been adjusted since
previous
imaging and now is located with the tip 2 cm above the carina.
There is no
pulmonary edema, chest consolidation. The heart size is
unchanged. There is
no pneumothorax or other complications noted. As before, there
is marked gas
distention of the large bowel which raises the question of a
possible
obstruction or ileus. Followup imaging of the abdomen should be
pursued to
further evaluate the large bowel. There is no evidence of free
abdominal air.
The large bowel is much more distended than on previous day.
IMPRESSION: Marked gaseous distention of the large bowel.
Recommend followup
abdominal radiographs to assess for obstruction or ileus.
Pulmonary
congestion and effusion is unchanged from imaging earlier today.
Abdominal X-ray [**2155-9-10**]
FINDINGS: Single frontal image of the abdomen shows some
dilated small bowel
loops with air and stool in the rectum and descending colon.
This represents
possible ileus. Surgical fixation device in the left proximal
femur remains
unchanged. The remainder of the visualized osseous structures
are
unremarkable.
IMPRESSION: Dilated small bowel loops indicating possible ileus
with no
definitive evidence of obstruction.
G tube placement by IR [**2155-9-12**]
CONCLUSION:
Uncomplicated percutaneous gastrostomy placement as above with a
12 French
wills [**Doctor Last Name 12433**] gastrostomy tube.
The tube may be used for feeding in 24 hours.
CXR [**2155-9-16**]
FINDINGS: Single frontal image of the chest demonstrates
bibasilar densities,
unchanged since previous imaging. The left-sided pleural
effusion has
improved slightly. There is no right-sided pleural effusion.
There is no
upper zone distribution. There is no discrete evidence of
pneumonia, but
bibasilar densities could be contributing to the patient's
clinical picture.
Cardiomegaly is again seen.
IMPRESSION: Essentially unchanged chest radiograph with
persistent bibasilar
opacities and left pleural effusion.
Head CT [**2155-9-16**]
FINDINGS: There is no evidence of hemorrhage, edema, masses, or
mass effect.
Encephalomalacic changes are seen in the right frontal lobe,
likely from prior
infarction or trauma. White matter hypodensity in the left
frontal region,
consistent with small vessel ischemic changes. The ventricles
and sulci are
moderately enlarged, consistent with moderate involutional
changes, slightly
advanced for age. The basal cisterns are normal. Mucosal
thickening is seen
in bilateral maxillary sinuses. The mastoid air cells are
clear. The orbits
are unremarkable.
IMPRESSION: Right frontal encephalomalacia. No acute
intracranial pathology.
CXR [**2155-9-22**]
CHEST: Comparison is made with prior chest x-ray of [**2155-9-16**].
Since this
time, there has been increase in the opacities within both bases
and they now
extend into the left upper lobe. These appearances could be due
to an
extending pneumonia, but some failure may also be present.
IMPRESSION: Worsening bilateral infiltrates.
EEG [**2155-9-22**]
CONTINUOUS EEG RECORDING: Began at 21:50 on the evening of [**9-22**] and
continued through 7:00 a.m. the next morning. In this continuous
recording,
there was diffuse background slowing with 6-7 Hz theta activity
superimposed
with delta activity. The video captured several episodes of
right arm and
hand myoclonic jerks, right hand finger minor myoclonus, as well
as left leg
myoclonic jerks. None of those episodes had clear EEG
correlates.
SPIKE DETECTION PROGRAMS: Showed electrode artifact. There were
no
epileptiform discharges.
SEIZURE DETECTION PROGRAMS: There were no electrographic
seizures.
PUSHBUTTON ACTIVATIONS: There were none.
SLEEP: The patient progressed from wakefulness to sleep with no
additional
findings.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This telemetry captured no pushbutton activations.
The video
captured several episodes of myoclonus with no EEG correlates.
There were no
electrographic seizures or epileptiform discharges. There was
diffuse
background slowing which indicates mild to moderate
encephalopathy.
Medications, metabolic disturbances, and infection are among the
most common
causes.
LUE Extremity Ultrasound [**2155-9-22**]
The internal jugular vein, axillary, subclavian, brachial,
basilic veins are
patent. The cephalic vein was not reliably visualized. There
are innumerable
large aggressive pathological appearing lymph nodes in the neck
and the upper
arm producing degree of mass effect and deviation of vascular
structures,
though no good frank evidence of of DVT . Examination was a
little limited
by the presence of the patient's arm infection/weeping.
CONCLUSION:
No DVT. Cephalic vein not visualized. Pathological
lymphadenopathy.
EEG [**2155-9-23**]
CONTINUOUS EEG RECORDING: Began at 7:01 on the morning of [**9-23**] and
continued through 15:48 afternoon. Throughout, it showed a
mildly
disorganized and slow background with posterior frequencies of
7.5 or so at
maximum. There are also several bursts of generalized slowing.
After 14:20,
the recording was markedly degraded by electrode artifact.
Several episodes
of jerking were recorded on video. They did not have any EEG
correlate.
Several appeared to be isolated jerking of the right arm without
rapid
repetition.
SPIKE DETECTION PROGRAMS: Showed muscle and other artifact, but
there were no
clearly epileptiform features.
SEIZURE DETECTION PROGRAMS: Showed no electrographic seizures.
PUSHBUTTON ACTIVATIONS: There were none.
SLEEP: No normal waking or sleep patterns were evident.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This telemetry captured no pushbutton activations.
The
background was mildly slow indicating a mild to moderate
encephalopathy. There
were no prominent focal findings. There were no clearly
epileptiform features
or electrographic seizures. Isolated episodes of right arm jerks
were seen on
video without any EEG correlate.
CT Neck [**2155-9-24**]
FINDINGS: The previously identified infiltrative mass in the
postcricoid
space is smaller than the [**2155-9-1**] study measuring 2.5 x
4.4 cm. The
focal narrowing of the supraglottic airway has improved, now
measuring 1.3 x
2.2 cm, increased in caliber from 0.8 x 1.3 cm. The mass in the
left piriform
sinus has decreased in size, now measuring 1 x 1 cm, decreased
from 1.5 x 1.1
cm. The previously identified metastatic cervical lymph nodes
have decreased
in size. The previously measured conglomerate at level IIb on
the left now
measures 11 x 14 mm and the lymph node at level IIb on the right
now measures
13 x 19 mm. Mild fat stranding is present throughout the soft
tissues. No new
masses are identified.
There are calcifications of the bilateral carotid bifurcations,
right greater
than left. The visualized intracranial structures are
unremarkable. There
are bilateral pleural effusions and ground-glass opacities at
the lung apices
bilaterally.
There is no acute fracture or malalignment. Mild degenerative
changes of the
cervical spine.
IMPRESSION:
1. Decrease in size of the postcricoid mass, the left piriform
sinus mass and
the bilateral cervical lymphadenopathy.
2. Pleural effusions and patchy ground-glass opacities in the
visualized lung
apices. Recommend correlation with chest CT of same date
CT Chest [**2155-9-24**]
FINDINGS: The exam is severely limited by noise and streak
artifact from the
patient's left arm, immobile because of humeral neck fracture.
The thyroid
gland is unremarkable. Specifically, evaluation of the left
axilla, where
prominent nodes were seen on the recent ultrasound, is limited
by streak
artifact. There is no mediastinal or hilar adenopathy. The
heart and great
vessels are of normal size and caliber. Mild coronary artery
calcifications
are restricted to the circumflex distribution. A pericardial
effusion is
small. This exam is not tailored to evaluate subdiaphragmatic
structures.
Visualized portions of the upper abdomen are unremarkable.
Large bilateral pleural effusions, substantially enlarged since
[**2155-9-4**]
are responsible for severe atelectasis, collapse in the lower
lobes, non
confluent elsewhere. This and respiratory motion interfere with
evaluation of
the lung parenchyma, but there appears to be some edema in the
upper lobes.
Small regions of ground-glass opacity, for example in both upper
lobes (4:60,
74, 137) could be due to viral infection. Small lung nodules
are likely to be
missed. Impacted left humeral neck fracture is unchanged since
[**8-31**].
There is a prominent lower thoracic Schmorl's node. There are
no concerning
osteolytic or sclerotic bone lesions.
IMPRESSION:
1. Increasing large bilateral pleural effusions, mild
pulmonary.
2. Recent PET CT showed evidence of left lower lobe pneumonia.
On the
current exam left lower lobe consolidation is mostly
attributable to collapse
rather than infection.
3. A PET avid subcarinal lymph node is not well assessed on
this limited CT.
4. Scattered ground glass opacity is likely viral infection.
ECHO [**2155-9-25**]
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 60%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is a small to moderate sized pericardial effusion. There
is significant, accentuated respiratory variation in
mitral/tricuspid valve inflows, consistent with impaired
ventricular filling. There is also diastolic invagination of the
right ventricular free wall. Serial clinical and
echocardiographic evaluation is recommended.
Ultrasound Left Axilla [**2155-9-25**]
Exam is limited due to patient mobility due to recent fracture
of the left
humerus. In the left axilla there is a single prominent lymph
node measuring
5 mm in short axis with preserved fatty hilum, but somewhat
irregularly
thickened cortex which measures up to 3 mm. This lymph node has
a nonspecific
appearance. In the medial upper arm between the biceps and
triceps muscles is
a partially calcified ovoid focus measuring 2.3 x 1.3 x 1.5 cm
with multiple
punctate echogenic foci with an additional structure seen more
distally
measuring 5.1 x 1.4 x 1.8 cm with more heterogeneous
echotexture. These
structures insinuate between musculotendinous fibers. No other
suspicious
lymph nodes are seen in the region.
In comparison with prior CT chest, note is made that a
comminuted fracture of
the left proximal humerus is present, and calcified structures
were present in
the soft tissues of upper left arm possibly corresponding to the
above
described structures. Therefore, while calcified metastatic
nodes cannot be
excluded, post traumatic calcifications such as myositis
ossificans could
cause similar findings.
IMPRESSION:
Calcified nodules in the left upper arm, in the setting of
comminuted left
humeral fracture could represent post traumatic calcifications
such as
myositis ossificans although calcified metastases are not
excluded. CT or
radiograph may be helpful to distinguish.
Echo [**2155-9-26**]
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is a small to moderate sized
echolucent, circumferential pericardial effusion. There is
minimal diastolic invagination of the right ventricular free
wall without sustained right atrial or right ventricular
diastolic collapse. There is significant, accentuated
respiratory variation in the mitral valve inflow, consistent
with impaired ventricular filling.
IMPRESSION: Normal global biventricular systolic function. Small
to moderate sized circumferential pericardial effusion with
without frank echocardiographic tamponade.
Compared with the prior study (images reviewed) of [**2155-9-25**],
the findings appear similar.
CXR [**2155-9-27**]
FINDINGS: In comparison with the study of [**9-20**], the right
subclavian PICC
line extends to the lower portion of the SVC. There may be
increase in the
diffuse interstitial prominence seen on the right. On the left,
there is
increasing opacification with reduced area of aeration of the
lung. In the
absence of displacement of the mediastinal structures, this
suggests
combination of pleural effusion and volume loss in the
underlying lung. There
is suggestion of a cutoff of the left main stem bronchus.
Fracture of the left proximal humerus is again seen.
ECHO [**2155-9-29**]
The estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). There is no
ventricular septal defect. There is mild pulmonary artery
systolic hypertension. There is a small to moderate sized
pericardial effusion. There are no overt echocardiographic signs
of tamponade. No right ventricular diastolic collapse is seen.
Compared with the prior study (images reviewed) of [**2155-9-26**], no
change.
[**2155-10-6**] Radiology CHEST (PA & LAT)
Moderate right pneumothorax and small left pneumothorax are
stable. Left chest tube remains in place. Mild cardiomegaly and
tortuous aorta are unchanged. Bibasilar opacities , a
combination of large effusions and adjacent consolidations are
unchanged. These consolidations could be due to atelectasis but
superimposed infection cannot be excluded. Right PICC tube is in
the lower SVC.
[**2155-10-7**] Radiology CT NECK W/CONTRAST (EG:
IMPRESSION: 1. Infiltrative tumor in the post-cricoid region
involving the right hypopharynx and esophagus with focal airway
narrowing and effacement again noted. 2. Left piriform sinus
mass is less prominent on today's study. 3. Bilateral cervical
nodal metastases are less prominent on today's study. Thyroid
nodule unchanged from the prior examination. 4. Prominent right
palatine tonsil as well as edema and thickening of the soft
palate and base of the tongue with adjacent mass effect on the
oropharynx. 5. Bilateral pneumothoraces with right pleural
effusion.
[**2155-10-8**] 4:55 AM # [**Telephone/Fax (1) 112387**]
As compared to the previous radiograph, there is no change in
severity and dimension of the known bilateral apical
pneumothoraces. The effusion on the right has minimally
increased. The atelectasis on the left has also increased.
Endotracheal tube and the left-sided chest tube are in constant
position. No signs of tension are seen.
=========
MICRO:
[**2155-10-8**] SPUTUM:
GRAM STAIN (Final [**2155-10-8**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
CULTURES PENDING
[**2155-10-8**] Mini-BAL:
GRAM STAIN (Final [**2155-10-8**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
CULTURES PENDING.
Time Taken Not Noted Log-In Date/Time: [**2155-9-29**] 4:52 pm
TISSUE PERICARDIUM.
GRAM STAIN (Final [**2155-9-29**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2155-10-5**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**5-/3093**] [**2155-9-30**]
3:45PM.
PLEASE REFER TO [**Numeric Identifier 112388**] ([**2155-9-29**]) FOR VORICONAZOLE
RESULTS.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16437**]. SPARSE GROWTH.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16437**]. SPARSE GROWTH STRAIN 2.
ANAEROBIC CULTURE (Final [**2155-10-5**]): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final [**2155-9-30**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2155-9-30**]):
NO FUNGAL ELEMENTS SEEN.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
--------
Time Taken Not Noted Log-In Date/Time: [**2155-9-29**] 4:52 pm
FLUID,OTHER PERICARDIAL EFFUSION.
GRAM STAIN (Final [**2155-9-29**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2155-10-2**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2155-10-5**]): NO GROWTH.
ACID FAST SMEAR (Final [**2155-9-30**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2155-9-29**]):
Test cancelled by laboratory.
PATIENT CREDITED.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
CXR [**2155-10-9**]:
FINDINGS:
Patient is known with head and neck cancer with bilateral
pleural effusions
that are longstanding, moderate on the right side and small on
the left side
with biapical stable minimal pneumothorax. Left-sided chest
tube is in
unchanged position projecting in mid left hemithorax. Bibasilar
heterogeneous
opacities are unchanged since [**10-7**] and could represent
atelectasis
however a superimposed infection or aspiration cannot be
excluded.
Right-sided PICC line ends in lower SVC. Mediastinal and
cardiac contours are
normal.
CONCLUSION:
There is no significant change since prior exam.
1. Bilateral longstanding pleural effusion are unchanged with
minimal
pneumothorax.
2. Bibasilar opacities are unchanged since [**10-7**] and
could represent
atelectasis, however superimposed infection or aspiration cannot
be excluded.
Brief Hospital Course:
66 year old male with hypopharyngeal mass and alcohol abuse
presented with left proximal humerus fracture and femur fracture
who subsequently developed respiratory distress.
# Dysphagia / SOB / Repiratory distress: likely secondary to
extensive hypopharyngeal and piriformis mass. He had
significant upper airway sounds with ? stridor on presentation.
Pt was given 5 mg IV decadron. ENT wanted ICU monitoring in
setting of increase edema and airway compromise. ENT did not
think this was operable and wanted to initiate radiation to help
shrink the tumor and airway compromise. Biopsy was taken of mass
in OR and showed squamous cell carcinoma. Pt monitored overnight
in ICU and extubated the morning after left hip ORIF. ENT
consulted rad onc and heme onc. Speech and swallow was consulted
and through testing saw risk for aspiration. They recommendeded
pt remain NPO including meds. Could not place NG tube in OR.
They thought pt would likely need a peg, however patient
initially resisted PEG placement. PEG placed [**2155-9-12**], and tube
feeds were begun. Breathing improved following chemotherapy,
although patient continued to have intermittent coughing and
difficulty dealing with oral secretions. Pt developed acute
respiratory distress on [**2155-10-7**] early morning and was transferred
to the ICU for management of his airway. He spiked a fever to
102.9F on arrival. Exam was suggestive of upper airway
compromise, and there was concern for obstruction secondary to
tumor mass effect although acuity of decompensation would be
unusual for mass progression. Patient was intubated by ENT soon
after arrival to the ICU. In the peri-intubation period, he
became hypotensive likely related to the medications used for
intubation. He required 1 pressor but was quickly weaned off.
The cause of his acute decompensation remains unclear but per
ENT and repeat CT imaging after intubation, pt had significant
edema and swelling of his soft palate and tonsils but there was
no notable change in the size of his neck mass. Patient had an
easy cuff [**Last Name (LF) 3564**], [**First Name3 (LF) **] he was not given [**Last Name (un) **]/oids. In discussions
with ENT, delirium/altered mental status may have affected Pt's
ability to protect airway from oral secretions. Pt was covered
broadly with vancomycin and meropenem (he previously completed
an 8-day course of vanc/cefepime/clinda earlier in his
hospitalization). Patient has known bilateral pneumothoraces
after bilateral chest tube placement, stable from prior. Pt was
extubated without issue on [**2155-10-8**]. Pt had a sputum on [**10-8**] that
showed gram positive cocci in pairs and clusters but cultures
have not shown any growth to date. [**10-8**] mini-BAL did not show
any organisms on gram stain. Pt was transferred back to the
medical floor for continued management on [**10-9**]. While on medical
floor pt completed full course of IV Vanco/Meropenum and ID
followed pt. ID recommended follow up visit once pt discharged.
# Squamous cell carcinoma
Pathology ultimately revealed SCC of the head/neck. Hem/onc and
radiation oncology were consulted. Patient underwent PET CT
which revealed large FDG avid hypopharyngeal mass inseparable
from esophagus
and causing significant narrowing of the airway. Patient was
transferred to the oncology service for induction chemotherapy.
He received cycle 1 of TPF (docetaxel, cisplatin, 5-FU) on
[**2155-9-8**]. Patient had subsequent anemia requiring transfusions
[**9-14**] and [**9-17**], [**10-17**] thrombocytopenia (which resolved without
necesitating platelet transfusion), and neutropenia (treated
with neupogen earlier in admission). CT of neck and chest [**9-24**]
showed significant improvement in disease burden and degree of
airway narrowing. Pt restarted chemotherapy on [**2155-10-15**] and
started day 1 of 30 of XRT on [**2155-10-14**]. Pt received chemotherapy
on [**2155-10-22**] (day of discharge) and will continue chemo as
outpatient on [**2155-10-29**].
# Left proximal humerus fracture and femur fracture. Taken for
TRF. got 1 unit of blood in the OR and another unit in MICU post
op. Hct stabilized after that. ortho recommended 40mg lovenox
daily starting day after [**Doctor First Name **]. Lovenox will be continued after
discharge for DVT prophylaxis as pt has not been ambulating and
will defer to rehab facility to readdress whether pt needs it
once he is ambulating on own out of bed. Lovenox was briefly
held after chemo when platelet counts fell below 50, but was
then restarted. no range of motion restrictions, no weight
bearing restrictions, humerus non op management with sling for
comfort.
#. Pericardial effusion, pleural effusions: Patient appeared
chronically volume overloaded on exam after transfer to oncology
service, had no known history of cardiac disease. Diuretics
given on multiple occasions, volume status continued to be
challenging to manage. CT of the chest on [**9-24**] showed large
bilateral pleural effusions significantly increased from
previous imaging, as well as small pericardial effusion. Unclear
etiology of effusions, concern for malignant disease, however
thoracentesis done [**2155-9-27**] which removed 1.2L showed fluid that
appeared transudative. Echo done to evaluate for decreased EF,
wall motion abnormalities found pericardial effusion causing
significant, accentuated respiratory variation in
mitral/tricuspid valve inflows, consistent with impaired
ventricular filling. There was also diastolic invagination of
the right ventricular free wall. Pulsus was difficult to measure
due to right sided PICC line and LUE edema secondary to fracture
and lymphadenopathy, but was approximately 8. Serial echos were
stable. Cardiology was consulted, and judged that the effusion
was too small for safe percutaneous drainage. Cardiothoracic
surgery was consulted and decision was made for pericardial
window, which was performed [**2155-9-29**].
#, Hyponatremia: Sodium consistently in the low 130s, with some
readings in the 120s. Response to hydration variable. Response
to diuresis variable. Urine electrolytes showed FENa <1% but
urine Na >40 and concentrated urine. SIADH vs. hypervolemic
state (given peripheral edema, pleural effusions).
# Alcohol Withdrawal with history of seizures. Last drink day
prior to admission. maintained on CIWA scale plus Thiamine. MVI.
He did not score on CIWA throughout hospital course.
# Fever/leukocytosis: Patient developed fever and leukocytosis
[**2155-9-1**]. Patient started on ciprofloxacin for UTI, urine culture
grew Klebsiella sp. CXR later became c/w PNA and given history
of aspiration, he was started on unasyn [**2155-9-2**]. Unasyn was
ultimately discontinued and he was continued on cipro with
continued improvement. Upon to transfer to oncology service and
given continued opacities suggestive of aspiration on CXR,
anitbiotics were switched to levofloxacin and clindamycin
[**2155-9-7**], which were continued for a 5 day course. The patient
developed another fever on [**2155-9-20**], and was broadly covered with
vanc, cefepime and clindamycin given risk for skin infections
due to pressure ulcers as well as aspiration risk. Cultures
negative, antibiotics discontinued [**2155-9-26**]. Pt's pleural
effusion and pericardial tissue but not pericardial effusion
cultures from [**2155-9-29**] grew [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16437**]. Pt was
started on voriconazole on [**10-4**] but this was switched to
micafungin on [**10-7**] due to concerns about possible QT
prolongation. Voriconazole sensitivities are still pending.
There were concerns by ID service that 2 other patients recently
had [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16437**] infections after having a pericardial
window procedure. ID followed pt and initially started
Micafungin which was later switched to Fluconazole. Pt to remain
on Fluconazole for several more weeks until his appointment with
ID on [**2155-11-26**]. Pt's PICC line was somewhat erythematous on [**10-7**]
and was removed. Tip culture has remained negative to date. Pt
had a sputum on [**10-8**] that showed gram positive cocci in pairs
and clusters but cultures have not shown any growth to date.
[**10-8**] mini-BAL did not show any organisms on gram stain.
# Myoclonic jerks/altered mental status: patient intermittently
confused during hospitalization. Developed myoclonic jerks of
right side [**9-21**], concerning for seizures given altered mental
status. EEG ordered, showed generalized slowing consistent with
encephalopathy, no seizure activity. Patient's symptoms started
around the same time antibiotics restarted, so possibly a drug
effect. Also with chronic hyponatremia, metabolic alkalosis. No
asterixis on exam. Not uremic.
# Hypertensive urgency: episode of HR 30's BP 220/110 after
peripheral was flushed with Neo in it, Levo stopped, and BP
trended down to 180's systolic and HR stable in the 50's.
# Hypothyroidism
Patient carries diagnosis of hypothyroidism for which he has not
been treated. TSH was WNL. Thyroid hormone supplementation was
not initiated initially. TSH found to be elevated on repeat
testing in course of workup for hyponatremia and thyroid hormone
supplementation was begun.
TRANSITIONAL ISSUES:
======================
- Radiation: pt to continue XRT for a total of 30 days. Day of
discharge was day 8 of therapy therefore pt has 22 more sessions
he will receive as outpatient.
- Chemo: pt to contine chemotherapy, Paclitaxel and Carboplatin.
Days 1, 8 already given on [**10-15**] and [**10-22**]. Pt to receive third
dose on day 15, [**10-29**].
- Pt to follow up with ID as outpt on WEDNESDAY [**2155-11-26**] at
10:00 AM
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Bisacodyl 10 mg PR HS:PRN constipation
3. Docusate Sodium (Liquid) 100 mg PO BID constipation\
4. Fluconazole 200 mg IV Q24H
5. Guaifenesin 10 mL PO Q6H:PRN Cough or Increased secretions
6. Labetalol 100 mg PO BID
hold for SBP <95 or HR<55
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Lidocaine 5% Patch 1 PTCH TD DAILY
apply to left arm
9. Ondansetron 4 mg IV Q8H:PRN nausea
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. senna *NF* 8.8 mg/5 mL Oral [**Hospital1 **]:PRN constipation Reason for
Ordering: Pt has cancer of larynx and unable to swallow pills
12. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
hold for oversedation
13. Outpatient Lab Work
Daily CBC, CHEM7, ANC
14. Morphine Sulfate IR 15 mg PO/NG Q4H:PRN pain
15. Enoxaparin Sodium 40 mg SC DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Hospital1 8**]
Discharge Diagnosis:
Hypopharyngeal Squamous Cell Carcinoma
Pericardial Effusion
Candidiasis
Pneumonia
Hip fracture
Shoulder fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname 4427**],
It has been a pleasure taking care of you here at [**Hospital1 18**]. You
were initially admitted with a broken hip and shoulder. Because
of some respiratory symptoms you were having you had several
tests done where it was found that you have cancer of the neck
and head. You were admitted to the oncology service where your
hospital course was complicated by infections, respiratory
distress, and fluid around your heart. You were transferred to
the ICU to stablize you several times. You received treatment
for pneumonia and you required mechanical ventilation. You
initiated chemotherapy while here and are currently receiving
chemo and radiation to shrink the tumor in your neck. You will
continue this treatment as an outpatient. Also it was found that
yeast was growing in your blood for which you will be continued
on Fluconazole until your follow up appointment with infectious
disease on [**2155-11-26**].
Followup Instructions:
Please keep the following appointments:
Daily Radiation Therapy
Every weekday Monday- Friday at 3 pm until [**2155-11-25**]
[**Hospital1 18**] [**Hospital Ward Name 516**]
[**Hospital Ward Name 12573**] Basement
[**Location (un) **]
[**Location (un) 86**], MA
phone: [**Telephone/Fax (1) 9710**]
Chemotherapy Appointment
DEPARTMENT: Oncology
When: [**2155-10-29**]- please call for the appointment time.
Phone: ([**Telephone/Fax (1) 14703**]
[**Hospital Ward Name 23**] 9
[**Hospital Ward Name 516**]
Department: OTOLARYNGOLOGY-AUDIOLOGY
When: TUESDAY [**2155-11-11**] at 2:00 PM
With: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 895**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2155-11-20**] at 8:40 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2155-11-20**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**2155-11-26**] 10:00a ID,[**Last Name (un) 23870**] [**Doctor Last Name **]
LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT
PHONE: ([**Telephone/Fax (1) 4170**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Name: [**Last Name (LF) 89697**],[**First Name3 (LF) **] L.
Location: [**Hospital3 **] FAMILY MEDICINE
Address: 5 INDUSTRIAL DR [**Last Name (STitle) **], [**Location (un) **],[**Numeric Identifier 88844**]
Phone: [**Telephone/Fax (1) 89698**]
[**Name6 (MD) **] [**Name8 (MD) 10341**] MD [**MD Number(2) 14690**]
ICD9 Codes: 5070, 2851, 2761, 2449, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8624
} | Medical Text: Admission Date: [**2203-6-29**] Discharge Date: [**2203-7-8**]
Date of Birth: [**2133-2-23**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Rectal Cancer
Major Surgical or Invasive Procedure:
s/p Robotic to Open Proctosigmoidectomy with Loop Ileosotomy
History of Present Illness:
70 year old male patient diagnosed with rectal cancer and
followed in outpatient colorectal surgery clinic with PMH
significant for Type 2 Diabetes, chronic pain, myocardial
infarction, hyperlipidemia, carotid stenosis, and hypertension
presented to [**Hospital1 18**] for elective surgical intervention for rectal
cancer with Dr. [**Last Name (STitle) 1120**].
Past Medical History:
DMII
Chronic Pain
Myocardial Infarction
Hyperlipidemia
Carotid Stenosis
Hypertension
Rectal Cancer
Social History:
Married with Son, supportive family.
Physical Exam:
General:
VS:
Cardiac:
Lungs:
Abd:
Lower Extremities:
Pertinent Results:
[**2203-7-8**] 06:30AM BLOOD WBC-11.7* RBC-3.28* Hgb-8.7* Hct-27.9*
MCV-85 MCH-26.5* MCHC-31.2 RDW-16.6* Plt Ct-444*
[**2203-7-7**] 12:05PM BLOOD WBC-11.0 RBC-3.16* Hgb-8.5* Hct-27.0*
MCV-85 MCH-26.8* MCHC-31.4 RDW-15.4 Plt Ct-396
[**2203-7-7**] 04:08AM BLOOD WBC-11.1* RBC-3.25* Hgb-8.6* Hct-28.2*
MCV-87 MCH-26.5* MCHC-30.6* RDW-15.4 Plt Ct-429
[**2203-7-6**] 05:52AM BLOOD WBC-11.9* RBC-3.53* Hgb-9.5* Hct-29.6*
MCV-84 MCH-27.0 MCHC-32.1 RDW-15.9* Plt Ct-399
[**2203-7-5**] 05:09AM BLOOD WBC-9.8 RBC-3.37* Hgb-9.3* Hct-29.2*
MCV-87 MCH-27.5 MCHC-31.8 RDW-15.8* Plt Ct-304
[**2203-7-4**] 02:00AM BLOOD WBC-6.6 RBC-3.32* Hgb-8.9* Hct-28.5*
MCV-86 MCH-27.0 MCHC-31.4 RDW-15.4 Plt Ct-265
[**2203-7-3**] 04:05AM BLOOD WBC-5.1 RBC-3.33* Hgb-9.2* Hct-28.6*
MCV-86 MCH-27.7 MCHC-32.3 RDW-15.5 Plt Ct-248
[**2203-7-2**] 02:56AM BLOOD WBC-3.5* RBC-3.35* Hgb-9.1* Hct-28.0*
MCV-84 MCH-27.2 MCHC-32.6 RDW-16.0* Plt Ct-193
[**2203-7-1**] 06:28PM BLOOD WBC-4.0# RBC-3.42* Hgb-9.3* Hct-29.0*
MCV-85 MCH-27.3 MCHC-32.2 RDW-15.8* Plt Ct-227
[**2203-7-1**] 01:12AM BLOOD WBC-13.0* RBC-3.64* Hgb-9.7* Hct-30.1*
MCV-83 MCH-26.8* MCHC-32.3 RDW-16.1* Plt Ct-181
[**2203-6-30**] 02:28AM BLOOD WBC-9.6 RBC-4.09* Hgb-11.3* Hct-34.0*
MCV-83 MCH-27.5 MCHC-33.1 RDW-16.1* Plt Ct-196
[**2203-6-29**] 05:24PM BLOOD WBC-6.7 RBC-3.93* Hgb-10.7* Hct-32.8*
MCV-83 MCH-27.2# MCHC-32.6 RDW-16.0* Plt Ct-188
[**2203-7-8**] 06:30AM BLOOD Plt Ct-444*
[**2203-7-7**] 12:05PM BLOOD Plt Ct-396
[**2203-7-7**] 04:08AM BLOOD Plt Ct-429
[**2203-7-6**] 05:52AM BLOOD Plt Ct-399
[**2203-7-2**] 02:56AM BLOOD PT-13.3* PTT-30.8 INR(PT)-1.2*
[**2203-7-1**] 01:12AM BLOOD PT-17.2* PTT-32.9 INR(PT)-1.6*
[**2203-6-29**] 05:20PM BLOOD PT-15.3* PTT-28.3 INR(PT)-1.4*
[**2203-7-8**] 06:30AM BLOOD Glucose-123* UreaN-10 Creat-0.9 Na-140
K-3.6 Cl-104 HCO3-27 AnGap-13
[**2203-7-7**] 04:08AM BLOOD Glucose-125* UreaN-15 Creat-1.2 Na-142
K-4.0 Cl-102 HCO3-28 AnGap-16
[**2203-7-6**] 05:52AM BLOOD Glucose-162* UreaN-10 Creat-0.8 Na-141
K-4.1 Cl-105 HCO3-27 AnGap-13
[**2203-7-5**] 05:09AM BLOOD Glucose-139* UreaN-9 Creat-0.8 Na-138
K-4.3 Cl-101 HCO3-27 AnGap-14
[**2203-7-4**] 02:00AM BLOOD Glucose-163* UreaN-10 Creat-0.7 Na-136
K-4.0 Cl-101 HCO3-29 AnGap-10
[**2203-7-3**] 04:15PM BLOOD Na-138 K-3.9 Cl-101
[**2203-7-3**] 04:05AM BLOOD Glucose-140* UreaN-11 Creat-0.7 Na-137
K-4.0 Cl-100 HCO3-27 AnGap-14
[**2203-7-2**] 02:00PM BLOOD Glucose-160* UreaN-15 Creat-0.7 Na-137
K-4.0 Cl-101 HCO3-27 AnGap-13
[**2203-7-2**] 02:56AM BLOOD Glucose-149* UreaN-19 Creat-0.8 Na-137
K-4.3 Cl-100 HCO3-25 AnGap-16
[**2203-7-1**] 06:28PM BLOOD Glucose-172* UreaN-20 Creat-0.8 Na-134
K-4.3 Cl-100 HCO3-22 AnGap-16
[**2203-7-1**] 01:12AM BLOOD Glucose-166* UreaN-17 Creat-0.9 Na-135
K-4.7 Cl-100 HCO3-25 AnGap-15
[**2203-6-29**] 05:24PM BLOOD Glucose-204* UreaN-11 Creat-0.7 Na-141
K-4.3 Cl-107 HCO3-26 AnGap-12
[**2203-7-7**] 04:08AM BLOOD ALT-12 AST-21 AlkPhos-53 TotBili-0.4
[**2203-6-29**] 05:24PM BLOOD ALT-27 AST-45* AlkPhos-28* TotBili-0.8
[**2203-7-2**] 02:00PM BLOOD CK-MB-4 cTropnT-0.35*
[**2203-7-2**] 02:56AM BLOOD CK-MB-6 cTropnT-0.27*
[**2203-7-1**] 06:28PM BLOOD CK-MB-9 cTropnT-0.26*
[**2203-7-8**] 06:30AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.6
[**2203-7-7**] 04:08AM BLOOD Albumin-3.0* Calcium-8.3* Phos-4.4 Mg-2.5
Iron-18* Cholest-145
[**2203-7-6**] 05:52AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.2
[**2203-7-5**] 05:09AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.1
[**2203-7-4**] 02:00AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.1
[**2203-7-3**] 04:15PM BLOOD Calcium-8.7 Phos-3.3 Mg-2.1
[**2203-7-3**] 04:05AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.1
[**2203-7-2**] 02:00PM BLOOD Calcium-8.7 Phos-3.0 Mg-2.4
[**2203-7-2**] 02:56AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.3
[**2203-7-1**] 06:28PM BLOOD Calcium-8.8 Phos-2.5* Mg-2.3
[**2203-7-1**] 01:12AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.2
[**2203-6-30**] 02:28AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.2
[**2203-6-29**] 05:24PM BLOOD Albumin-3.4* Calcium-8.5 Phos-4.1 Mg-1.8
CT ABD & PELVIS WITH CONTRAST Study Date of [**2203-7-6**] 2:49 PM
IMPRESSION:
1. Status post proctosigmoidectomy with dilated small bowel
loops and
decompressed distal loops. While no definite transition point is
seen there is a relative caliber change with angulation of the
bowel in the right hemipelvis. These findings could reflect a
small bowel obstruction, though post-operative ileus is also
possible. Correlation with clinical circumstance and ostomy
output is recommended.
2. Small volume free intra-abdominal and pelvic fluid could
reflect recent surgery.
3. Bilateral mild hydronephrosis with delayed contrast excretion
and
distended bladder.
4. Right greater than left small pleural effusions with right
basal
consolidation could be atelectasis or infection.
5. Ectasia of the left internal iliac artery to 1.8 cm.
6. Prominent paraesophageal node measuring 12mm.
Brief Hospital Course:
The patient presented to [**Hospital1 18**] for elective surgical treatment
of rectal cancer. The planned procedure was laparoscopic
however, the patient required open surgery because of bleeding
the patient received 4 units of packed red blood cells and the
patient's hematocrit stabilized postoperatively and can be seen
in the results section of this report. The patient remained on
the [**Hospital Ward Name **] of [**Hospital1 18**] as pre-operatively, his cardiac work up
revealed he was at risk but cleared for surgery. He was seen by
cardiology preoperatively. The patient recovered in the ICU
intubated and on [**2203-6-30**] extubated was extubated, he was stable
on room air. The patient's pain was managed post-operatively
with PCA however this was discontinued related to confusion. The
patient's abdomen was noted to be distended. On [**2203-7-1**] the
patient had a temperature to 103.2 overnight, he was noted to
have mild EKG changes and increase in troponin and cardiology
was consulted. [**2203-7-2**] troponin to 0.35, ultimately the patient
was started on labetalol IV and metoprolol which stabilized the
patient's tachycardia. The patient was transitioned to the floor
on metoprolol. While in the intensive care unit the patient
continued to have some delirium. The patient high ileostomy
output and was repleated with cc/cc repletion. On [**2203-7-3**]
spiked to 102.3, cultured and the patient started clonidine
patch for agitation. Behavior improving and [**2203-7-4**] he was
transferred to the floor. Aspirin and Plavix was restarted and
he continued therapy with metoprolol. The patient was started on
octreotide and Imodium. On [**2203-7-5**] ostomy output decreased and
the octreotide and Imodium was held. Intravenous repletions were
discontinued. On [**2203-7-6**] the patient was noted to have
increased abdominal pain and abdominal distension A CT scan of
the abdomen and pelvis was done which showed likely ileus and
small pleural effusion. The patient had been started on
vancomycin and Zosyn IV for empiric cover and vancomycin trough
values were monitored appropriately and were in appropriate
range. A nasogastric tube was placed to decompress the stomach
however, overnight the patient removed the NG tube. The
ileostomy began to function in appropriate amounts and the ileus
was believed to be resolving and the tube was not replaced.
Because of the patient's difficult behavior at times and
possible sun downing geriatric medicine was consulted for
recommendations and attributed much of behavior issues to
medications and difficult personality. The patient started a
regular diet. The patient was noted to have urinary incontinence
however a urinalysis was sent and was negative and he did not
have post void residuals. The patient began to use the urinal
prior to discharge. [**2203-7-8**] the patient's ileostomy output is
stable, the patient has worked with physical therapy, he has
been trasitioned to antibiotics by mouth for 7 days. The patient
was followed closely by the wound/ostomy nursing team however,
has not fully engaged with taking care of the ileostomy and will
require continued physical therapy. The patient was stable for
discharge. His staples will be removed in outpatient surgical
clinic. He should follow-up with cardiology for continued
cardiac care. Of note, the patient's stoma is known to have
yellow discoloration, slightly necrotic appearing from 3 o'clock
to 9 o'clock and the surgical attending is aware of this. Please
see the wound/ostomy notes for details. Please see the
cardiology note included in this discharge summary.
Medications on Admission:
gabapentin 400 qid
glipizide 10mg [**Hospital1 **]
lisinopril 40mg qd
metformin 1250mg qd
percocet prn
Crestor 10mg qd
viagra prn
Iron 325mg qd
Discharge Medications:
1. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain: hold for increased sedation or RR<12.
6. metformin 500 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
7. glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every 6-8 hours
as needed for pain for 5 days: Do not take more than 4000mg of
tylenol in 24 hours.
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain: do not take more than 4000mg
of tylenol daily.
10. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 7 days: Please complete 7
Days of therapy. First day of therapy [**2203-7-8**].
11. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**] - [**Location (un) 8117**]
Discharge Diagnosis:
Rectal Cancer
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 after a laparoscopic to open
proctosigmoidectomy with loop ileostomy for surgical management
of rectal cancer. You have recovered from this procedure well
and you are now ready to return home. Samples from your colon
were taken and this tissue has been sent to the pathology
department for analysis. You will receive these pathology
results at your follow-up appointment. If there is an urgent
need for the surgeon to contact you [**Name2 (NI) 19605**] these results
they will contact you before this time. You have tolerated a
regular diet, passing gas and your pain is controlled with pain
medications by mouth. You may be dicsharged to a rehabilitaion
facility to finish your recovery.
Please monitor your bowel function closely. If you have any of
the following symptoms please call the office for advice or go
to the emergency room if severe: increasing abdominal
distension, increasing abdominal pain, nausea, vomiting,
inability to tolerate food or liquids, prolonges loose stool, or
constipation. You have a new ileostomy. The most common
complication from a new ileostomy placement is dehydration. The
output from the stoma is stool from the small intestine and the
water content is very high. The stool is no longer passing
through the large intestine which is where the water from the
stool is reabsorbed into the body and the stool becomes formed.
You must measure your ileostomy output for the next few weeks.
The output from the stoma should not be more than 1200cc or less
than 500cc. If you find that your output has become too much or
too little, please call the office for advice. The office nurse
or nurse [**Name2 (NI) 3639**] can recommend medications to increase or
slow the ileostomy output. Keep yourself well hydrated, if you
notice your ileostomy output increasing, take in more
electrolyte drink such as Gatorade. Please monitor yourself for
signs and symptoms of dehydration including: dizziness
(especially upon standing), weakness, dry mouth, headache, or
fatigue. If you notice these symptoms please call the office or
return to the emergency room for evaluation if these symptoms
are severe. You may eat a regular diet with your new ileostomy.
However it is a good idea to avoid fatty or spicy foods and
follow diet suggestions made to you by the ostomy nurses. Please
continue to take the immodium/metamucil wafers/tincture of opium
to control the output. As your condition improves you may not
need all of this medication, our goal is that you have
500-1200cc from the ostomy every 24 hours. Please call the
office to assist you in adjusting your medications. Please keep
your Ins and Out's on the provided graft and bring this to any
follow-up appointment.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. You have a
bridge in place and this will be removed in clinic by the
wound/ostomy nurse. Monitor the skin around the stoma for
bulging or signs of infection listed above. Please care for the
ostomy as you have been instructed by the wound/ostomy nurses.
You will be able to make an appointment with the ostomy nurse in
the clinic 7 days after surgery. You will have a visiting nurse
at home for the next few weeks helping to monitor your ostomy
until you are comfortable caring for it on your own.
You have a long vertical incision on your abdomen that is closed
with staples. This incision can be left open to air or covered
with a dry sterile gauze dressing if the staples become
irritated from clothing. The staples will stay in place until
your first post-operative visit at which time they can be
removed in the clinic, most likely by the office nurse. Please
monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may
gradually increase your activity as tolerated but clear heavy
excercise at your follow up appointment.
You will be prescribed a small amount of the pain medication
oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
Call the colorectal surgery office to make an appointment for
follow-up two weeks after surgery with the colorectal surgery
outpatient nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) 1123**] [**Last Name (NamePattern1) 1124**], NP. At that
appointment you will be set up with an appointment for your
second post-operative check.
Call [**Telephone/Fax (1) 160**] to make this appointment
Please make an appointment with your cardiologist 2-3 weeks
after discharge.
Completed by:[**2203-7-8**]
ICD9 Codes: 2724, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8625
} | Medical Text: Admission Date: [**2135-4-11**] Discharge Date: [**2135-4-15**]
Service: Cardiothoracic Surgery Service
HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old
female who was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] with known aortic
stenosis. She had previously had an outpatient cardiac
catheterization in [**2134-7-22**]. In [**2134-6-21**], she had
left arm heaviness and numbness along her chest and back.
She was admitted to the [**Hospital1 69**]
where her cardiac enzymes were negative and her thallium test
was negative for ischemia, but an echocardiogram showed an
ejection fraction of 55% with severe aortic stenosis.
She was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] for aortic valve
replacement.
PAST MEDICAL HISTORY: Question of peptic ulcer
disease/gastroesophageal reflux disease
PAST SURGICAL HISTORY: Appendectomy.
ALLERGIES: She has no known drug allergies.
MEDICATIONS ON ADMISSION: Her only medication was aspirin 81
mg p.o. once per day.
PERTINENT LABORATORY VALUES ON PRESENTATION: Preoperative
laboratory work was as follows; white blood cell count was
4.5 and hematocrit was 37.6. Prothrombin time was 12.1,
partial thromboplastin time was 23.7, and INR was 1.
Platelet count was 215,000. The patient was in a sinus
rhythm at a rate of 86.
PERTINENT RADIOLOGY/IMAGING: Carotid studies in [**2134-6-21**] showed minimal plaque bilaterally with less than 40%
carotid stenosis.
A preoperative electrocardiogram revealed a sinus rhythm with
no atrial ectopy present at this time, but could not rule out
old inferior myocardial infarction.
HOSPITAL COURSE: The patient was referred to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1537**]. On [**2135-4-11**], the patient underwent limited
access aortic valve replacement with a 19-mm pericardial
[**Last Name (un) 3843**]-[**Doctor Last Name **] tissue valve.
She was transferred to the Cardiothoracic Intensive Care Unit
in stable condition on a Neo-Synephrine drip at 0.5 mcg/kg
per minute and titrated propofol drip.
On [**Doctor Last Name **] day one, the patient had been extubated.
The patient was saturating 96% on a face mask. She received
her perioperative antibiotics. Blood pressure was 122/53
with a central venous pressure of 7. She was on a
nitroglycerin drip at 1. Her white blood cell count was 11
and hematocrit was 31. Sodium was 139, potassium was 3.9,
chloride was 107, bicarbonate was 23, blood urea nitrogen was
11, creatinine was 0.7, and blood glucose was 109. The
patient was also on an insulin drip at 2. Her lungs were
clear. There were bowel sounds. The examination was benign.
The patient began diuresis and had been extubated without any
difficulty. She was seen by Case Management.
On [**Doctor Last Name **] day two, the patient was alert and awake
with a heart rate in sinus rhythm at 108. Her blood pressure
was 137/53 with good urine output. She was started on
Lopressor and Lasix diuresis. Blood urea nitrogen was 21.
Creatinine was 0.7. Potassium was 3.6. Temperature maximum
was 99.2. Her lungs were clear. Her sternum was stable.
She began her beta blockade. Her H2 blockers were stopped.
Of note, her platelet count continued to drop to 92,000 on
[**Doctor Last Name **] day one and then 62,000 on [**Doctor Last Name **] day
two. Her platelet count was rechecked. A heparin-induced
thrombocytopenia panel was sent, and all heparin was stopped.
The central venous line was also discontinued. The patient
was responsive and doing very well and was transferred out to
[**Hospital Ward Name 121**] Two on [**4-13**] and was also seen by Physical Therapy.
Her sternal incision was dry. Pacing wires remained in
place. She was monitored on the floor, and ambulation was
begun.
She was switched over to oral Percocet and encouraged to
ambulate with the physical therapist and the nurse [**First Name (Titles) **]
[**Last Name (Titles) **] day three. She was in a sinus rhythm with a
heart rate of 90 to 100 with a blood pressure of 98/45. She
was saturating 94% on room air. Her blood sugar was 132.
She was making good urine output. Her platelet count [**Known firstname **]
slightly from 62,000 to 67,000. White blood cell count was
11, and hematocrit was 31. She began her beta blockade as
well as Lasix diuresis. She was continued on Protonix. She
was alert and oriented. She continued to work with Physical
Therapy and was seen again by Case Management to work for a
plan for discharge.
On [**Known firstname **] day four, she had a temperature maximum of
98.8. She was in a sinus rhythm at 85. Her blood pressure
was 103/60. Her blood sugar was in the range of 97 to 155.
Her white blood cell count dropped to 7.1. Her hematocrit
was 26.4. Platelet count was holding at 67,000. Blood urea
nitrogen was 23, and creatinine was 0.7. Her heart was
regular in rate and rhythm. Her lungs were clear. Her
incision was clean, dry, and intact. She remained on an
insulin sliding-scale with plans to discharge her to home
with [**Hospital6 407**] services. She was transfused
one unit of packed red blood cells for her hematocrit and was
receiving oral pain medications. She was walking
independently on the floor. Discharge planning included
having her see her doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 6691**] for her wound check
and to follow up there also.
DISCHARGE STATUS: The patient was discharged to home with
her daughter on [**2135-4-15**].
DISCHARGE DIAGNOSES:
1. Status post limited access aortic valve replacement with
pericardial tissue valve.
2. Gastroesophageal reflux disease.
3. Question peptic ulcer disease.
4. Decreased vision in the left eye.
MEDICATIONS ON DISCHARGE: (Discharge medications were as
follows)
1. Aspirin 325 mg p.o. once per day.
2. Lasix 20 mg p.o. twice per day (times one week).
3. Potassium chloride 10 mEq two tablets p.o. twice per day
(for one week).
4. Colace 100 mg p.o. twice per day (for 30 days).
5. Tylenol 325 mg p.o. q.4h. as needed.
6. Percocet 5/325 one to two tablets p.o. q.4h. as needed
(for pain).
7. Metoprolol 50 mg p.o. twice per day (times 30 days).
8. Protonix 40 mg p.o. once per day.
9. Magnesium hydroxide 40-mg oral suspension 30 mL p.o.
q.6h. as needed for one month (for constipation).
DISCHARGE DISPOSITION: The patient was discharged to home.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was given instructions to follow up with her
primary care physician in [**Name9 (PRE) 6691**].
2. The patient was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] in
four weeks in [**Location (un) 86**] for her [**Location (un) **] visit.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2135-6-15**] 14:14
T: [**2135-6-22**] 08:08
JOB#: [**Job Number 44132**]
ICD9 Codes: 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8626
} | Medical Text: Admission Date: [**2156-8-3**] Discharge Date: [**2156-8-13**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
colonoscopy
Transfusion 4 Units blood
History of Present Illness:
[**Age over 90 **]yo male w/h/o L-sided diverticulosis ('[**43**]) presents with 1
episode of BRBPR during a bowel movement this evening. Pt denies
abdominal pain, nausea, straining, dizziness, rectal pain,
melena, coffee ground emesis or hemoptysis. He reports feeling
well and denies recent epiosodes of bleeding. His vitals in ED
were T 96.9, HR 56, BP 186/66, RR 16, and 96% RA. Hct = 30
(baseline 32-38). No recent changes in stool consistency; last
colonoscopy in '[**43**].
.
While in the ED the patient had a stool containing a significant
amount of red blood. Hct taken 3 hours after episode was 29.
Past Medical History:
1. Hypertension.
2. ?Congestive failure.
3. Gout.
4. Rectal bleeding from diverticulosis
5. anemia not consistent with iron deficiency on w/u outpatient,
more likely ACD
6. L inguinal hernia repair ([**2146**])
Social History:
Widower ~7 yr. No children. Lives alone at [**Hospital3 **] at
[**Location (un) **] Place??????provides meals and cleaning although the patient
works out regularly and ambulates at baseline without any
assistance. Retired lawyer and worked for costumer service of
the Postal Service. Minimal smoking hx (sniffed but never
smoked). ~1 glass of wine a day. Works out and lifts weights
regularly.
Family History:
noncontributory
Physical Exam:
PE: T 96.9 P 56 BP 186/66 RR 16 O2 96 on RA
Gen - A+Ox3 NAD
HEENT - EOMI, pale conjuntivae, no JVD
Cor - RRR sys murmur
Chest - CTA B
Abd - s/nt/nd +BS
Rectal (per ED) blood in rectal vault, no hemorrhoids
Ext - w/wp, no c/c/e, 2+ DP
Pertinent Results:
EKG - Sinus brady flat T in V2, LAD, nl intervals
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man with delirium, doing infectious work-up.
REASON FOR THIS EXAMINATION:
r/o infiltrate.
AP CHEST, [**2156-8-7**], 08:27 HOURS
HISTORY: [**Age over 90 **]-year-old man with delirium. Rule out sepsis.
IMPRESSION: AP chest compared to [**2156-5-29**]:
Heart is mildly enlarged and the pulmonary vasculature engorged.
There is no pneumonia or pleural effusion. Thoracic aorta is
generally tortuous and calcified, but not focally dilated.
HISTORY: Acute GI bleed.
REPORT: Following intravenous injection of autologous red blood
cells labelled
Tc-[**Age over 90 **]m, blood flow and delayed images of the abdomen for 60
minutes were
obtained.
Blood flow images show normal, expected uptake of tracer. No
areas of
extravasation are seen.
Delayed blood pool images again show no evidence of
extravasation of tracer to
indicate a location of gastrointestinal hemorrhage.
IMPRESSION: No extravasation of tracer identified to indicate
location of
gastrointestinal hemorrhage.
/nkg
Reason: eval for bleed
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man with HTN, admitted with gi bleed, now suddenly
confused with blown right pupil
REASON FOR THIS EXAMINATION:
eval for bleed
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Hypertension, now confused with dilated right pupil.
TECHNIQUE: Noncontrast head CT. This study is limited by motion.
FINDINGS: Comparison with [**2156-5-29**]. No hydrocephalus, shift
of normally midline structures, intra- or extra-axial
hemorrhage, or acute major vascular territorial infarct is
identified. There is prominence of the sulci and ventricles;
however, this is not significantly changed since the last
examination. Minor mucosal maxillary thickening is again noted
in the right maxillary sinus. No fractures are identified.
IMPRESSION: Study limited by motion, however, no acute
intracranial pathology identified. No significant interval
change since [**2156-5-29**].
Brief Hospital Course:
A/p: [**Age over 90 **] yo M
1. GI Bleed: patient with mult episodes of BRBPR. Likely from
lower source given that Hct slowly going down. Has remained
hemodynamically stable in ED. No reoccurrence of GI bleed in
past 3 days. Location of bleed is yet to be determined. Bleeding
test was negative. Continue to monitor for any changes.
Colonoscopy is necessary to determine location, as per GI. HCT
has been running in 27-29 for the past days. It has been stable
but it low. Lab results today show that crit has decreased to
27.6. A unit of blood is necessary as the crit has dropped.
Discussed patient with GI. GI is following patient. Feel that he
is stable at the moment. [**Name2 (NI) **] plan from them. ON [**8-9**], crit had
increased to over 30. Still awaiting decision if f/u colonoscopy
is warranted given pt HX with the prep. Pt was given senna and
had 200 cc melena over night on [**8-12**]. Pt had not had bowel
movement since GI prep; this could just be residual blood from
initial GIB/. Repeat colonoscopy was decided against due to pts
present state
.
2. Delirium: Pt has remained in a confused state for the past 4
days. He has been placed in restraints due to threatening
behavior and trying to pull at tubes. MS change has been
improving. He remains confused. He is responsive to voice and
tactile stimulation. Pt is mumbling but beginning to make more
sense. Concern remains what MS change is due to. Infectious work
up is in process. Began pt on olanzapine as per geriatric
consult. Pt had a run of SVT over the night on [**8-7**] but was
easily arousable. NO concern felt. ON [**8-8**], pt was conversing.
He appeared to be returning to his original state. Foley was d/c
and ucx and BCX taken. ucx was negative. UA obtained showed some
bacteria and WBC. That evening, Foley replaced due to lack of
output. Pt became combative and was given olanzapine. On rounds
on [**8-9**], pt unarousable. Tried to arouse him with multiple
stimuli with little response. Suction was used to remove sputum
and fluid accumulating in his throat and mouth. Pt was
responsive to this measure. His eyes would bunch up and he tried
to block the suction. His blood pressure decreased to 90/60.
But then returned between 118-120 and then increased to 130/85.
CXR showed Left retrocardiac opacity. Pt afternoon, pt
responsive and more alert. D/c haldol and olanzapine. If
combative, pt will be placed in restraints. Trying to have
patient come off the past medications. On [**8-9**], began Levaquin
due to CXR showing possible aspiration pneumonia and a possible
UTI as shown by UA. These are both possible causes for patients
current state. Marked improvement noted on [**8-10**]. Pt became more
responsive and was able to tell the story of how he ended up in
the hospital. SPS consulted again for evaluation. Vanco was d/c
as blood CX on [**8-3**] showed that bacteria was susceptible to
oxacillin.
-Bacteremia seems to be the cause of the delirium
Pt given trazodone and lodaxaprine on the night of [**8-10**]. The
following morning, pt arousable but became agitated. Mitt
restraints initiated to stop patient from pulling foley. Pt
continues to wax and wane in his knowledge of place and time.
The AM of [**8-12**], pt was conversive and alert to his location. He
then proceeded to begin pulling on his IV and trying to removed
bandages. Pt continues to have bouts of waxing and [**Doctor Last Name 688**]. He
alert to people but confused over who people are and various
events that are occurring.
.
3. HTN: Hydralazine
- if pt becomes re-oriented, possibly return to Univasc 15mg PO
daily. On [**8-13**], began Univasc as replacement for hydralazine.
4.PPX: pneumonic boots have been placed on patient since initial
changes. Request for patient to be repositioned q2h to avoid
pressure ulcers.
5. FEN: Pt begun on D5W upon admission. When MS change,
continued on D5W. On [**8-9**], begun on D5 [**12-28**] N. SPS consulted and
found pt should remain NPO. Decision made to check the next day
for alertness. If pt remains alert and partially oriented, SPS
will be re consulted. if not, NG tube and nutrition consult will
be obtained. SPS reevaluated patient on [**8-11**] and determined that
soft foods are acceptable. Recommended a video swallow which
showed that ground food was acceptable. Switched all meds to PO
form to see how patient fairs.
Medications on Admission:
lasix 20mg qd
univasc 15mg qd
Discharge Medications:
1. Erythromycin 5 mg/g Ointment Sig: [**12-28**] Ophthalmic QID (4
times a day).
Disp:*1 5* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Moexipril 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*8 Tablet(s)* Refills:*0*
8. Dicloxacillin Sodium 250 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) for 8 days.
Disp:*32 Capsule(s)* Refills:*0*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Primary diagnosis:
GI bleed
Mental status change
.
Secondary Diagnosis:
L-sided diverticulosis hx
anemia - likely ACD
HTN
CHF
gout
Discharge Condition:
good
Discharge Instructions:
continue antibiotics as directed.
Continue to monitor any abnormal bleeding
Return for bleeding, bowel changes, pain , any changes in mental
status
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] Where: [**Name12 (NameIs) **] Date/Time:[**2156-9-27**] 2:00
Completed by:[**2156-8-13**]
ICD9 Codes: 4280, 5070, 5990, 7907, 2851, 2930, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8627
} | Medical Text: Admission Date: [**2162-7-24**] Discharge Date: [**2162-7-30**]
Date of Birth: [**2098-6-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Syncope, wide complex tachycardia
Major Surgical or Invasive Procedure:
EP study, atrial and biventricular pacemaker and ICD placement
History of Present Illness:
64 yo male with no prior cardiac hx presenting with 5 episodes
of syncope over the past 2 weeks. On [**2162-7-12**], patient was
admitted at [**Hospital1 18**] for series of 3 syncopal episodes thought to
be vasovagal secondary to dehydration based on history, negative
CT of head, and unremarkable EKG. He improved with IV fluids and
was discharged on same day.
.
Patient was subsequently re-admitted [**Date range (1) 64025**] for another
syncopal episode. Telemetry and EKG's showed occasional PVC's
and possible LAFB c/w prior EKG's. Cardiac enzymes were negative
for MI. TTE showed normal LVEF, no significant valvular disease,
LVOT obstruction, or septal defects. MRI of the head and neck
was negative for mass lesions concerning for mets or signs of
infarction. Patient was discharged with [**Doctor Last Name **] of Hearts cardiac
monitor and f/u outpatient EEG's, which were negative for
seizure activity.
.
Around noon today, patient had been doing light trimming in yard
for about 30 min. before feeling sudden sensation of fluttering
("like worms crawling") across chest and radiating across neck,
similar to previous syncopal episodes. He sat down, felt
lightheaded, and lost consciousness for few seconds. Patient
became diaphoretic, shaky, and tachypneic immediately after
regaining consciousness. Denies urinary or fecal incontinence or
disorientation.
.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts heart monitor recorded a wide complex
tachycardia 200-280 bpm. EMS was called and patient was found to
be awake, alert, with stable VS upon EMS arrival. Lidocaine gtt
was initiated in the field. Patient was taken via ambulance to
[**Hospital3 20284**] Center ED, where he did not receive any electical
shocks and was continued on the lidocaine. He was transferred to
[**Hospital1 18**] per patient request.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative. He is able to climb up 4 to 5
flights of stairs without limiting symptoms.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations. (+) for syncope, presyncope,
palpitations as above.
.
On arrival in CCU, patient went into wide complex tachycardia
with rate in 200s. Patient had pulses but was unresponsive. Code
was called and patient was cardioverted immediately.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: none
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- ?hypertension per patient for past year (130s-160s/80)
- malignant melanoma lesion in L shoulder removed 2 years ago
with wide margins
- GERD relieved by Prilosec
- h/o R knee trauma ~[**2137**]; occasional pain [**12/2144**]...
- Herniated cervical disc --> C6-7 anterior cervical diskectomy
and fusion Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1338**], neurosurgery [**1-/2151**]
- L 1st toe swelling and pain with normal uric acid by history
[**11/2151**]
- Podagra ascribed to gout Dr [**Last Name (STitle) **], rheumatology [**8-/2153**]
- R 2nd trigger finger --> release scheduled by Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
[**12-25**]
- R carpal tunnel syndrome per Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**12-25**]
- L posterior neck pain [**11-27**]- attributed to trapezius spasm
Social History:
Retired art teacher with two masters degrees. He is also a
professional painter.
Alcohol-[**12-22**] drinks 4x per week
Illicits- none
Tobacco: none
ADLS: Indep with dressing, ambulating, hygiene, eating,
toileting
IADLS: Indep with shopping, accounting, telephone use, food
preparation
Lives with: family
Walks without cane/walker/crutch/wheelchair at baseliine
No h/o fall within past year
+ Visual aides
- Dentures
- Hearing Aids
Family History:
Father died in early 70s with colon cancer, after developing
diabetes in 60s.
Mother died at 73 from "lung cancer" 15 years after
mastectomy for breast cancer
Paternal grandfather died in 40s from diabetes
Brother, 9 years older than pt, died from colon cancer at 33
Sister, died of colon CA in her 50s
Father died of colon CA in his 70s.
Sister younger than pt was born when mother was 42,
developed learning disability (? mild developmental disability),
now lives independently
Children, two, both alive and well.
Physical Exam:
VS: T=97.2 BP=151/97 HR=65 RR=14 O2 sat=96% on L NC
GENERAL: WDWN, in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVD appreciated
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, 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+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
On Admission:
[**2162-7-24**] 05:10PM PT-12.1 PTT-24.5 INR(PT)-1.0
[**2162-7-24**] 05:10PM WBC-8.5 RBC-5.22 HGB-15.9 HCT-46.3 MCV-89
MCH-30.5 MCHC-34.4 RDW-13.0
[**2162-7-24**] 05:10PM PLT COUNT-212
[**2162-7-24**] 05:10PM TSH-2.7
[**2162-7-24**] 05:10PM GLUCOSE-107* UREA N-19 CREAT-1.4* SODIUM-143
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-30 ANION GAP-13
[**2162-7-24**] 05:10PM CALCIUM-9.5 PHOSPHATE-4.5 MAGNESIUM-2.2
[**2162-7-24**] 05:10PM cTropnT-0.12*
[**2162-7-24**] 05:10PM CK-MB-5
[**2162-7-24**] 05:10PM ALT(SGPT)-88* AST(SGOT)-44* LD(LDH)-223
CK(CPK)-152 ALK PHOS-66
[**2162-7-24**] 11:20PM CK-MB-5 cTropnT-0.18*
[**2162-7-24**] 11:20PM CK(CPK)-139
On Discharge:
[**2162-7-30**] 07:40AM BLOOD WBC-8.5 RBC-5.12 Hgb-15.6 Hct-46.8 MCV-91
MCH-30.5 MCHC-33.4 RDW-13.0 Plt Ct-193
[**2162-7-30**] 07:40AM BLOOD Plt Ct-193
[**2162-7-30**] 07:40AM BLOOD Glucose-175* UreaN-17 Creat-1.4* Na-140
K-4.1 Cl-103 HCO3-25 AnGap-16
[**2162-7-30**] 07:40AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.0
.
EKG [**2162-7-24**] 16:47:
NSR @ 80bpm, no ectopy, normal PR and QRS intervals, no
hypertrophy, LAD (-60 deg), qR in I/aVL and rS in II/III/aVF c/w
LAFB. No QT prolongation.
.
TELEMETRY [**2162-7-24**] 20:28-20:29:
sustained monomorphic regular wide-complex tachycardia @ 225 bpm
-> NSR @ 100 bpm with ocassional PVC's
.
2D-ECHOCARDIOGRAM [**2162-7-19**]:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no left ventricular outflow obstruction at
rest or with Valsalva. There is no ventricular septal defect.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. The mitral
valve leaflets are elongated. Mild (1+) mitral regurgitation is
seen. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
Chest XRAY [**2162-7-24**]:
FINDINGS: A single bedside frontal chest radiograph shows
opacity laterally
at left lung base, consistent with atelectasis or scar.
Cardiomediastinal and
hilar contours are normal. Included osseous structures are
unremarkable.
IMPRESSION: No acute cardiopulmonary abnormality.
.
Cardiac MRI [**2162-7-28**]:
Impression:
1. Normal left ventricular cavity size with mild global
hypokinesis and
akinesis of the basal inferolateral wall. The LVEF was mildly
depressed at
49%. The effective forward LVEF was moderately depressed at 38%.
Possible
focal hyperenhancement of the basal inferolateral wall
consistent with
probable prior myocardial scarring/infarction.
2. Normal right ventricular cavity size and systolic function.
The RVEF was
normal at 47%.
3. Moderate mitral regurgitation.
4. The indexed diameter of the ascending was normal with a
mildly dilated
descending thoracic aorta. The main pulmonary artery diameter
index was
normal.
Brief Hospital Course:
.
# RHYTHM: Patient presented with symptomatic wide-complex
tachycardia concerning for monomorphic ventricular tachycardia.
DCCV to NSR shortly after admission to CCU, patient was bolused
and started on amiodarone gtt. EKG changes were suggestive of
triggered v-tach from focus near LVOT.
.
Patient received EP study on [**2162-7-27**] that was unsuccessful during
which patient went into polymorphic v-tach and v-fib and was
shocked to NSR. EP study was unable to identify aberrant focus
responsible for the triggered v-tach seen clinically. Prior to
the study, amiodarone was discontinued, and lidocaine gtt was
available but not required. Post-procedure, patient was
maintained on sotalol 80 mg [**Hospital1 **] in place of metoprolol. EKG
after each sotalol dose did not show any QT prolongation. On
[**2162-7-29**], patient had placement of [**Company 2267**] Telogen 100
dual-chamber ICD DDI 60. Upon discharge on [**2162-7-30**], Sotalol was
increased to 120 mg [**Hospital1 **], and patient is to follow up in [**Hospital **]
clinic in 1 week. Pt was also given a two day course of
Cephalexin to be completed upon discharge.
.
# CORONARIES: No known CAD with recent lipid panel in [**12-28**]
showing total chol 217, LDL 146. Troponin-T was mildly elevated
at admission (0.12) and continued to be above normal limits,
likely due to DCCV. He was started on aspirin 81 mg daily.
Cardiac catheterization was not felt to be indicated.
.
# PUMP: No evidence of systolic or diastolic heart failure on
history and exam. Normal systolic function on last echo on
[**2162-7-19**] (LVEF>55%). Results of cardiac MRI obtained on [**2162-7-28**] to
evaluate for scarring showed mild global hypokinesis and
akinesis of the basal inferolateral wall. LVEF was mildly
depressed at 49% and effective forward LVEF was moderately
depressed at 38%. Possible focal hyperenhancement of the basal
inferolateral wall consistent with probable prior myocardial
scarring/infarction.
.
# HYPERTENSION: Systolic BP remained around 130s-140s. Patient
was started on lisinopril 5mg daily for hypertension, given low
effective LVEF and chronic renal insufficiency.
.
# CHRONIC RENAL INSUFFICIENCY: creatinine slightly elevated at
1.3-1.4 from documented baseline of 1.2. Chronic renal
insufficiency was thought to be secondary to hypertension with
acute component of mild dehydration. IVF hydration was given
initially. Did not have any electrolyte abnormalities.
.
# ANXIETY: Patient received Ativan prn for anxiety and Valium
prior to cardiac MRI study due to claustrophobia during prior
MRI studies.
.
# GOUT: Indomethacin was given for acute flare-up of gout in
right great toe.
.
By Hospital day #7, ([**2162-7-30**]), the Pt was asymptomatic,
hemodynamically stable, afebrile and doing well. The Pt was
discharged to home on the medications described above, with
stable vital signs, in good condition.
Medications on Admission:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Astelin 137 mcg Aerosol, Spray Sig: [**11-20**] puff Nasal twice a
day as needed for allergy symptoms.
3. Ibuprofen 200 mg Tablet Sig: One (1) Tablet PO once a day as
needed for pain.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Sotalol 120 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
4. Indomethacin 75 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily) as needed for for
toe pain: Discontinue when pain resolved.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 days.
Disp:*8 Capsule(s)* Refills:*0*
7. Outpatient Lab Work
Please check Chem-7 on Tuesday [**8-3**] and call results to
[**First Name8 (NamePattern2) 892**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 15347**].
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular tachycardia
Gastroesophageal Reflux
Hypertension
Acute on Chronic Kidney Disease
Discharge Condition:
stable
Discharge Instructions:
You had ventricular tachycardia that caused you to pass out. We
were unable to fix the source of the ventricular tachycardia so
we placed an internal defibrillator and started you on Sotolol
to prevent the irregular heart rhythm. You will be seen in the
device clinic in 1 week to check your incision site and the ICD
function. Until that time, do not get the ICD dressing wet or
remove the dressing. No lifting more than 10 pounds with your
left arm for one week, no raising your left arm over your head
for 6 weeks. No swimming or tennis. Please refer to the d/c
instructions given to you. Please drink plenty of fluids after
you are home. Call Dr. [**First Name (STitle) **] if your dizziness worsens or if
you feel you cannot walk safely.
Medication changes:
1. Start Cephalexin, an antibiotic to prevent infection at the
ICD site
2. Start Sotolol: to prevent further episodes of ventricular
tachycardia
3. Start a baby aspirin: to prevent blood clots
4. Start Lisinopril: please wait until after you see Dr. [**First Name (STitle) **]
to start this medicine
.
Please call Dr.[**Name (NI) 1565**] office if the ICD fires, if you have
fevers, swelling bleeding at the ICD site, if you have chest
pain or trouble breathing or if you pass out. Do not drive for 6
months, you cn speak with Dr. [**Last Name (STitle) **] about this at your next
appt.
Followup Instructions:
Cardiology:
DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2162-8-4**] 11:00
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/Time: [**9-17**]
at 3:30pm
Dermatology:
Provider: [**Name10 (NameIs) 2975**] [**Name8 (MD) 2976**], MD Phone:[**Telephone/Fax (1) 2309**]
Date/Time:[**2162-10-1**] 8:45
Primary Care:
Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1849**], M.D. Date/Time:[**2163-1-11**] 2:20.
Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1849**], M.D. Date/Time:[**2162-8-4**] 10:00
Completed by:[**2162-8-2**]
ICD9 Codes: 4271, 2749, 2724, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8628
} | Medical Text: Admission Date: [**2160-10-5**] Discharge Date: [**2160-10-10**]
Date of Birth: [**2082-7-30**] Sex: M
Service: MED
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Transferred from MICU for continued txt of GIB.
Major Surgical or Invasive Procedure:
EGD: normal espohagus, stomach: Dieulafoy's lesion on post. wall
of prox. stomach which was txt with epi and 3 endoclips
History of Present Illness:
78 M with CAD s/p stent in [**2152**], Crohn's disease, and
hemorhoids, who came to [**Hospital1 18**] on [**10-6**] for [**6-9**] SSCP, no
radiation, no other cardiac sxs. EKG showed ST seg elevations.
Transferrred to floor at which time his Hct was 18 and he had
vomitted 500-700 cc BRB likely related to ASA, plavix, heparin
gtt which pt was on. Also 25 beat run of NSVT. Pt transferred to
MICU for further evaluation. He recieved a total of 5 units of
PRBC and 2 units of FFP over the next 36 hrs. He had an EGD
which showed a bleedign lesion treated with clips. Cards consult
recc. holding ASA, plavix, and heparin gtt. Pt maintained good
pressure, no further bleeding, and did not have any events on
telemetry. He was called out to the floor on [**10-7**] afternoon after
a repeat stable Hct this am. He denies any BRBPR, abd pain, N/V,
CP, occ. dyspnea/"gasping for breath".
ROS: otherwise negative
All: PCH (swells)
Past Medical History:
1. Legally blind from macular degeneration
2. CAD s/p [**2152**] stent
3. Crohn's disease
4. Hemorrhoids
5. BPH
6. Colon. 1 yr ago with 2 polyps removed
Social History:
Lives with wife. 30 ppy smoking, quit 23 years ago. Social EtOH.
Family History:
non-contributory
Physical Exam:
Temp
BP
Pulse
Resp
O2 sat
Gen - Alert, no acute distress
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - no JVD, no cervical lymphadenopathy
Chest - few crackles at bases bilaterally
CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Back - No costovertebral angle tendernes
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, cranial nerves [**3-13**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact
Skin - No rash
Pertinent Results:
Labs:
CXR:
[**10-7**]: no evidence of CHF
EKG:
EGD: see above
Brief Hospital Course:
A and P/ 78 M with CAD who comes in with question of angina on
plavix, and acutely ASA and heparin gtt who subsequently
developed a GIB which was intervened on via EGD. Callout from
MICU to floor after 2 days in MICU.
1. GI Bleed: Eitiolgy likely related to ASA, plavix, and heparin
txt. Hct remained stable while on the floor. ASA, plavix, and
heparin were avoided. Pt able to advance to regualr diet with
out any problem.
2. CAD: Pt has fixed CAD lesion which unlikely to intereven on.
Given GIB, must consider consequences of further
anticoagulation. Unclear as to origin of CP. Official cardiology
EKG read as STEMI however after discussing this with Dr [**Name (NI) **], pt
cardiologist, this does not appear to be the case since pt has a
fixed lesion from a test few weeks prior. No further chest pain
or events on telemetry. Pt continued to be managed medically
with beta blocker and statin.
3. NSVT: PT had a few runs of NSVT while on telemetry prior to
the MICU. No further evetns since. Electrolytes remained normal.
4. Crohn's disease: PT maintained on azathiorpine, sulfasalzine,
cipro during this admisison.
5. Low grade fever: Pt has low grade fever, with a chest xray
without evidence of pneumonia and a urinalysis and culture which
were normal. Likely related to immobiltity while in hosptial and
atelectasis. Pt D/c with incentive spirometer.
6. CHF: Pt has a mild amount of CHF secondary to txfn in the
MICU with blood products. Pt diueresed well with additional 40
mg lasix x 1 with improving symptoms requiring no additional
oxygen.
Pt D/c in good condition after PT evaluation.
Medications on Admission:
Meds: sulfasalzine 500 mg [**Hospital1 **], atenolol 50/25 qd, lisinopril 2.5
mg qd, cipro 50 mg qd, vit c, FE, folic acid, ASA, lasix 40 mg
qd, plavix 75 mg qd, lipitor 20 mg qd, azathiprine 50 mg qd
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
2. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
Disp:*30 Cap(s)* Refills:*2*
3. Azathioprine 50 mg Tablet Sig: 2.5 Tablets PO QD (once a
day).
Disp:*75 Tablet(s)* Refills:*2*
4. Sulfasalazine 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*30 Tablet(s)* Refills:*2*
6. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
11. Atenolol 25 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
12. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. GI Bleed
2. CHF exaccerbation
3. Hypothyroidism
Secondary:
1. Hypertension
2. Hyperlipidemia
3. Crohn's disease
Discharge Condition:
Good.
Discharge Instructions:
Please call you PCP or come to ED for chest pain, shortness of
breath, nausea/vomiting, fevers/chills, blood in your stool,
bloody vomitus, dizziness.
Followup Instructions:
Call Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for follow up appointment. [**Telephone/Fax (1) **]
Call Dr [**First Name (STitle) **] at [**Hospital1 336**] for follow up in [**2-1**] months. [**Telephone/Fax (1) 25917**]
ICD9 Codes: 4280, 4111, 5849, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8629
} | Medical Text: Admission Date: [**2193-5-2**] Discharge Date: [**2193-5-6**]
Date of Birth: [**2112-8-6**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
BRBPR, lightheadedness
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy (EGD) [**2193-5-3**]
Colonoscopy [**2193-5-3**]
Colonoscopy [**2193-5-6**]
History of Present Illness:
80 year-old woman with HCV cirrhosis and IVDU admitted with
rectal bleeding. Patient has had BRBPR since Tuesday morning. It
started out as thick and dark with streaks of red. She continued
to have her usual [**4-18**] BMs daily with the same black stools with
streaks of blood. BEcause she was feeling dizzy when she stood
up, she decided to go to PCP [**Name Initial (PRE) 1262**]. PCP referred her to our
ED but she didnt want to go yesterday but decided to come today.
On exam in the ED initial vs:T:98 HR:86 BP:164/74 RR:16 O2Sat100
She had maroon stool, guaiac +++ on rectal exam. 2 EJ PIVs were
inserted. She had an NG lavage that returned no blood. She
remained hemodynamically stable in ED. Pressures 140s systolic
or better for majority of time in ED. Sat 95% RA and stable. Gi
was consulted and recommended serial hcts only. No scope today
unless profuse bleeding.
On the floor, patient had no complaints. She denies nausea and
vomiting. She has no h/o GIB and a colonscopy in [**2186**] was wnl
per her report. She has been taking advil 2tabs twice daily for
back pain for the last few months and before that was on
naproxen. She denies ETOH use.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bladder
habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
COPD followed by Dr. [**Last Name (STitle) **]
Cervical Spondylosis
HCV
Med non-compliance
HTN
GERD
Hypothyroid
Osteoporosis
S/P bilateral hip replacement
CKD, baseline Cr 1.1
Social History:
She lives alone but her son is involved in her care. She smokes
currently but does not drink. She has a prior history of IVDU
and is on methadone. Her methadone administrator is [**First Name8 (NamePattern2) 2048**]
[**Last Name (NamePattern1) 1968**] ([**Telephone/Fax (1) 64437**]).
Family History:
Father with emphysema
Physical Exam:
Vitals: T:99.3 PO BP:167/72 P:77 R: 18 O2: 98%Ra
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dryMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, 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:
[**2193-5-2**]
LACTATE-1.7 K+-4.4
GLU-99 UREA N-27* CR-1.2* SODIUM-137 POTASSIUM-5.3* CHLORIDE-99
CO2-31
cTropnT-<0.01
WBC-8.3 RBC-3.88* HGB-12.1 HCT-35.8* MCV-92 PLT-148*
NEUTS-71.0* LYMPHS-17.6* MONOS-7.6 EOS-3.2 BASOS-0.6
PT-11.3 PTT-20.9* INR(PT)-0.9
EGD [**2193-5-3**]:
Impression: Normal mucosa in the esophagus
Erythema and nodularity in the antrum compatible with antral
gastritis Normal mucosa in the duodenum
A few scattered non bleeding AVMs were noted in the second part
of duodenum
Small hiatal hernia
Otherwise normal EGD to third part of the duodenum
Colonoscopy [**2193-5-3**]: !Procedure was incomplete due to poor prep!
Impression: Stool in the colon
Normal mucosa in the colon up to 40 cm
Diverticulosis of the sigmoid colon
Otherwise normal colonoscopy to descending colon
Colonoscopy [**2193-5-6**]:
Grade 2 internal hemorrhoids
Diverticulosis of the transverse colon, descending colon,
sigmoid colon and distal ascending colon
Otherwise normal colonoscopy to cecum
Discharge labs:
[**2193-5-6**] 05:31AM BLOOD WBC-5.5 RBC-3.16* Hgb-10.2* Hct-29.7*
MCV-94 MCH-32.2* MCHC-34.3 RDW-14.1 Plt Ct-122*
[**2193-5-6**] 05:31AM BLOOD Glucose-85 UreaN-11 Creat-1.0 Na-140
K-3.4 Cl-100 HCO3-34* AnGap-9
[**2193-5-6**] 05:31AM BLOOD Calcium-9.0 Phos-2.5* Mg-1.6
Brief Hospital Course:
Mrs. [**Last Name (STitle) 64438**] is an 80 yo F with h/o HCV, COPD, and GERD
admitted with BRBPR.
# LGIB: NG lavage negative. BRBPR possibly from diverticular
bleed. She remained hemodynamically stable and the bleed had
resolved by the time she was admitted to the [**Hospital Unit Name 153**]. EGD revealed
antral gastritis and a colonoscopy showed diverticulosis (bowel
prep was not adequate, so a complete study could not be
performed). She was treated with IV PPI [**Hospital1 **]. The patient was
observed over the weekend and had stable Hct between 28-31. She
had a repeat colonoscopy on [**5-6**] which showed diverticulosis but
no active bleed was found. No bleeding lesions were seen. She
was restarted on a regular diet and tolerated this well prior to
discharge. She was transitioned to Pantoprazole 40mg daily on
discharge. She was also instructed to stop naprosyn given her
EGD report with antral gastritis. She can follow up with her
PMD regarding restarting naprosyn in the future.
She has follow up appointment scheduled with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26211**] on
[**5-14**] with CBC check at that time as well. She will also
follow up with GI in [**2193-5-16**].
# HCV: Previously followed by Dr. [**Last Name (STitle) **]. Coags normal
indicating good liver synthetic function.
# HTN: Lisinopril intially held for GIB, restarted when BP
stable. This was restarted at her home dose on the floor.
# H/O IVDU: Has been on methadone for 40 years. She was
continued on her methadone dose of 120mg daily.
# COPD: Advair was continued
# Hypothyroidism: Levothyroxine was continued
# Osteoporosis: Vitamin D and calcium was restarted on discharge
# GERD: As above, the pt was started on IV pantoprazole 40mg
[**Hospital1 **], then transitioned to 40mg daily
# Smoking dependence: Nicotine patch
# Code status: RESUSCITATE but DO NOT INTUBATE (confirmed with
patient).
The patient was encouraged to either be entirely full code or
DNR/DNI. She will discuss further with her son at a later time
and reconsider.
Medications on Admission:
(Per note from [**Hospital1 778**] Health on [**2193-5-2**])
Protonix 40mg daily
Methadone 125mg daily
Levoxyl 137mcg daily
Lisinopril 10mg [**Hospital1 **]
Fosamax 70mg weekly
Loratadine 10mg daily
Colace 200mg [**Hospital1 **]
MVI
Proair HFA 108mcg 2 puffs q4-6hrs prn SOB
Advair 500-50 [**Hospital1 **]
Naproxen 375mg Q8h
Atrovent 17mcg 1-2 puffs q6hrs prn
Oscal D3 500/200 daily
Tylenol 1000mg q6hrs prn pain
Lexapro 10 vs 20 vs 30 daily
Discharge Medications:
1. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Methadone 40 mg Tablet, Soluble Sig: Three (3) Tablet,
Soluble PO DAILY (Daily).
5. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please take this medication 2 hours after your calcium.
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily): Please take this medication in the
afternoon 2 hours after your calcium. Please note, that you
should not take this medication at the same time as your thyroid
and calcium medictions.
Disp:*30 Tablet(s)* Refills:*0*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
11. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: [**2-16**]
puffs Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
12. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain: Do NOT exceed 2grams of Tylenol in 24
hours .
13. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
15. loratidine Sig: One (1) once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Diverticulosis
GI bleed
Hepatitis C
COPD
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:
You were admitted for evaluation and management of GI bleed. An
endoscopy was performed on [**2193-5-3**] that revealed gastritis
(inflammation in the lining of your stomach), but no bleeding.
A colonoscopy was attempted but not completed on [**2193-5-3**] because
of incomplete bowel prep. A repeat colonoscopy was performed on
[**2193-5-6**] that revealed diverticulosis and this is the likely
source of your GI bleed. Your diet was advanced after your
colonoscopy and you tolerated this well.
Medication changes:
1. Please stop taking Naproxen as you had inflammation on your
EGD. Naproxen can worsen this. Please discuss this with your
primary care doctor at your next visit.
Followup Instructions:
Name: [**Last Name (LF) 26211**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital6 5242**] CENTER
Address: [**Last Name (un) **], [**Location (un) **],[**Numeric Identifier 6425**]
Phone: [**Telephone/Fax (1) 64439**]
Appointment: [**2193-5-14**] 9:20am
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2193-6-12**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 10314**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
ICD9 Codes: 2767, 2859, 5859, 496, 3051, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8630
} | Medical Text: Admission Date: [**2184-1-22**] Discharge Date: [**2184-2-5**]
Date of Birth: [**2125-2-24**] Sex: M
Service:
PRIMARY DIAGNOSIS: Coronary artery disease.
PRIMARY PROCEDURE: Coronary artery bypass graft times four.
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
gentleman who was admitted with chest pain on [**2184-1-22**]. The patient has a history of hypertension,
hypercholesterolemia, diabetes, and has had intermittent
chest pain for two months.
The patient had a non-ST-elevation myocardial infarction at
an outside hospital and was transferred to [**Hospital1 346**] for cardiac catheterization. The
patient has had a prior episode last [**Month (only) 547**] that manifested as
burning chest pain and was told at that time that he had
gastroesophageal reflux disease.
One week prior to admission, the patient developed substernal
pressure with burning. This was intermittent but was
recurrent.
On [**1-19**], the patient presented to the Emergency
Department and was given sublingual nitroglycerin which
resolved his chest pain and then left against medical advice
after his treatment at that time.
On the day prior to admission, the patient was awakened from
sleep with substernal chest pressure which radiated down both
arms and into his hands. He had nausea and diaphoresis at
this time. The patient denied palpitations or shortness of
breath. The patient admitted to dizziness. He took two
sublingual nitroglycerin and the pressure improved but did
not fully resolve.
At the outside hospital Emergency Department, the patient
received Lovenox, morphine, aspirin, Plavix, a nitroglycerin
drip, and Lopressor. His pain decreased but did not resolve.
The patient was transferred to the [**Hospital1 190**]. On arrival, he was chest pain free. His
electrocardiogram changes at that time had resolved. He
underwent cardiac catheterization upon arrival.
PAST MEDICAL HISTORY: (The patient's past medical history is
significant for)
1. Non-insulin-dependent diabetes mellitus.
2. Hypertension.
3. Hypercholesterolemia.
4. Peripheral vascular disease with claudication.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: (Medications on admission
included)
1. Atenolol 100 mg by mouth once per day.
2. Lipitor 10 mg by mouth once per day.
3. Glucovance 1.25/250 mg by mouth every day.
4. Hydrochlorothiazide 50 mg by mouth once per day.
FAMILY HISTORY: Family history is significant for his
mother who had a myocardial infarction at the age of 65.
SOCIAL HISTORY: Social history is significant for being a
smoker of one pack per day for 40 years. The patient denies
any alcohol use. The patient lives with his wife in [**Name (NI) 1456**],
[**State 350**].
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
upon admission revealed the patient's blood pressure was
148/71, his heart rate was 61, his respiratory rate was 20,
and his oxygen saturation 97% on room air. On general
examination, the patient was pleasant and in no apparent
distress. Head, eyes, ears, nose, and throat examination was
significant for the sclerae being anicteric. There was no
jugular venous distention. Cardiovascular examination
revealed the heart was regular in rate and rhythm. There was
a normal first heart sounds and second heart sounds. Lung
examination was significant for bilateral basilar crackles.
The abdomen was soft and nontender. There were positive
bowel sounds. There was no hepatosplenomegaly. Extremity
examination revealed there were 1+ dorsalis pedis pulses.
The extremities were warm and well perfused and without
edema. Neurologic examination revealed the patient was alert
and oriented times three. The pupils were equal, round, and
reactive to light and accommodation. The extraocular
movements were intact.
PERTINENT RADIOLOGY/IMAGING: An electrocardiogram revealed a
normal sinus rhythm. There were Q waves in leads II, III,
and aVF. In addition, the electrocardiogram revealed T wave
flattening in V4 through V6 and ST depressions in leads V4
through V6 which had resolved on a follow-up
electrocardiogram done in the Emergency Department.
A chest x-ray on admission revealed borderline enlarged heart
without infiltrates or effusions.
Cardiac catheterization revealed an ejection fraction of 50%
with moderate inferoapical hypokinesis. Left main coronary
artery with 30%, left anterior descending artery with 40% mid
and 40% diagonal, left circumflex with 95% origin involving
origin of first obtuse marginal and 80% mid, right coronary
artery 70% proximal and 50% mid occlusion posterolateral
filling via left-to-right collaterals. Saphenous vein graft
nothing. Left internal mammary artery to left anterior
descending artery nothing.
Descending aortography performed because of an inability to
pass wire from either femoral artery revealed occluded distal
aorta with huge lumbar collaterals to legs, 80% right renal
artery, and 60% left renal artery.
PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's
white blood cell count was 19.6, his hematocrit was 48.1, and
his platelets were 223. The patient's Chemistry-7 revealed
sodium was 135, potassium was 3.9, chloride was 98,
bicarbonate was 28, blood urea nitrogen was 14, creatinine
was 1.2, and his blood glucose was 170. His creatine kinase
was 156. MB was 5.6. Troponin was 2.23. Index was 3.5.
ASSESSMENT: Assessment at this time was to have the
Cardiology team consult for question coronary artery bypass
graft.
CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted
onto the Cardiology Service and was followed. The patient
was managed medically at that time.
On [**2184-1-23**] the patient returned to the
Catheterization Laboratory for selective renal angiography.
A percutaneous transluminal angioplasty stent times one to
the right renal artery, and a percutaneous transluminal
angioplasty stent times two the left renal artery was
performed. This procedure was successful, resulting in a
final residual of 0% with normal flow in the right renal
artery and final residual was 0% with normal flow in the left
renal artery.
The patient was prepared by the Cardiology Service and was
taken to the operating room on [**2184-1-27**] for coronary
artery bypass graft with a left internal mammary artery to
the left anterior descending artery, saphenous vein graft to
the first obtuse marginal, saphenous vein graft to the third
obtuse marginal, and saphenous vein graft to the right
coronary artery. The surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] and
assisted by Dr. [**Last Name (STitle) **].
The patient tolerated the procedure well and was taken to the
Coronary Care Unit with an arterial line, a Swan-Ganz
catheter, atrial and ventricular wires, and a mediastinal and
left pleural chest tube. The patient was on a milrinone drip
at 0.5, Neo-Synephrine at 7.5, and propofol at 10 upon
transfer.
The patient did well and was extubated. He was weaned down
to Neo-Synephrine 1.25 on postoperative day one. At that
time, the patient was on aspirin and Plavix. He was
neurologically intact. The patient was out of bed. His
Neo-Synephrine was weaned to off. He was started on
Lopressor. He had adequate urine output.
On postoperative day two, he was on Neo-Synephrine at 0.5
with a temperature maximum of 100.6 degrees Fahrenheit. The
patient was given Toradol for pain control, and his
perioperative vancomycin was continued. His chest tubes were
discontinued.
On [**2184-1-29**] the patient was transferred to the
floor. On postoperative day three, he was doing well. His
pacing wires were discontinued, and he was ambulatory. He
was also afebrile at that time.
On postoperative day four (on [**2184-2-2**]), the patient
was continued on Lasix, Kefzol, Plavix, and metoprolol at 25
twice per day. He continued to have an uneventful
hospitalization; although, he did have drainage from the
distal aspect of his sternotomy wound. This drainage did
decrease, and none was noted on the final two days of his
hospitalization.
On [**2184-2-2**] the patient was found to be tearful and
depressed. A Psychiatry consultation was obtained. The plan
from the psychiatrist was reassurance that he would be safe
at the hospital and that he was in good control of his care.
They also felt that he needed to evaluate his life in the
context of his major surgery and that this was a normal
feeling. If he continued to feel overwhelmed by these
emotions in three months, they suggested a referral to
Psychiatry at that time. The consulting physician was Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1693**] (pager #39-333). Their feeling was that he did
not have a depressive or anxiety disorder at their time of
seeing the patient.
On [**2-3**], given his continued drainage from his
sternum, he was started on vancomycin and was pan-cultured.
These cultures were negative with negative blood cultures
after 72 hours, and a sternal culture which had no growth and
no organisms. For that reason, the vancomycin was
discontinued and the patient was placed on Keflex for a
period of ten days starting on the day of discharge.
Otherwise, he was stable. He was tolerating activity. He
was to be discharged with home therapy for physical
assessment and assistance with his medications.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Diabetes.
3. Hypertension.
4. Hypercholesterolemia.
5. Peripheral vascular disease.
6. Gastroesophageal reflux disease (GERD).
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed
to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**], and primary care
physician, [**Name10 (NameIs) **] his cardiologist.
MEDICATIONS ON DISCHARGE: (The patient's discharge
medications included)
1. Aspirin 325 mg by mouth once per day.
2. Plavix 75 mg by mouth once per day.
3. Lopressor 75 mg by mouth twice per day.
4. Glucovance 1.25/250 mg by mouth once per day.
5. Hydrochlorothiazide 50 mg by mouth once per day.
6. Lipitor 10 mg by mouth once per day.
7. Keflex 500 mg by mouth four times per day (times seven
days).
DISCHARGE DIET: Discharge diet was a cardiac diet.
DISCHARGE STATUS: The patient was to be discharged with home
services from [**Hospital6 407**] of Middle Sexton
East.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Dictator Info 31934**]
MEDQUIST36
D: [**2184-2-5**] 12:21
T: [**2184-2-5**] 12:32
JOB#: [**Job Number 53453**]
ICD9 Codes: 4280, 496, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8631
} | Medical Text: Admission Date: [**2129-5-23**] Discharge Date: [**2129-6-22**]
Date of Birth: [**2093-5-18**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Common bile duct dilation, ERCP Perforation
Major Surgical or Invasive Procedure:
[**2129-5-23**] Endoscopic Retrograde Cholangiopancreatography
[**2129-5-24**] Exploratory laparotomy, debridement retroperitoneum,
kocherization of the duodenum and washout.
[**2129-6-5**] 1. Exploratory laparotomy. 2. Retroperitoneal
debridement.
3. Temporary abdominal closure.
[**2129-6-8**] Abdominal washout and closure.
History of Present Illness:
The patient is a 35F previously known to Dr[**Name (NI) 1369**] service in
evaluation prior to potential surgical resection of a
choledochal cyst. She was admitted today for an ERCP to further
characterized this lesion. A 4 CM type I choledochal cyst was
seen and, following a sphincterotomy, brushings and bipsy
samples
were taken from within the cyst. Post-procedure, she complained
of severe abdominal pain and there was concern for perforation
or other procedure-related complication such as pancreatitis.
She was admitted on the [**Hospital Ward Name 516**] and a CT scan obtained which
did demonstrate some evidence of a contained retroperitoneal
perforation with a small fluid collection.
In briefly reviewing her presentaion with the cyst itself, Ms.
[**Known lastname 16913**] undeerwent a left ovarian cyst excision with concomitant
D&C [**2129-4-20**], complicated by a portsite hematoma which required
evacuation [**2129-4-21**]. She resentd with recurrent abdominal pain
initiall thought to be PID. However, review of a CT obtained in
evaluation showed no evidence of pelvic pathology, but did
demonstrate a choledochal cyst. She endorses intermittent RUQ
and
epigastric pain with radiation to the right back, which she
prior to her recent surgery. The pain is worsened by eating and
improves slightly with ambulation. She denies nausea or
vomiting. Reports passing flatus and patient continues to stool
without difficulty and denies hematemesis, melena, BRBPR,
fevers, chills,
or rigors.
Past Medical History:
PMH: denies
PSH: Wisdom Teeth, D&C, left ovarian cystectomy and evacuation
of
hematoma-[**3-/2129**]
Social History:
Works in a lawyer's office, lives with daughter and husband.
Denies alcohol, tobacco, or illicit drug use. Immigrated from
[**Location (un) 6847**].
Family History:
Father with prostate cancer. Mother with hypertension. Denies
family history of biliary disease.
Physical Exam:
Vitals: Tm 98.1 76 113/70 18 99%RA UOP not recorded
Somnolent and in obvious pain when aroused
S1S2 no murmurs
decreased BS throughout
Abd soft and diffusely tender with redound and guarding
extremities without edema
Pertinent Results:
Labs on admission:
WBC-6.9 Hct-39.6 MCV-88 Plt-321
PT-12.8 PTT-33.1 INR-1.1
UreaN-10 Creat-0.6 Na-141 K-4.1 Cl-104
ALT-4 AST-19 AlkPhos-43 Amylase-52 TotBili-0.3 DirBili-0.1
IndBili-0.2
Lipase-40
.
Labs on discharge:
[**2129-6-16**] 01:12PM BLOOD WBC-12.8* RBC-3.45* Hgb-9.8* Hct-30.3*
MCV-88 MCH-28.6 MCHC-32.5 RDW-16.0* Plt Ct-563*
[**2129-6-6**] 12:06AM BLOOD Fibrino-900*
[**2129-6-21**] 05:50AM BLOOD Glucose-115* UreaN-17 Creat-0.7 Na-137
K-3.8 Cl-101 HCO3-27 AnGap-13
[**2129-6-19**] 12:40PM BLOOD ALT-15 AST-23 AlkPhos-127* TotBili-0.2
[**2129-6-17**] 05:42AM BLOOD Lipase-110*
[**2129-6-21**] 05:50AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.0
[**2129-6-10**] 04:53AM BLOOD Triglyc-294*
[**2129-5-26**] 08:26AM BLOOD PTH-179*
[**2129-6-3**] 05:49AM BLOOD Vanco-16.1
.
AMPULLA BIOPSY [**2129-5-23**]: Scant strips of superficial biliary
type mucosa, no evidence of malignancy.
KUB [**2129-5-23**]: No evidence of perforation with normal bowel gas
pattern
KUB [**2129-6-21**]: Findings suggestive of ileus, unchanged from
[**2129-6-16**].
ERCP [**2129-5-23**]:
- Normal major papilla
- Contrast medium was injected resulting in complete
opacification
- Severe diffuse dilation seen at the biliary tree
- CBD measuring 4 cm
- Sphincterotomy performed
- Cold forceps biopsies were performed for histology at the
Inta-ampullary bile duct
- Cytology samples were obtained for histology using a brush in
the biliary
- Excellent drainage of bile and contrast noted
- Otherwise normal ercp to third part of the duodenum
Brief Hospital Course:
Mrs. [**Known lastname 16913**] is a 36 year old female who presents after
undergoing an diagnostic ERCP on [**2129-5-23**] for a type 1 choledochal
cyst complicated by a questionable perforated duodenum vs. ERCP
pancreatitis with subsequent RP phlegmon. She was initially
admitted for an ERCP to biopsy a 4cm type I choledochal cyst;
following a sphincterotomy, brushings and biopsy samples were
taken from within the cyst. Immediately after the procedure, the
pt developed diffuse abdominal pain and findings concerning for
perforation. She was admitted for IVF, abxs and pain control,
undergoing a CT scan abdomen later in the day which showed
evidence of a contained perforation. She was washed out in the
operating room on [**2129-5-24**], was transferred to the floor, and was
doing well. She was eating but her WBC was rising. CT showed a
large RP phlegmon. She kept eating and was on abx. She then
spiked a temperature to 102 on prior to her repeat washout on
[**6-3**], dropped her hct, received 2u PRBC, and developed
peritoneal signs. She was taken to the OR for exlap, debridement
of RP, and washout with pulse lavage on [**6-3**]. Multiple drains
were placed, and her abdomen was left open; pt was left
intubated and paralyzed s/p 2nd ex-lap. Abdomen was closed on
[**6-8**] with drains left in place; patient was extubated and
transferred to the regular floor.
.
Pt was initially covered on Daptomycin and Meropenem until [**6-16**];
final tissue and blood cultures negative. PICC line was placed
during admission, removed prior to discharge. Nutritional status
was suboptimal during admission and patient received TPN; this
was discontinued on day prior to discharge and PO intake was
encouraged. Pt's pain was well controlled on PO dilaudid prior
to discharge. Pt was tolerating regular PO diet, ambulating and
passing flatus and stool without difficulty prior to discharge.
Physical therapy worked with patient and cleared her for home.
Multiple KUBs revealed no evidence of obstruction or free air in
the abdomen. Surgical staples were removed prior to discharge.
Pt is being discharged home with VNA services to monitor
surgical incision and GI function, assess nutritional intake and
monitor for weight loss.
Medications on Admission:
Ibuprofen prn
Oxycodone prn
Acetaminophen prn
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO prn: every
8 hours: no more than 3000mg per day.
2. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
choledochal cyst
hemorrhagic pancreatitis
Retroperitoneal phlegmon and necrosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
[**Location (un) 932**] Visiting Nurse services have been arranged. They will
call you to set up a home visit.
Please call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] if you have any of
the following:
fever (101 or greater), chills, nausea, vomiting, inability to
eat or drink, increased abdominal pain or distension, incision
redness/bleeding/drainage
You may shower
Please do not remove steri-strips; they will come off on their
own
No heavy lifting (no heavier than 10 pounds)/straining
No driving while taking pain medications
Followup Instructions:
Department: TRANSPLANT CENTER
When: THURSDAY [**2129-7-7**] at 1:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: WEDNESDAY [**2129-8-17**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 17194**], MD [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
ICD9 Codes: 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8632
} | Medical Text: Admission Date: [**2143-8-15**] Discharge Date: [**2143-8-24**]
Date of Birth: [**2098-12-27**] Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin / Hydralazine
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Hypertension, headache
Major Surgical or Invasive Procedure:
Arterial line placement-right radial.
History of Present Illness:
Mr. [**Known lastname 784**] is a 44 y/o man with h/o malignant hypertension and
ESRD on HD (s/p recent removal of failed transplanted kidney in
[**7-19**]) who presents with headache X 5 days and hypertension. The
patient noted occipital headache for past 5 days. Similar in
character & location to prior headaches associated with high
blood pressure. No visual symptoms. No numbness/tingling of
either arm or leg. No fevers or neck stiffness. Did not take any
meds for the pain. Took blood pressure which was 190s/110s at
home; tells me that last week, when he was feeling well, he saw
blood pressures in the range of 115-120 systolic. Contact[**Name (NI) **] PCP
office today and seen at [**Company 191**] where his BP was 180/120 on the L
and 190/110 on the right. He was directed to the emergency room
at that time for further workup and treatment.
In the ED, the patient's initial BP was 241/130 with HR 62. He
was treated with 40 mg IV labetalol and a nitroglycerin drip. He
complained of headache and was treated with IV dilaudid after
which time he was nauseous and vomited several times. He
received zofran for his nausea and was given 2 L NS. His blood
pressure improved to 170s-180s/90s and he was transferred to the
MICU.
On arrival to the MICU, the patient is complaining of [**4-20**]
posterior headache. No visual symptoms. Slight shortness of
breath (for past several days). No chest pain. No abdominal
pain, dysuria, fevers, constipation/diarrhea, or blood in his
stool. No particular precipitating event per his report. He has
been compliant with all medications by his report. He denies any
increased salt intake or alcohol intake. He also denies illicit
drug use. He is dialyzed on MWF so is due on [**8-16**].
Past Medical History:
- ESRD secondary to chronic ureterovesical junction obstruction
leading to bilateral hydronephrosis, on hemodialysis
- S/p living-related renal transplant [**2134**] ([**Name (NI) 106515**] brother),
failed, now on hemodialysis since [**12-18**]
- Malignant hypertension
- PRES
- s/p SAH
- Gout
- Peptic Ulcer disease
- Bladder neck stricture
- Atypical chest pain
Social History:
40py, quit 2 yrs ago. No EtOH or other drugs. Lives in apartment
building with his wheelchair-bound wife where he works as
superintendent.
Family History:
Father had MI mid 50s. No DM. Brother had cancer of jaw which
was resected.
Physical Exam:
VS - Temp 96.6 F, BP 185/113, HR 53, R 12, O2-sat 99% 2L NC
GENERAL - alert male, pleasant, appropriately interactive, in no
acute distress
HEENT - PERRL bilaterally, EOMI, no scleral icterus, MMM, tongue
midline
NECK - supple, no thyromegaly or lymphadenopathy, JVD at 7 cm
LUNGS - clear bilaterally without crackles or rhonchi, good
inspiratory effort
HEART - RRR, normal S1 & S2, loud crescendo-decrescendo murmur
heard best at LUSB radiating to carotids
ABDOMEN - normoactive bowel sounds, nondistended, soft, no
appreciable tenderness to palpation, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no peripheral edema, 2+ DP & radial pulses
bilaterally
NEURO - A&O X 3. CN II-XII intact. Strength 5/5 bilateral
biceps, triceps, hand grip, hip flexors, ankle dorsiflexion &
plantarflexion. DTRs 2+ bilaterally at biceps. Sensation to
light touch intact bilateral upper & lower extremities. No
pronator drift. Finger to nose testing intact.
Pertinent Results:
Admission Labs:
[**2143-8-15**] 08:50PM BLOOD WBC-4.0 RBC-4.26* Hgb-12.1* Hct-37.3*
MCV-88 MCH-28.4 MCHC-32.4 RDW-14.0 Plt Ct-191
[**2143-8-15**] 08:50PM BLOOD Neuts-65.7 Lymphs-25.8 Monos-5.7 Eos-2.3
Baso-0.4
[**2143-8-15**] 08:50PM BLOOD Plt Ct-191
[**2143-8-16**] 01:10AM BLOOD PT-15.7* PTT-40.4* INR(PT)-1.4*
[**2143-8-15**] 08:50PM BLOOD Glucose-95 UreaN-42* Creat-11.0* Na-141
K-4.8 Cl-99 HCO3-25 AnGap-22*
[**2143-8-15**] 08:50PM BLOOD ALT-2 AST-12 CK(CPK)-25* AlkPhos-71
TotBili-0.3
[**2143-8-15**] 08:50PM BLOOD cTropnT-0.02*
[**2143-8-16**] 06:44AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2143-8-15**] 08:50PM BLOOD Calcium-9.8 Phos-6.6* Mg-2.2
[**2143-8-16**] 06:44AM BLOOD Cortsol-27.3*
[**2143-8-16**] 11:47PM BLOOD Cortsol-21.4*
Metanephrines: <0.20
Discharge Labs:
[**2143-8-24**] 06:30AM BLOOD WBC-4.1 RBC-4.25* Hgb-12.4* Hct-37.9*
MCV-89 MCH-29.3 MCHC-32.8 RDW-13.4 Plt Ct-164
[**2143-8-24**] 06:30AM BLOOD Plt Ct-164
[**2143-8-24**] 06:30AM BLOOD Glucose-101 UreaN-37* Creat-8.7*# Na-140
K-4.6 Cl-98 HCO3-30 AnGap-17
[**2143-8-16**] 06:44AM BLOOD CK(CPK)-24*
[**2143-8-24**] 06:30AM BLOOD Calcium-10.0 Phos-6.4* Mg-2.2
Studies:
[**2143-8-15**] CT head: HEAD CT WITHOUT IV CONTRAST: There is no
fracture, hemorrhage, edema, mass effect, or shift of normally
midline structures. The visualized paranasal sinuses again
demonstrate a small amount of secretion in the right sphenoid
sinus, which demonstrates a slight decrease in degree of
aerosolization. The soft tissues are unremarkable.
IMPRESSION: No evidence of hemorrhage. Findings posted to the ED
dashboard
at time of scan completion.
[**2143-8-16**] Echo: The left atrium is mildly dilated. The right atrium
is moderately dilated. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal for the patient's body size. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Dilated thoracic aorta.
[**2143-8-17**] CXR: FINDINGS: There is a right IJ line with tip in the
SVC/RA junction. The heart remains mildly enlarged. There is no
focal infiltrate or effusion.
Brief Hospital Course:
44 y/o M with h/o malignant hypertension & ESRD on HD (s/p
recent removal of transplanted kidney) admitted with
hypertensive urgency with headache.
.
#. Hypertensive urgency: Patient's blood pressure at [**Company 191**] in the
180s-190s systolic but up to 240s/130s in the ED. He received
labetalol with good effect but HR down to 50s. Because he was
bradycardic, nitroglycerin gtt was started. Arterial line
placed on arrival to the MICU registering blood pressures 50
points higher systolic than noninvasive monitoring. The morning
following admission, his oral antihypertensives were restarted
and renal was consulted for urgent dialysis. During this time
he was still requiring nitro gtt for BP control. In the course
of restarting all home meds he had a drop in BP and thus, his
meds were staggered. Also per renal recs, minoxidil was
initiated for further control. Following the minoxidil, he had
one episode of orthostasis. Unclear if minoxidil was the cause.
On the day of transfer to the floor, he was 190s/100s in the
am, but once he received his meds he dropped 100-110s/60s.
.
On the floor, the patient BP remained initially labile with
peaks in the 200s and lows systolic 100s-110s. He was
asymptomatic with high blood pressures at this time, but did
complain of some lightheadedness with ambulation when he blood
pressure was systolic 110s. The patient had two episodes of
dizziness in the setting of SBP in the 100-110s which were
attributed to the combination of 120mg nifedepine and 600mg
labetalol given at night. At the time of discharge his regimen
consisted of:
AM: lisinopril 40mg, Nifedipine CR 30mg, Labetalol 400mg,
metoprolol XL200mg, minoxidil 5mg and valsartan 160mg.
Noon: Labetalol 400mg, minoxidil 5mg.
PM: Nifedipine CR 90mg, Labetalol 600mg, lisinopril 40mg.
He wears a Clonidine patch 0.3 put on every Sunday and was being
treated with oral Clonidine 0.1mg for elevated blood pressures.
He will continue with his outpatient dialysis schedule and will
go to his HD center on a regular basis for BP checks. He was
also scheduled to see Dr. [**Last Name (STitle) **] in follow up on [**8-27**].
#. Headache, resolved: Likely related to his hypertension. Had
a negative head CT upon admission. In the MICU, the patient was
treated for pain with morphine as well as with compazine for
nausea. The headache resolved by time of transfer with improved
BP control.
.
#. ESRD on HD: HD on MWF. The patient received sevelamer & renal
vitamin. Electrolytes were managed per Renal during dialysis.
Plan for follow up with Dr. [**Last Name (STitle) **] to discuss future options.
Medications on Admission:
Renagel 1600 mg TID
Omeprazole 20 mg daily
Renal caps (renal MVI) daily
Lisinopril 40 mg [**Hospital1 **]
Nifedipine ER 120 mg daily
carvedilol 50 mg [**Hospital1 **]
diovan 160 mg [**Hospital1 **]
hydralazine 50 mg PO q6h
labetalol 400 mg TID
clonidine patch 0.3 weekly
Discharge Medications:
1. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSUN (every Sunday).
3. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for headache.
4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for PRN insomnia.
5. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Labetalol 200 mg Tablet Sig: 2-3 Tablets PO three times a
day: 400 mg at 6 AM and 2 PM, and 600 mg at 10 PM.
Disp:*210 Tablet(s)* Refills:*0*
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*0*
8. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
9. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily): take at 8am.
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO HS (at bedtime): Please take at 8pm.
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
11. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO ONCE (Once)
as needed for headache associated with high blood pressure.
Disp:*30 Tablet(s)* Refills:*0*
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
- Hypertensive urgency.
- End stage renal failure.
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted for elevated blood pressure and headaches.
Your high blood pressure was treated with a combination of
antihypertensive medications as well as hemodialysis. Your
headaches were felt to be due to elevated blood pressure.
In the future, please come to the dialysis center to have your
blood pressure recorded everyday. This has been arranged for
you by your dialysis doctors.
If you experience similar headaches please take 0.1mg Clonidine
by mouth. If the headaches are not alleviated by clonidine or if
you experience other symptoms such as blurry vision, please
return to the emergency room.
Followup Instructions:
Please keep your primary care doctor's appointment with Dr.
[**Last Name (STitle) **] on Tuesday, [**8-27**] at 4pm. His phone number is
[**Telephone/Fax (1) 250**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 5856, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8633
} | Medical Text: Admission Date: [**2115-12-20**] Discharge Date: [**2115-12-28**]
Date of Birth: [**2063-9-11**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: Fifty-two year old previously
healthy male who had constant headache with a slight neck
stiffness for the past four weeks. Noticed the evening prior
to admission to have poor coordination on the left side. On
the morning of admission, noticed to have continued poor
coordination on the left side. Patient does not usually have
headaches. Denies any vision changes or sensory changes.
Patient did take some over-the-counter medication with relief
of his headache. No family history of head bleeds,
aneurysms. Patient does not smoke.
Patient presented to an outside hospital which showed a right
lateral ventricle hemorrhage.
REVIEW OF SYSTEMS: Positive for recent URI.
PAST MEDICAL HISTORY: Negative.
PAST SURGICAL HISTORY: Negative.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Pulse 85, blood pressure 183/156,
respirations 12, and 97% on room air. Alert, awake, oriented
in no acute distress. Cranial nerves II through XII are
intact. Pupils are equal, round, and reactive to light and
accommodation. Normal sensation to bilateral lower
extremities. Motor strength is [**6-17**] in both upper and lower
extremities. Reflexes were +2 bilaterally.
LABORATORIES: White count was 9.6, hematocrit 42, platelets
259. Sodium 141, potassium 3.7, chloride 107, CO2 24, 23
BUN, creatinine 1.3, 13 for his PT, 24.9 PTT, 1.1 INR.
CT of his head showed slightly expanded interventricular
hemorrhage compared to the outside films, extension the third
ventricle, no hydrocephalus.
Patient had a CTA done which was poor quality and showed no
AVM, and no aneurysms found.
Patient was admitted to the ICU for closely monitor and blood
pressure control. Started on Nipride and keep systolic blood
pressure less than 130, q1h vital signs, EKG was done, and
patient was kept NPO. EKG showed normal sinus rhythm with a
Q wave in both leads III and aVF.
On his first admission day, the patient remained
neurologically intact. Vital signs were stable. Blood
pressure was kept between 109 and 140 on Nipride. The
patient had a MRI done that day which showed interventricular
hemorrhage in the lateral ventricles predominantly on the
left side, no hydrocephalus. Findings indicative of
thrombosis of the right vertebral artery. MRA of the neck
demonstrated normal flow in the vertebral and both carotid
arteries on reconstructive images, no flow signal was
identified within the right vertebral artery on the source
images. Faint signal is identified in the cervical right
vertebral artery, no signal flow identified in the distant
right vertebral artery.
Overall impression was slow flow or occlusion of the right
vertebral artery. The head MRA showed a thrombosis of the
right distal vertebral artery as mentioned.
Also on the [**1-20**], patient underwent a cerebral
angiogram by the diagnostic radiology group which showed no
gross anatomy seen, however, right vertebral and distal
arteries could not be visualized because of motion, no gross
malformation.
Postoperatively, the patient was awake, alert, and had couple
episodes of vomiting. Denied headache or blurred vision.
Blood pressures are in the 140.
On the [**1-21**], patient underwent a second angiogram
by Dr. [**Last Name (STitle) 1132**], which showed an intracranial right vertebral artery
dissection without signs of aneurysmal dilation.
Postoperatively, was alert, awake, oriented. Vital signs
were stable. No complications with the procedure.
A Stroke Neurology consult was obtained on the [**1-21**] to discuss anticoagulation. It was recommended to
start patient on Heparin with a goal PT of 40-50. PTT rate
was kept low due to the difficult situation where there is
complications for anticoagulating and not anticoagulating.
Due to the patient's intracranial dissection, there is a
hyperpencity for bleeding. Patient already had
interventricular bleed. Also, however, thrombosis sitting in
the vertebral artery results that in order to minimize the
effect of the thrombosis with anticoagulation that the
patient be placed on Heparin, and thus the goal rate was 40
and his neurologic examination was followed very closely. He
remained in the ICU and he had a number of laboratory tests
to rule out what the possible source of the dissection could
be.
ESR rate came back at 11. Homocysteine level is pending at
time of dictation. [**Doctor First Name **] also pending at time of dictation.
Alpha-1 antitrypsin and HIV also pending at time of
discharge.
On the [**1-23**], patient continued to be on Heparin
with a rate of 40 to 50 and neurologically stable. He was
started on aspirin 325 p.o. q.d. His blood pressure was very
labile and was started on a number of medications. He
required high doses of Nipride while in the ICU and became
resistant to it. He was on amlodipine 5 mg q.d., metoprolol
100 mg b.i.d., hydralazine 25 mg q.4h.
Medicine consult was obtained to help manage blood pressure,
who recommended weaning clonidine and hydralazine and
starting an ACE inhibitor, Captopril 12.5 mg p.o. t.i.d. and
titrating aggressively. Patient can be followed up with Dr.
[**First Name (STitle) **] [**Name (STitle) **] with one week of discharge.
DISCHARGE MEDICATIONS:
1. Norvasc 5 mg two tablets p.o. q.d.
2. Aspirin 325 mg one p.o. q.d.
3. Metoprolol 100 mg tablets one p.o. t.i.d.
4. Hydrochlorothiazide 25 mg one p.o. q.d.
5. Hydralazine 25 mg one p.o. q.12h.
6. Dexamethasone 0.5 mg on day of discharge and 0.5 mg on day
one postdischarge, which would be Sunday, [**12-29**].
7. Captopril 25 mg p.o. q.d.
DISCHARGE INSTRUCTIONS: No heavy lifting greater than 10
pounds. No driving until he needs with Dr. [**Last Name (STitle) 1132**]. He should
monitor his blood pressure at home and call primary care M.D.
if greater than 150 mm Hg. Return if he develops a bad
headache, dizziness, or visual changes. He should follow up
with Dr. [**Last Name (STitle) 1132**] in two weeks. He was given the phone number
for that. He should find a new primary care manager, but he
should also follow up in one week for his hypertension issues
with Dr. [**Last Name (STitle) 53962**] or Dr. [**First Name (STitle) **] [**Name (STitle) **] within one week of
discharge. He was given a phone number to make that
appointment for them to continue to decrease his clonidine
and to titrate his ACE up.
CONDITION ON DISCHARGE: The patient was discharged
neurologically stable.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern4) 26792**]
MEDQUIST36
D: [**2115-12-28**] 11:44
T: [**2115-12-30**] 10:53
JOB#: [**Job Number 53963**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8634
} | Medical Text: Admission Date: [**2167-4-5**] Discharge Date: [**2167-4-10**]
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Myocardial infarction
Major Surgical or Invasive Procedure:
[**2167-4-5**] - Coronary artery bypass grafting to three vessels.
(left internal mammary artery->Left anterior descending artery,
saphenous vein graft->posterior descending artery, saphenous
vein graft->obtuse marginal artery).
[**2167-4-5**] - Cardiac Catheterization
History of Present Illness:
88 year old female who had been feeling fatigued for 3 days with
increasing shortness of breath. She awoke the morning of
admission with shortness of breath and a cough. She presented to
the emergency department where her EKG showed ST depressions in
the anterolateral leads. She was taken for a cardiac
catheterization which revealed severe left main and three vessel
disease. She was thus referred for urgent surgical
revascularization.
Past Medical History:
Coronary artery disease status post coronary artery bypass
grafting
Myocardial infarction
Hypertension
Hypothyroid
Diet controlled diabetes
Breast cancer
Social History:
Pt. lives alone in [**Location (un) 620**] and has few supports. She is a widow.
Physical Exam:
72 regaular 26 resp 122/66 95% on 4 L
GEN: Alert and oriented x3
LUNGS: Clear
HEART: Regular rate and rythm, III/VI systolic ejection murmur.
ABD: Soft/nontender/nondistended/normoactive bowel soounds
EXT: Warm well perfused. trace edema. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2167-4-5**] Cardiac Catheterization
1. Selective coronary angiography of this right-dominant system
revealed three-vessel coronary artery disease. The LMCA had a
99%
distal stenosis. The LAD had minimal luminal irregularities.
The LCX
had a 99% ostial stenosis. The RCA had a proximal total
occlusion with
prominant left-to-right collaterals.
2. Limited resting hemodynamics demonstrated systemic arterial
hypertension as above.
4/19/9 ECHO
PRE-BYPASS:
1. The left atrium is markedly dilated. No atrial septal defect
is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is mild to
moderate regional left ventricular systolic dysfunction with
inferoseptal basal to mid dyskinesis and anterior, lateral and
anteroseptal hypokinesis in the mid to apical walls. Overall
left ventricular systolic function is moderately depressed
(LVEF= 35 %).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. There is mild aortic
valve stenosis (area 1.2-1.9cm2). No aortic regurgitation is
seen.
6. The mitral valve leaflets are mildly thickened. Moderate to
severe (3+) mitral regurgitation is seen. Posterior leaflet is
restricted. Annulus is not dilated.
Dr. [**First Name (STitle) **] was notified in person of the results.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being A paced
1. LV function is slightly improved. RV function is unchanged
2. Aorta is intact post decannulation
3. MR is now slightly improved.
4. Other findings are unchanged
[**2167-4-5**] 07:45AM BLOOD WBC-9.0 RBC-3.10* Hgb-10.0* Hct-28.7*
MCV-93 MCH-32.2* MCHC-34.7 RDW-13.8 Plt Ct-155
[**2167-4-9**] 05:25AM BLOOD WBC-9.0 RBC-3.28* Hgb-10.2* Hct-30.2*
MCV-92 MCH-31.0 MCHC-33.6 RDW-15.2 Plt Ct-117*
[**2167-4-5**] 07:45AM BLOOD Glucose-135* UreaN-38* Creat-1.3* Na-139
K-3.7 Cl-105 HCO3-23 AnGap-15
[**2167-4-9**] 05:25AM BLOOD Glucose-127* UreaN-24* Creat-1.2* Na-142
K-4.3 Cl-108 HCO3-26 AnGap-12
[**2167-4-9**] 05:25AM BLOOD Mg-1.8
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 1170**] on [**2167-4-5**] via transfer from [**Hospital3 628**] for further
management of her evolving myocardial infarction. She was taken
for a cardiac catheterization which revealed severe left main
and three vessel coronary artery disease. Given the severity of
her disease the cardiac surgical service was consulted. She was
worked up in the usual preoperative manner. Given her critical
left main disease, she was taken urgently to the operating room
where she underwent coronary artery bypass grafting to three
vessels. Please see operative note for details. Postoperatively
she was taken to the intensive care unit for monitoring. On
postoperative day one, she awoke neurologically intact and was
extubated. Beta blockade, aspirin and a statin were started. She
was later transferred to the step down unit for further
recovery. She was gently diuresed towards her preoperative
weight. The physical therapy service was consulted for
assistanced with her postoperative strength and mobility. An ace
inhibitor was started given that she had a preoperative
myocardial infarction and her ejection fraction was 35%. The
patient continued to make good progress, and she was discharged
to rehab on POD 5.
Medications on Admission:
Tamoxifen
Nifedical XL
Synthroid
Discharge Medications:
1. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
3. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): per sliding scale.
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Thyroid 30 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
13. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
Coronary artery disease status post coronary artery bypass
grafting
Myocardial infarction
Hypertension
Hypothyroid
Diet controlled diabetes
Breast cancer
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) 11302**] in [**1-20**] weeks. [**Telephone/Fax (1) 29110**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2167-4-10**]
ICD9 Codes: 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8635
} | Medical Text: Admission Date: [**2139-3-27**] Discharge Date: [**2139-4-9**]
Date of Birth: [**2071-7-26**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
elective cholecystectomy
Major Surgical or Invasive Procedure:
Open cholecystectomy
History of Present Illness:
HISTORY: Mr. [**Known lastname 86409**] is well known to the acute care surgery
service after being admitted on [**2139-1-18**] with acute
cholecystitis and gallstone pancreatitis. On that day, he had a
percutaneous cholecystostomy performed and was subsequently
discharged on [**2139-1-20**] with a prolonged hospital course related
to sepsis and delirium which has resolved. The patient also has
multiple medical problems including hypertension, chronic renal
failure, coronary artery disease, diabetes, and depression,
takes
diltiazem, Protonix, Zoloft, and Lantus. He presents today for
routine followup and discussion about possible cholecystectomy.
The patient is anxious to have the tube removed as soon as
possible. He denies pain in the area except for the drain site.
He has been moving his bowels without difficulty and eating
well.
He is having some shortness of breath as his baseline, but
otherwise, he seems to be making a slow recovery.
Past Medical History:
HTN, CRF, CHF, DM-2 (requires insulin), Depression, recent
trauma (pedestrian struck)
Social History:
NC
Family History:
Noncontributory
Physical Exam:
Physical examination: operative [**2139-3-28**]
Vital signs: bp=140/71, hr=68, resp. rate 16
General: Obese, NAD
CV: RRR
LUNGS: Rhonchi
Physical examination: [**2139-2-5**]
Pertinent Results:
[**2139-4-6**] 09:05AM BLOOD WBC-7.6 RBC-3.11* Hgb-9.2* Hct-28.7*
MCV-93 MCH-29.5 MCHC-31.9 RDW-15.0 Plt Ct-505*
[**2139-4-5**] 06:00AM BLOOD WBC-6.2 RBC-2.95* Hgb-9.0* Hct-27.3*
MCV-92 MCH-30.4 MCHC-32.9 RDW-15.2 Plt Ct-507*
[**2139-4-4**] 05:45AM BLOOD WBC-6.4 RBC-2.52* Hgb-7.8* Hct-23.5*
MCV-93 MCH-30.8 MCHC-33.0 RDW-15.2 Plt Ct-397
[**2139-4-3**] 05:50AM BLOOD WBC-7.1 RBC-2.62* Hgb-8.0* Hct-24.0*
MCV-92 MCH-30.4 MCHC-33.1 RDW-14.9 Plt Ct-429
[**2139-3-27**] 03:35PM BLOOD Neuts-70.1* Lymphs-23.1 Monos-3.7 Eos-2.6
Baso-0.5
[**2139-4-6**] 09:05AM BLOOD Plt Ct-505*
[**2139-4-5**] 06:00AM BLOOD Plt Ct-507*
[**2139-4-4**] 05:45AM BLOOD Plt Ct-397
[**2139-3-27**] 03:35PM BLOOD PT-13.2 PTT-22.1 INR(PT)-1.1
[**2139-4-8**] 05:10AM BLOOD UreaN-8 Creat-1.0 Na-134 K-3.8 Cl-104
[**2139-4-7**] 11:10AM BLOOD Na-140 K-5.2* Cl-107
[**2139-4-6**] 09:05AM BLOOD Glucose-112* UreaN-10 Creat-1.0 Na-138
K-5.2* Cl-105 HCO3-26 AnGap-12
[**2139-4-4**] 05:45AM BLOOD Glucose-99 UreaN-16 Creat-1.2 Na-142
K-3.7 Cl-105 HCO3-31 AnGap-10
[**2139-3-31**] 02:33AM BLOOD ALT-16 AST-32 AlkPhos-109 TotBili-0.5
[**2139-3-30**] 12:15PM BLOOD ALT-20 AST-33 AlkPhos-119 TotBili-0.4
[**2139-3-29**] 09:35PM BLOOD CK(CPK)-272
[**2139-3-30**] 12:50AM BLOOD CK-MB-3 cTropnT-0.02*
[**2139-3-29**] 09:35PM BLOOD CK-MB-3 cTropnT-0.04*
[**2139-4-6**] 09:05AM BLOOD Calcium-9.1 Phos-2.6* Mg-1.9
[**2139-3-27**]: EKG:
Sinus rhythm and frequent atrial ectopy. Low precordial lead
voltage. Compared
to the previous tracing of [**2139-1-8**] no diagnostic interim change.
TRACING
[**2139-3-27**]: Chest x-ray:
FINDINGS: Frontal and lateral views of the chest were obtained.
There has
been interval removal of the previously seen left PICC line.
Opacification
over the left costophrenic angle and inferior lateral left
hemithorax may
relate to overlying soft tissue and external artifact. However,
a trace
effusion, although not seen on the lateral view cannot be
excluded, neither can atelectasis. The right lung is clear. The
cardiac silhouette is top normal
[**2139-3-29**]: Chest x-ray:
New interstitial abnormality at the lung bases and probable
right pleural
effusion are explained by cardiac decompensation. Heart shadow
and
mediastinal vascular caliber are also increased. Nevertheless,
there is
greater opacification in the right lower lung, which makes it
difficult to
exclude pneumonia.
[**2139-3-30**]: Chest x-ray:
FINDINGS: In comparison with the study of [**3-29**], there are lower
lung volumes.
Enlargement of the cardiac silhouette with pulmonary vascular
congestion and probable bilateral pleural effusions are again
seen. It is difficult to definitely exclude pneumonia in the
absence of a lateral view.
[**2139-3-31**]: Echo:
Overall left ventricular systolic function is normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion appear to be normal . The
number of aortic valve leaflets cannot be determined. There is
no aortic valve stenosis. No aortic regurgitation is seen. No
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Sub-optimal study but [**Hospital1 **]-ventricular systolic
function appear to be normal with no evidence of valvular
pathology.
[**2139-4-1**]: Chest x-ray:
Mild-to-moderate pulmonary edema and moderate right pleural
effusion have
increased since [**3-31**]. Left lower lobe remains collapsed,
and the
larger left pleural effusion may have increased as well. Cardiac
silhouette is partially obscured, but may have increased in
size. There is no pneumothorax. Right subclavian line ends
centrally. No pneumothorax.
[**2139-4-2**]: Chest x-ray:
Portable AP chest radiograph was reviewed in comparison to
[**2139-4-1**]
radiographs.
The right internal jugular line tip is at the level of mid SVC.
The feeding tube tip is not included in the field of view but on
the prior study demonstrated it to be in the stomach. Bibasal
opacities appear to be
unchanged since the most recent prior radiograph. There is no
interval
increase in pleural effusion. There is no evidence of pulmonary
edema but
mild degree of vascular engorgement is still present, although
improved since the prior radiograph.
[**2139-4-4**]: EKG:
Normal sinus rhythm. Non-specific ST-T wave abnormalities.
Compared to the
previous tracing of [**2139-4-4**] the underlying artifact has improved
[**2139-3-31**] 4:31 pm SPUTUM Source: Induced.
**FINAL REPORT [**2139-4-2**]**
GRAM STAIN (Final [**2139-3-31**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2139-4-2**]):
SPARSE GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 316-4888H ON
[**2139-3-30**]
[**2139-3-30**] 11:34 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2139-3-31**]**
MRSA SCREEN (Final [**2139-3-31**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS
GENERAL URINE INFORMATION Type Color Appear Sp [**Last Name (un) **]
[**2139-3-27**] 14:47 Yellow Clear 1.016
Source: Kidney
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub
Urobiln pH Leuks
[**2139-3-27**] 14:47 NEG NEG NEG NEG NEG NEG NEG 5.0 NEG
Source: Kidney
[**2139-3-30**] 12:13 pm BLOOD CULTURE Source: Line-right
subclavian.
**FINAL REPORT [**2139-4-5**]**
Blood Culture, Routine (Final [**2139-4-5**]): NO GROWTH.
Brief Hospital Course:
Patient is a 67M with a presented for an elective
cholecystectomy. Post operatively on day 2, he started
developing a decline in mental status and worsening respiratory
status/hypoxia. He was given lasix and diuresed ~800 with some
improvement in mental status but still had persistent
desaturations with copious secretions. He was transfered to the
SICU for management of secretions, pulmonary toilet and
diuresis.
At baseline patient with altered mental status. He was
receiving adequate pain control with oxycodone. He was
hemodynamically unstable and was placed on pressors. He
responded to fluid bolus and was weaned off of pressors. He has
a history of CHF and was given lasix 20mg for diuresis. He was
started on his home diltiazem and lisinopril. Patient was on
face mask in the ICU and weaned down to o2 nasal cannula. He
was continued on a pulmonary toilet with IS. He was found to
have pseudomonas in sputum cx and started cipro for additional
coverage.
On POD #6, he was transferred to the floor. He continued with
pulmonary toilet and lasix for diuresis. A dobhoff feeding tube
was placed for tube feedings because there was a concern for
aspiration. He was evaluated by Speech and Swallow and found to
aspirate, because of this, he was maintained NPO. Tube feedings
were not started because the patient discontinued the feeding
tube and would not allow placment of another. He again was
evaluated by speech and swallow and again made NPO.
Recommendations for a PEG were addressed with the patient, but
he refused this. During this time, he did have periods of
confusion and somulence and his anti-psychotics and narcotics
were discontinued. As his mental status improved, he was
gradully introduced to pureed foods under supervision which he
did tolerate. His foley catheter was discontinued on POD # 8
and he has been voiding without difficulty.
His vital signs are stable and he is afebrile He continues on
his ciprofloxacin for pneumonia and required encouragement to
cough. He has been out of bed and ambulates with assistance to a
chair. He continues to have occasional bouts of confusion, but
has been cooperative.
He is preparing for discharge to an extended care facility.
He will follow-up with the Acute Care service in 2 weeks.
Medications on Admission:
Lisinopril 20', Loratatidine 10', Diltiazem 120''', Trazadone 50
QHS, Zoloft 50', Lantus 20 QHS, senna 8.6 2 tabs QHS, bisacodyl
10 suppository PRN', Milk of Mag PRN'
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc
Injection TID (3 times a day).
2. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB.
3. sodium chloride 3 % Solution for Nebulization Sig: 3-5 MLs
Inhalation Q4H (every 4 hours) as needed for secretions.
4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day:
hold for systolic blood pressure <110, hr <60.
5. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. senna 8.6 mg Tablet Sig: Two (2) Tablet PO once a day: hold
for diarrhea.
7. Lantus 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime: monitor blood sugar prior to meals and
bedtime.
8. trazadone Sig: Fifty (50) mg at bedtime.
9. Zoloft 50 mg Tablet Sig: One (1) Tablet PO once a day.
10. ducolax Sig: One (1) suppository at bedtime: as needed for
constipation.
11. diltiazem HCl 120 mg Tablet Sig: One (1) Tablet PO three
times a day: hold for blood pressure <110, hr <60.
12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 6 days: 2 week course, started on [**4-2**].
13. insulin lispro 100 unit/mL Solution Sig: 0-6 units
Subcutaneous ASDIR (AS DIRECTED): prior to meals, as per scale.
14. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 6598**] Manor Extended Care Facility - [**Location (un) 6598**]
Discharge Diagnosis:
cholecystitis
pneumonia
dysphagia
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 hospital for removal of your
gallbladder. You did develop pneumonia during your stay and have
been on antibiotics. You are now preparing for discharge to an
extended care facility with the following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-16**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Please follow up with the Acute Care service in 2 weeks. You
can schedule this appointment by calling # [**Telephone/Fax (1) 600**]
Completed by:[**2139-4-9**]
ICD9 Codes: 5185, 4280, 5859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8636
} | Medical Text: Admission Date: [**2134-5-21**] Discharge Date: [**2134-6-1**]
Date of Birth: [**2070-5-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Morphine / Carvedilol
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
AVR (21mm SA Regent mech.) [**5-21**]
History of Present Illness:
63 yo F with severe AS and worsening DOE over the past few
months referred for surgery.
Past Medical History:
AS/CHF, HTN, OSA on cpap, depression, obesity, pickwickian
physiology, putm htn, hysterectomy, LLE varicose vein stripping
Social History:
lives alone
denies etoh
denies tobacco
Family History:
NC
Physical Exam:
HR 76 RR 20 BP 140/70
NAD
Lungs CTAB
Heart RRR, SEM
Abdomen obese, soft, NT
Extrem warm, 2+ BLE edema
No varicosities
Pertinent Results:
[**2134-5-30**] 07:25AM BLOOD
WBC-12.6* RBC-3.05* Hgb-8.0* Hct-25.9* MCV-85 MCH-26.1*
MCHC-30.8* RDW-16.7* Plt Ct-501*
[**2134-5-30**] 07:25AM BLOOD
PT-21.4* PTT-75.9* INR(PT)-2.0*
[**2134-5-30**] 07:25AM BLOOD
Glucose-111* UreaN-24* Creat-0.9 Na-138 K-4.4 Cl-100 HCO3-29
AnGap-13
[**2134-5-30**] 07:25AM BLOOD
Calcium-8.7 Phos-4.5 Mg-2.5
[**2134-5-25**] 03:42PM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-1
CHEST (PORTABLE AP) [**2134-5-28**] 8:09 AM
Persistent blunting of the left costophrenic angles are again
seen with minimal atelectasis in the lower lobes. The heart size
is moderately enlarged status post cardiac surgery. The
pulmonary vessels are slightly indistinct reflecting minimal
pulmonary edema.
IMPRESSION:
1. Small bilateral pleural effusion.
2. Scattered atelectasis in the lower lobes.
3. Probable early edema.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Annulus: 2.1 cm <= 3.0 cm
Aorta - Sinotubular Ridge: 1.9 cm <= 3.0 cm
Aorta - Ascending: 3.1 cm <= 3.4 cm
Aorta - Descending Thoracic: *2.7 cm <= 2.5 cm
Aortic Valve - Peak Gradient: *42 mm Hg < 20 mm Hg
Aortic Valve - LVOT diam: 1.9 cm
Aortic Valve - Valve Area: *1.0 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 1.3 m/sec
Mitral Valve - Mean Gradient: 3 mm Hg
Mitral Valve - Pressure Half Time: 88 ms
Mitral Valve - MVA (P [**1-6**] T): 2.5 cm2
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Normal interatrial
septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Symmetric LVH. Suboptimal technical quality, a
focal LV wall motion abnormality cannot be fully excluded.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Abnormal systolic septal motion/position consistent with RV
pressure overload.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta. Complex (>4mm) atheroma
in the aortic arch. Mildly dilated descending aorta. Simple
atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Moderate AS (AoVA 1.0-1.2cm2) No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. No MS. Mild (1+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Suboptimal image
quality. The patient appears to be in sinus rhythm. Results were
Conclusions
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. There is symmetric left ventricular hypertrophy. Overall left
ventricular systolic function is normal (LVEF>55%). A focal wall
motion abnormality can not be fully excluded to to suboptimal
image quality.
3. Right ventricular chamber size and free wall motion are
normal.
4. There are complex (>4mm) atheroma in the aortic arch. The
descending thoracic aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is moderate to severe
aortic valve stenosis (area 1 cm2). No aortic regurgitation is
seen.
6. The mitral valve leaflets are moderately thickened. Mild (1+)
mitral regurgitation is seen.
7. The tricuspid valve leaflets are mildly thickened.
POST CPB
1. Grossly normal biventricular systolic function though poor
image quality prevents complete exclusion of a focal wall motion
abnormality.
2. Bileaflet mechanical prosthesis in the aortic position. The
valve is only very poorly seen but it does appear well seated
and both leaflets appear to be moving normally. Aortic
regurgitation can not be apppreciated secondary to poor image
quality. The maximum gradient across the valve is 64 mm Hg with
a mean of 31 at a cardiac output of about 6 liters/min. The
effective orifice area is about 1.1 cm2.
3. The mitral regurgitation remains mild.
4. The thoracic aorta appears intact.
5. No other cahnges from pre-bypass study.
Dr. [**Last Name (STitle) **] informed of all findings in the operating room
at the time of the study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Brief Hospital Course:
She was taken to the operating room on [**5-21**] where she underwent
an AVR. She was transferred to the ICU in stable condition. She
was extubated post operatively. She was transfused for HCT 20.
She was transferred to the floor on POD #3. She was started on
heparin gtt and coumadin for her mechanical valve. She continued
to use nasal CPAP at night as prior to surgery. On Dc her INR is
2.0. She is off the heperiin drip. Pt foley, PW , CT were all
DC"d without sequele. She did work with PT. They recommended
rehab.
Pt top have INR folowed at rehab. Rehab to set up INR draws with
PCP on her discharge from rehab.
Medications on Admission:
lasix 40', norvasc 5', atacand 16', kcl 20', mvi
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day). Tablet(s)
7. Coumadin 7.5 mg Tablet Sig: One (1) Tablet PO mon / wends /
fri: INR goal is 2.5-3.0. Tablet(s)
8. Coumadin 5 mg Tablet Sig: One (1) Tablet PO sat / sun / tues
/ thurs: INR goal is 2.5- 3.0.
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days. Tablet(s)
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 7 days.
11. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
12. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) **]
Discharge Diagnosis:
AS now s/p AVR
CHF, HTN, OSA on cpap, depression, obesity, pickwickian
physiology, putm htn, hysterectomy, LLE varicose vein stripping
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4640**] 2 weeks [**Telephone/Fax (1) 20221**]
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6254**] 2 weeks
Dr. [**First Name (STitle) **] 4 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2134-5-30**]
ICD9 Codes: 4241, 4280, 4019, 311, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8637
} | Medical Text: Admission Date: [**2165-6-18**] Discharge Date: [**2165-7-2**]
Date of Birth: [**2091-5-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Pleural effusion
Major Surgical or Invasive Procedure:
[**2165-6-21**]: Right VATS (video-assisted thoracic surgery)
exploration, right thoracotomy and decortication, flexible
bronchoscopy with bronchoalveolar lavage.
History of Present Illness:
Ms. [**Known lastname **] is a 74 year old woman who underwent RML sleeve
resection on [**2165-5-31**] for carcinoid of the bronchus intermedius.
She was sent home POD4 in stable condition with no specific
complaints. She has been doing well at home and
returns to clinc today for 2 week follow-up. She reports feeling
well, that her cough is nearly gone and her pain is well
controlled on <3 dilaudid tabs per day. Her CXR today shows
right pleural effusion and small pneumothorax. She denies
productive cough, pleuritic pain, fevers, chills or other
concerning
symptoms.
Past Medical History:
Right bronchus intermedius Carcinoid s/p sleeve resection
[**2165-5-31**]
Thyroidectomy for fetal adenoma [**2127**]
Hyperlipidemia
Asthma
GERD
Osteoporosis
Social History:
Married lives with spouse. Children. [**Name2 (NI) 1139**] never. ETOH social.
Family History:
Mother COPD died age 84
Father died of MI at age 48 [**2114**]
Siblings MI younger brother died age 60
Physical Exam:
VS: T: 99.8 HR: 78 SR BP: 140-170/78 Sats: 98% RA
General: 74 year-old female in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1.S2 no murmur
Resp: clear breath sounds throughout
GI: benign
Extr: warm no edema
Incision: Right thoractomy incision clean, dry intact no
erythema
Neuro: awake, alert oriented
Pertinent Results:
[**2165-7-2**] WBC-12.7* RBC-2.98* Hgb-9.1* Hct-27.3 Plt Ct-363
[**2165-7-1**] WBC-10.5 RBC-2.75* Hgb-8.3* Hct-24.8 Plt Ct-268
[**2165-6-29**] WBC-15.2* RBC-3.05* Hgb-9.4* Hct-27.9 Plt Ct-322
[**2165-6-28**] WBC-10.3 RBC-3.16* Hgb-9.5* Hct-28.5 Plt Ct-307
[**2165-6-21**] WBC-27.0* RBC-3.86* Hgb-12.5 Hct-34.9 Plt Ct-468*
[**2165-6-18**] WBC-12.3* RBC-3.92* Hgb-12.2 Hct-35.1 Plt Ct-420
[**2165-7-2**] Glucose-96 UreaN-15 Creat-2.0* Na-142 K-3.8 Cl-103
HCO3-28
[**2165-7-1**] Glucose-93 UreaN-15 Creat-2.2* Na-139 K-3.5 Cl-105
HCO3-27
[**2165-6-30**] Glucose-86 UreaN-15 Creat-2.2* Na-139 K-3.6 Cl-104
HCO3-25
[**2165-6-27**] Glucose-90 UreaN-10 Creat-1.5* Na-137 K-4.0 Cl-101
HCO3-30
[**2165-6-21**] Glucose-102* UreaN-24* Creat-1.1 Na-126* K-4.1 Cl-88*
HCO3-25
[**2165-6-18**] Glucose-124* UreaN-9 Creat-0.7 Na-140 K-3.8 Cl-103
HCO3-25
[**2165-7-2**] Calcium-8.7 Phos-3.9 Mg-1.9
Micro:
[**2165-6-21**] TISSUE RIGHT PLEURAL DEBRIS. GRAM STAIN (Final
[**2165-6-21**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
TISSUE (Final [**2165-6-24**]):
STAPH AUREUS COAG +. SPARSE GROWTH.
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2165-6-25**]): NO ANAEROBES ISOLATED.
[**2165-6-30**] C diff negative
[**2165-6-29**] C diff negative
[**2165-6-21**] PLEURAL FLUID + MRSA
[**2165-6-21**] PLEURAL FLUID + MRSA
[**2165-6-21**] BRONCHOALVEOLAR LAVAGE negative
[**2165-6-21**] URINE CULTURE negative
[**2165-6-21**] BLOOD CULTURE MRSA 4/4 bottles
[**2165-6-18**] PLEURAL FLUID negative
[**2165-6-18**] PLEURAL FLUID + MRSA
IMAGING DATA:
CT chest:[**2165-6-21**]
1. Large, probably loculated right pleural effusion and smaller
volume of pleural air, projecting through the intercostal plane
into the submuscular right chest wall, probably facilitated by
separated surgical rib fractures.
2. Diffuse narrowing, right bronchial tree distal to the main
bronchus, not due to hematoma.
3. Moderately severe atelectasis, right lung, probably due to a
combination of bronchial narrowing and restriction by thickened
pleura and pleural effusion. No right pleural drain is seen
currently.
CXR [**6-27**]
There is no change from [**2165-6-26**]. The right chest tube remains
in place. Small bilateral pleural effusions and associated
atelectasis, right greater than left, are stable. The cardiac
and
mediastinal silhouettes and hilar contours are unchanged. A
small
right apical air collection is stable without evidence of
tension. Subcutaneous air in the right chest wall is again
noted.
The left PICC ends in the mid to low SVC.
Echogardiogram
[**2165-7-2**]:
A patent foramen ovale is present. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened. Trace aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. Mild
(1+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: No echocardiographic evidence of endocarditis. A
patent foramen ovale was present.
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted [**2165-6-18**] from the thoracic clinic
following thoracentesis for 600 mL and placement of a right
pigtail. Serial chest films revealed no change in right pleural
effusion and pneumothorax. Chest CT [**2165-6-21**] revealed a
loculated effusion and the patient had a rising white count. She
was taken to the operating room for a Right VATS (video-assisted
thoracic surgery) exploration, right thoracotomy and
decortication, flexible bronchoscopy with bronchoalveolar
lavage. Intraoperative she was found to a have a couple
purulence pockets which was drained and cultures sent. She was
started on Vancomycin and Zosyn. The cultures were MRSA
vancomycin sensitive. The Zosyn was discontinued and a week
course of Vancomycin was continued. She transfer to the PACU was
hypotensive and tachycardic requiring pressors and volume and
was transfer to the TICU with MAPs in the 70's. Overnight she
improved titrated off pressors with MAPs > 60. She was given IV
fluids. Her free water was restricted for hyponatremia and she
normalized over the next 48 hrs. Her Lopressor was restarted for
occasional ectopy. On [**2165-6-24**] she remained stable and was
transfer to the floor. Below is a systems review of her hospital
course:
Respiratory: Nebulizers and incentive spirometry were continued,
and she titrated off oxygen with saturations of 93-97% on room
air.
Chest tubes: She had right anterior and basilar chest tubes.
Once the culture were finalized the anterior chest tube was
removed on [**2165-6-26**] and the basilar converted to a Pneumostat
and will slowly be removed over several weeks to prevent a
pocket formation.
Cardiac: The patient remained hemodynamically stable in sinus
rhythm 80-90's with no further ectopy. Her Lopressor was
continued. Blood pressures were 140-150's and her HCTZ was
restarted. She continued to be hypertensive. Amlodipine 2.5 mg
daily was started [**2165-7-2**].
GI: PPI and bowel regime
Nutrition: tolerated a regular diet
Renal: The patient developed climbing creatinine on [**2165-6-27**]
plateau to 2.2 on discharge was 2.0. This was felt to be due to
vancomycin which was discontinued [**2165-6-27**]. Her urine output was
excellent.
ID: She remained afebrile. Leukocytosis peak 27 which normalized
following empyema drainage and antibiotics. She was initially
started on vanc/Zosyn per above history but changed to
ceftaroline 400mg IV bid on [**2165-6-28**] switched to 300mg IV bid
(renal dosing). C.diff x 2 was negative. TEE on [**2165-7-1**] was
negative for endocarditis.
Pain: The patient had confusion with narcotics transition to
Lidoderm patch, tramadol and acetaminophen with good pain
control.
Neuro: episode of confusion while in ICU which cleared once
transfer to floor, limited narcotic use and a good night sleep.
No further confusion occurred while on the floor.
Disposition: She was seen by physical therapy and transfer to
[**Hospital1 **] on [**2165-7-2**]. She will follow-up with Dr.
[**Last Name (STitle) **] in 1 week for chest tube to be pulled back slowly
and infectious disease.
Medications on Admission:
Albuterol IH, Atorvastatin 40 mg daily, Ezetimibe 10 mg daily,
Fenofibrate 48 mg daily, HCTZ 25 mg daily, Levothyroxine 125 mcg
daily, Metoprolol 50 [**Hospital1 **], Singulair 10 mg daily, Omeprazole 20
mg daily, Raloxifene 60 mg daily, Calcium Carbonate [**Telephone/Fax (1) 89122**]
[**Hospital1 **], Fish Oil daily
Discharge Medications:
1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for stomach discomfort.
7. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours).
10. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: Flush with
10mL of NS followed by heparin.
13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): cut in
[**1-13**] on either side of thoracotomy incision.
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation Q6H (every 6 hours) as
needed for dyspnea.
15. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
16. ceftaroline fosamil 600 mg Recon Soln Sig: Four Hundred
(400) mg Intravenous every twelve (12) hours for 4 weeks:
continue until seen by ID [**2165-7-29**].
17. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Right MRSA empyema s/p R VATS decortication [**2165-6-21**]
Right middle lobe carcinoid s/p RML sleeve resection [**2165-5-31**]
Thyroidectomy for fetal adenoma [**2127**]
Hyperlipidemia
Asthma
GERD
Osteoporosis
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) 2348**] if you experience
-Fevers greater than 101.5, chills, sweats
-Increased shortness of breath, cough or chest pain
Pneumostat (chest tube)
-Empty daily. Change dressing daily
Pain:
-Acetaminophen 650 mg every 6 hours as needed for pain
-Neurontin 100mg po tid
-Ultram 25-50 mg mg take every 6 hours as needed for pain
Activity
-Shower daily. Wash incision with mild soap & water, rinse pat
dry
-No swimming, tub baths or hot tubs until incision healed
Antibiotics:
Ceftaroline 400 mg IV BID continue until seen by infectious
diseae on [**7-16**]
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**0-0-**] Date/Time:[**2165-7-9**]
3:00
on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**]
Chest X-Ray 4th Radiology 30 minutes before your appointment
Follow-up with Dr. [**Last Name (STitle) **] Radiation oncology when the
chest-tube has been removed.
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **] ID WEST (SB) Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2165-7-16**] 12:00 in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **]
Basement level
Weekly CBC, Chem 7 LFTs, ESR, CRP fax to ID RN [**Telephone/Fax (1) 1419**]
Completed by:[**2165-7-9**]
ICD9 Codes: 0389, 5845, 5119, 2761, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8638
} | Medical Text: Admission Date: [**2177-2-25**] Discharge Date: [**2177-3-5**]
Date of Birth: [**2114-11-4**] Sex: M
Service: NEUROLOGY
Allergies:
Infliximab / Latex / Shellfish Derived
Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
Bilateral leg numbness
Major Surgical or Invasive Procedure:
-intubation
-lami T2-L2, fusion in situ without instrumentation T2-L2
History of Present Illness:
The pt is a 62 year-old right-handed gentleman who presented as
a transfer from an OSH with lower extremity numbness and
weakness.
Briefly, he was admitted to [**Hospital 8**] Hospital on [**2177-2-19**] for
elective repair of a left ankle deformity. He apparently
tolerated the procedure well. Yesterday, he was in his room
walking with his walker and tripped. He fell onto his back and
immediately noticed neck and upper back pain. He was helped back
into bed. He did not notice any weakness or numbness of the legs
at that point.
Shortly thereafter, he was noted to become slightly hypotensive
(systolic in the 80's). He was given volume resuscitation
(unclear how much per the available notes) and eventually
transferred to the ICU on a dopamine gtt. It was noted hours
later that his urine output was minimal despite aggressive IVF.
He described no sensation of a full bladder, but apparently when
he was subsequently catheterized a large volume of urine was
drained. Of note, he was also started on empiric antibiotics
with the thought that the hypotension may be due to sepsis
(though no documentation of fever, etc). Subsequent to the fall,
he underwent a head CT which was normal.
To the best of his knowledge, the pt believes that he was able
to move his legs last evening prior to falling asleep. When he
awoke this morning, he found that he was unable to move or feel
his legs. He has had full strength and sensation in his arms. He
has been catheterized since his bladder was decompressed as
above. He has not had a bowel movement since the fall. CT scan
of the spine
as well as of the torso was performed at the OSH prior to
transfer and demonstrated no notable abnormality. He was
transferred to [**Hospital1 18**] this afternoon for further evaluation.
At the time of my encounter, he complained of neck, upper back,
and left elbow pain. He denied headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, or tinnitus. He is hard of hearing at baseline and
wears hearing aids.
Past Medical History:
-ankylosing spondylitis
-s/p bilateral knee replacements
-s/p bilateral ankle surgeries with hardware, most recently [**2-19**]
as above
-history of PE, multiple DVT, thought to be secondary to
clotting
disorder (he is unsure exactly which one), on anticoagulation
(stopped on [**2-13**] in preparation for recent procedure, apparently
restarted [**2-24**])
-hypertension
Social History:
He denied history of tobacco, alcohol, or illicit drug use
Family History:
Not elicited
Physical Exam:
Vitals: T: 99.2F P: 73 R: 16 BP: 114/62 SaO2: 96% 3L NC
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Cervical collar in place.
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and comprehension. Normal prosody. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
-Cranial Nerves: Olfaction not tested. PERRL 3 to 2mm and
brisk. VFF to confrontation. There is no ptosis bilaterally.
EOMI without nystagmus. Facial sensation intact to pinprick. No
facial droop, facial musculature symmetric. Hearing intact to
finger-rub bilaterally. Palate elevates symmetrically. [**6-9**]
strength in trapezii and SCM bilaterally. Tongue protrudes in
midline.
-Motor: Normal bulk throughout. Tone is flaccid in the lower
extremities. No pronator drift bilaterally. No adventitious
movements noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 0 0 0 0 0 0 0
R 5 5 5 5 5 5 5 0 0 0 0 0 0 0
-Sensory: Absent light touch, pinprick, cold sensation to a T2
level. Lack of vibratory sense, proprioception up to iliac
crests bilaterally.
-Coordination: No dysdiadochokinesia noted. No dysmetria on FNF
bilaterally.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 0 0
R 2 2 2 0 0
Plantar response mute on the right, could not assess left due to
extensive bandaging.
-Gait: Deferred given paraplegia.
Pertinent Results:
[**2177-2-25**] 02:17PM BLOOD WBC-11.1* RBC-3.27* Hgb-10.2* Hct-29.8*
MCV-91 MCH-31.3 MCHC-34.4 RDW-12.8 Plt Ct-281
[**2177-2-25**] 02:17PM BLOOD PT-14.6* PTT-23.2 INR(PT)-1.3*
[**2177-2-25**] 02:17PM BLOOD Glucose-128* UreaN-14 Creat-0.7 Na-141
K-4.2 Cl-109* HCO3-25 AnGap-11
[**2177-2-25**] 07:27PM BLOOD ALT-18 AST-30 LD(LDH)-220 CK(CPK)-694*
AlkPhos-53 Amylase-20 TotBili-0.2
[**2177-2-25**] 07:27PM BLOOD Lipase-13
[**2177-2-25**] 07:27PM BLOOD CK-MB-13* MB Indx-1.9 cTropnT-<0.01
[**2177-2-25**] 02:17PM BLOOD Calcium-8.6 Phos-1.6* Mg-2.2
[**2177-2-26**] 03:39AM BLOOD Calcium-7.8* Phos-3.9# Mg-2.0
[**2177-2-25**] 07:27PM BLOOD calTIBC-217* Ferritn-188 TRF-167*
[**2177-2-25**] 07:27PM BLOOD Ammonia-20
[**2177-2-26**] 01:29AM BLOOD Glucose-149* Lactate-1.9 Na-138 K-4.0
Cl-106
[**2177-2-26**] 01:29AM BLOOD Hgb-10.2* calcHCT-31
[**2177-2-26**] 03:54AM BLOOD freeCa-1.11*
Brief Hospital Course:
The pt is a 62 year-old gentleman with PMH of Ankylosing
spondylitis and a known coagulopathy off coumadin for a recent L
foot surgery but bridged with lovenox. He who presented with the
relatively acute onset of paraplegia after a fall at an OSH.
After the fall he was hypotensive and required pressors.
Neurologic examination at the time of admission was notable for
flaccid paraplegia and a T2 sensory level. He also related a
history of a flaccid bladder and it is possible that his
episodes of hypotension are also related to dysautonomia of
spinal origin.
Concerned for spinal cord compression in the upper thoracic
region given the history and exam. The patient was intially sent
for emergent CT myelogram due to recently placed plates and
screws in the left ankle. CT myelogram done showed large
extradural collection extending posteriorly from T2 to L2
concerning for hematoma or less likely abscess. Spine surgery
was consulted & he was then sent to MRI which confirmed the the
epidural hematoma and he was taken to the OR on [**2-25**] for
emergent T2-L2 fusion and laminectomy. Please see operative
report for full details of procedure.
His remaining hospital course by system is as follows:
Neuro:
He was treated with cefazolin for 1 day post-operatively and
extubated. His dexamethasone was tapered. He reported some
sensation down to his calves on post-op day 1, however
afterwards he had no sensation or movement below T2. Serial
neurologic exams revealed persistent flaccid paraplegia, absent
tendon reflexes in the lower extremities and absent sensation
from T3 below. Given little improvement since surgical
decompression, his prognosis for functional recovery is poor. He
should remain in TLSO brace for all transfers given risks of
injury if the patient were to fall. He does not need to wear the
brace while in bed or sitting upright. The patient prefers to
wear a soft cervical collar, but does not require the collar
from a spine stability standpoint. Wound staples should be
removed in 2 weeks ([**2177-3-17**]). He should follow up with the
orthopedic spine surgeon (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**]) in 2 weeks
following discharge.
CV: His hypotension was treated with neosynephrine which was
gradually tapered. He did not have any further blood pressure
lability or other signs of dysautonomia in the subsequent
hospital course.
RESP: He was extubated on [**2-26**] without complication.
ID: He had a fever on post-op day 1 but his WBC was trending
down. Blood cultures, incluiding intraop cultures were negative
for growth.He was treated with cefazolin for 1 day
post-operatively.
HEME:
1) He had a normocytic anemia and iron studies were consistent
with chronic disease. He also lost about 1200cc of blood in the
OR and was transfused 750cc of PRBC. His hematocrit was stable
at 28 following serial measurements. He was started on oral iron
x 2 weeks given his blood loss.
2) Coagulopathy- Multiple DVT's and PE relating to prior
orthopedic procedures. He was evaluated by hematology as an
outpatient and told that he did not have a factor deficiecy. On
admission to this hospital anticoagulation was held. His
anticoagulation was restarted with Heparin on post-op day #3.
Given hemodynamic stability and no evidence for further
bleeding, coumadin was restarted. Daily PT/INR should be drawn
at rehab and coumadin dosing adjusted accordingly for goal INR
2-2.5. INR at time of discharge was 1.8
GI: A liver lesion measuring 4 cm was noted on the MRI of the
T-spine; this should be followed up as an outpatient with a
liver ultrasound or CT torso. Care should be taken to monitor
for regular bowel movements considering his spinal cord injury
and lack of sensation.
FEN: He will be discharged with a foley catheter; voiding trials
should take into consideration his spinal cord injury and the
possibility that he will not sense bladder fullness - timed
straight catheterizations versus chronic foley would be
recommended therapy if this does not recover within 1-2 weeks.
Medications on Admission:
Meds at time of transfer:
-lovenox 100mg SQ Q12H
-dopamine ggt
-decadrom 10mg IV Q6H
-Colace 100mg PO TID
-Beconase 2 sprays nasally [**Hospital1 **]
-Proscar 5mg PO QHS
-Flexeril 15mg PO QHS
-CaCO3 500mg PO QD
-Vit D 400 units PO QD
-Vancomycin 1.5gm IV Q12H
-Gentamycin 500mg IV Q24H
Outpatient Meds:
-Vit D 600 units PO BID
-Finaseteride 5mg PO QHS
-flexeril 50mg PO QHS
-Meloxicam 15mg Qam
-Tramadol 50mg PO BID
-Toprol XR 100mg PO QAM
-Ipratropium spray 0.03% 2 puffs in each nostril PRN
-Prednisone 10mg PO BID prn arthritis flare
-fluticasone 50mcg [**2-5**] sprays per nostril
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
2. Famotidine 20 mg Tablet Sig: One (1) Tablet 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. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) as
needed.
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 14 days.
8. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
9. Insulin Regular Human 100 unit/mL Solution Sig: Per sliding
scale Injection ASDIR (AS DIRECTED).
10. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day:
check PT/INR daily for goal 2-2.5.
11. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ML
PO Q4H (every 4 hours) as needed for constipation: please
titrate bowel regimen to one bowel movement per day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Spinal compression
Discharge Condition:
Flaccid Paraplegia with T3 sensory level.
Discharge Instructions:
You were admitted following a fall that resulted in bleeding
around your spinal cord. You were taken to the OR for T2-L2
laminectomy to relieve the pressure on your spinal cord.
Please continue to take all medications as prescribed
On an MRI of the spine, you were found to have an incidental
liver lesion 4cm - a liver ultrasound or CT torso as an
outpatient has been recommended.
Followup Instructions:
Please see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**] (orthopedic spine surgery) for
follow up, office phone: ([**Telephone/Fax (1) 2007**] in 2 weeks.
You should have a CT torso or liver ultrasound for further
evaluation of liver nodules noted incidentally on your spine
studies.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
ICD9 Codes: 4019, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8639
} | Medical Text: Admission Date: [**2186-5-10**] Discharge Date: [**2186-5-18**]
Date of Birth: [**2160-11-6**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
Mr. [**Known lastname 61289**] is a 25M with DM, ESRD on HD, recent PE at [**Hospital1 112**] [**3-8**] mo
ago, who was sent in after routine labs showed hyperkalemia.
In the ED, initial vitals were: 97.8 87 172/111 18 100.
Complained of CP similar to prior PE. Exam without neuro
deficits per ER. EKG done showed peaked Ts but felt similar to
prior. Admit labs notable for hypoglycemia to 30, K 6.5, flat
CK, tropn at his baseline. Bedside echo showed no pericardial
effusion. Given kayexalate, calcium, insulin/glucose for his
hyperK. Also given zofran, benadryl, dilaudid 1.25mg IV, and
labetalol 100mg bolus and now on labetalol drip. Started on
heparin drip given INR of 1 here. Last HD Monday, was due for HD
today. Vitals prior to transfer 89 [**Telephone/Fax (2) 61291**]%RA. Access PIV
x2, HD cath.
On evaluation in the MICU, he is most concerned about pruritis.
He says he wouldn't have come into the hospital had he not been
told to do so because of his labs. He is not willing to give a
detailed history but on specific questioning endorses midsternal
chest discomfort that began in the cab, currently resolved. He
says he felt dizzy with it, no SOB, no leg pains. He endorses a
mild headache, no back pains. No vision changes - he is blind.
He says he took pills the morning of admission, but can't recall
the names of his medications. His mother helps him with his
meds. He denies depression or substance use.
Review of systems is otherwise negative for fevers, chills,
sweats, recent illness.
Past Medical History:
Diabetes mellitus, type I. Diagnosed in [**2162**]. Poorly controlled
with past DKA. Complicated with retinopathy, nephropathy.
Hypertension, poorly controlled
ESRD on HD MWF - nephrologist is [**Doctor Last Name 4090**]
Pericarditis and pericardial effusion ?minoxidil related per
renal note
PE dx at [**Hospital1 112**] ~1mo ago per patient
Chronic constipation
Chronic anemia
Oppositional defiant disorder
Social History:
Lives with mother. On disability. Smokes since age 16 - he can't
say amount. Denies recent alcohol use. Denies illicit drug use
including meth or cocaine.
Family History:
Father, grandmother with diabetes mellitus. No relatives
currently on dialysis. Mother with [**Last Name **] problem, details
unknown to him. No history of clot.
Physical Exam:
Vitals 97 80 [**Telephone/Fax (2) 61292**]% on RA
General Young man, scratching at body, no acute distress
HEENT Anicteric, conjunctiva pale, MMM. PEARL, EOMI. +Bruxism
Neck no JVD appreciated
Pulm lungs clear bilaterally, no rales or wheezing
CV regular S1 S2 no m/r/g +S4
Abd soft bowel sounds present nontender no bruit
Extrem warm no edema palpable distal pulses. legs symmetric,
nontender
Neuro eyes closed but following commands, CN 2-12 intact aside
light-only vision, full strength in bilateral upper and lower
extremities, sensation intact to light touch, no pronator drift,
able to sit up when asked to do so.
Skin Multiple tattoos, nodules at sites of itching
R tunneled catheter without tenderness or purulence.
Pertinent Results:
Admission Labs:
[**2186-5-10**] 02:35PM WBC-7.7 RBC-2.75* HGB-8.2* HCT-25.8* MCV-94
MCH-30.0 MCHC-31.9 RDW-16.5*
[**2186-5-10**] 02:35PM NEUTS-66.1 LYMPHS-22.4 MONOS-7.5 EOS-3.4
BASOS-0.5
[**2186-5-10**] 02:35PM PLT COUNT-541*#
[**2186-5-10**] 02:35PM CK-MB-3 cTropnT-0.35*
[**2186-5-10**] 02:35PM CK(CPK)-117
[**2186-5-10**] 02:35PM GLUCOSE-32* UREA N-47* CREAT-8.7* SODIUM-133
POTASSIUM-6.5* CHLORIDE-93* TOTAL CO2-28 ANION GAP-19
[**2186-5-10**] 11:00PM CK-MB-3 cTropnT-0.32*
STUDIES:
EKG SR @84, borderline L axis, normal intervals, TWI in I and
vL. No pathologic q's. Nonspecific STD, likely [**3-7**] LV strain.
T's do appear peaked. +LVH by voltage. In comparison to [**2185-10-16**]
EKG, TWI in I is new and axis is more leftward
Repeat EKG 1am: notable for TWI in V5-V6 in setting of HTN
220/110's.
[**5-10**] CT CHEST WITH IV CONTRAST: There is no pulmonary embolus or
aortic
dissection. Cardiomegaly is noted with a small amount of
pericardial fluid. There is no pleural effusion or pneumothorax.
There is no lymphadenopathy. A dialysis catheter terminates in
the cavoatrial junction. There is no worrisome nodule, mass, or
consolidation. Subsegmental atelectasis is noted at the left
lung base.
A hyperenhancing focus is seen in segment [**Doctor First Name 690**] of the liver
measuring
approximately 4 mm, not completely characterized on single phase
study (3:61). A second hyperenhancing focus is seen in segment
II of similar size (3:74).
BONES: Osseous structures appear unremarkable.
IMPRESSION:
1. No pulmonary embolus or aortic dissection.
2. Cardiomegaly with trace pericardial effusion.
3. Two tiny hyperenhancing foci in the liver, may represent
focal nodular
hyperplasia, though incompletely characterized on this exam.
[**5-10**] CXR
SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: There is moderate to
marked cardiomegaly, with no evidence of congestive heart
failure. There is no focal consolidation to suggest pneumonia.
There is left lung base atelectasis, slightly less severe than
previously seen. A right IJ dialysis catheter terminates near
the cavoatrial junction.
IMPRESSION: Cardiomegaly and left lung base atelectasis.
[**2186-5-11**] TTE: The left atrium is elongated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF 70%). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is mild
mitral valve prolapse. An eccentric, posteriorly directed jet of
Mild to moderate ([**2-4**]+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
[**2186-5-12**] CT Head: No acute intracranial process.
[**2186-5-14**]: ECG: Sinus rhythm. Possible left atrial abnormality.
Left ventricular hypertrophy. Lateral ST-T wave changes may be
due to left ventricular hypertrophy or ischemia. Compared to the
previous tracing of [**2186-5-11**] there are more T wave inversions in
leads V5-V6 which may be due to lead placement. However,
clinical correlation is suggested.
Discharge Labs:
WBC 12.6, Hematocrit 32.1, Plts 467, INR 2.6, Na 141, K 4.2, Cl
92, HCO2 27, BUN 28, Crt 6.0, Gluc 186, AST 49, ALT 58, AlkP
696, T Bili 0.4
Pending Labs:
Insulin antibody
Brief Hospital Course:
Mr. [**Known lastname 61289**] is a 25 year old man with ESRD on HD, Type 1 DM,
recent PE who presented with hyperkalemia, chest pain, and
hypertensive urgency.
#. Hypertensive urgency: It was unclear what medication regimen
he was taking as an outpatient prior to admission. It was felt
that his hypertension on admission was most likely related to
medication nonadherence, anxiety, and volume overload. He was
initially managed on a labetalol drip but subsequently weaned
off once his oral/transdermal medications used during his recent
[**Hospital1 112**] hospitalization were initiated. His blood pressure remained
difficult to control on an oral regimen as well and his oral
labetalol was uptitrated. His blood pressure goal was
160-180/90-100 during this admission. He did have episodes of
transient hypertension with SBP>200. He also had one episode of
hypotension with SBP's in the 80's during hemodialysis. This
was treated by giving back fluid during dialysis and his blood
pressure normalized.
#. Type 1 Diabetes Mellitus: He had labile blood sugars
throughout this admission with both hypoglycemic and
hyperglycemic episodes. He was followed closely by the [**Hospital **]
clinic and his lantus dose and humalog sliding scale were
adjusted.
#. Anxiety: He was very agitated on admission and did not always
show insight and judgement about his medical conditions. He was
initially treated with lorazepam and haloperidol as needed for
anxiety. In the ICU, he was initially felt to not have capacity
to leave against medical advice given his inconsistent ability
to communicate his wishes and express understanding of the
medical consequences of his decisions to refuse treatment. He
became more agreeable during the rest of his hospitalization
upon transfer to the floor, although commonly refused blood
pressures and blood sugar monitoring.
#. Hyperkalemia: He had hyperkalemia on admission with peaked T
waves on ECG. He was given kayexalate with good effect. He had
one further episode of hyperkalemia during his stay prior to
dialysis and was given calcium gluconate and kayexalate for
peaked T waves on ECG. On discharge, he was given a handout of
foods high in potassium to avoid.
#. Chest pain: He had chest pain on presentation to the ED but
had no further CP on admission to the MICU. He had no evidence
of dissection or PE on CTA chest. His cardiac enzymes were
negative. It was felt that his CP symptoms were likely anxiety-
related.
#. History of PE: He had no evidence of recurrent PE on CTA. He
had a subtherapeutic INR on admission and was started on a
heparin drip as a bridge to Couamdin therapy. His INR at
discharge was 2.6 and his heparin drip was stopped. He will
need close monitoring of his INR after discharge. He will have
his labs drawn at dialysis and faxed to his primary care
provider.
#. ESRD on HD: He was continued on HD MWF schedule. He was also
continued on sevelemer, neutraphos. He had a few extra sessions
of ultrafiltration while he was an inpatient.
#. Pruritis: He had generalized pruritis and skin lesions
thought to be consistent with prurigo nodularis. This was felt
to possibly be related to uremia and he was managed with
hydroxyzine.
#. Elevated LFTs: He had persistently elevated LFTs (most
notably Alk phos to the 600 range with mild elevation in
AST/ALT). Upon review of his records from [**Hospital1 112**], he was
extensively worked up there with RUQ ultrasound, hepatitis
serologies, ceruloplasmin, automimmune workup, hemochromatosis
labs, as well as other viral serologies. At that time, his
elevated LFTs were thought to possible be due to right heart
failure in the setting of PE. However, his lab abnormalities
have persisted. Medication liver injury was considered a
possibility and his statin was stopped due to this possibility
in addition to some complaints of lower extremity muscle pain.
Medications on Admission:
patient says he gets refills at [**Company 4916**] pharmacy [**Hospital1 8**] St
in [**Location (un) 577**]. **many medications on hold as has not picked up for
per [**10/2185**] DC summary he endorses names (with exceptions noted
below) but can't recall doses.
Lisinopril 40mg daily - on hold, not picked up since [**2186-2-22**]
Clonidine 0.3mg patch qwednesday - on hold, last on [**2186-1-23**]
Labetalol 800mg TID - last filled [**2186-2-23**] and picked up
Hydral 10mg TID - last filled [**2186-2-13**]
ASA 81mg daily - pt denies taking
Sevelmer 667mg TID - on hold
Famotidine 20mg QHS - last filled [**12/2185**]
Simvastatin 20mg daily - last filled [**12/2185**]
Metaclopramide 5mg q6h - not seen in system
Insulin glargine 14 units [**Hospital1 **] and humalog sliding scale - picked
up [**2-/2186**]
Nephrocaps daily - on hold
Colace [**Hospital1 **] prn - on hold
Zofran prn
Coumadin 8mg daily - on hold, not picked up
Neurontin 300mg QHS - on hold, not picked up
Celexa 20mg daily - on hold, last picked up [**2186-1-23**]
Minoxidil 5g daily - on hold, last picked up [**1-/2186**]
Iron - last picked up [**12/2185**]
s/p Nifedipine 90mg XL
.
MEDICATIONS ON DISCHARGE [**Hospital1 112**] [**4-18**]
Labetalol 400mg TID
Lisinopril 40mg daily
Losartan 50mg daily
Coumadin 7.5mg QPM
Tylenol 650mg Q6h
Aspirin 81mg daily
Clonidine 0.3mg/day Qweek patch
Benadryl 25-50mg PO Q6hr
Colace 100mg PO BID
Fluocinonide 0.05% cream topical [**Hospital1 **]
Folic acid 1mg PO daily
Gabapentin 400mg QAM, 400mg PM, 600mg QHS
Dilaudid 1-2mg Q4hr
Hydroxyzine 25mg QID
Ibuprofen 600mg PO TID
Lantus 25units QAM
Aspart [**2188-9-14**]
Reglan 10mg TID with meals
Nephrocaps 1 tab PO daily
Nicotine patch
Omeprazole 20mg daily
Sarna lotion daily prn
Senna [**Hospital1 **]
Sevelamer 1600mg PO TID with meals
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
Disp:*5 Patch Weekly(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 capsules* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
Disp:*1 tube* Refills:*2*
10. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for itching.
Disp:*90 Tablet(s)* Refills:*2*
11. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*2*
12. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
13. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO Once Daily at
4 PM.
Disp:*60 Tablet(s)* Refills:*2*
14. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times
a day).
Disp:*45 Tablet(s)* Refills:*2*
15. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO twice a day.
Disp:*300 Tablet(s)* Refills:*2*
16. Insulin Glargine 100 unit/mL Solution Sig: Twenty Two (22)
units Subcutaneous at bedtime.
Disp:*qs * Refills:*2*
17. Humalog 100 unit/mL Solution Sig: Insulin sliding scale as
directed Subcutaneous four times a day.
Disp:*qs * Refills:*2*
18. Outpatient Lab Work
You should have your potassium and INR checked at your dialysis
center on [**2186-5-19**] and [**2186-5-22**]. These results should be faxed to
your primary care doctor Dr. [**Last Name (STitle) 14166**] at [**Telephone/Fax (1) 43090**].
19. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
20. Prodigy Lancets Misc Sig: One (1) lancet Miscellaneous
four times a day.
Disp:*120 lancets* Refills:*2*
21. Prodigy Strip Sig: One (1) strip In [**Last Name (un) 5153**] five times a
day.
Disp:*150 strips* Refills:*2*
22. Alcohol Wipes Pads, Medicated Sig: One (1) pad Topical
five times a day.
Disp:*1 box* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Hyperkalemia
Hypertensive Urgency
Secondary Diagnosis:
End Stage Renal Disease on Hemodialysis
Type 1 Diabetes Mellitus
History of Pulmonary Embolus
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 with high potassium levels and
high blood pressure. You underwent dialysis while you were here
and your potassium levels returned to [**Location 213**]. Your blood
pressure medications were changed as well.
You had a low Coumadin level (INR) on admission and were placed
on a heparin drip until your INR was in therapeutic range. It
is important that you take your Coumadin at home and that you
have your INR checked when you are at dialysis. These results
should be faxed to Dr. [**Last Name (STitle) 14166**] who will help manage your dose of
Coumadin.
Changes to your medications:
Increased labetalol to 1000mg by mouth two times daily
Stopped hydralazine
Started aspirin 325mg by mouth daily
Increased Sevelamer to 1600mg by mouth three times daily with
meals
Stopped famotidine
Added omeprazole 20mg by mouth daily
Added metoclopramide 5mg by mouth three times daily
Added nephrocaps 1 cap by mouth daily
Added docusate 100mg by mouth twice daily
Changed Coumadin to 5mg by mouth daily
Changed insulin dosing: Lantus 22 units at bedtime and humalog
sliding scale as directed
Stopped simvastatin
Followup Instructions:
You have the following appointments scheduled:
Name: [**Last Name (LF) **],[**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1105**] MD
Location: [**Hospital3 **] HEALTH CENTER
Address: [**State **], [**Location (un) **],[**Numeric Identifier 60377**]
Phone: [**Telephone/Fax (1) 14167**]
Appointment: [**2186-6-1**] 10:00am
Name: [**Last Name (LF) 978**], [**First Name7 (NamePattern1) 7208**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Appointment: [**2186-6-8**] 2:00pm
Name: [**Doctor Last Name **] Zrebiec, LICSW
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 61293**]
Appt: [**2186-6-8**] at 1:00pm
ICD9 Codes: 5856, 2761, 3051, 2767, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8640
} | Medical Text: Admission Date: [**2125-8-4**] Discharge Date: [**2125-11-19**]
Date of Birth: [**2050-5-9**] Sex: M
Service: SURGERY
Allergies:
Vancomycin / Linezolid
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Sepsis and cellulitis
Major Surgical or Invasive Procedure:
angio [**2125-8-17**]
rt. pig tail chest catheter placement [**2125-8-28**]
left pigtail catheter placement [**2125-9-7**]
Mechanical ventilation
History of Present Illness:
75M with CAD s/p BMS, CHF, COPD, pleural effusions, PVD s/p
femeral endarterectomy and fem to posterior tibial bypass with
saphenous vein graft [**2125-5-28**] who was admitted [**8-4**] with a Right
Lower extremity MRSA surgical wound infection.
Past Medical History:
COPD (home O2)
CAD
Paroxysmal atrial fibrillation (anticoagulated)
PVD
H/O EtOH abuse
SIADH
Possible urinary retention
Coronary artery stenting, vessels unknown
Social History:
Lives at home with wife. The pt has been nearly immobilitezed
during his last 6 weeks at home with minmal ambulation.
Originally, pt was able to ambulate and take care of himself
before it became to painful to walk.
Smoker: [**12-20**] PPD x 60 years, quit 4 mos ago
H/o alcoholism, pt now admits to drinking 1 12oz beer per night.
Family History:
NC
Physical Exam:
On admittance
PE:
Gen: mild distress, diffuse erythema
HEENT: WNL
Chest: CTAB, A-fib
Abd: S/NT/ND
Ext: 5 cm open wound with purulent drainage on medial aspect of
right calf. blanching erythema from R toes to R thigh.
Skin: Red, dry, peeling sking; pt arrived with several small
stg. decubitis on both buttocks; dry brittle nails
Pulses: L R
Femoral Mono Mono
[**Doctor Last Name **] Mono
DP None None
PT None Mono
Graft - Dop
Radial Dop Palp
Pertinent Results:
[**2125-8-4**] 11:08PM
URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 BLOOD-MOD
NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG
UROBILNGN-NEG PH-5.0 LEUK-MOD RBC-0-2 WBC-[**5-29**]* BACTERIA-FEW
YEAST-MOD EPI-0 HYALINE-0-2
[**2125-8-4**] 09:00PM
GLUCOSE-69* UREA N-31* CREAT-1.5* SODIUM-126* POTASSIUM-5.7*
CHLORIDE-95* TOTAL CO2-23 ANION GAP-14 CK(CPK)-314* proBNP-5151*
CALCIUM-8.6 PHOSPHATE-3.5 MAGNESIUM-1.7
[**2125-8-4**] 09:00PM
WBC-16.8*# RBC-3.43* HGB-10.4* HCT-30.2* MCV-88 MCH-30.2
MCHC-34.3 RDW-14.8 NEUTS-80.9* LYMPHS-5.9* MONOS-3.7 EOS-9.4*
BASOS-0.1 PLT COUNT-441*# PT-39.8* PTT-38.1* INR(PT)-4.3*
[**2125-8-10**] TTE
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%).
Regional left ventricular wall motion is normal. There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with borderline normal free wall function. The
ascending aorta is moderately dilated. 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. There is no mitral valve
prolapse. Mild to moderate ([**12-20**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
CT CHEST [**2125-8-27**]
IMPRESSION:
1. Moderate-to-large bilateral pleural effusions, new compared
to [**2125-5-22**].
2. Right [**Doctor Last Name **] lobe consolidation consistent with pneumonia.
3. Mild-to-moderate pulmonary edema superimposed over diffuse
emphysema.
4. Large solitary left paratracheal lymph node.
5. No evidence of abscess or osteomyelitis.
6. Extensive vascular calcifications including coronary arteries
and great
vessels (arteries), aorta, iliac arteries, common femoral
arteries. Minimal
arterial flow diffusely through out lower extremities.
8. Atrophy of the left leg.
9. Focal aneurysmal dilation of right common femoral artery
where in-situ
saphenous bypass arises.
CT CHEST [**2125-9-6**]
CT CHEST WITHOUT CONTRAST: Since the prior CT, there has been
placement of a
right posterior pleural pigtail catheter which terminates in the
major fissure
at the base of the right lung. There is a moderate pneumothorax
including a
basal component and smaller component along the anterior
junction line and the
pleural catheter courses through the largest air pocket. The
fluid component
is also moderate in size and is mostly unloculated, but the
attenuation of the
adjacent pleura is increased which can be seen in empyema. This
becomes a
further possibility as there is a large airspace consolidation
in the right
lower lobe consistent with pneumonia
On the left, there is a moderate partially loculated pleural
effusion which is
relatively unchanged with the prior, with associated
atelectasis. There is
severe emphysema of both lungs and severe anasarca of the soft
tissues.
There is no pericardial effusion. Multiple enlarged mediastinal
lymph nodes,
largest 22-mm left paratracheal (2:23), are very slightly
enlarged and likely
reactive. There are severe coronary artery calcifications and
severe aortic
valvular calcifications. An NG tube is located in the stomach.
The patient
is not intubated. Right PICC tip terminates in the lower SVC.
Study is not tailored for subdiaphragmatic evaluation, but no
abnormality is
noted except for high attenuation of a medullary pyramid in the
right upper
renal pole. No suspicious lesions are identified in the bones.
In the bones, there are multiple anterior wedge deformities of
T6, T7, T8, T9,
and L1, all stable from [**2125-8-27**].
IMPRESSION:
1. Moderate right hydropneumothorax with large right lower lobe
pneumonia.
The pleural effusion may be empyema.
2. Stable partially loculated moderate left pleural effusion
with underlying
atelectasis.
3. Stable enlarged mediastinal adenopathy, which may be
reactive.
4. Severe anasarca.
5. Severe coronary artery and aortic valvular calcifications.
VIDEO OROPHARYNGEAL SWALLOW STUDY [**2125-10-18**]
This study was performed in conjunction with speech pathology
department.
Continuous fluoroscopic observation was provided during
administration of
pudding and nectar-thick consistencies. During initial
nectar-thick
administration in a more recumbent position, there was marked
premature
spillover and frank aspiration, which remained silent. Cough
reflex was
inadequate in clearing the aspirated material. Subsequent
delivery of pudding
and nectar-thick consistency redemonstrated prolonged transit
times of the
oral phase and decreased epiglottic deflection. A
mild-to-moderate residue
was also again noted within the valleculae and piriform sinuses.
While no
laryngeal penetration or aspiration was identified during
swallow, there
appeared to be at least episodes of laryngeal penetration after
swallow from
leftover residue within the piriform sinus. Patient's O2
saturations were
noted to transiently decrease during these episodes.
IMPRESSION:
Episodes of laryngeal penetration and aspiration as described
above.
Technically suboptimal study.
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). 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 are moderately
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is mild
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a fat pad.
Compared with the prior study (images reviewed) of [**2125-8-10**],
right ventricular cavity size is smaller and the severity of
pulmonary artery systolic hypertension and tricuspid
regurgitation are reduced. Aortic regurgitation and mitral
regurgitation are not appreciated on the current study, but the
image quality is suboptimal and may not reflect a true change.
[**2125-11-8**]. RLE LENI.
IMPRESSION: Deep vein thrombosis of the right superficial
femoral vein.
[**2125-11-12**]. CT Chest.
IMPRESSION:
1. Abnormality on recent chest radiograph corresponds to an
enlarging
loculated left pleural effusion. There is no evidence of a
discrete lung
abscess in this region.
2. Persistent pneumonia in the right upper and right lower lobes
with likely necrotizing component in right lower lobe. Slight
improvement in right upper lobe since prior study.
3. New obstruction of airway proximal to the tracheostomy tube,
likely due to intraluminal secretions.
2. Mild hydrostatic edema superimposed on emphysema. Widespread
anasarca.
[**2125-10-6**] 10:00 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2125-10-8**]**
GRAM STAIN (Final [**2125-10-6**]):
<10 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2125-10-8**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. MODERATE
GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 78211**]
[**2125-10-3**].
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 78211**]
[**2125-10-3**].
[**2125-10-3**] 7:54 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2125-10-8**]**
GRAM STAIN (Final [**2125-10-3**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2125-10-8**]):
OROPHARYNGEAL FLORA ABSENT.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
gram stain reviewed: 3+ (5-10 per 1000X FIELD): GRAM
NEGATIVE
ROD(S). were observed [**2125-10-5**].
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. SPARSE
GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| STENOTROPHOMONAS
(XANTHOMONAS) MALTOPH
| |
AMIKACIN-------------- <=2 S
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R 2 S
[**2125-9-24**] 1:15 pm BRONCHOALVEOLAR LAVAGE LLL SUPERIOR.
GRAM STAIN (Final [**2125-9-24**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2125-9-26**]):
OROPHARYNGEAL FLORA ABSENT.
ACINETOBACTER BAUMANNII COMPLEX. >100,000
ORGANISMS/ML..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 78212**]
([**9-24**]).
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 78212**]
([**9-24**]).
FUNGAL CULTURE (Final [**2125-10-8**]): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2125-9-25**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2125-9-24**] 1:15 pm BRONCHIAL WASHINGS WASH RIGHT ( RLL ).
**FINAL REPORT [**2125-9-29**]**
GRAM STAIN (Final [**2125-9-24**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2125-9-29**]):
OROPHARYNGEAL FLORA ABSENT.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
ACINETOBACTER BAUMANNII COMPLEX. MODERATE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. SPARSE
GROWTH.
AMIKACIN >32 MCG/ML.
CEFEPIME >16 MCG/ML.
LEVOFLOXACIN <=2.0 MCG/ML.
sensitivity testing performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII COMPLEX
| KLEBSIELLA PNEUMONIAE
| |
NON-FERMENTER, NOT PSEUDOMO
| | |
AMIKACIN-------------- 16 S R
AMPICILLIN/SULBACTAM-- 8 S =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 32 R R
CEFTAZIDIME----------- =>64 R =>64 R 4 S
CEFTRIAXONE----------- =>32 R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R 1 S
GENTAMICIN------------ =>16 R =>16 R =>8 R
IMIPENEM-------------- 8 I 4 S
LEVOFLOXACIN---------- S
MEROPENEM------------- <=0.25 S 2 S
PIPERACILLIN---------- =>64 R
PIPERACILLIN/TAZO----- 8 S <=8 S
TOBRAMYCIN------------ 4 S =>16 R =>8 R
TRIMETHOPRIM/SULFA---- <=1 S =>16 R <=2 S
[**2125-9-19**] 4:38 pm PLEURAL FLUID
**FINAL REPORT [**2125-10-18**]**
GRAM STAIN (Final [**2125-9-19**]):
THIS IS A CORRECTED REPORT ([**2125-9-20**]).
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 78213**] @ 10:25 AM ON [**2125-9-20**].
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
.
PREVIOUSLY REPORTED AS.
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS
([**2125-9-19**]).
FLUID CULTURE (Final [**2125-9-23**]):
ACINETOBACTER BAUMANNII COMPLEX. MODERATE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 78214**]
([**2125-9-18**]).
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMIKACIN-------------- 16 S
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC CULTURE (Final [**2125-9-23**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Final [**2125-10-18**]): NO FUNGUS ISOLATED.
[**2125-9-18**] 1:27 pm PLEURAL FLUID
**FINAL REPORT [**2125-9-22**]**
GRAM STAIN (Final [**2125-9-18**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 78215**] AT 1725 ON [**2125-9-18**].
FLUID CULTURE (Final [**2125-9-22**]):
ACINETOBACTER BAUMANNII COMPLEX. MODERATE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
GRAM NEGATIVE ROD #2. RARE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 78216**]
([**2125-9-19**]).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII COMPLEX
|
AMPICILLIN/SULBACTAM-- 16 I
CEFEPIME-------------- 32 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- =>16 R
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- 2 S
ANAEROBIC CULTURE (Final [**2125-9-22**]): NO ANAEROBES ISOLATED.
[**2125-9-7**] 2:11 am SWAB Source: CT site.
**FINAL REPORT [**2125-9-11**]**
WOUND CULTURE (Final [**2125-9-11**]):
ACINETOBACTER BAUMANNII COMPLEX. MODERATE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII COMPLEX
| KLEBSIELLA PNEUMONIAE
| |
AMIKACIN-------------- 16 S
AMPICILLIN/SULBACTAM-- 16 I =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 32 R R
CEFTAZIDIME----------- =>64 R =>64 R
CEFTRIAXONE----------- R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R =>16 R
IMIPENEM-------------- =>16 R
MEROPENEM------------- <=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ 8 I =>16 R
TRIMETHOPRIM/SULFA---- <=1 S =>16 R
[**2125-8-5**] 5:03 am SWAB Source: r groin.
**FINAL REPORT [**2125-8-8**]**
WOUND CULTURE (Final [**2125-8-8**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
[**2125-9-6**] 11:37 am PLEURAL FLUID
**FINAL REPORT [**2125-10-5**]**
GRAM STAIN (Final [**2125-9-6**]):
REPORTED BY PHONE TO DR. [**Last Name (STitle) 3172**] [**2125-9-6**] @ 1552..
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI
(PROBABLE
BIPOLAR STAINING GRAM NEGATIVE RODS).
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final [**2125-9-17**]):
ACINETOBACTER BAUMANNII COMPLEX. HEAVY GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
AMIKACIN AND COLISTIN REQUESTED BY DR.[**Last Name (STitle) **].
SENT TO [**Hospital1 4534**] FOR COLISTIN SENSITIVITY.
AMIKACIN sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
COLISITIN = SENSITIVE AT <=2 MCG/ML , SENSITIVITIES
PERFORMED BY
[**Hospital1 4534**] LABORATORIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII COMPLEX
|
AMPICILLIN------------ R
AMPICILLIN/SULBACTAM-- 16 I
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- =>16 R
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final [**2125-9-10**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Final [**2125-10-5**]): NO FUNGUS ISOLATED.
[**2125-10-18**] 04:39AM BLOOD WBC-13.5* RBC-3.42*# Hgb-10.6* Hct-31.9*#
MCV-93 MCH-30.9 MCHC-33.2 RDW-15.9* Plt Ct-804*
[**2125-8-4**] 09:00PM BLOOD WBC-16.8*# RBC-3.43* Hgb-10.4* Hct-30.2*
MCV-88 MCH-30.2 MCHC-34.3 RDW-14.8 Plt Ct-441*#
[**2125-10-18**] 04:39AM BLOOD Neuts-60.1 Lymphs-16.5* Monos-6.3
Eos-16.7* Baso-0.5
[**2125-9-27**] 04:15AM BLOOD Neuts-61.7 Lymphs-12.7* Monos-4.0
Eos-21.5* Baso-0.1
[**2125-10-18**] 04:39AM BLOOD PT-15.6* PTT-29.2 INR(PT)-1.4*
[**2125-8-14**] 09:30AM BLOOD PT-33.8* PTT-41.7* INR(PT)-3.5*
[**2125-9-24**] 07:17PM BLOOD Fibrino-312 D-Dimer-881*
[**2125-10-1**] 12:22AM BLOOD FDP-10-40*
[**2125-10-3**] 12:30AM BLOOD Ret Man-1.7*
[**2125-10-18**] 04:39AM BLOOD Glucose-86 UreaN-19 Creat-0.6 Na-133
K-4.8 Cl-99 HCO3-28 AnGap-11
[**2125-8-4**] 09:00PM BLOOD Glucose-69* UreaN-31* Creat-1.5* Na-126*
K-5.7* Cl-95* HCO3-23 AnGap-14
[**2125-10-8**] 09:08AM BLOOD CK(CPK)-18*
[**2125-8-7**] 11:30AM BLOOD ALT-30 AST-73* LD(LDH)-394* AlkPhos-52
Amylase-20 TotBili-0.5
[**2125-8-4**] 09:00PM BLOOD proBNP-5151*
[**2125-8-9**] 12:51PM BLOOD CK-MB-16* MB Indx-6.3* cTropnT-0.09*
[**2125-8-10**] 10:39AM BLOOD CK-MB-13* MB Indx-3.3 cTropnT-0.12*
[**2125-8-11**] 03:26AM BLOOD CK-MB-12* MB Indx-2.9 cTropnT-0.13*
[**2125-10-8**] 05:41PM BLOOD CK-MB-3 cTropnT-0.16*
[**2125-10-8**] 09:08AM BLOOD CK(CPK)-18*
[**2125-10-17**] 03:50AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.1
[**2125-9-4**] 04:00AM BLOOD Ferritn-812*
[**2125-10-3**] 08:27PM BLOOD Hapto-222*
[**2125-8-7**] 08:55AM BLOOD TSH-3.3
[**2125-9-3**] 11:48AM BLOOD TSH-17*
[**2125-10-2**] 03:28AM BLOOD TSH-2.4
[**2125-10-2**] 03:28AM BLOOD T4-5.3
[**2125-9-13**] 04:32AM BLOOD T4-5.8 T3-52* calcTBG-0.96 TUptake-1.04
T4Index-6.0 Free T4-1.4
[**2125-10-7**] 05:25AM BLOOD Type-ART Temp-36.1 pO2-78* pCO2-49*
pH-7.47* calTCO2-37* Base XS-10
[**2125-10-5**] 04:31AM BLOOD Type-ART pO2-68* pCO2-61* pH-7.44
calTCO2-43* Base XS-13
[**2125-10-4**] 11:43AM BLOOD Type-ART Temp-35.9 FiO2-35 pO2-69*
pCO2-60* pH-7.40 calTCO2-39* Base XS-9 Intubat-INTUBATED
[**2125-10-4**] 04:13AM BLOOD Lactate-0.6
Brief Hospital Course:
In brief, this is a 75M with CAD s/p BMS, CHF, COPD, pleural
effusions, PVD s/p femeral endarterectomy and femoral to
posterior tibial bypass with saphenous vein graft [**2125-5-28**] who was
admitted [**8-4**] with a Right Lower extremity MRSA surgical wound
infection. He has had a complicated hospital course, summarized
as follows.
He was initially treated with Vancomycin, however, developed an
exfoliative rash to this medication. He completed a treatment
course with Linezolid and Unasyn. He developed pancytopenia
during this time. Hematology was consulted; it was thought to be
secondary to Linezolid. PF4Ab was negative for HIT. He also
developed acute renal failure and a NSTEMI during this time.
The patient developed increasing respiratory distress on [**8-26**];
eventually a respiratory code was called. He was found to be
unresponsive, with T = 92 degrees, BP 44/P, HR 82; he was
intubated. Nursing assessment at this time noted necrotic L
toes, necrotic calcaneous, as well as having thick bloody
secretions. His sputum ultimately grew Klebsiella. He was
treated initially with Daptomycin, Ceftazidime, and Fluconazole;
then Ceftriaxone alone from [**Date range (1) 78217**] then Meropenem started on
[**8-31**] (due to MIC levels) for a planned 10 day course (last day
planned as: [**9-6**]). A R pigtail chest tube was placed for his
pleural effusions. He was treated with stress dose steroids.
TFT's consistant with hypothyroid-- endocrine was consulted and
levothyroxine was started.
He was extubated on [**8-29**] and called out of the unit on [**8-30**]. He
was started on a heparin gtt on [**9-1**]. A L pigtail catheter
attempted but not able to be placed [**9-4**]; the R pigtail was
adjusted at that time.
On [**9-5**], the patient had an episode of respiratory distress with
hypertension to 190's/100's. He was reportedly "cyanotic" and
had blue fingertips, however, an O2 sat was unable to be
obtained. ABG around that time was 7.44/51/60/36. He was started
on a nonrebreather, given lasix/diamox and metoprolol. His
pigtail was TPA'd and put out several hundred cc's. His
respiratory status then improved and he was weaned to 2L NC. (Of
note, his I/Os were 1.6/.6 overnight). On [**9-6**] he developed
fever and hypotension and was transferred to the MICU.
The following issues were addressed during his MICU course:
1. Sepsis: He grew acinetobacter from his pleural fluid (right).
IP was consulted and a pigtail was placed on the left side; the
right pigtail continued to drain well. ID was consulted. He was
treated with Daptomycin/Meropenem. Unclear if acinetobacter was
a contaminant. Daptomycin was discontinued and he completed a
course of Meropenem to cover for Klebsiella Ventilator
Associated pneumonia. He then developed another Klebsiella &
Acinetobacter pneumonia, so was treated with Meropenem/Bactrim
which was switched to Mereopenem/Cefepime when his acinetobacter
was found to be resistant to Bactrim. He was on stress dose
steroids which were tapered and completed on [**11-13**]. He will
continue cefepime and meropenem until ???
2. Necrotic L foot: The patient requires a L AKA and a fem-fem
bypass.
Followed by vascular surgery and plan to take patient to OR when
medically clear. Cardiology saw patient and recommended stress
test prior to surgery. Plan is for patient to go to rehab to get
in better condition before undergoing vascular surgery. He will
eventually followup with Dr. [**Last Name (STitle) 1391**]. Plavix was held, but
patient was started on pentoxyphyline and continued on aspirin.
3.Nutrition: The patient was on tube feeds throughout his
hospital stay. He underwent several speech and swallow
evaluations and did not pass. Prior to discharge, he had an IR
guided PEG tube placed which is functioning well. He had an
ileus for approximately 5 days which prevented him from getting
tube feeds. He was started on an aggressive bowel regimen,
opioids were minimized, and patient was started on standing
reglan and hte ileus resolved.
4.Pain control: Patient was continuously experiencing intense
pain with any type of movement of his lower extremities. He was
treated with gabapentin, oxycodone, and a fentanyl patch to
achieve ideal pain control. He developed an ileus so pain
medications were weaned. He was resumed on ultram and around
the clock tylenol.
5.Respiratory Status: Patient had a continued and persistent
hypercarbic respiratory acidosis, likely from underlying COPD,
and several episodes of pneumonia. Tracheostomy was performed.
He was eventually weaned off the vent, with only intermittent
support on trach mask. Then over [**10-30**] developed
worsening infilatrates, reaccumulation of pleural fluid and
fever on Mereopenem/Cefepime.
6.Cellulitis: The patient developed a left knee cellulitis.
This was treated with daptomycin and ciprofloxacin for a total
of two weeks. Daptomycin was chosen because the patient had a
history of MRSA infection and he had an allergy to vancomycin.
His antibiotics were stopped on [**10-17**].
7.Mental Status: The patient went through several weeks of being
quite sedated and unarousable. This was evenually attributed to
the combination of high doses of tramadol and gabapentin. His
gabpentin dosing was decreased and his tramadol was
discontinued. The patient's mental status returned to him being
alert and interactive within two days of making these
interventions.
8.Congestive heart failure: The patient was total body fluid
overloaded. He had marginal blood pressures and so was placed
on a lasix drip. the patient diureses quite a bit, remaining on
the lasix drip for two weeks. It was eventually discontinued
once his fluid status was optimized. He still remains fluid
overloaded, but diuresis has not yet been initiated. Would
recommend diuresisi in the future.
9.NSTEMI: The patient was treated with metoprolol, aspirin.
Plavix was held due to coffee ground emesis from NGT.
10.Atrial Fibrilation: the patient was rate controlled with
metoprolol. He was initially placed on heparin gtt, but this
was discontinued as he began to bleed from a coccygeal ulcer.
His HR was in the 90s at discharge in A. fib.
11. RLE DVT. Patient was initiated on lovenox when he was
found to have a RLE DVT. He is currently getting bridged to
coumadin. Hematocrit has been stable.
12. Pleural effusion. Patient has bilateral pleural effusion.
He underwent several thoracenteses during hospital stay. A
thoracentesis on [**2125-11-12**] was suggestive of empyema
Upper GU bleed: [**11-4**] stablized on proton pump inhibitor.
Medications on Admission:
Coumadin 2.5 mg daily
lasix 40 mg daily
pravachol 40 mg daily
toprol xl 100 mg [**Hospital1 **]
cardizem 120 mg daily
Kcl 40 meq daily
flomax 0.4 mg daily
vitamin D
Advair 250/50 [**Hospital1 **]
xopenex
citracal
Discharge Medications:
N/A
Discharge Disposition:
Expired
Facility:
[**Hospital3 105**] Northeast-[**Location (un) 86**]
Discharge Diagnosis:
Death
Septic shock
Respiratory arrest
Peripheral vascular disease with critical limb
ischemia/necrosis.
right lower extremity cellulitis/wound infection
Ventilator associated/hospital acquired pneumonia
delerium with agitation, etology multifactorial,resolved
drug eruption,resolving with desqumation ? Bactrium ? Vanco,
improved
eosinophilia
Non ST elevation MI
left buttocks pressure decubitus Stg.[**12-20**],left heel decubitus
stage 1-2
history of MRSA
history of coronary artery disease, s/p PCI/stenting
atrial fibrillation
COPD
history of ETOH abuse
history of former tobacco use
history of hyponatremia-fluid restricted
acute blood loss anemia,on chronic, transfused
thrombocytopenia on linezolid with negative HIT
bone marrow suppression [**1-20**] linezolid
Urinary tract infection
bilateral pleural effusions
adrenal insuffiency- stress steroids
hypothyroid by thyroid function studies-synthroid
acute diastolic CHF
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2126-5-10**]
ICD9 Codes: 5849, 5119, 5070, 2851, 5990, 4280, 496, 2875, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8641
} | Medical Text: Admission Date: [**2116-2-11**] Discharge Date: [**2116-2-13**]
Date of Birth: [**2048-2-14**] Sex: M
Service: Urology
HISTORY OF PRESENT ILLNESS: Benign prostatic hypertrophy.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed the patient was a well-developed and well-nourished
male in no apparent distress. Head, eyes, ears, nose, and
throat examination revealed no evidence of cervical
lymphadenopathy. The mucous membranes were moist. No oral
ulcers. Cranial nerves II through XII were intact. No
evidence of scleral icterus. The chest was clear to
auscultation bilaterally. Cardiovascular examination
revealed a regular rhythm and rate. No murmurs. The abdomen
was soft, nontender, and nondistended. No evidence of
abdominal incisional scars. Pelvic/rectal examination
performed prior to the surgery indicated report of benign
prostatic hypertrophy. No inguinal lymphadenopathy was
noted, and Foley was intact with no evidence of gross blood
from the meatus of urethra, and urine was clear.
PERTINENT LABORATORY VALUES ON DISCHARGE: On the day of
discharge, the patient's sodium was 140 and hematocrit was
stable at 26.7.
SUMMARY OF HOSPITAL COURSE: Mr. [**Known firstname **] [**Known lastname 47233**] is a
67-year-old male who presented with increasing difficulty
with urination secondary to benign prostatic hypertrophy.
The patient underwent transurethral resection of prostate
with intraoperative complication of hyponatremia to 117 with
corresponding confusion. The procedure was completed, and
the patient was transferred to the Postanesthesia Care Unit
where hyponatremia was corrected with normal saline fluids
and Lasix.
To preserve cardiac and neurologic stability, magnesium and
calcium were administered. Status post diuresis,
hypocalcemia was counteracted with oral potassium and
intravenous potassium administration. The patient's cardiac
enzymes were not elevated during the postoperative period,
and no electrocardiogram changes were noted. After
monitoring, the patient with every one hour vital signs and
every four hour electrolyte checks, the patient achieved
normonatremia by postoperative day one.
The decision was made to transfer the patient to the floor
where continuous bladder irrigation was weaned secondary to
association of postoperative gross hematuria. No blood
transfusion was required since the patient's hematocrit
remained stable throughout the postoperative course. The
patient was discharged on postoperative day two with a Foley
in place.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to home.
DISCHARGE DIAGNOSES: Status post transurethral resection of
prostate, transurethral resection of prostate syndrome.
MEDICATIONS ON DISCHARGE: The patient was discharged with
five days of Levaquin and a Foley catheter in place.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed
to follow up with Dr. [**Last Name (STitle) 4229**] the following week.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 13920**]
Dictated By:[**Name8 (MD) 11079**]
MEDQUIST36
D: [**2116-2-14**] 09:53
T: [**2116-2-17**] 09:39
JOB#: [**Job Number 40733**]
ICD9 Codes: 2761, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8642
} | Medical Text: Admission Date: [**2152-11-28**] Discharge Date: [**2152-12-10**]
Date of Birth: [**2086-5-31**] Sex: F
Service: CCU SERVICE
HISTORY OF PRESENT ILLNESS: This is a 66 year old female
with paroxysmal atrial fibrillation, status post prior
ablation and cardioversion with a recent recurrence of her A
fib who is admitted for a reablation procedure. She had
hypotension during the procedure to the 60s systolic. She
was found to have a hematocrit drop from 41 to 29 at this
time and was found to have a retroperitoneal bleed and a
rectus sheath bleed on CT scan done emergently.
The patient was transfused two units of blood and placed on a
Dopamine drip with good blood pressure response to the 120s
to 150s and was transferred to the CCU for her critical care
intubated. The patient had been intubated electively prior
to the procedure. Her Heparin was reversed with Protamine
after her drop in hematocrit.
PAST MEDICAL HISTORY: Paroxysmal atrial fibrillation
starting in [**2133**], status post ablation in [**9-/2152**],
cardioversion in 12/[**2151**]. She has been treated in the past
with Sotalol and Cardizem.
Echocardiogram on [**2152-11-28**] showing an ejection fraction of
greater than 55%, mildly dilated left atrium and a small
secundum atrial septal defect. Also a history of
hypertension, dyslipidemia, mitral valve prolapse, status
post hysterectomy, appendectomy, right leg vein ligation.
Also status post a recent left eye hemorrhage and a right
ankle fracture.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Accupril 10 p.o. q d.
2. Propafenone 300 mg q a.m., 225 mg q noon time and q p.m.
3. Coumadin 2.5 mg p.o. q hs which was stopped two days
prior to admission.
4. Multivitamin.
5. Atenolol 25 mg p.o. q d.
SOCIAL HISTORY: The patient is a part time teacher. No
tobacco, no alcohol. No drug use. She is divorced. She has
four grown children.
PHYSICAL EXAMINATION ON ADMISSION TO THE CCU: Temperature,
94.8; pulse, 87; blood pressure, 130/76; saturation, 100% on
ventilator of AC, 614; PEEP, 5; FIO2, 0.4. General, she is
intubated and sedated on Propofol. Head, eyes, ears, nose
and throat, pupils were mid size and sluggish. Anicteric
sclera. Mucous membranes, dry. Left subconjunctival
hemorrhage. Neck, without jugular venous distention. Chest,
clear to auscultation. Vented breath sounds anterolaterally.
Cardiac, regular rate and rhythm. S1, S2. No rubs, gallops
or murmurs. Abdomen, soft, hypoactive but present bowel
sounds. Left rectus abdominal mass. No ecchymoses.
Extremities, there is a cast on her right lower extremity.
Pulses are 1+ in the left dorsalis pedis with good capillary
refill. Extremities are cool. No edema. Mild cyanosis of
her nail beds. The patient had a left femoral A line and two
right groin venous lines and one femoral venous line. Her
popliteal pulse on the right leg was intact.
LABORATORY ON ADMISSION TO THE CCU: Show a white blood count
of 12; hematocrit, 32; platelets, 173. INR, 1.3; PTT, 30.
Sodium, 143; potassium, 3.7; chloride, 112; bicarbonate, 20;
BUN, 17; creatinine, 0.7. Glucose, 219. Calcium, 6.8.
Magnesium, 1.3. Free calcium, 0.98. Initial blood gas,
7.28/41/473. Lactate, 3.0. Subsequent blood gas of
7.48/26/200 on FIO2 of 40%.
CT of abdomen shows left rectus sheath hematoma 4.9 x 7 cm.
Pelvic CT shows 5.5 x 4.7 right pelvic and 7.8 x 6 cm
hematoma which is likely bleeding from the left common
femoral vein.
HOSPITAL COURSE: This is a 66 year old female with
paroxysmal atrial fibrillation which is recurrent, status
post past ablation procedures in cardioversion and trials of
antiarrhythmics, now with large retroperitoneal bleed status
post atrial fibrillation ablation with hypotension.
The [**Hospital 228**] hospital course was complicated by a demand
ischemic event to her myocardium with elevation in her CK and
troponin, a right common and superficial femoral deep venous
thrombosis with subsequent multiple small pulmonary emboli
and urinary tract infection.
1. Hypotension - The patient was hypovolemic status post
large bleed with good response to Dopamine and blood, status
post a bleed. Her blood pressure normalized after this
volume repletion and the patient actually became hypertensive
later in her hospital course.
2. Atrial fibrillation - The patient had a history of
recurrent atrial fibrillation with completed ablation this
admission. She did have brief episodes of atrial
fibrillation and atrial tachycardia on one to two occasions
during this hospital admission. She was started on
Flecainide which was discontinued status post her myocardial
infarction and started on Sotalol which was also
discontinued. She will just be continued for now on
Metoprolol 100 mg p.o. b.i.d. for rate control. She will
follow up with the EP Service with Dr. [**Last Name (STitle) **] for further
management of her atrial fibrillation.
3. Right lower extremity deep vein thrombosis/pulmonary
embolus - The patient began having increased right lower
extremity edema after being transferred to the Floor from the
Unit. This is the leg in which she has a cast for her right
ankle fracture. Lower extremity ultrasound showed a common
femoral and superficial femoral deep vein thrombosis in her
right leg. Because the patient was still showing evidence of
decreasing hematocrit at this time and had a contraindication
to anticoagulation initially with this decreasing hematocrit,
an IVC filter was placed. This was placed through the left
femoral vein without rebleed. The patient tolerated this
procedure well.
One day after placement of the IVC filter, the patient
started to complain of feeling short of breath and began to
require O2 via nasal cannula to keep her sats in the 90%,
with her room sat being in the high 80 percents. A trial CT
scan done at that time showed multiple small pulmonary emboli
in the second and third order pulmonary arteries. At this
time her hematocrit had been stable and she was started on
Heparin with a goal PTT of 50 to 60.
After 72 hours of a stable hematocrit on the Heparin GTT, she
was started on Coumadin for her deep vein thrombosis,
pulmonary emboli and atrial fibrillation. She was given 5 mg
q d and finally reached therapeutic Coumadin level on the
26th. She will be discharged on her former Coumadin dose of
2.5 mg p.o. q hs with follow up of her INRs with her Primary
Care Physician in [**Location (un) 3844**].
4. Myocardial ischemia - The patient did show evidence of
myocardial infarction in the setting of her bleed. This was
most likely a low flow demand infarct rather than an acute
coronary syndrome. Her peak CK was 300 and she did rule in
by index.
5. Pump function - An echocardiogram done after her rule in
showed a decrease in her ejection fraction from 55% to 50%.
She had normal PA pressures of 18 mm of Mercury. She did
have evidence of global right ventricular free wall
hypokinesis which was most likely secondary to her multiple
small pulmonary emboli.
6. Urinary tract infection - The patient was found to have a
urinary tract infection after complaining of abdominal pain.
She was started on a three day course of Ciprofloxacin and
tolerated this well.
DISCHARGE PLAN: The patient was discharged after
demonstrating a stable hematocrit while being therapeutic on
her Coumadin for 24 hours. She will follow up with her
Primary Care Doctor [**First Name (Titles) **] [**Last Name (Titles) 766**], which is in 24 hours after
discharge, for checking of her INR. She will follow up with
Dr. [**Last Name (STitle) **] to follow up on her atrial fibrillation and
ablation this week.
She has decided to keep her IVC filter in place. It had the
option of being a removable IVC filter, however, she felt
that she would feel more comfortable leaving the IVC filter
in place and remaining on her anticoagulation as she would
need to anyway.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSIS:
1. Atrial fibrillation.
2. Deep venous thrombosis with pulmonary embolism.
3. Urinary tract infection.
4. Hypertension.
5. Demand ischemic myocardial infarction.
MEDICATIONS ON DISCHARGE:
1. Accupril 20 mg p.o. q d.
2. Coumadin 2.5 mg p.o. q hs as dose per INR.
3. Metoprolol 100 mg p.o. b.i.d.
4. Ciprofloxacin.
5. .................... 40 mg p.o. q d.
6. Senna.
7. Colace.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**First Name3 (LF) 20049**]
MEDQUIST36
D: [**2152-12-13**] 16:40
T: [**2152-12-13**] 18:43
JOB#: [**Job Number 20050**]
ICD9 Codes: 2851, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8643
} | Medical Text: Admission Date: [**2139-8-26**] Discharge Date: [**2139-9-2**]
Date of Birth: [**2139-8-26**] Sex: F
Service: NB
NAME CHANGE: After discharge the infant's last name will be
[**Name (NI) 68322**].
HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname 68323**] was born at
[**Hospital1 18**] to a 19-year-old mother, primigravida, at 34 weeks
gestation via a C-section for nonreassuring fetal heart rate
with a birth weight of 2,750 grams and an Apgar of 5 and 8 at
1 and 5 minutes. Maternal prenatal screens included a blood
type A positive, antibody negative, rubella immune, RPR
nonreactive, HBSAG negative, GBS unknown. Maternal history is
remarkable for insulin-dependent diabetes mellitus which was
poorly controlled. Mother received Fentanyl prior to
delivery. At delivery the infant was given positive-pressure
ventilations for 30 seconds due to lack of respiratory
effort.
PHYSICAL EXAMINATION: On admission, birth weight of 2,750
which is 90th percentile, length of 50 cm which is greater
than 90th percentile, head circumference 33.5 cm which is
90th percentile. The infant was pink and well perfused.
Anterior fontanelle open and flat. No cleft lip or palate or
central cleft gum noted. Heart: Normal rate and rhythm with a
soft systolic murmur. Pulse is equal. No palmar pulses.
Chest: No retractions. Clear and equal breath sounds.
Abdomen: Soft with no masses palpable. Bowel sounds present.
Normal external female genitalia. Normal tone for a premature
infant with a normal Moro reflex and appropriate response
with exam, strong cry, and sucking present.
HOSPITAL COURSE: RESPIRATORY: The infant initially had some
intermittent retracting initially shortly after birth which
resolved. She has remained stable on room air. She did have 1
episode of a desaturation with a p.o. feeding on [**2139-8-28**] and has had no further issues since that time. She has
had no increased respiratory effort in the past several days.
She has required no methylxanthine therapy.
CARDIOVASCULAR: She has maintained a normal hemodynamic state
with no further murmurs since the initial murmur audible on
admission. Her heart rate and blood pressure have remained
within normal limits.
FLUIDS, ELECTROLYTES, AND NUTRITION: IV fluid was started on
admission to the NICU. The initial D stick was 27. She
initially received 2 D10W boluses for hypoglycemia, at which
time IV fluids were switched over to D12.5. She started
enteral feedings on the newborn day but continued to require
D12.5 infusion for hypoglycemia. The IV fluid infusion was
slowly weaned away over the course of 4 days due to
borderline and transient hypoglycemia. She has for the past 5
days been stable on all enteral feedings with normal D sticks
throughout. She is taking approximately 150 ml per kilogram
per day of breast milk or [**Doctor Last Name **] 20 with iron. Her most recent
weight is . She has only had initial electrolytes measured
at 24 hours of life and those were within normal limits with
a hemolyzed potassium, otherwise normal.
GI: She has had hyperbilirubinemia and was started on
phototherapy on day of life #3 for a bilirubin level of 15.
She received a total of 3 days of phototherapy. Phototherapy
was discontinued on [**2139-9-1**] and her rebound
bilirubin level on [**2139-9-2**] was 10.3
HEMATOLOGY: CBC was done at birth. The crit was 51. Platelet
count was 193. No further CBCs have been measured. No blood
typing has been done on this infant.
INFECTIOUS DISEASE: A CBC and blood culture were screened on
admission to the NICU. The CBC was benign. The blood culture
remained negative. She received a total of 72 hours of
ampicillin and gentamicin. An additional 24 hours was given
after the 48 hour rule out due to an IV infiltrate in the
hand.
INTEGUMENTARY: At 24 hours of life she developed an
extravasation of IV fluid in her left hand that had tissue
sloughing and edema. A plastics consult was done at that time
and dressing changes were done. The IV infiltrate site has
continued to improve daily and is healing very well. She is
no longer receiving any dressing changes for that. She will
require no further follow-up with plastics.
NEUROLOGY: The infant has maintained a normal neurologic exam
for gestational age. No further neurologic studies have been
done.
SENSORY: Audiology-A hearing screen was performed with
automated auditory brainstem responses. The results are
PSYCHOSOCIAL: A [**Hospital1 **] social worker has been involved with the
family. There is no active ongoing psychosocial issues at
this time. If there are any concerns the social worker can be
reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the family.
PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) **], telephone number [**Telephone/Fax (1) 68324**].
CARE RECOMMENDATIONS: Ad lib breast feeding or
supplementation with breast milk of [**Doctor Last Name **] 20 with iron ad lib.
MEDICATIONS: None.
CAR SEAT SCREENING:
STATE NEWBORN SCREEN: Sent on [**2139-8-29**]. Results are
pending.
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine was given on
[**2139-8-29**].
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 less than 32 weeks
gestation. 2) Born between 32 and 35 weeks gestation with
2 of the following. Either Day Care during RSV season, a
smoker in the household, neuromuscular disease, airway
abnormalities, or school age siblings; or 3) with chronic
lung disease.
2. Influenzae 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 influenzae is
recommended for household contacts and out of home
caregivers.
Follow-up appointment is scheduled with the pediatrician on
[**2139-9-4**]. VNA referral has been made. VNA follow-up
will occur after discharge.
DISCHARGE DIAGNOSIS:
1. Prematurity, born at 34 weeks gestation.
2. Large for gestational age infant.
3. Infant of a diabetic mother.
4. IV extravasation.
5. Hyperbilirubinemia.
6. Sepsis, ruled out.
[**Doctor First Name **] [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 62348**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2139-9-1**] 20:18:56
T: [**2139-9-1**] 22:05:14
Job#: [**Job Number 68325**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8644
} | Medical Text: Admission Date: [**2179-5-21**] Discharge Date: [**2179-5-25**]
Date of Birth: [**2158-5-11**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Codeine
Attending:[**First Name3 (LF) 3129**]
Chief Complaint:
Hypertensive Emergency/Seizure/Hyperkalemia
Major Surgical or Invasive Procedure:
Hemodyalisis
History of Present Illness:
Ms. [**Known lastname 76867**] is a 20 year old female with MPGN s/p renal
transplant ([**7-13**]) and recurrent MPGN who was recently admitted
over the last few months for hypertensive emergency twice.
.
She started peritoneal dialysis and tried to do this at home
today. Around 3:30 pm she had a generalized seizure and was
found on the floor at home by her father, drooling and
nonverbal, and he called EMS. She was brought to the ED and had
a seizure in the ED as well witnessed by the ED staff and her
mother. She had quite elevated BP with SBP > 250 and a cough
over the last few days.
.
In the ED, she was hypertensive to 258/168. She was given
labetalol 10 iv x 2 then started on labetalol GTT. She was noted
to have a K of 7 so she was given bicarb, insulin, glucose, and
calcium. She had an additional generalized seizure in the ED.
She got 1 gram of vancomycin and 1 gram of ceftriaxone. She was
admitted to the ICU for emergent hemodialysis
Past Medical History:
) MPGN: Diagnosed age 9 by biopsy. S/p LRRT in 08/[**2175**]. Post
transplant pt was doing well, but had rising Cr for two year. In
[**6-/2178**] pt presented with uncontrolled BP requiring ICU
admission for Isradipine drip. Repeat biopsy showed a type 1
MPGN. Negative HepC,HepB,[**Doctor First Name **], and renal U/S from NMEC showed
stable AVF. Her creatinine peaked to 4's and she was started on
steroids, prograf and cellcept. In [**1-/2179**], she required 3
sessions of HD through a right upper chest catheter. Creatinine
slowly recovered to 3.2. Plasmapheresis was then initiated with
plan to then treat with Rituximab. She only underwent 3 sessions
of [**Year (4 digits) **]. She is now transferred her care to Dr. [**Last Name (STitle) **]
at [**Hospital1 18**] to an adult clinic.
2) Peripheral edema and abdominal striae [**1-9**] steroids
3) HTN [**1-9**] steroids and renal disease, multiple admissions for
Hypertensive emergency.
4) Hemolytic Anemia - was seen by heme/onc who felt it was [**1-9**]
to malignant hypertension.
5) Migraines
Social History:
Lives at home with [**Month/Day (2) **], brother and sister, college student
at [**Name (NI) 498**] [**Name (NI) 86**] in the health sciences. Denies ETOH, illicit
drugs, tobacco.
Family History:
No history of kidney disease, malignancy, heart disease, or
diabetes.
Physical Exam:
VS: T98.6 BP 196/132 P106 R29 98% 3L NC
GEN: eyes close, opens to voice, sedated
[**Name (NI) 4459**]: Pupils reactive direct and consentual biaterally. OP
clear, MMM
RESP: crackles all areas posteriorly
CV: RRR 2/6 SEM LUSB
CHEST: HD catheter in right chest wall
ABD: Soft NT/ND + BS no rebound or guarding. PD catheter in
place
EXT: Warm well perfused, no peripheral edema
SKIN: slight skin discoloration over right tibia
NEURO: moves hands and feet slightly to command. Opens eyes to
voice. Nonverbal.
Pertinent Results:
[**2179-5-21**] 04:30PM CALCIUM-10.0 PHOSPHATE-9.2* MAGNESIUM-2.0
[**2179-5-21**] 04:30PM estGFR-Using this
[**2179-5-21**] 04:30PM GLUCOSE-158* UREA N-54* CREAT-9.9*#
SODIUM-142 POTASSIUM-7.4* CHLORIDE-100 TOTAL CO2-21* ANION
GAP-28*
[**2179-5-21**] 04:37PM GLUCOSE-154* LACTATE-4.4* K+-7.0*
[**2179-5-21**] 04:37PM COMMENTS-GREEN TOP
[**2179-5-21**] 05:25PM PLT SMR-NORMAL PLT COUNT-185
[**2179-5-21**] 05:25PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-3+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
SPHEROCYT-OCCASIONAL OVALOCYT-1+ TARGET-OCCASIONAL SCHISTOCY-1+
BURR-1+ TEARDROP-OCCASIONAL
[**2179-5-21**] 05:25PM NEUTS-96.8* BANDS-0 LYMPHS-1.7* MONOS-0.8*
EOS-0.5 BASOS-0.2
[**2179-5-21**] 05:25PM WBC-12.2*# RBC-3.56* HGB-10.7* HCT-33.8*
MCV-95 MCH-30.0 MCHC-31.6 RDW-22.9*
[**2179-5-21**] 05:25PM CALCIUM-9.9 PHOSPHATE-9.1* MAGNESIUM-1.9
[**2179-5-21**] 05:25PM GLUCOSE-261* UREA N-55* CREAT-10.1*
SODIUM-142 POTASSIUM-7.0* CHLORIDE-100 TOTAL CO2-24 ANION
GAP-25*
[**2179-5-21**] 05:48PM LACTATE-4.9*
[**2179-5-21**] 07:44PM PLT COUNT-177
[**2179-5-21**] 07:44PM WBC-14.3* RBC-3.66* HGB-10.9* HCT-34.8*
MCV-95 MCH-29.9 MCHC-31.4 RDW-22.1*
CT
NDICATION: 21-year-old woman status post seizure.
COMPARISON: None.
TECHNIQUE: Contiguous axial images of the cervical spine were
obtained without IV contrast. Sagittal and coronal
reconstructions were also obtained.
FINDINGS: No disc, vertebral or paraspinal abnormality is seen.
There is no sign of a fracture or abnormal alignment. While CT
is not able to provide intrathecal detail comparable to MRI, the
visualized outline of the thecal sac appears unremarkable.
The lung apices demonstrate multifocal, patchy airspace
opacities, worrisome for an infectious process, and are
incompletely evaluated on this study.
IMPRESSION: No acute abnormalities of the cervical spine. Patchy
airspace opacities seen at the lung apices, incompletely
evaluated. Please refer to dedicated chest radiograph obtained
[**2179-5-21**] at 1700 hours.
..
CT HEAD W/O CONTRAST
Reason: bleed?
[**Hospital 93**] MEDICAL CONDITION:
21 year old woman with ESRD on PD, sz and hypertensive today.
also with fall with seizure
REASON FOR THIS EXAMINATION:
bleed?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 21-year-old woman with fall, seizure, and
hypertension today. History of ESRD on PD.
COMPARISON: Head CT of [**2179-4-27**].
TECHNIQUE: Contiguous axial images were obtained through the
brain. No contrast was administered.
FINDINGS: There is no acute intracranial hemorrhage, edema, mass
effect, shift of normally midline structures, or evidence of
major vascular territorial infarct. The ventricles and sulci are
normal in contour and configuration. There is no fracture and
the sinuses and mastoid air cells are well aerated. Soft tissues
are unremarkable.
IMPRESSION: No acute intracranial abnormalities.
.
========
CHEST (PORTABLE AP) [**2179-5-21**] 5:11 PM
CHEST (PORTABLE AP)
Reason: pna? pulm edema?
[**Hospital 93**] MEDICAL CONDITION:
21 year old woman with ESRD and seizure. recent cough.
REASON FOR THIS EXAMINATION:
pna? pulm edema?
HISTORY: 21-year-old woman with ESRD and seizures; ? pneumonia
or pulmonary edema.
FINDINGS: Single bedside AP examination labeled "supine at 1700
p.m." is compared with studies dated [**5-2**] and [**2179-5-3**]. The
overall appearance is dramatically worse, now with diffuse and
more confluent airspace opacity and lower lung volumes, which
could represent progressive pulmonary infection, pulmonary
edema, or both. The heart appears further enlarged with "water-
bottle" configuration, supporting a contribution of edema,
though there is no large pleural effusion. The right-sided
dual-lumen venous access device is unchanged.
Brief Hospital Course:
ASSESSMENT/PLAN: 21 year-old woman with with ESRD, h/o MPGN-type
1 s/p transplant now with recurrence in transplanted kidney,
recent transition to peritoneal dialysis admitted to MICU with
hyperkalemia, volume overload, hypertensive urgency, and
seizures
#MICU course: In the MICU, she was continue on labetalol drip
and was emergently dialized. Peritoneal fluid was sent on
admission and was negative for SBP. 14 WBC. Remained afebrile.
Labetalol drip was off at 11pm [**2179-5-21**]. All her oral BP meds
were started. She also received another dose of antibiotics but
after discussion with renal team it was determined to stop them
given no signs of infections. She has also cmplained of
intermittent headache while in the unit treated with dilauded
PRN. This am labs her K came back as 6.5. No EKG changes. It was
also discusssed with renal team not to give her any kayexalate
unles EKG changes.
# Headaches: per prior discharge summarys, patient with h/o of
headaches. They are not always related to her elevated BP.
Patient has a follow up appointment with neurology in [**Month (only) 205**] for
further evaluation.
.
# Hypertensive Emergency: BP currently well control with oral PO
meds when transfer to the floor.She was kept on losartan,
metoprolol, isradipine, hydralazine, clonidine and lisinopril.
Also after peritoneal dialysis was on board, her BP's improved.
.
# Hyperkalemia: on admission due to CKD. Electrolytes
disturbances were managed with HD.
.
# CKD: Upon transfer to the floor, her PD scheduled was
optimized. She had [**3-14**] dwells with 2.5% per day. Her weights
were followed closely. The day of discharge she had 1 HD
treatment with 2L off at the end. Her weight ~ 47kg.
Instructions wer given upon discharge to continue to peritoneal
dialysis at home.
.
# seizures - likely secondary to hypertensive emergency and
electrolyte imbalance. No new episodes since admission to MICU.
Head Ct negative on admission. Infectious work up remained
negative. Patient will have a follow up with neurology in [**Month (only) 205**].
.
# Hypoxia/volume overload : on admission secondary to being
unable to do her Peritoneal dialysis. Her oxygenation improved
after dyalisis was re-started.
.
# ? infection Peritoneal dialysis: Given seizures and low grade
temperatue on admission, there was a concern for infection upon
presentation. Peritoneal fluid analysis was negative for SBP. Cx
remained negative until discharge. Initial empiric antibiotic
therapy was discontinued.
.
Medications on Admission:
B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Capsule
PO once a day.
Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Isradipine 2.5 mg Capsule Sig: Six (6) Capsule PO TID (3
times a day).
Losartan 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily)
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
2. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO three times a
day.
5. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO three times
a day.
6. Isradipine 5 mg Capsule Sig: Three (3) Capsule PO three times
a day.
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
8. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: Thirty
(30) ML PO Q 8H (Every 8 Hours) for 1 days.
Disp:*1 bottle* Refills:*0*
11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
12. Sevelamer HCl 800 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
15. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
Disp:*1 botttle* Refills:*0*
16. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive Emergency
Hyperkalemia
Discharge Condition:
Good
Discharge Instructions:
You were admitted with high blood pressure, seizures and
elevated K
Please continue your dialysis as instructed by the renal team.
Please take all your blood pressure meds as prescribed.
If fevers, chills, nausea/vomit, worsening headache or any other
symptoms that may concern you, call your PCP or come to the
emergency department
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 8222**], MD Phone:[**Telephone/Fax (1) 2928**]
Date/Time:[**2179-6-8**] 7:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2179-6-17**] 1:20
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2179-7-22**] 9:40
Completed by:[**2179-5-27**]
ICD9 Codes: 5856, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8645
} | Medical Text: Admission Date: [**2128-3-29**] Discharge Date: [**2128-4-15**]
Date of Birth: [**2082-6-7**] Sex: M
Service: SURGERY/GOLD
HISTORY OF PRESENT ILLNESS: The patient is a 45 year old
male with a 24 year history of ulcerative colitis, who on
recent colonoscopy was found to have marked polypoid changes
in the transverse colon, making ongoing surveillance
impossible in terms of cancer prevention. The patient's
gastroenterologist performed numerous biopsies in the region
with no dysplasia noted on pathology. The ascending colon
and cecum were normal grossly as was the rectosigmoid portion
of the colon. The patient's gastroenterologist also noted
some liver abnormalities on the patient's blood work in terms
of decreased platelet count and elevated AST.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Aortic and mitral valve insufficiency.
3. Alcoholism.
4. Crohn's disease.
PAST SURGICAL HISTORY: Appendectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Wellbutrin.
2. Sulfasalazine.
3. Benadryl.
4. Vitamins.
PHYSICAL EXAMINATION: The patient was afebrile with stable
vital signs. He appeared reasonably healthy. The patient
was hard of hearing. The patient'a abdomen was notable for
an umbilical hernia. The patient had a normal anus, anal
verge, sphincter tone and mucosa on rectal examination.
There was no palpable mass. The patient had early
Dupuytren's contracture in both palms. No cutaneous spiders
were noted.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2128-3-29**], and taken to surgery
where he had a total colectomy performed with ileorectal
anastomosis. Surgery was performed without complications.
Please refer to the operative note for details. The patient
was thereafter transferred to the surgical floor for
continued management. Over the course of postoperative day
number one and postoperative day number two, the patient had
moderate and then increasing quantities of blood per rectum.
The patient's hematocrit was noted to drop from 30.5 to 25.0.
He ultimately required transfer to the Surgical Intensive
Care Unit for continued management for continued bleeding per
rectum as well as frequent need for transfusions. By the
morning of postoperative day number two, the patient had
received six units of packed red blood cells as well as a
unit of platelets. A decision was ultimately made to return
the patient to the operating room for suspected bleed at his
ileorectal anastomosis. In the operating room, the patient
had a Hartmann's procedure performed with an end ileostomy
and rectal and abdominal washout. The patient was thereafter
transferred to the Intensive Care Unit for continued
management. The patient's Intensive Care Unit course was
notable for persistent low grade temperature that was
ultimately determined to be secondary to pneumonia. The
patient was appropriately treated with the fever resolving.
During the course of the patient's nine day admission in the
Intensive Care Unit, the patient also developed significant
alcohol withdrawal symptoms. The patient required sedation
and remained on a ventilator for much of his Intensive Care
Unit stay. He was ultimately extubated on the night of
[**2128-4-8**]. The patient was also started on total parenteral
nutrition while in the Intensive Care Unit. While in the
Intensive Care Unit, the patient also developed some erythema
of the proximal and distal portions of his midline abdominal
incision and was started on Kefzol. The erythema ultimately
resolved with the therapy. A small portion of the distal end
of his wound was opened and was managed with wet to dry
packings twice a day. By the time of discharge, the patient
continued on wet to dry dressings twice a day and the wound
bed was looking healthy and granulating. As part of the
workup of the patient's persistent fevers, the patient
underwent CAT scan of his abdomen on [**2128-4-7**]. The CAT scan
revealed a fluid collection with an enhancing rim adjacent to
the patient's rectal suture line. This finding prompted the
scheduling of a pouchogram of the patient's rectal stump on
[**2128-4-8**]. The patient's stump was found not to have a leak
on this study. The patient was transferred to a general
surgery floor on postoperative day number eleven/nine. His
antibiotic therapy was discontinued. As the gas offered from
his ostomy increased, the patient's diet was advanced. His
nasogastric tube was also discontinued on postoperative day
thirteen/eleven. The patient's total parenteral nutrition
was discontinued. The patient was ultimately deemed stable
and ready for discharge on postoperative day number
seventeen/fifteen. Prior to discharge, the patient was seen
by an addiction counselor. The patient was to follow-up with
his primary care physician with arrangements made for further
addiction counseling. The patient was also given the name
and number of [**Hospital1 69**] counselor
that he could contact. The patient received teaching on the
management of his stoma while in house.
CONDITION ON DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE:
1. Clonidine 0.2 mg once daily patch.
2. Metoprolol 50 mg, 0.5 tablets twice a day.
3. Percocet one to two tablets every four to six hours.
4. Lorazepam 1 mg p.o. one half tablet every six hours as
needed.
FOLLOW-UP: The patient was to follow-up with Dr.
[**Last Name (STitle) **] following discharge. The patient was also to
follow-up with his primary care physician following
discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11126**]
Dictated By:[**Name8 (MD) 997**]
MEDQUIST36
D: [**2128-4-15**] 18:22
T: [**2128-4-17**] 15:19
JOB#: [**Job Number 46122**]
ICD9 Codes: 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8646
} | Medical Text: Admission Date: [**2138-6-2**] Discharge Date: [**2138-6-18**]
Date of Birth: [**2138-6-2**] Sex: M
Service: NEONATOLOGY
HISTORY: Baby [**Name (NI) **] [**First Name4 (NamePattern1) **] [**Known lastname 42701**] was born at full term by
spontaneous vaginal delivery to a 38-year-old gravida 6,
para 2 now 3. Maternal prenatal screens were blood
negative. The pregnancy was notable for a prenatal
diagnosis of trisomy 21. The mother had spontaneous onset of
labor and an uncomplicated peripartum course. Apgars were 7 at
one minute and 8 at five minutes. The infant went to the
Newborn Nursery but was transferred to the Newborn Intensive
Care Unit on day of life number one for hypothermia and
hypoglycemia.
PHYSICAL EXAMINATION: Revealed a full-term infant, anterior
fontanel soft and flat, up-slanting palpebral fissures,
positive Brushfield spots, ears normally set, palate intact.
Some redundant neck folds. Normal palmar creases. Lungs clear
and equal, with good aeration. Regular rate and rhythm of the
heart, a II/VI systolic murmur at the left mid to left upper
sternal border. 2+ femoral and brachial pulses. Soft abdomen, no
hepatosplenomegaly. Testes descended bilaterally, patent
anus. Well perfused, jaundiced. Generalized hypotonia with
significant head lag.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: [**Doctor Last Name **] had a persistent nasal cannula oxygen
requirement in the Newborn Intensive Care Unit without
respiratory distress, most likely due to general
hypotonia and hypoventilation. He weaned to room air on day
of life 14. On examination, his respirations are unlabored,
lung sounds are clear and equal.
2. Cardiovascular: A cardiac echo done on day of life
number three revealed just a patent foramen ovale. No
further cardiac follow up is recommended. He does have an
intermittently audible Grade I-II/VI systolic ejection murmur. He
is pink and well perfused in room air.
3. Fluids, electrolytes and nutrition: Birth weight was
3595 grams. His birth length was 49.5 cm, and birth head
circumference 33 cm. At the time of discharge, his weight is
3640 grams, his length 51 cm, and head circumference 34 cm.
He is breast feeding or drinking bottled breast milk, taking
adequate volumes, and has established consistent weight gain
prior to discharge. ([**Doctor Last Name **] is not as "demanding" as other term
infants and will benefit from close attention to feeding cues.)
He and his mother have been followed by the [**Hospital1 18**] lactation
service, and his mother may call here for [**Name (NI) 42702**] support as needed
after discharge ([**Telephone/Fax (1) 42703**]).
4. Gastrointestinal: The infant was treated with
phototherapy for exaggerated physiologic hyperbilirubinemia from
day of life number three through 8 and again from day 10 until
day of life 14. His peak bilirubin occurred on day of life number
11, with total 19.6, direct 0.5. His last bilirubin was done on
[**6-18**], two days after phototherapy was finally discontinued, and
was stable at 11.7/0.4.
5. Hematology: His last hematocrit on [**6-10**] was 61.8,
platelets were 174,000. The infant's blood type is O
negative, direct Coombs negative. The infant has never
received any blood products during his Newborn Intensive Care
Unit stay.
6. Infectious Disease: A blood culture was drawn at the
time of admission. He never required any antibiotics, and
the blood culture remained negative. There have been no
other Infectious Disease issues.
7. Sensory: Hearing screening was performed with automated
auditory brain stem responses, and the infant passed in both
ears.
8. Psychosocial: The parents have been visiting daily
during the Newborn Intensive Care Unit stay, and have been
very involved in the infant's care.
9. Genitourinary: The infant was circumcised on [**2138-6-17**].
There was a small amount of oozing just after the procedure.
10. Genetics: Chromosome testing done on [**2138-6-3**] confirmed
the prenatal diagnosis of 47-XY (trisomy 21).
CONDITION AT DISCHARGE: The infant is discharged in good
condition.
DISCHARGE STATUS: The infant is discharged home with his
parents.
PRIMARY PEDIATRIC CARE: Will be provided by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4427**]
of [**Hospital6 42704**] in [**Hospital1 392**], [**State 350**],
telephone number [**Telephone/Fax (1) 42705**].
CARE RECOMMENDATIONS:
1. Feedings: Breast feeding ad lib.
2. Medications: The infant is discharged on no medications.
3. A car seat position screening test is being done on the
day of discharge.
4. Immunizations received: The infant received his
hepatitis B vaccine on [**2138-6-8**].
5. State newborn screens were sent on [**6-5**] and [**2138-6-17**].
6. Follow up appointments:
a. The infant will have First Early Intervention, telephone
number [**Telephone/Fax (1) 42644**].
b. Genetics at [**Hospital3 1810**], Dr. [**Last Name (STitle) 42706**], telephone
number [**Telephone/Fax (1) 37200**], appointment for Tuesday, [**7-29**], at 3
P.M.
c. The Down's syndrome clinic at [**Hospital3 1810**],
attending physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. The mother has the phone number
to make an appointment.
DISCHARGE DIAGNOSIS:
1. Full-term newborn infant
2. Status post hypothermia
3. Status post hypoglycemia
4. Trisomy 21
5. Sepsis ruled out
6. Status post circumcision, [**2138-6-17**]
7. Status post phototherapy for physiologic hyperbilirubinemia
8. Status post persistent oxygen requirement due to
hypoventilation
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 36532**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2138-6-18**] 02:04
T: [**2138-6-18**] 02:17
JOB#: [**Job Number 42707**]
ICD9 Codes: V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8647
} | Medical Text: Name: [**Known lastname 14938**], [**Known firstname 651**] T Unit No: [**Numeric Identifier 14939**]
Admission Date: [**2159-12-11**] Discharge Date: [**2159-12-14**]
Date of Birth: [**2104-11-10**] Sex: M
Service: CA/TH [**Doctor First Name 1379**]
HISTORY OF PRESENT ILLNESS: This is a 55 -year-old gentleman
who presented to [**Hospital3 **] - [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] with
acute onset chest pain and ruled in for a non-Q-wave
myocardial infarction. He had no history of orthopnea,
paroxysmal nocturnal dyspnea. The patient had no history of
CVA, transient ischemic attack, or aortic insufficiency. He
has denied any neurologic symptoms. The patient denies any
symptoms of claudication.
PAST MEDICAL HISTORY:
1. Back pain.
2. Erectile dysfunction.
3. Hypercholesterolemia.
4. Obesity.
PAST SURGICAL HISTORY:
1. Status post hernia repair.
2. Status post spinal cord biopsy.
SOCIAL HISTORY: Tobacco abuse, quit one month ago.
ADMITTING MEDICATIONS: Amitriptyline, Atenolol,
methacarbond, nitroglycerin, Ultram, aspirin.
PHYSICAL EXAMINATION: Height: 5' 11", weight 110 kg. Vital
signs: blood pressure 134/81, pulse 73. Mental status: alert
and oriented times three. General impression: looks well.
Neck is supple. Chest is clear to auscultation bilaterally.
Cardiac: regular rate and rhythm, S1, S2, no murmurs.
Neurologic: the patient has pins and needles over the tips of
his fingers and his feet. The patient has palpable pulses in
all four extremities. Abdomen is soft, nontender,
nondistended.
PERTINENT LABORATORY DATA: Cardiac catheterization performed
on [**12-5**] showed three vessel coronary artery disease.
Summary of lesions include patent left main coronary artery,
left anterior descending 80% stenosis, left coronary artery
80% stenosis, right coronary artery 60% stenosis. Left
ventricular ejection fraction 55%.
HOSPITAL COURSE: On the day of admission, the patient was
admitted to the hospital and went to the Operating Room with
Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] where he was placed under anesthesia
and had a coronary artery bypass graft, three vessels. He
had left ventricular mammary artery anastomosed to the left
anterior descending, saphenous vein graft anastomosed to the
posterior descending artery, saphenous vein graft to the
obtuse marginal. Please see previously dictated operative
note for more details. The patient tolerated the procedure
well and was transferred to the Cardiac Surgery Recovery Unit
postoperatively. Of note, the patient's vein harvest was
performed endoscopically.
The patient was transferred to the Cardiac Surgery Recovery
Unit only on a Propofol drip. His postoperative course was
uneventful and he was extubated on postoperative day one. On
postoperative day one, his chest tube had decreased output,
had no evidence of air leak, and was removed. He was
transferred to the Patient Care Floor on postoperative day
one.
On postoperative day two, he was tolerating a regular diet,
ambulating on level II to III. On this day, his Foley
catheter was removed, as were his pacer wires. By
postoperative day three, the patient was tolerating a regular
diet, was ambulating to a level V, Foley had been out and he
was able to void without problem. [**Name (NI) **] was to be discharged
home pending his comfort and the family's comfort taking him
home.
The [**Hospital 1325**] hospital course was complicated only by a
temperature to 101.5 F on the evening of postoperative day
two going into postoperative day three. For this, a
urinalysis was sent which was negative. A white count was
checked which was 8.3, which was decreased from previous
measurements. A chest x-ray was shot which had no evidence
of acute cardiopulmonary disease. The wound had no evidence
of erythema or drainage.
DISCHARGE CONDITION: Stable.
DISPOSITION: To home.
DISCHARGE MEDICATIONS: Lasix 20 mg po bid times one week,
potassium chloride 20 mEq po bid while on Lasix, aspirin 81
mg po q day, amitriptyline 150 mg po q HS, Colace 100 mg po
bid while on Vicodin, Vicodin one to two tablets po q four to
six hours prn, Lopressor 75 mg po bid, Lipitor 10 mg po q day
(The patient was started on Lipitor during this
hospitalization as he had a history of hyperlipidemia. Prior
to starting him, his liver function tests were checked which
were all within normal limits. The patient will follow with
his primary care physician to increase the dose of Lipitor.)
DISCHARGE DIAGNOSIS:
Status post coronary artery bypass graft times three on
[**2159-12-11**]. Left internal mammary artery to left
anterior descending, saphenous vein graft to obtuse marginal,
saphenous vein graft to posterior descending artery.
FO[**Last Name (STitle) 6646**]P: The patient will follow up with Dr. [**Last Name (Prefixes) **]
in three to four weeks. The patient will follow up with his
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1801**] in three weeks.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**]
Dictated By:[**Last Name (NamePattern1) 2383**]
MEDQUIST36
D: [**2159-12-14**] 16:25
T: [**2159-12-19**] 08:20
JOB#: [**Job Number 14940**]
ICD9 Codes: 9971, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8648
} | Medical Text: Admission Date: [**2150-12-2**] Discharge Date: [**2150-12-3**]
Date of Birth: [**2083-9-7**] Sex: F
Service: NEUROSURGERY
Allergies:
Lipitor / cefazolin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Elective admission for coiling of the recanalized R PCOMM
aneurysm
Major Surgical or Invasive Procedure:
[**2150-12-2**]: Cerebral angiogram with coiling
History of Present Illness:
Elective admission to re-coil R PCOMM aneurysm. Previous
admission in [**2150-3-10**] for SAH.
Past Medical History:
[**3-/2150**] SAH, aneurysmal rupture, R PCOMM aneursym,
hydrocephalus, VP shunt inserted. PEG placement.
hypothyroid, hyperlipidemia, s/p cholecystectomy, s/p
craniotomy (unknown history at this time), ? right ear surgery
Social History:
Lives with husband, supportive family nearby.
Family History:
non-contributory
Physical Exam:
On admission:
Nonfocal, thick speech
Upon discharge:
Nonfocal, thick speech
Brief Hospital Course:
67F elective admission for recoiling of the R PCOMM aneurysm.
Post-angio the sheath remained in placed, the patient was
admitted to the Neuro ICU for monitoring. The sheath was removed
and pressure was held. The angio site remained intact.
Overnight, the patient remained stable. Her diet and activity
was advanced. Her foley was removed. She was discharged on [**12-3**]
to home.
Medications on Admission:
Pravastatin
Levothyroxine
Discharge Medications:
1. acetaminophen 325 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. aspirin 325 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily):
For one month.
3. pravastatin 20 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY
(Daily).
4. levothyroxine 75 mcg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
R PCOMM Aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily for one month.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please follow-up with Dr [**First Name (STitle) **] in 6 months with a MRI/MRA with
and without contrast ([**Doctor Last Name **] protocol). Please call [**Telephone/Fax (1) 4296**]
to make this appointment.
Completed by:[**2150-12-3**]
ICD9 Codes: 2449, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8649
} | Medical Text: Admission Date: [**2152-3-20**] Discharge Date: [**2152-3-28**]
Date of Birth: [**2096-7-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Esophago-gastro-duodenoscopy (EGD), with clipping of duodenal
ulcer
History of Present Illness:
This is a 55yo Jehovah's Witness trasferred from Cape Code
Hospital for further care after an upper GI tract bleed. The
patient was admitted to Cape Code Hospital on [**2152-3-17**] for 4 days
of melena, shortness of breath, fatigue, and dizziness. The
patient was noted to have a hct of 18 on that admission,
dropping to 13 on the night of admission. EGD on [**3-17**] revealed
a superficial gastric ulcer and a duodenal ulcer, neither of
which were bleeding. Repeat endoscopy on [**3-18**] revealed a small
oozing gastric ulcer which was cauterized and a small dot of
bleeding on the duodenal ulcer. The pt has reported use of
excessive Excedrin for treatment of his carpal tunnel (1000 mg
q6hr). The pt was maintained on protonix, IV ferrous gluconate,
epogen, and sucralfate. While at the outside hospital, the
patient was noted to be persistently febrile to 100.8 on [**1-14**]
and 101.8 upon transfer. Last labs at outside hospital from
[**3-19**]: plt 228, WBC 8.3, hct 15, INR 1, Troponin I of 0.66 on
[**3-17**]. The pt currently denies chest pain, abdominal pain,
shortness of breath. He does feel feverish. He also denies
nausea, hematemesis, bleeding from the rectum. He denies
headache, congestion, cough, dysuria.
Past Medical History:
duodenal ulcer at age 24
carpal tunnel
borderline hypertension
Social History:
Denies illicit drug or cigarette use, drinks alcohol only
occasionally with 1 glass of wine q1-2 weeks. Lives with his
wife and children in [**Name (NI) 108241**]. Works as a builder.
Family History:
Father died of myocardial infarction at the age of 53, mother
has hypertension, children are healthy, no history of GI
malignancy.
Physical Exam:
Vitals: T 102.3, HR 105, BP 130/53 R 12 sat 100%2LNC
GEN: WDWN man, lying in bed, NAD, pale appearing
HEENT: pale conjunctivae, PERRL, no sinus ttp, OP clear
Neck: no JVD, no cervical/supraclavicular LAD
Chest: CTAB
CV: tachy, nl S1/S2, no m/r/g
ab: soft, NTND, NABS
Extrem: no c/c/e, cool toes, 1+radial and dp/pt pulses
neuro: a and ox 3.
Rectal: Guaiac + with melena
Pertinent Results:
----------
Studies
----------
CXR: no acute cardiopulm process
.
EKG: leftward axis, prolonged QTc at 487 ms, , U waves present,
.
EGD results:
Multiple large cratered non-bleeding ulcers were found in the
stomach body and antrum. Four were found in the body and one
large ulcer was found in the antrum. There were no active
bleeding, visible vessels or adherent clots seen.
Duodenum:
Excavated Lesions Two large cratered ulcers were found in the
duodenal bulb. There was no active bleeding seen. However, there
was a red dot seen in one of the ulcers. Two resolution clips
were applied to the red dot.
.
Carotid u/s:
1. Increased velocities in the bilateral internal carotid
artery, external carotid artery, and common carotid artery. This
may be the result of a hyperdynamic state related to the
hematocrit of 10.
2. 40 to 59% hemodynamically significant stenosis in the right
carotid artery.
3. No carotid stenosis was demonstrated on the left.
.
TTE:
Conclusions:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Left ventricular systolic
function is hyperdynamic (EF>75%). Tissue velocity imaging
demonstrates an E/e' <8 suggesting a normal left ventricular
filling pressure. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are mildly
thickened. There is no valvular aortic stenosis. The increased
transaortic gradient is likely related to high cardiac output.
No aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
----------
Labs
----------
[**2152-3-20**] 07:03PM BLOOD WBC-10.0 RBC-0.94* Hgb-3.3* Hct-9.7*
MCV-104* MCH-35.0* MCHC-33.7 RDW-23.5* Plt Ct-317
[**2152-3-28**] 05:56AM BLOOD WBC-6.5 RBC-1.96* Hgb-6.4* Hct-21.3*
MCV-109* MCH-32.5* MCHC-29.9* RDW-19.2* Plt Ct-541*
[**2152-3-20**] 07:03PM BLOOD Ret Man-18.6*
[**2152-3-28**] 05:56AM BLOOD Ret Man-37.7*
[**2152-3-20**] 07:03PM BLOOD calTIBC-215* Ferritn-55 TRF-165*
[**2152-3-22**] 06:13AM BLOOD Hapto-213*
[**2152-3-23**] 04:24AM BLOOD PT-11.8 PTT-25.0 INR(PT)-1.0
[**2152-3-20**] 07:03PM BLOOD Glucose-107* UreaN-15 Creat-0.8 Na-141
K-3.2* Cl-107 HCO3-27 AnGap-10
[**2152-3-28**] 05:56AM BLOOD Glucose-84 UreaN-10 Creat-0.8 Na-143
K-3.8 Cl-108 HCO3-25 AnGap-14
[**2152-3-28**] 05:56AM BLOOD Calcium-8.2* Phos-3.9 Mg-2.0
[**2152-3-21**] 08:11AM BLOOD %HbA1c-5.2 [Hgb]-DONE [A1c]-DONE
[**2152-3-20**] 07:03PM BLOOD CK(CPK)-715*
[**2152-3-21**] 08:11AM BLOOD CK(CPK)-552*
[**2152-3-22**] 06:13AM BLOOD ALT-18 AST-20 LD(LDH)-149 CK(CPK)-360*
TotBili-0.2
[**2152-3-20**] 07:03PM BLOOD CK-MB-3 cTropnT-0.03*
[**2152-3-21**] 08:11AM BLOOD CK-MB-7 cTropnT-0.12*
[**2152-3-22**] 06:13AM BLOOD CK-MB-3 cTropnT-0.17*
[**2152-3-21**] 08:11AM BLOOD Triglyc-121 HDL-32 CHOL/HD-3.6 LDLcalc-58
[**2152-3-23**] 04:24AM BLOOD CRP-26.1*
[**2152-3-20**] 05:46PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2152-3-20**] 05:46PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2152-3-23**] 05:52PM URINE Hours-RANDOM Creat-60 Na-123 K-11
[**2152-3-23**] 05:52PM URINE Osmolal-391
----------
Micro
----------
[**2152-3-23**] SEROLOGY/BLOOD HELICOBACTER PYLORI ANTIBODY TEST --
positive
[**2152-3-22**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; CLOSTRIDIUM DIFFICILE TOXIN ASSAY -- all studies
negative
[**2152-3-21**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN
TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL -- all studies
negative
[**2152-3-20**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-
all studies negative
Brief Hospital Course:
Briefly, this is a 55 year old Jehovah's Witness trasferred from
Cape Code Hospital for further care after an upper GI tract
bleed, who underwent emergent endoscopy upon arrival. No
actively bleeding ulcers were found. The patient developed
ischemic optic neuropathy of the right eye and myocardial
ischemia (non ST elevation), also likely related to his low
hematocrit.
.
#Upper GI tract bleed: The patient had a history of bleeding
gastric and duodenal ulcers at the outside hospital. His
hematocrit was 11% on admission. The GI service was consulted
and decided to perform endoscopy upon arrival to evaluate for
active GI bleed. On emergent endoscopy on this admission,
patient was found to have nonbleeding gastric and duodenal bulb
ulcers with a clip applied to one of the duodenal ulcers.
Underlying etiology was likely excessive nonsteroidal use. The
pt was started on an IV protonix drip. Given the patient's
religion, he was unable to receive any blood products. H.
Pylori antibody was sent, found to be positive, so patient was
begun on appropriate treatment to eradicate this infection.
.
#Anemia: The patient had a hematocrit of 11% on admission,
related to his GI bleed. Iron and ferritin were both low
normal, but transferrin was also low, consistent with anemia
from iron deficiency and from chronic inflammation. Reticulocyte
count was 18% with low RPI. Hemolysis labs were negative. The
Hematology/Oncology service was consulted, and per their recs
the patient received IV dextran, Vitamin B12 injections, folate,
Epogen 20,000 units three times per week. His anemia slowly
resolved over the course of his hospital stay, and his energy
level improved concurrently.
.
#Fever: The pt had fevers at the outside hospital and presented
to [**Hospital1 18**] with a temp of 102F of unclear source. His chest X-ray
was negative for infiltrate and urinalysis was negative for
infection. Patient had mild nasal congestion, but no significant
cough or sore throat. An echocardiogram was performed on [**3-21**]
and showed normal left ventricular filling pressures but
hyperdynamic ejection fraction of 75%, mildly thickened aortic
valve leaflets. Vegetations were felt to be unlikely. The
patient was started on Unasyn and Vanc on admission, but these
were discontinued after 2 days given that the pt continued to
have low grade fevers while on the antibiotics (which were
chosen to cover GI sources).
.
#Elevated cardiac enzymes: myocardial ischemia felt to be
secondary to demand in the setting of profound anemia. CK level
trended down as his hematocrit improved. Patient was instructed
to undergo outpatient cardiac stress testing once his hematocrit
normalized to investigate the possibility of coronary artery
disease. He was instructed to start on a beta blocker,
Metoprolol, until he can arrange for the cardiac stress test. A
prescription was given to the patient for this medication. Given
his recent bleeding, he was instructed not to start on aspirin
until he consulted with his PCP.
.
#Prolonged QT: The patient's initial EKG had a prolonged QT,
likely related to hypokalemia. This resolved with potassium
repletion.
.
#Right visual loss: On the morning after admission the patient
complained of loss of vision in inferior and superior fields
which started at the outside hospital. Per Neurology and
Ophthamology, this was likely due to his low red blood cell
count resulting in an ischemic retina and optic nerve. The
patient was noted to have a right afferent pupil defect as well
as right eye pain, consistent with ischemic optic neuropathy. He
was taken for slit lamp examination by Ophthalmology. Per
Neurology recs, carotid ultrasound was performed, which revealed
40 to 59% hemodynamically significant stenosis in the right
carotid artery. Discussed with Neurology resident Dr. [**Last Name (STitle) **] who
spoke with her attending, who both felt that patient should be
followed for now to see if his optic symptoms return once his
hematocrit normalizes. It seems likely that his carotid artery
narrowing is asymptomatic and hence does not require surgical
intervention at this time. Patient was instructed to return to
the Emergency Room for evaluation if he developed stroke
symptoms. ESR and CRP were ordered to rule out temporal
arteritis, which they effectively did. The patient was given
the number to set up an appointment with Ophthalmology 1-2 weeks
after discharge for follow up.
.
#Prophylaxis: Protonix twice a day; no bowel regimen given GI
bleed; pneumoboots
.
#FEN: clear liquid diet; encourage po intake
.
#Communication: wife [**Name (NI) 2147**] [**Telephone/Fax (1) 108242**]
.
#Access: 3 peripheral IVs
.
#Code: FULL
Medications on Admission:
Excedrin
Tylenol
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 4 weeks.
Disp:*28 Tablet(s)* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
1 months.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day) for 1 months.
Disp:*120 Tablet(s)* Refills:*0*
5. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 12 days.
Disp:*24 Tablet(s)* Refills:*0*
6. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) for 12 days.
Disp:*48 Capsule(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Gastric ulcers, likely related to NSAID use
2. Duodenal ulcers
3. Acute blood loss anemia
4. Non ST elevation myocardial infarction
5. Ischemic optic neuritis/retinitis
6. Prolonged QT syndrome
Discharge Condition:
Hemodynamically stable with increasing hematocrit and guaiac
negative stool.
Discharge Instructions:
Please take all your medications as ordered. Return to the
nearest Emergency Room if you develop any bleeding from your
rectum, lightheadedness, shortness of breath, chest pain, visual
changes, difficulty speaking or understanding speech, numbness
or tingling, weakness, or any other concerning symptoms. Avoid
taking any medications that can thin your blood or irritate your
stomach lining, including ibuprofen, naproxsyn and aspirin.
Tylenol is safe for you to take. If you have any questions about
which meds are safe, please call your doctor. Until you have a
stress test that evaluates your coronary arteries, you should
take a medication known as a beta blocker to protect you from
further heart injury. In several months, if you have no further
issues from your gastric ulcers, it would also be reasonable to
consider starting on a low dose buffered aspirin after
discussing this with your doctor.
Followup Instructions:
Please call to schedule follow up appointments with the
following physicians:
1. PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] call [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 72199**] [**Telephone/Fax (1) 21384**] to set up an
appointment with a new primary care doctor.
2. Ophthalmology - ([**Telephone/Fax (1) 5120**]
Your new PCP should check your hematocrit to make sure that it
has returned to baseline. You should also have an outpatient
stress test arranged in several months if your bleeding does not
recur. This test will let us know if you have any significant
coronary artery disease, as this will change your health
management.
ICD9 Codes: 2851, 2859, 4019, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8650
} | Medical Text: Admission Date: [**2140-12-26**] Discharge Date: [**2141-1-2**]
Date of Birth: [**2114-12-26**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Aleve
Attending:[**First Name3 (LF) 3853**]
Chief Complaint:
"nausea, vomiting."
Major Surgical or Invasive Procedure:
none
History of Present Illness:
26yoF with h/o leukopenia reportedly in the past when taking
Aleve and Bactrim a few years ago who presents with fever to
104, sore throat, nausea x1d, and body aches. Felt well
yesterday, went to a club in [**Location (un) 7349**], drove back before super bowl.
Woke up febrile today, took Tylenol with some relief, and had
emesis x3 (no blood). Frontal, retro-orbital headache that is
pounding/disabling. Stiff, sore neck. Pt denied diarrhea,
abdominal pain, CP, SOB, cough. Endorses sick contacts with
colds.
.
In the ED, initial vs were: 102.6 p120 98/53 20 98%RA. Pt was
found to be leukopenic with WBC count 1.4, neutrophil 54%.
Peripheral smear sent per Heme Onc recommendation; also pan
culture and start broad spectrum ABx. Pt was given Ceftriaxone
and Flagyl and 3L NS. Admit VS: Temp: 100.6, Pulse: 82, RR: 16,
BP: 114/67, O2Sat: 98, Pain: 2
.
On the floor, complaining of nausea, shortness of breath, and
body aches. HR was sustained at 140. Temp near 104. Arterial
lactate was drawn and was 4.0. Given high fevers, tachycardia,
and evidence of hypoperfusion, she was transferred to the MICU
for further evaluation.
Past Medical History:
-Leukopoenia [**2136**]
-Nipple abscess from piercing [**2136**]
-Chlamydia [**2135**]
Social History:
She is a nonsmoker. She drinks alcohol twice a
week on average. She denies illicit drug use. Works two jobs,
BOA and Insurance company. Previously worked as a lab tech at
[**Hospital1 2025**]. She lives alone at school with her mother when she is at
home. She has no pets. She denies exotic travel. She is sexually
active with women. Past partners have been men and women. But no
men since before [**2136**]. She has a remote history of genital warts
and chlamydia, which were treated and have not recurred.
Family History:
Mother is 37, has a history of hypertension.
Father is 40 and healthy. She has one brother who is healthy.
There is no family history of early coronary disease,
malignancies, or diabetes.
Physical Exam:
ADMISSION EXAM
Triage 102.6 p120 98/53 20 98%RA.
Admit VS: Temp: 100.6, Pulse: 82, RR: 16, BP: 114/67, O2Sat: 98,
General: Alert, oriented, no acute distress, uncomfortable
HEENT: Sclera anicteric, MMM, oropharynx clear. tongue piercing.
Neck: supple, JVP not elevated, no LAD, lymphadenopathy along
left anterior cervical chain. tattoo along left clavicle
Chest: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachy and reg rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender LUQ, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, umbilicus
piercing
GU: foley in place, clitoral piercing
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
.
DISCHARGE EXAM:
99.6, 100.1, 80-90, 100-126/50-80, 18, 96-100RA
General: Alert, oriented, no acute distress, comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, full ROM
Lungs: CTAB
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, distended, normal bowel sounds no
rebound tenderness or guarding, no organomegaly
GU: exfoliative rash with scale, limited to external vulva and
surrounding skin, minimal erythema and well healed skin below
scale
Ext: warm, well perfused, 2+ pulses, bilateral calf tenderness
to palpation
Skin: Rash improved on ble
Pertinent Results:
ADMISSION LABS
[**2140-12-26**] 03:50PM BLOOD WBC-1.4*# RBC-3.88* Hgb-12.1 Hct-35.4*
MCV-91 MCH-31.2 MCHC-34.2 RDW-12.5 Plt Ct-164
[**2140-12-26**] 03:50PM BLOOD Neuts-54 Bands-4 Lymphs-27 Monos-3 Eos-0
Baso-1 Atyps-0 Metas-7* Myelos-4* NRBC-1*
[**2140-12-27**] 08:01AM BLOOD PT-18.1* PTT-31.5 INR(PT)-1.7*
[**2140-12-27**] 04:19AM BLOOD Ret Aut-1.4
[**2140-12-26**] 03:50PM BLOOD Glucose-114* UreaN-10 Creat-1.1 Na-135
K-3.6 Cl-100 HCO3-22 AnGap-17
[**2140-12-26**] 03:50PM BLOOD ALT-22 AST-25 AlkPhos-54 TotBili-0.8
[**2140-12-26**] 03:50PM BLOOD Lipase-38
[**2140-12-27**] 04:19AM BLOOD Albumin-3.1* Calcium-6.6* Phos-0.8*
Mg-0.8* UricAcd-4.8 Iron-PND
[**2140-12-27**] 04:19AM BLOOD PTH-64
[**2140-12-27**] 04:19AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2140-12-27**] 08:04AM BLOOD PEP-PND IgG-693* IgM-72
[**2140-12-27**] 04:19AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2140-12-27**] 03:21AM BLOOD Type-ART pO2-89 pCO2-24* pH-7.44
calTCO2-17* Base XS--5
[**2140-12-26**] 09:12PM BLOOD Lactate-3.8*
[**2140-12-27**] 04:30AM BLOOD freeCa-0.88*
.
DISCHARGE LABS:
[**2141-1-2**] 07:40AM BLOOD WBC-9.7 RBC-3.59* Hgb-11.2* Hct-33.2*
MCV-93 MCH-31.3 MCHC-33.8 RDW-13.2 Plt Ct-286
[**2140-12-29**] 08:31PM BLOOD Neuts-77* Bands-2 Lymphs-11* Monos-6
Eos-2 Baso-1 Atyps-1* Metas-0 Myelos-0
[**2141-1-2**] 07:40AM BLOOD PT-11.1 INR(PT)-1.0
[**2141-1-2**] 07:40AM BLOOD Glucose-94 UreaN-15 Creat-0.7 Na-134
K-4.1 Cl-101 HCO3-23 AnGap-14
[**2141-1-2**] 07:40AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.1
[**2140-12-29**] 05:54PM BLOOD Lactate-1.6
.
MICRO:
Blood Culture, Routine (Final [**2141-1-1**]):
Reported to and read back by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2140-12-29**], 8:33AM.
NEISSERIA MENINGITIDIS. BETA LACTAMASE NEGATIVE.
Blood Culture, Routine (Final [**2141-1-1**]):
NEISSERIA MENINGITIDIS.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
340-1950R
[**2140-12-26**].
Blood Culture, Routine (Final [**2141-1-2**]): NO GROWTH.
Blood Culture, Routine (Final [**2141-1-3**]): NO GROWTH.
Blood Culture, Routine (Final [**2141-1-4**]): NO GROWTH.
.
CXR [**2140-12-26**]
Subtle left base retrocardiac opacity could relate to
atelectasis, although in the appropriate clinical setting an
early consolidation due to infection is not entirely excluded.
CT Neck with contrast [**2140-12-27**]
1. No evidence of retropharyngeal abscess.
2. Prominent lymph nodes in the carotid spaces, but none are
pathologically enlarged.
3. Ectatic right jugular vein is of unclear significance, and
likely a
chronic finding.
4. Small bilateral pleural effusions and right mid lung
opacification are
better evaluated on concurrent chest CT.
CT Abd/Pelvis/Chest [**2140-12-27**]
1. Findings consistent with multifocal pneumonia involving the
right lung
2. Small-to-moderate bilateral pleural effusions.
3. Soft tissue in the anterior mediastinum likely represents
thymic remnant. This could be confirmed with MRI if clinically
warranted.
4. Gallbladder wall edema without evidence for cholecystitis,
this may
represent third spacing. Please correlate with albumin level.
ECHO
The left atrium is moderately dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild global
left ventricular hypokinesis (LVEF = 45-50 %). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve leaflets are structurally normal. No
mass or vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
Brief Hospital Course:
26 F with hx of leukopoenia presents with leukopoenia,
neutopoenia and fever.
.
# Meningitis/Bacteremia: She wasa starteed on broad spectrum
antibiotics including ceftriaxone on admission. An lumbar
puncture was attempted twice but was unsuccessful. However blood
cultures grew neisseria meningitidis. She had high grade fevers
as well as a petechial rash that both improved throughout her
admission. Surveillance blood cultures drawn on several
following days. She did have diffuse myalgias which improved but
did not resolve by the time of her discharge so she was started
on vicodin on discharge. She completed 8 days of ceftriaxone as
per infectious disease recommendations. Follow up with
infectious disease was set up prior to discharge as well as
instructions to return to the emergency department if she had
new fevers headache or neck stiffness.
.
# Volume overload: During this admission she was given
significant volume of IV fluids and she developed significant
peripheral and pulmonary edema. She underwent an echo cardiogram
which showed global systolic dysfunction. Myocarditis was
considered but she did not have an CK, CKMB, or troponin
elevations. This was felt to be stress-induced cardiomyopathy.
The cardiomyopathy, IV fluids and leaky cappiliaries sepsis was
believed to be the cause of her edema. She was diuresed with IV
lasix and she was euvolemic on discharge.
.
# Chronic Neutropenia - She has a history of neutropenia and
presented with a WBC count of 1.4 with 50% polys. She rapidly
developed a robust WBC elevation in the setting of her
infection. Hematology was consulted though no clear cause of her
neutropenia was found. It is unclear if this low initial WBC
count predisposed her to an infection or is only an incidental
finding. She should follow up with hematology/oncology for
further work up.
.
# Transitional Issues
-Follow up pending viral stool cultures
-Follow up with ID in [**12-24**] weeks and you PCP [**Last Name (NamePattern4) **] [**11-21**] weeks and
consider Dermatology follow up if vulvar/perineal rash is not
resolving
Medications on Admission:
none
Discharge Medications:
1. ibuprofen 200 mg Tablet Sig: 2-4 Tablets PO every eight (8)
hours.
2. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain for 1 weeks.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
presumed n. meningitidis Meningitis
Bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 8260**],
Thank you for coming to the [**Hospital1 1170**]. You were in the hospital because you had a serious
infection called meningitis and bacteria in your blood. We
treated you with IV antibiotics. We are happy that you are doing
much better. You finished your course of antibiotics and do not
need to continue taking these. You should follow up with the
infectious disease clinic as instructed.
.
You were also noted to have a low white blood cell count. White
blood cells are the cells that fight infections. It is not
likely that this made your infection worse but you should follow
up with the Hematology doctors to make sure you are not at risk
of future infections.
.
Medication Recommendations:
Please START
-Vicodin 1-2 tabs every 4-6 hours as needed for pain
-Ibuprofen 400-800 mg every eight hours as needed for pain
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2141-1-6**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], RNC [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] None
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: TUESDAY [**2141-2-14**] at 9:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2141-1-25**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 2762, 2859, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8651
} | Medical Text: Admission Date: [**2101-1-1**] Discharge Date: [**2101-2-22**]
Date of Birth: [**2030-7-19**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Left facial droop and some mild slurring of speech from
glioblastoma multiforme.
Major Surgical or Invasive Procedure:
Right frontal parietal craniotomy on [**2101-1-2**].
PEG placed on [**2101-1-16**].
History of Present Illness:
History obtained from sister who accompanied patient and
translated. Patient is Portuguese speaking. This is a
70-year-old man who has had URI for one week slowly resolving.
Yesterday noticed some left drooling but speech was fine.
Today, family noticed left facial droop and some mild slurring
of speech with some left hand weakness. He complained of HA one
week ago, but resolved with Tylenol. He denies HA, visual
changes, pain, numbness, or weakness.
Past Medical History:
Tonsilectomy.
Social History:
Originally from [**Country 6257**]. He is a retired factory worker, lives
with sister. non-[**Name2 (NI) 1818**], and drinks occasional wine.
Family History:
Cousins with stomach cancer.
Physical Exam:
Vital Signs: Blood Pressure 140/70, Heart Rate 80, Respiratory
Rate 16.
General: WD/WN, comfortable, NAD.
HEENT: NC/AT. Anicteric.
Extremities: Warm and well-perfused. No C/C/E.
Neurological:
Mental status: Awake and alert, cooperative with exam, normal
affect. He did appear to have some confusion with following some
commands even considering language barrier.
Orientation: Oriented to person, place, and date.
Attention: Attended examiner
Language: Speech fluent.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial drrop present on left nasiolabial fold.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-22**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing right and upgoing left.
Coordination: normal on finger-nose-finger
Gait: wide-based
Pertinent Results:
Admission Labs:
[**2100-12-31**] 07:36PM PT-13.0 PTT-26.1 INR(PT)-1.1
[**2100-12-31**] 07:36PM PLT COUNT-358
[**2100-12-31**] 07:36PM WBC-7.0 RBC-5.01 HGB-14.7 HCT-40.8 MCV-81*
MCH-29.3 MCHC-36.0* RDW-14.0
[**2100-12-31**] 07:36PM OSMOLAL-291
[**2100-12-31**] 07:36PM GLUCOSE-110* UREA N-15 CREAT-0.9 SODIUM-136
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-25 ANION GAP-14
[**2101-1-1**] 03:11PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2101-1-1**] 03:11PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2101-1-1**] 08:40PM PHENYTOIN-9.8*
[**2101-1-1**] 08:40PM GLUCOSE-122* UREA N-17 CREAT-0.9 SODIUM-141
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-22 ANION GAP-17
MRI OF THE BRAIN:[**2101-1-1**] (PREOP)
There is an approximately 4.5 x 3.5 cm mass in the right frontal
lobe with irregular shape and thick rim enhancement. The central
portion of the mass is hypointense on T1-weighted images,
without enhancement and demonstrate no evidence of slow
diffusion. There is mild mass effect on the right lateral
ventricle without midline shift. There is no evidence of acute
or chronic blood products seen within the mass. There is
surrounding white matter edema noted. There are no other
abnormal areas of enhancement seen within the brain. There is no
midline shift or hydrocephalus identified.
MRI OF THE BRAIN:[**2101-1-2**] (POSTOP)
Extensive postsurgical changes are noted in the right frontal
region consistent with recent surgery. Enhancement is noted in
the postsurgical bed may represent residual tumor versus
postsurgical changes. A followup MRI is recommended in two to
three weeks for further evaluation.
Moderate brain edema and mild-to-moderate midline shift noted,
which appears to be not significantly changed since the prior
examination. Minimal subdural collections are noted in the
postsurgical bed.
[**1-6**] CT Head: Essentially stable study compared to the previous
examination. Slight reduction in subdural gas.
[**1-7**] KUB: Prominent small bowel and large bowel gases throughout
down to the rectum, probably representing ileus. Please
correlate clinically, and please perform close followup by
abdominal radiograph.
[**1-8**] KUB: Nonspecific bowel gas pattern without significant
interval change. There is some minimal decrease of the air in
the small bowel. Most of the gas is within the transverse colon.
[**1-9**] KUB: Improvement of the bowel gas pattern since the
previous study. No signs of bowel obstruction.
[**1-18**] KUB: Nonspecific bowel gas pattern. No evidence of free air
or small-bowel obstruction.
[**1-22**] CT Torso: 1. Moderate free air within the abdomen. This may
be related to recent placement of a percutaneous gastrostomy
tube, but correlation with examination and laboratory findings
is recommended. Bowel loops within the abdomen appear normal.
2. Rim-enhancing collection within the left inferior pelvis, at
the medial and posterior aspects of the left acetabulum. This
collection could represent a small abscess within the obturator
internus and gluteus minimus muscles, or may represent an
infectious arthritis. Correlation with physical exam is
requested. An MRI may be helpful for further evaluation.
3. Mild pulmonary edema, manifested as ground glass opacity.
4. Distended bladder, with a tiny air bubble. This may be
related to instrumentation, but correlation with urinalysis is
requested.
5. A couple of nodular opacities within the lungs. A 3-month CT
followup could be considered if clinically indicated.
[**1-29**] CXR: Free air under the diaphragm.
[**1-31**] CXR: Interval decrease in pneumoperitoneum.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 65087**] is a 70-year-old Portugese speaking man admitted
with slurred speech and left sided droop noticed by sister.
[**Hospital 4695**] Hospital course:
Patient taken to OR on [**2101-1-2**] for right craniotomy for
resection of fronto-parietal mass under general anesthesia
without intraoperative anesthesia. Patient stayed in the PACU
overnight. He was started on dexamethasone and phenytoin.
Postoperative day one([**2101-1-3**]) patient transferred to NeuroICU
due to continuing intubation.
Immediate postoperative neurologic exam was lethargic, speech
unintelligible, moves right side spontaneously. Patient
extubated on [**2100-1-4**]. After extubation still somnolent,
opens eyes to voice but doesn't follow commands, speech is
unintelligible, moves right side vigorously, moving left toes
but less vigorously, not moving left arm.
Transferred to Neuro Step-Down unit on [**2101-1-6**], his Decadron
was weaned, he followed commands intermittently ans was
purposeful on the right and had tone on the left. Neurology was
following along with the patient recommended starting Keppra if
he was to start chemotherapy.
On [**2101-1-7**], his abdomen was noted to be distended a KUB showed
an ileus and LFTs were slightly elevated. He was made NPO
started, NG tube was put to low intermittent suction on on
[**2101-1-10**] his repeat KUB showed improvement in the ileus. He was
advanced back to tube feeds on the [**1-11**] a speech and swallow
consult was obtained and a general surgery consult in
anticipation of failure of speech and swallow to place a G-tube.
[**2101-1-10**] he was started on Cipro for a UTI for 10 days course
(to end after last dose on [**1-20**]). Postoperative ileus
resolved.
[**2101-1-16**] PEG was placed, TF at goal tolerating well. Patient
being seen bu PT/OT.
[**2101-1-18**] a Foley catheter was placed back again for urinary
retention. Urine cultures taken on [**2101-1-17**] showed E. coli
resistant to Cipro, switched to Augmentin.
Examination at the time of transfer to Oncology: Eyes open
spont. PERRL. Speech dysarthric, speaking in Portuguese. Moves
right side spontaneously, follows commands in Portuguese on
right side. LUE w/ no spont movement. LLE can move toes
minimally. Receiving PT/OT. Multi-podis boots on for heel
protection.
[**Hospital **] Hospital Course:
1. Glioblastoma: The patient was treated as above on the
neurosurgery service, and was then transferred to oncology to
receive radiation therapy. He received 15 treatments of whole
brain radiation. Dilantin was continued, with monitoring of
levels, and decadron taper was also continued.
2. Confusion: Throughout the hospital course the patient was at
times confused, although he remained alert and interactive.
This was likely multifactorial, with his neoplasm and recent
surgery, along with related brain edema, as well as medications,
constipation, and urinary retention and UTI all contributing.
Each of these conditions was managed as best as possible, and
the patient was oriented frequently.
3. Constipation/Abdominal Distention: This was likely related to
lying in bed, opiates, and illness in general. The patient had
serial abdominal films with no evidence of obstruction. He was
given an aggressive bowel regimen, resulting in resolution of
constipation. The patient was also started on reglan and
simethicone and encouraged to get out of bed and work with
physical therapy frequently to prevent recurrence of his
constipation and distention.
4. Urinary retention: When the patient's foley catheter was
removed, he was unable to void spontaneously. Initially he was
catheterized every 8 hours, in the hopes that his urinary
retention would resolve, but after several days he no longer
tolerated catheterization (and refused further straight cath)
and the foley catheter was replaced. Doxazosin was started as
well, but at the time of discharge the patient still required an
indwelling catheter.
5. UTI: The patient was patient was initially started on
ciprofloxacin on [**2101-1-10**] for a UTI. The urine culture grew E.
coli resistant to TMP/SMX and ciprofloxacin, so the patient was
switched to augmentin to complete the course of treatment. On
on [**2101-2-3**], the patient was noted to have an elevated WBC
count, and UA was found to be positive. Culture again grew E.
coli with similar sensitivities, so he was treated with
ceftriaxone for 1 week. A follow up urine culture grew
10,000-100,000 colonies of vancomycin resistant enterococcus,
but the UA at that time was negative and the patient was
afebrile and had a normal WBC count so this was considered
likely to be a colonizer.
6. Thrush: The patient was initially unable to effectively swish
and swallow with nystatin, so he was treated with a course of
fluconazole. This did not result in a significant improvement
in his thrush. Nystatin swish and swallow was then initiated,
and thrush was stable.
7. FEN: A PEG tube was placed on [**2101-1-16**] and tube feeds were
started. A repeat swallow evaluation prior to discharge was
done, and the patient was then allowed to take small amounts of
pureed food and nectar prethickened liquids with supervision for
comfort. The patient was also kept on sliding scale insulin
coverage while he was on steroids.
8. Code: It was decided during this hospitalization that the
patient's code status was DNR/DNI, and this was confirmed with
his family.
Medications on Admission:
None.
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO every
eight (8) hours.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
7. Phenytoin 100 mg/4 mL Suspension Sig: Two Hundred (200) mg PO
BID (2 times a day).
8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
9. Doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
11. Dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 6257**] Hospital
Discharge Diagnosis:
Right frontal parietal glioblastoma s/p craniotomy.
Discharge Condition:
Stable.
Discharge Instructions:
If you experience fever, chills, nausea, vomiting, abdominal
pain, or any other new or concerning symptoms, please call your
doctor or return to the emergency room for evaluation.
Please take all medications as prescribed.
Keep incision clean and dry; watch for redness, swelling, or
bleeding.
Followup Instructions:
As scheduled by your doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 6257**].
Completed by:[**2101-2-22**]
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8652
} | Medical Text: Admission Date: [**2170-12-8**] Discharge Date: [**2170-12-8**]
Date of Birth: [**2170-12-8**] Sex: M
Service: NB
The infant is a 34-2/7 week, 1875 gram male newborn Twin II
who is admitted to the NICU with prematurity, imperforate
anus and cleft palate. Infant was born to a 35-year-old G1,
P0 mother with prenatal screens of A+, antibody negative,
hepatitis B surface antigen negative, RPR nonreactive,
Rubella immune, and GBS unknown. No known prenatal concerns of
fetal anomalies. Pregnancy was followed closely for a
diamniotic, dichorionic twin gestation and suspected growth
restriction in this twin. Decision was made to deliver today
for poor fetal growth. There was no maternal fever, nor fetal
tachycardia. Cesarean section for breech presentation in this
twin. Rupture of membranes were at the time of delivery.
Maternal anesthesia was by spinal anesthesia.
The infant emerged breech, ruddy with good tone and activity
and spontaneous cry. Routine neonatal resuscitation was
provided with bulb suctioning, drying and stimulation. He
responded well with Apgars of 8 and 9. Initial physical
examination revealed an imperforate anus, passage of
meconium via the urethral opening and a cleft palate. The
infant was shown to parents and transferred to the NICU.
PHYSICAL EXAMINATION: Vital signs are registered in the
CareView system. Initial D stick was 21. Weight was 1875
grams which is the 25 to 50 percentile. Head circumference of
28 cm which is less than 10th percentile. Length was 43.5 cm
which is at the 25 to 50th percentile. The anterior fontanel
was soft and flat. He is microcephalic, red reflexes were
present in both eyes without any presence of colobomas. His
ears were low set, he had a cleft palate, intact clavicles.
Neck was supple. Lungs were clear to auscultation and equal.
Cardiac examination revealed a regular rate and rhythm, no
murmur and 2+ femoral pulses. Abdomen was soft, good bowel
sounds, 3 vessel cord. The genitourinary examination revealed
a normal phallus with testes down bilaterally. There is an
imperforate anus, spinal dimple. The hips were stable.
Extremities were good tone and equal movement and there is a
question of short stubby fingers and toes and bilateral
clinodactyly. Skin: ruddy, well-perfused.
IMPRESSION:
1. Preterm male newborn.
2. Appropriate for gestational age.
3. Imperforate anus.
4. Cleft palate.
5. Additional subtle dysmorphology.
6. Rule out polycythemia.
7. Hypoglycemia.
PLAN:
- Given the imperforate anus with fistula, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] was
placed and a KUB was obtained. The KUB revealed the [**Last Name (un) **]
to be in good position with no evidence of TEF. There was a
question of abnormal sacral bones. The lungs were clear with
no cardiomegaly. Surgery was consulted. Surgery service
would like to arrange for transfer to begin repair of
imperforate anus this evening.
- Cleft palate. Dr. [**Last Name (STitle) 64487**] in the plastic surgery service
will need to be consulted at [**Hospital3 28900**].
- Dysmorphology: Genetic consult is indicated and additional
testing will need to be done to rule out syndrome associated
anomalies such as chromosomes, renal ultrasound and spinal
ultrasound.
- Initial hypoglycemia was noted and an additional
dextrose boluses was given. If the hematocrit is elevated and
this persistent hypoglycemia, may need to consider exchange
however, he is also about to enter surgery. Will discuss
with the surgical service.
- He is NPO with maintenance intravenous fluids, D10-W at 80
cc per kilo per day.
- Ampicillin and gentamicin as well as Zantac were begun per
surgery recommendations.
The parents have been updated extensively at the bedside.
Ultimately the plan is to transfer the infant to [**Hospital3 41581**] for repair of the imperforate anus. Surgical
attending at [**Hospital3 28900**] is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 62802**]. OB
was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Delivering OB was Dr. [**Name6 (MD) **] [**Name (STitle) **], M.D.,
the pediatrician is Dr. [**Last Name (STitle) 3394**] at [**Location (un) 4047**].
Discharge Diagnoses:
1. Preterm male newborn
2. Microcephaly
3. Cleft palate
4. Imperfortate anus
5. Dysmorphology
6. Hypoglycemia
[**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern4) 56994**]
MEDQUIST36
D: [**2170-12-8**] 21:29:40
T: [**2170-12-8**] 22:52:31
Job#: [**Job Number 64488**]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8653
} | Medical Text: Admission Date: [**2185-6-16**] Discharge Date: [**2185-6-27**]
Service:
CHIEF COMPLAINT: Melena intraoperatively complication from
plastic surgery.
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
female with diabetes mellitus Type 2 complicated by end-stage
renal disease on hemodialysis, history of retinopathy
(legally blind) hypertension, hypercholesterolemia, status
post cerebrovascular accident, peripheral vascular disease,
who is admitted to the [**Hospital1 69**]
Plastic Surgery service on [**2185-6-16**] for incision and drainage
of a left hand abscess.
The patient initially admitted [**2185-5-28**] for left hand
abscess with gram positive bacteria and underwent incision
and drainage on [**2185-5-29**]. The patient was discharged on
Vancomycin. The patient was seen in [**Hospital 3595**] Clinic on [**6-7**]
and had a 6 cm area of necrotic tissue over the dorsum of the
hand with edema more proximal to this area that was warm.
The patient was admitted to the [**Hospital1 188**] on [**2185-6-16**] and underwent a second incision and
drainage and Vac placement and started on Cefazolin
intravenous.
On admission the patient had a crit of 35 with baseline 35 to
40. Following incision and drainage the patient was given
Percocet for pain control, noted to have some tiny confusion
and the Percocet was discontinued and the patient was started
on Toradol, received 60 mg intramuscular on [**6-18**] mg
intramuscular on [**2185-6-19**], 30 mg on [**2185-6-20**]. On [**6-22**] the
patient was found to have decreased flow through the
Permacath at hemodialysis. The patient was given TPA in both
ports. At dialysis the patient complained of stomach pain
and hematocrit was drawn that showed it was 30 down from 35
on admission. The patient was subsequently transferred to
the MICU on [**2185-6-23**]. The patient had initially gone to the
O.R. for a skin flap with a full thickness skin graft to the
left hand. The patient received 15 mg intramuscular of
Toradol preop. Following the procedure the patient passed
approximately 250 cc's of melanotic stool. Crit at the time
was 23.5 at 11 AM and 20.3 at 3 PM. The patient remained
hemodynamically stable with heart rates in 70's to 90's and
blood pressure of 100 to 160/40 to 60. Anesthesia placed a
left IJ for central venous access and the patient received
approximately 700 cc's of intravenous fluids
intraoperatively. In the Post Anesthesia Care Unit the
gastrointestinal team was consulted and
esophagogastroduodenoscopy performed which was normal
(bilious material in the stomach, no signs of bleeding).
Recommended colonoscopy following transfusion. The labs were
drawn postoperatively showing platelets of 255, BUN 107 up
from 51 from [**2185-5-23**], an INR of 1.7 and a PTT of 55.1. The
patient was subsequently given DDAVP. At 7:15 PM the patient
passed approximately 200 cc's of melena and was subsequently
transferred to the medical Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes mellitus times 50 years,
complicated by end-stage renal disease on hemodialysis,
complicated by retinopathy, legally blind, complicated by
neuropathy.
2. Hypertension.
3. Hypercholesterolemia.
4. Dementia.
5. Status post cerebrovascular accident with left sided
residual weakness and right sided weakness.
6. Hypothyroidism.
7. Peripheral vascular disease.
8. Status post total abdominal hysterectomy for fibroids.
9. Status post right knee surgery.
10. Gout.
11. Scoliosis progressive.
12. Hip "fusion" with back pain requiring narcotics.
The patient has no known coronary artery disease.
MEDICATIONS ON ADMISSION:
1. Synthroid 150 mg p.o. q day.
2. Neurontin 300 mg p.o. q day.
3. Aspirin 81 mg q day.
4. Norvasc 10 mg p.o. q day.
5. Timolol eyedrops 0.5%
6. Renagel
7. Ultram.
8. Colace.
9. Lisinopril.
ALLERGIES: Codeine, question renal failure.
PHYSICAL EXAMINATION: Temperature 97.7, heart rate 84, blood
pressure 125/37, respiratory rate 14, sating 95% on three
liters. General: Awake but drowsy, answers questions
appropriately, well nourished in no apparent distress. The
patient having periods of apnea greater than 20 seconds.
Head, eyes, ears, nose and throat anicteric sclera,
oropharynx benign. Cardiovascular: Regular rate and rhythm.
No murmurs, rubs or gallops. Lungs: Clear to auscultation
bilaterally. Abdomen is soft, nontender, nondistended,
positive bowel sounds. Extremities: No edema, nonfunctional
arteriovenous fistula in the right upper extremity and left
upper extremity.
LABORATORY: On [**2185-6-22**] white count 14.8, hematocrit 20.3,
potassium 5.1, BUN 107, creatinine 7.3, CPK 34, Troponin
0.11.
Electrocardiogram is normal sinus rhythm at 75 beats per
minute, normal axis and intervals, no acute ST changes, no
changes when compared to previous Echocardiogram.
Chest x-ray for left IG placement. Heart normal size. No
pneumothorax. Right upper lobe opacity stable compared to
previous chest x-ray. Recommend follow-up CT scan.
Microbiology: Wound cultures left hand from [**6-16**] no growth.
HOSPITAL COURSE:
1. Gastrointestinal bleed: During the hospital course
hematocrit declined 35 to 30 to 24 on day of transfer. The
patient went for skin graft of the left hand. After the
procedure the patient passed 250 cc's of melena as before
though remained hemodynamically stable with a repeat crit of
20. Underwent an esophagogastroduodenoscopy which was
negative with transfer to the TCU for monitoring. The
patient was typed and crossed, matched for four units with a
goal crit of 30. Protonix was started 40 mg intravenous q
day for gastrointestinal prophylaxis and aspirin and
non-steroidal anti-inflammatory drugs were held off. The
recommendation was to move further with a colonoscopy for
further evaluation of the gastrointestinal bleed however, in
the MICU there was a long discussion with the patient's two
health care proxies and they felt that the patient did not
want to have invasive procedures done including colonoscopy
and angiography, said that the patient often declined medical
care and would not wish to have invasive procedures done now.
They were given information regarding the procedure,
benefits and risks including the possibility of finding a
source of bleeding that is relatively easily treatable. They
said they would like her to have more done but do not want to
go against the relatives wishes, they hope that with time she
will be able to wake up more and more and to make the final
decision for herself. They understand she could have a life
threatening bleed in the meantime and she could expire.
Given the patient's multiple comorbidities and the quality of
life and her wishes the decision was to withdrawal invasive
procedures appears reasonable. If she did re-bleed she would
be transfused with packed red blood cells only and provide
supportive care. This was discussed with the MICU team and
the decision was to transfer the patient to the Medicine
service on the floor and the patient was transferred on
[**2185-6-26**].
After the family meeting and made DNR/DNI no colonoscopy was
to be done to diagnose the source of gastrointestinal bleed.
On the Medicine Team her crit remained stable and she
continued to refuse colonoscopy and a type cell scan with
angio. Serial crits were followed. Her hematocrit was
stabilizing at 26.9.
2. Coagulations, heme. There was an initial increase of her
INR of unclear reasons throughout to be done due to it being
drawn from the Heparin site and the patient was status post
Vitamin K reversal and now had stable INR at 1.3. On the
floor she was continued to follow and no obvious pathology
was found.
3. End-stage renal disease. The patient continued to have
hemodialysis during hospital stay. She was continued on
Nephrocaps with the Renal Team following and repletion of K
and subsequent following of her creatinine which was 8.0 at
discharge.
4. Elevation of Troponin T. Likely thought to be due to
decreased renal clearance as per the Renal Team. The patient
did not have any acute electrocardiogram changes and no chest
pain and there is consideration of repeating the Troponin T
after hemodialysis to follow. Otherwise there was no
significant medical changes that needed to occur.
5. Endo. The patient with hypothyroid and diabetes
mellitus. Levothyroxine was continued in the house as is
regular insulin sliding scale. Fingersticks were monitored
closely.
6. Plastic surgery and hand. The patient's arm was kept
elevated, dressing changes were done q day. Ancef 1 gram
intravenous q 48 hours was continued.
7. Pain. The patient was maintained on Hydrocodone and
Acetaminophen 1 tab p.o. q 6 hours while in house.
8. FEN. The patient was unable to take p.o's and
intravenous meds were continued.
9. Hypertension. Elevation of her blood pressure given the
stable hematocrit, after transfer to the floor the patient
was restarted on her anti-hypertensive meds and titrated as
needed Amlodipine and Captopril.
10. Prophylaxis. The patient was given a proton pump
inhibitor for gastrointestinal, pneumo boots were in place.
11. Access. The patient has a left IJ in position placed on
[**2185-6-23**].
12. Code: DNR/DNI.
13. Disposition: On the day of discharge [**2185-6-27**] the
patient refused transfusion of packed red blood cells after a
crit of 26.0 from 29.1 was noted. The patient also refused
all meds and requested desire to go home alone with health
care proxies. The attending was [**Name (NI) 653**], Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
and plan was for patient to be discharged on current
inpatient meds with hemodialysis three times a week at her
current location with follow-up with Plastic Surgery and
continued antibiotics changed from Ancef to Keflex p.o. with
follow-up with the PCP.
14. Pulmonary nodule seen on a recent chest x-ray and will
be required to follow-up with CT scan as an outpatient.
CONDITION ON DISCHARGE: Fair. Patient requested to go home.
DISCHARGE STATUS: Poor. Patient refusing blood transfusion
and all in house medications. Requesting desire to go home
and leave along with [**Hospital 228**] health care proxies.
DISCHARGE DIAGNOSIS:
1. Gastrointestinal bleed (melena)
2. Escharotomy.
3. Left hand abscess status post full thickness skin
graft from the abdomen to the left hand and
VAC placement on left hand dorsum.
FOLLOW-UP PLANS: The patient to follow-up with Plastic
Surgery provider, [**Name10 (NameIs) 648**] has been made for 7/25/0 after
the regular dialysis [**Name10 (NameIs) 648**].
Primary care provider with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to be followed
with an [**Last Name (NamePattern1) 648**] within two weeks, call [**Telephone/Fax (1) 16315**].
Continue to go to weekly dialysis appointments as you have
done prior to this admission.
DISCHARGE MEDICATIONS:
1. Levothyroxine 150 mcg q day.
2. Folic Acid.
3. Vitamin B Complex 1 mg capsule q day.
4. Calcium carbonate 1000 mg three times a day with meals.
5. Lisinopril 5 mg q day.
6. Cephalexin 250 mg q 12 hours.
7. Amlodipine 5 mg one tab q day.
8. Pantoprazole 40 mg q day.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, MPH[**MD Number(3) 96753**]
Dictated By:[**Last Name (NamePattern1) 11210**]
MEDQUIST36
D: [**2185-8-1**] 15:55
T: [**2185-8-1**] 16:02
JOB#: [**Job Number 96754**]
ICD9 Codes: 5789, 2449, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8654
} | Medical Text: Admission Date: [**2168-10-20**] Discharge Date: [**2168-10-28**]
Date of Birth: [**2094-3-23**] Sex: F
Service: MEDICINE
Allergies:
Lorazepam / Morphine / Penicillins / Zosyn
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
"Tachy-brady syndrome"
Major Surgical or Invasive Procedure:
-flutter ablation
-right subclavian central line with temporary pacer placement
-dual chamber pacer placement
History of Present Illness:
HPI: Ms. [**Known lastname 1263**] is a 75 y/o female with PMH significant for
COPD/asthma, systolic CHF (EF<20%), HTN, Afib, CRI (baseline Cr
1.1), and seizure d/o, with recent [**Hospital1 18**] admission from [**2168-8-17**]
to [**2168-9-22**], who presents from rehab with Afib/Aflutter that was
difficult to rate control. She was initially admitted to [**Hospital Unit Name 153**]
[**8-17**] for resp distress thought [**2-10**] COPD failure and CHF, and
eventually transferred to CCU for tailored CHF therapy. Major
issues during this extended hospitalization included rate
control of a fib s/p failed cardioversion, amiodarone (increased
LFTs) and procainamide trials without effect, failed rate
control as dilt caused hypotension, as well as placement of a
trach after development of pneumonia, contained bowel
perforation, maroon-colored stools and GI bleed, and management
of volume overload. She was subsequently discharged to [**Hospital **]
hospital. Discharged on Dig 0.25 mcg qd as only nodal blocking
[**Doctor Last Name 360**].
.
She now returns from NESH after noted to have HR in 140s
(flutter), given extra dose of 12.5 mg PO Lopressor, and
subsequently having a [**3-11**] second pause at rehab.
.
In ED, was noted to have ABG with hypoxia/hypercarbia, CXR
consistent with mild CHF though improved from prior with
elevated BUN/Cr and seeming dry on exam. Also with leukocytosis,
left shift, bandemia; lactate wnl. Troponin T elevated at 0.17
from first set. In ED, NGT and PIV placed, received 500cc NS,
Levaquin 500mg, Vanc 1gm, Tylenol 650mg. Evaluated by Cards
fellow, felt to be likely infected with early ARF. Cards fellow
recommended decreasing digoxin to 0.125, checking dig level,
considering cautious hydration, normalizing electrolytes,
avoiding lopressor with consideration of pindolol as an
alternative, holding anticoagulation, and consulting EP for
possible AVN ablation +PPM.
Past Medical History:
PMH:
Afib/Aflutter
CHF (Echo [**2168-8-18**]: LV EF < 20%. Global hypokinesis. 3+ MR, 2+ TR
HTN
COPD/asthma
?renal insufficiency (bl Cr 1.1), but 0.5 at OSH
remote hx of seizure
h/o GI Bleed
.
Social History:
.
SH: lives at [**Hospital1 700**]; daughter is HCP
former [**Name2 (NI) 1818**], no EtOH/drug use
Family History:
noncontributory; no known hx of heart/lung dz
Physical Exam:
PE
Vitals: HR 99 BP 111/40(57)
Vent: TV 500 RR 18 (set at 15bpm) Sat 100% on 70% FiO2
PEEP 8
Gen: elderly frail caucasian woman lying in bed sleeping in no
acute distress, breathing easily via trach, easily arousable
HEENT: PERRL, EOMI, dry MM (mouth breather)
Neck: trach site clean with no erythema
Chest: anterior exam CTA bilaterally, no rales appreciated
CVS: decreased heart sounds, irreg irreg, no m/g/r appreciated
Abd: obese, soft, nt, nd, guiaic negative per ED
Extrem: thin with decreased muscle mass, no edema, R forearm
with ecchymosis, mildly tender to palpation
Neuro: somnolent but arousable, communicating by writing on pad,
moving all extremities with no apparent deficits
Pertinent Results:
[**2168-10-20**] 04:46PM CK(CPK)-19*
[**2168-10-20**] 04:46PM CK-MB-NotDone cTropnT-0.17*
[**2168-10-20**] 04:46PM PTT-66.2*
[**2168-10-20**] 01:08PM TYPE-ART PO2-236* PCO2-64* PH-7.34* TOTAL
CO2-36* BASE XS-6
[**2168-10-20**] 12:12PM URINE HOURS-RANDOM UREA N-427 CREAT-78
SODIUM-25
[**2168-10-20**] 09:04AM CK(CPK)-18*
[**2168-10-20**] 09:04AM CK-MB-NotDone cTropnT-0.21*
[**2168-10-20**] 07:25AM WBC-17.7* RBC-3.71* HGB-11.6* HCT-34.7*
MCV-94 MCH-31.3 MCHC-33.5 RDW-15.9*
[**2168-10-20**] 07:25AM PT-13.1 PTT-24.3 INR(PT)-1.1
[**2168-10-20**] 01:10AM GLUCOSE-97 UREA N-71* CREAT-0.8 SODIUM-136
POTASSIUM-5.1 CHLORIDE-94* TOTAL CO2-34* ANION GAP-13
[**2168-10-20**] 01:10AM CK-MB-4 cTropnT-0.17*
[**2168-10-20**] 01:10AM DIGOXIN-1.4
[**2168-10-20**] 01:10AM WBC-20.0*# RBC-3.79* HGB-11.8* HCT-35.4*
MCV-94 MCH-31.2 MCHC-33.4 RDW-15.9*
[**2168-10-20**] 01:10AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2168-10-20**] 01:10AM URINE RBC-[**11-27**]* WBC-[**3-12**] BACTERIA-FEW
YEAST-NONE EPI-0-2 TRANS EPI-0-2
[**2168-10-20**] 01:06AM LACTATE-1.6
.
Admit CXR: The heart is upper limits of normal in size and the
mediastinal contours appear unchanged. There is interval
improvement in pulmonary vascular congestion with probable mild
persistent congestive heart failure. A focal opacity is seen at
the right base, possibly representing atelectasis. There is a
small right pleural effusion. No pneumothorax.
.
Admit EKG: aflutter at 150bpm, nl axis, QRS wnl, no q waves,
scooped out ST vs ST depressions in V1-6, II, III, aVF, STE in
avL, avR
.
Echo [**2168-8-18**]:
LV EF < 20%. Global hypokinesis. mild LVH. mild LAE.
TR gradient 25-36%. severe RV free wall hypokinesis
Valves: 3+ MR, 2+ TR, No AR.
.
Brief Hospital Course:
A/P: 74 y/o female with CHF (EF <20%), h/o afib/flutter s/p
failed cardioversion, COPD, HTN, renal insufficiency, h/o GIB,
now presenting with atrial flutter/tachycardia to 150s and
bradycardia with pauses of as long as [**3-11**] secs. Unsuccessful
ablation therapy. Now s/p permanent dual chamber pacer
placement.
.
1. Tachy-brady syndrome: The pt has past history of atrial
flutter/fib. The pt may have gone into aflutter this time
secondary to infection vs. hypoxia vs. prerenal failure. On
admission the pt's digoxin level was decreased to 0.125 per EP
and she was maintained on this level throughout her admission.
On [**2168-10-21**] EP evaluated the pt for flutter ablation. EP
evaluated the pt for atrial ablation which was performed.
However, on [**10-23**] the pt had recurrent episodes of tachy/brady
with HRs as hisg as the 150s and as low as the 30s. The pt was
asx during periods of tachy, lightheaded/pre-syncopal during
brady, That evening a temporary pacer was placed after gaining
consent from the pt's HCP. The following day a permanent dual
chamber pacemaker was placed. EP has followed the pacer since
placement. The pt's HR has been well-controlled since placement
and the pacer was adequate upon EP interrogation.
2. CV
#? Ischemia: On admission the pt experienced ST depressions in
inferior leads and V2-V6. However, these changes were felt to be
[**2-10**] to dig effectc. The pt's troponin was initially slightly
elevated. However, the pt's cardiac enzymes contined to cycle
down.
#Pump: The pt has a h/o of significant CHF (EF 20% by echo).
Throughout admission, the pt remained euvolemic-to-hypovolemic
on exam. She was diuresed gently as needed. She was started and
maintained on lisinopril and hydralazine.
#Rhythm: as above.
.
3. Leukocytosis/fever: Following permanent pacer placement, the
pt spiked a temp to 103 and had elevated WBCs. Pan cxs were sent
and her right SC cordis was removed. The pt demonstrated no
evidence of pna on exam or cxr. Blood cxs were all negative,
therefore infected pacer lines were felt to be unlikely. The pt
was initially treated with keflex. However, her Ucx grew out
enterococcus. It was also postulated that given her longterm NG,
the pt possibly has sinusitis. The pt was started on a 7 day
course of augmentin for UTI and possible sinusitis. After the
pt's initial spike, her temp has trended down and on the day of
d/c was 98 off all antipyretics.
.
4. Resp Failure s/p trach: The pt has been at [**Hospital1 **]
long term for ventilator maintenance and possible weaning. She
was a h/o COPD. During her stay, potential vent weaning was
deferred until til discharge. She was continued on
albuterol-ipratropium nebs. She was given supplemental oxygen as
required.
.
5. ARF/CRI: Upon presentation the pt had an elevated BUN and Cr.
She was pre-renal by FENA (0.21%). Her renal function resolved
shortly after admission.
6. Foot pain--The pt had focal 1st to 2nd MTP joint pain. This
was ? [**2-10**] to plantar nerve inflammation vs. musculoskeletal
contractures vs. fx. PT has followed and has recommended
longterm rehab and evaluation to clarify the etiology.
7. PPX: The pt was maintained on SQ Heparin, PPI and bowel
regimen.
.
8. FEN: The pt was maintained on TFs+hydration started via NGT.
9. FULL CODE
10. Communication--Son [**Name (NI) **]
11. [**Name (NI) 13694**] pt is to be d/c'd back to [**Hospital1 **] for
further vent management.
Medications on Admission:
Allergies: Lorazepam/MSO4
.
Meds on Admission:
Digoxin 0.25mg qod, 0.125mg qod
Lopressor 12.5 mg po bid
Alprazolam 0.125mg prn
Colchicine 0.6mg qd
Nexium 20mg qd
Flovent 2 puffs [**Hospital1 **]
Lasix 60mg qd
Hydral 25mg q8h
RISS
Discharge Medications:
1. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for
Reconstitution Sig: Five Hundred (500) mg PO Q8H (every 8 hours)
for 7 days.
Disp:*21 doses* Refills:*0*
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
4. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
5. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
6. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO QID (4 times
a day).
7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-10**]
Puffs Inhalation Q6H (every 6 hours) as needed.
8. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100)
mg PO BID (2 times a day).
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
13. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
14. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO BID (2 times a day).
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day): Give while on bedrest or not
mobile.
18. Phenol-Phenolate Sodium 1.4 % Mouthwash Sig: One (1) Spray
Mucous membrane Q4H (every 4 hours) as needed.
19. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Tachy/brady syndrome s/p pacemaker placement
Sinusitis
Discharge Condition:
Stable. Requires chronic ventilator, functioning tracheostomy
in place.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5 L per day
Followup Instructions:
Please keep the following appointments:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2168-11-1**]
11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 4022**]
Date/Time:[**2168-11-28**] 2:00
ICD9 Codes: 4280, 4240, 5849, 5859, 5990, 4254, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8655
} | Medical Text: Admission Date: [**2167-8-3**] Discharge Date: [**2167-8-10**]
Date of Birth: [**2081-6-11**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Aortic Stenosis presenting for Corevalve
Major Surgical or Invasive Procedure:
[**2167-8-4**] Corevalve/transcatheter aortic valve replacement
History of Present Illness:
Mr. [**Known lastname 112078**] is a 86 y/o man with severe aortic stenosis
(transaortic valve gradient of 41 with a valve area of 0.78 cm2
on [**6-11**]), CAD (LHC and RHC on [**2167-6-11**] showed right dominant 60%
stenosis in the prox diag, a 30% stenosis in the prox circ, 40%
distal RCA and 60-70% distal PDA), dCHF NYHA Class [**Date Range 1105**] for
dyspnea, Afib on Coumadin and Dig, Severe COPD (FEV1 27%, on 2L
O2), pulmonary HTN, who presents for percutaneous AVR. Deemed to
be an Extreme Risk candidate for surgical aortic valve
replacement (> 50% 30-day mortality or irreversible morbidity).
- In the last year he has worsening SOB with minimal exertion
leading to four hospitalizations (last [**4-26**] at OSH).
- Preop admitted on [**8-3**]. Plavix loaded.
- INTRA OP: HD stable during procedure. Pt received propofol,
phenylephrine, rocuronium, 2L NS, had UOP 600 and ESBL 200. Pt
was in Afib except during pacing, received vanc/ancef at 1300.
- Came to floor on vent initially, then successfully extubated
within two hours. After extubation patient vitals were stable
with HR 84, BP 165/58(64), SpO2 94 on 2.5L, was weaned off all
pressors, started on Nitro gtt, and Heparin gtt.
- MAC line in right groin, 2 16PIV, RIJ Pacer, left A Line
Past Medical History:
PAST MEDICAL HISTORY:
1. Severe aortic stenosis ([**Location (un) 109**] 0.78 cm2, mean gradient 41 mmHg)
2. CAD no PCI/CABG s/p cardiac catheterization in [**2166**] and [**2159**]
at [**Hospital1 1012**] with 80% diagonal and 80% distal right PDA stenosis
treated medically
3. dCHF EF 55% on [**6-11**]
4. Pulmonary hypertension (mean PAP 37 mmHg)
5. Atrial fibrillation, on warfarin and digoxin
6. Hypertension, essential with heart failure
7. Dyslipidemia
8. Asthma
9. COPD on continuous oxygen 2L
10. s/p pneumonia in [**2166-11-23**]
11. Nephrolithiasis
12. S/P cholecystectomy
Social History:
SOCIAL HISTORY
Tobacco: Quit 20-25 years ago, smoked one PPD since age 13 (~50
pack-year history)
EtOH: one drink/day, No other drug use
Residence: Lives with his wife in [**Location (un) 11790**], RI. Two grown sons.
Occupation: Retired [**Hospital Ward Name **]
Family History:
FAMILY HISTORY:
Mother deceased of old age (92)
Father deceased of intracranial hemorrhage in his 70s
Physical Exam:
ADMISSION EXAM:
VS: 97.4, 88, 158/62, 93% on 2.5L,
Weight: 72.7kg
GENERAL: Elderly pleasant caucasian male. Laying flat.
HEENT: Moist. Sclera anicteric. EOMI. Conjunctiva pink.
NECK: Right IJ for pacers in place, bandaged. JVP not
appreciated given bandage.
CARDIAC: Irregular, No S3 or S4.
LUNGS:
ABDOMEN: Soft, NTND.
EXTREMITIES: Right femoral sheath bandaged, bloody, fellow
placed pressure. Left radial aline in place. Warm, no edema, no
clubbing, no cyanosis. No c/c/e. No femoral bruits.
PULSES: Palpable DP and PT
DISCHARGE EXAM:
General: elderly pleasant male with nasal cannula in use
Skin: color pale pink,skin turgor fair. No hair growth below
knees. No ulcerations noted.
HEENT: Normocephalic, thinning white hair, anicteric. Oropharynx
moist, good dentition.
Neck: supple trachea midline, bruit vs. murmer
Chest: round chest, decreased aeration throughout, no wheeze. No
nasal flaring, oxygen in use. Speaking in short sentences.
Heart: murmer RSB radiating throughout
Abdomen: soft, nontender, (+)BS
Extremities: 1+ lower extremity edema bilat. No lesions.
Neuro: alert and oriented x 3, calm and cooperative.
Pulses: Weakly palpable peripheral pulses.
Pertinent Results:
ADMISSION LABS:
[**2167-8-3**] 01:00PM GLUCOSE-104* UREA N-20 CREAT-0.7 SODIUM-140
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-35* ANION GAP-11
[**2167-8-3**] 01:00PM ALT(SGPT)-37 AST(SGOT)-30 CK(CPK)-64 ALK
PHOS-74 TOT BILI-0.9
[**2167-8-3**] 01:00PM CK-MB-4 proBNP-1546*
[**2167-8-3**] 01:00PM ALBUMIN-3.9
[**2167-8-3**] 01:00PM DIGOXIN-1.3
[**2167-8-3**] 01:00PM WBC-8.7 RBC-4.49* HGB-14.0 HCT-40.5 MCV-90
MCH-31.2 MCHC-34.6 RDW-14.4
[**2167-8-3**] 01:00PM PLT COUNT-200
[**2167-8-3**] 01:00PM PT-12.3 PTT-28.9 INR(PT)-1.1
POST-OPERATIVE ECHOCARDIOGRAM:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF >55%). The right ventricular cavity is
dilated with mild global free wall hypokinesis. An aortic
CoreValve prosthesis is present. The transaortic gradient is
normal for this prosthesis. A paravalvular aortic valve leak is
probably present. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
regurgitation. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
low-normal global systolic function. Dilated right ventricle
with mild global hypokinesis. Corevalve aortic prosthesis with
normal transvalvular gradient and a very small perivalvular
leak. Moderate pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2167-6-11**],
estimated pulmonary artery pressures are higher. A Corevalve
prosthesis is now present.
DISCHARGE LABS:
[**2167-8-10**] 05:46AM BLOOD WBC-8.6 RBC-3.52* Hgb-10.6* Hct-31.9*
MCV-91 MCH-30.2 MCHC-33.3 RDW-14.6 Plt Ct-195
[**2167-8-10**] 05:46AM BLOOD UreaN-23* Creat-1.0 Na-140 K-3.7 Cl-98
HCO3-39* AnGap-7*
[**2167-8-10**] 05:46AM BLOOD HEMOGLOBIN, FREE-PND
[**2167-8-10**] 05:46AM BLOOD PT-26.9* INR(PT)-2.6*
Brief Hospital Course:
ASSESSMENT AND PLAN: 86 yo M with severe AS, CAD, dCHF, severe
COPD, pulm HTN, and afib on warfarin presenting for CoreValve
placement.
.
# AO STENOSIS s/p CORE VALVE: orders per Protocol. Off Neo and
Propofol, extubated. Post op hemodynamics per above. With pacing
wires still in place. The procedure went well and was
uncomplicated. Post-operative echo showed normal LV systolic
function w/EF 55%, Mild symmetric LVH with low-normal global
systolic function (EF 55%). Dilated right ventricle with mild
global hypokinesis. Corevalve aortic prosthesis with normal
transvalvular gradient and a very small perivalvular leak.
Moderate pulmonary artery systolic hypertension. Labs prior to
d/c including CBC, ytes, GFR, and ECG were WNL. He was seen and
evaluted by physical therapy who recommended be discharged to
rehab for continued physical therapy.
.
# Atrial fibrillation: Currently in Afib with transvenous pacers
in place. On Digoxin, Dilt, and Warfarin at home, Last INR 1.2.
Diltiazem and warfarin were held post-operatively, but digoxin
was continued. Warfarin was restarted without a heparin bridge.
Initially, diltiazem was held in the setting of hypotension on
post-op day 1, but was restarted w/o complications prior to
discharge. In addition, warfarin was restarted prior to d/c and
will be followed by PCP. [**Name10 (NameIs) **] INR was 2.6 on the day of
discharge and he will also be continued on aspirin.
.
# dCHF chronic NYHA Class [**Name10 (NameIs) 1105**] (EF 45% on [**8-4**]): Currently
Euvolemic. Not complaining of SOB/dyspnea/PND. Will cont medical
management. BNP 1546. He was diuresed post operatively with IV
lasix until euvolemic. He was instructed to continue monitoring
his weight upon discharge as well. His home medications were
restarted prior to discharge as noted above. In addition, Lasix
was discontinued and he was discharged to skilled nursing
facility on Torsemide 40mg daily. Weight today ([**8-10**]) 74.2 kg.
.
# Pulmonary HTN - Due to severe obstructive and restrictive
pulmonary disease. Long standing COPD, on home O2, last PFT
shows FEV1 27%, FEV1/FVC 87%. Pulmonary team consulted and
recommended continuing home medications. Prednisone was
discontinued. He will follow-up as scheduled with his
outpatient pulmonologist (Dr. [**Last Name (STitle) 42452**] [**Telephone/Fax (1) 112079**]).
.
# HTN - essential with dCHF, currently SBP elevated to 160s. He
was initially tx with Nitro gtt, then post operatively his home
BP medications including Diltiazem and doxazosin were continued.
In addition, Losartan 25mg PO daily was started.
.
# CAD - 60% stenosis in the prox diag, a 30% stenosis in the
prox circ, 40% distal RCA and 60-70% distal PDA. Simvastatin
10, plavix 75, and asa 81 were continued during his hospital
stay. Plavix discontinued as INR >2.0.
.
TRANSITIONAL:
- Always talk to Dr. [**Last Name (STitle) **] before starting new medications
- Keep Simvastatin dose at 10mg at home while on Diltiazem
- torsemide 40 instead of lasix 80 to home
- dilt 90qid to home
- do not discharge over the weekend because needs study protocol
stuff on Monday
- follow-up final results of: [**2167-8-10**] 05:46AM BLOOD HEMOGLOBIN,
FREE-PND
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Digoxin 0.125 mg PO DAILY
2. Diltiazem 240 mg PO DAILY
3. Doxazosin 8 mg PO HS
4. Furosemide 80 mg PO DAILY
5. Warfarin 2 mg PO DAILY16
Takes alternating 2mg and 3mg doses daily
6. Aspirin 81 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
8. ipratropium-albuterol *NF* 0.5 mg-3 mg(2.5 mg base)/3 mL
Inhalation TID
for Nebulization
9. PredniSONE 5 mg PO DAILY
10. Simvastatin 40 mg PO HS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Digoxin 0.125 mg PO DAILY
3. Doxazosin 4 mg PO HS
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
5. Simvastatin 10 mg PO HS
6. Warfarin 2 mg PO DAILY16
Takes alternating 2mg and 3mg doses daily - will need to be
adjusted based on INR results
7. Acetaminophen 650 mg PO Q6H:PRN pain
8. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
9. Bisacodyl 10 mg PR [**Hospital1 **]:PRN const
10. Docusate Sodium 200 mg PO BID
11. Ipratropium Bromide Neb 1 NEB IH Q6H
12. Senna 2 TAB PO BID
13. Torsemide 40 mg PO DAILY
hold for sbp < 100
14. Losartan Potassium 25 mg PO DAILY
15. Diltiazem Extended-Release 360 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11292**] health care center
Discharge Diagnosis:
1. Severe aortic stenosis-s/p Corevalve [**2167-8-4**]
2. Coronary artery disease s/p cardiac catheterization in [**2159**]
at [**Hospital1 1012**] with 80% diagonal and 80% distal right PDA stenosis
treated medically
3. Diastolic congestive heart failure
4. Pulmonary hypertension
5. Atrial fibrillation, on warfarin
6. Hypertension, essential with heart failure
7. Dyslipidemia
8. Asthma
9. COPD on continuous oxygen 2L
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:
Mr [**Known lastname 112078**],
It has been a pleasure caring for you during your stay here
at [**Hospital1 18**] while you underwent treatment for your severe aortic
stenosis. You had a transcatheter aortic valve replacement
(Corevalve) on [**2167-8-4**] under general anesthesia. Your post
operative course was uneventful. You did very well. With your
history of lung disease, pulmonary specialists were consulted
prior to your procedure to assist us during your stay. Your lung
medications and inhalers are to remain the same as before,
however your prednisone has been discontinued. You received one
unit of blood during your stay. You have progressed nicely and
are now ready for discharge to a skilled nursing facility to
continue your recovery.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs. in 2 days, or 5 lbs in 5 days.
Followup Instructions:
Make an appointment to see your primary care physician upon
discharge from rehab ([**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 1105**] -[**Telephone/Fax (1) 112080**])
Make an appointment to see your pulmonologist upon discharge
from rehab (Dr. [**Last Name (STitle) 42452**], [**Telephone/Fax (1) 112079**]).
We will contact you regarding your 30day post procedure followup
with Dr [**Last Name (STitle) **], this visit will include an echocardiogram.
ICD9 Codes: 4241, 4280, 4168, 4589, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8656
} | Medical Text: Admission Date: [**2129-5-24**] Discharge Date: [**2129-5-27**]
Date of Birth: [**2062-11-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Thoracentesis [**2129-5-25**] (~1L drained)
History of Present Illness:
The patient is a 66 yo man with h/o amyloidosis who presented
with hypotension. Per the patient, he was in his normal state
of health until last [**Month (only) 547**], when he began to experience DOE. He
presented to his PCP who performed [**Name Initial (PRE) **] CXR and diagnosed the
patient with PNA. He was given a 2-week course of Avalox, which
did not improve his symptoms. In [**Month (only) 116**], the patient had a Myoview
which was positive for inducible ischemia and demonstrated an EF
of 48%. The next day, the patient developed substernal chest
pain and presented to [**Hospital 1474**] Hospital where he was found to
have negative cardiac enzymes and a clean cardiac
catheterization. The patient continued to have DOE, PND, and
orthopnea, and he was seen by cardiology at the beginning of
[**Month (only) **]. At this time, he had a TTE, which showed significant
concentric left ventricular hypertrophy. He then had a cardiac
MRI, which demonstrated findings c/w amyloidosis. The patient
was thus started on Lisinopril last night for this condition,
with the intent on transferring his care to [**Hospital1 2177**] for further
workup.
.
Over the past two months, the patient has developed recurrent
pulmonary effusions and has had five thoracenteses. He has been
followed closely by pulmonary and was scheduled to have an
elective right-sided thoracentesis this morning. On arrival to
the IP suite, the patient felt dizzy, nauseated, fatigued, and
complained of a headache. His BP was found to be 88/40. He was
given a 500 cc bolus of NS and his BP decreased to 75/35. On
further questioning, the patient stated that he was instructed
to take Lisinopril 2.5 mg last night as well as this morning.
Given the patient's underlying amyloid, he was admitted to the
CCU for further workup and monitoring.
.
On arrival to the CCU, the patient states that he feels "100%
better" and is no longer dizzy. He had a brief episode of upper
sternal chest pain, which lasted 2 minutes and was relieved with
rest and worsened with deep breaths. ECG at this time was
negative for acute ST/T wave abnormalities.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis. He
denies recent fevers, chills or rigors. He denies exertional
buttock or calf pain. He does endorse a 20 lb weight loss over
the past two months, and he admits to hemorrhoids which last
bled when he was on "blood thinners." All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
Past Medical History:
1. CARDIAC RISK FACTORS: None.
.
2. CARDIAC HISTORY:
- Cardiac Cath: [**2129-3-25**] reportedly normal at [**Hospital 1474**]
Hospital.
.
3. OTHER PAST MEDICAL HISTORY:
1. Right-sided nephrectomy [**2111**] for cancer (details unknown).
2. Pneumonia [**2129-2-23**].
3. Status post cataract surgery.
4. Status post TURP for BPH.
5. Hemorrhoids.
6. Question of carpal tunnel syndrome.
Social History:
He is a widower and remarried to his current wife. [**Name (NI) **] retired
in [**Month (only) 404**] of this year. He previously worked in auto body work
for 25 years but never as a mechanic and did not do brake
repair. He does not know of any exposures to asbestos. He
built fire trucks for many years. He smoked cigarettes only as
a teenager but had a significant secondhand smoke exposure
through his first wife
who smoked 2 packs per day. He denies any drug use and drinks
rare alcohol. He denies any TB exposure. He was in the service
in the [**Company **] but was never in the shipyards. They have 2
cats at home.
Family History:
The patient's father passed away at 62 yo from an MI. His
mother is [**Age over 90 **] [**Name2 (NI) **] and has CHF.
Physical Exam:
On admission:
VS: T 97.5 BP 74/51 HR 89 RR 19 O2 99% on RA
GENERAL: Elderly man, pleasant, anxious, in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm. Submandibular LAD on left
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR with multiple PVCs. Normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Dullness to percussion on right to mid-lung field and at left
base. Decreased BS on right to mid-lung. No w/c/r
ABDOMEN: Soft, NTND. No HSM or tenderness. Scar in RUQ from
previous nephrectomy. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 1+ PT 1+
Left: DP 1+ PT 1+
Pertinent Results:
ADMISSION LABS:
.
[**2129-5-24**] 03:10PM BLOOD WBC-6.3 RBC-3.98* Hgb-11.3* Hct-33.1*
MCV-83 MCH-28.5 MCHC-34.3 RDW-13.6 Plt Ct-321
[**2129-5-24**] 03:10PM BLOOD Neuts-71.6* Lymphs-20.9 Monos-4.8 Eos-2.3
Baso-0.4
[**2129-5-24**] 03:10PM BLOOD PT-13.2 PTT-25.7 INR(PT)-1.1
[**2129-5-24**] 03:10PM BLOOD Glucose-107* UreaN-35* Creat-1.9* Na-139
K-4.0 Cl-103 HCO3-24 AnGap-16
[**2129-5-24**] 03:10PM BLOOD Calcium-9.0 Phos-3.2 Mg-2.2
.
.
PERTINENT LABS/STUDIES:
.
Cr: 1.9 (baseline 1.2) -> 2.2 -> 2.1 -> 1.9 -> 1.8 ([**5-27**])
Troponin: 0.39
ALT: 19, AST 20, LDH 208, Alk Phos 76, Total bili 0.3
SPEP: TRACE ABNORMAL BAND BETWEEN BETA-1 AND BETA-2 REGIONS
IDENTIFIED PREVIOUSLY, BY IFE, AS MONOCLONAL FREE (BENCE-[**Doctor Last Name **])
LAMBDA
CANNOT QUANTIFY BY DENSITOMETRY SUGGEST FOLLOWING BENCE-[**Doctor Last Name **]
PROTEIN IN URINE ONLY HYPOGAMMAGLOBULINEMIA
Factor X: 65
.
CXR ([**5-24**]): In comparison with study of [**5-7**], the pigtail has
been removed. There is still a tiny apical pneumothorax. The
bilateral pleural effusions are again seen and essentially
unchanged. Some downward tilt of the minor fissure indicates
volume loss involving the right lower lobe and possibly the
right middle lobe as well.
Interval CXR ([**5-26**]): Slight increase in bilateral pleural
effusions. Unchanged retrocardiac and right basal atelectasis.
?mild overhydration
.
EKG: NSR with rate of 83. Diffusely low voltage in all leads.
[**Street Address(2) 4793**] elevation in V1 and V2 with no T wave inversions.
.
2D-ECHOCARDIOGRAM ([**5-5**]): The left atrium is mildly dilated.
There is moderate symmetric left ventricular hypertrophy with a
hyaline acoustic texture that raises the suspicion of an
infiltrative cardiomyopathy. The left ventricular cavity is
small. Overall left ventricular ejection fraction is normal
(LVEF 60%). There is no ventricular septal defect. The right
ventricular free wall is hypertrophied. Right ventricular
chamber size is normal. with normal free wall contractility. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is
borderline pulmonary artery systolic hypertension. There is a
rivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
.
CARDIAC MRI ([**5-18**]): 1. Normal left ventricular cavity size with
normal regional left ventricular systolic function. The LVEF was
mildly depressed at 43%. The effective forward LVEF is
moderately depressed at 30%. Delayed hyperenhancement imaging
findings are consistent with cardiac amyloidosis. 2. Normal
right ventricular cavity size and systolic function. The RVEF
was normal at 49%. 3. Mild aortic and pulmonic regurgitation.
Moderate mitral and tricuspid regurgitation. 4. The indexed
diameters of the ascending and descending thoracic aorta were
normal. The main pulmonary artery diameter index was normal. 5.
Moderate left atrial enlargement. 6. A cavitary or cystic
lesion in the right lower lobe of the lung as well as dilated
pancreatic duct with multiple pancreatic cysts were observed.
Correlation with CT imaging is advised.
.
Fat Pad Aspirate Pathology ([**2129-5-25**]): FNA, Abdominal fat pad:
NON-DIAGNOSTIC. Acellular specimen.
.
Abdominal U/S ([**5-25**]): The liver is homogeneous in echotexture.
Note is made of moderate right pleural effusion and trace
perihepatic ascites. The spleen is notable for cystic
structures, unchanged from the recent CT. The right lobe of the
liver contains a 9 x 10 x 9 mm hemangioma and there is no other
focal hepatic mass. There is no intra- or extra-hepatic biliary
ductal dilatation. The common bile duct is 4 mm. The gallbladder
is obscured by cholelithiasis and there is no pericholecystic
fluid or gallbladder mural edema. There is a negative
son[**Name (NI) 493**] [**Name (NI) **] sign. The main portal vein is patent with
normal hepatopetal flow. The patient is status post right
nephrectomy. The spleen is homogeneous in echotexture, measuring
10.3 cm. The left kidney is 12 cm and there is no evidence of
hydronephrosis. Prominence of the renal medullary pyramids is
indicative of increased echogenicity in the renal cortices,
possibly indicative of medical renal disease. Note is made of a
small left renal cyst measuring 9 x 8 x 7 mm. IMPRESSION:
Overall, minimal change since [**5-6**] with pleural effusion,
hepatic hemangioma, splenic cysts and left renal cyst. Slightly
echogenic left renal cortex may indicate medical renal disease.
.
Skeletal Survey ([**2129-5-25**]): LATERAL SKULL: No focal lytic or
blastic lesions are seen. There are some degenerative changes of
the mid cervical spine with some joint space narrowing.
THORACIC SPINE: There are multiple anterior mild wedge
compression deformities of the mid thoracic spine. Age of these
are indeterminate. LUMBAR SPINE: There is some mild scoliosis
with convexity to the right side centered at L3. There is loss
of intervertebral disc height at multiple levels, worse at L2-L3
where there is also some mild retrolisthesis. No compression
deformities are seen.
BILATERAL HUMERI: No focal lytic or blastic lesions are present.
AP PELVIS AND BILATERAL FEMORA: Joint spaces of both hips are
preserved.
Sacroiliac joints are unremarkable. No focal lytic or blastic
lesions are
seen in either femurs. IMPRESSION: 1. Degenerative changes of
the lumbar spine and some wedge deformities of several mid
thoracic vertebral bodies.
2. No focal lytic or blastic lesions identified.
.
PENDING LABS/STUDIES:
- B2 microglobulin
- UPEP
- Fat Pad aspirate pathology
- Bone Marrow biopsy
- Bone Marrow Cytogenetics
Brief Hospital Course:
ASSESSMENT AND PLAN: The patient is a 66 yo man with h/o
amyloidosis who presents with hypotension in the setting of
Lisinopril 2.5 mg HS/AM.
.
#. Hypotension: The patient's BP on admission was 74/51, and he
was experiencing dizziness, nausea, and HA. This was in the
setting of starting Lisinopril on [**5-23**] and taking two doses
over the past 24 hours prior to admission. His BP did not
improve with NS on [**5-24**], but the patient was no longer
symptomatic from his hypotension. Per the patient, his SBP
normally runs in the 80s-90s. Symptomatic hypotension was most
likely [**12-27**] Lisinopril in the setting of amyloidosis. Normal
saline boluses were given to maintain a MAP>60 and lisinopril
and lasix were held. The patient was ambulating without
symptoms on discharge. He was discharged on Lasix 20 mg daily,
which is decreased from his previous dose of 40 mg [**Hospital1 **].
.
#. Amyloidosis: The patient was recently diagnosed with
amyloidosis on findings from TTE and Cardiac MRI. The patient's
PCP and pulmonologist were interested in referral to the Amyloid
treatment program at [**Hospital6 **]. [**Hospital1 2177**] was contact[**Name (NI) **]
and recommended inital work-up here and outpatient referral.
Heme/Onc was consulted, who recommended fat pad biopsy and UPEP,
in addition to the cardiac MRI, echocardiogram and SPEP which
had already been done. Fat pad biopsy and fat pad aspirate were
done. Preliminary results of both were inconclusive, though
final staining results are pending. As a result, bone marrow
biopsy was done on [**5-26**] per Heme/Onc recs, to ensure good
sampling. Social work was also consulted to assist the patient
with coping with his new diagnosis of cardiac amyloidosis.
.
#. Pleural Effusions: The patient has large bilateral pleural
effusions that reaccumulates regularly; he had been scheduled
for elective thoracentesis on the day of admission. Spoke with
pulm on [**5-24**] and they took the patient for [**Female First Name (un) 576**] on [**5-25**] when
his pressures improved. Since [**Female First Name (un) 576**], pleural effusions have been
reaccumulating gradually. He was discharged on Lasix 20 mg
daily.
.
#. Acute Renal Failure: The patient's Cr on presentation was
1.9, which was increased from his baseline of 1.2 in [**4-2**]. This
was most likely pre-renal in the setting of poor forward flow.
Urine electrolytes were sent, showing a fractional excretion of
urea of 16%, suggesting a prerenal etiology. The patient was
given 250cc NS fluid boluses PRN, and his creatinine decreased
to 1.8 on discharge.
.
#. Abdominal Pain: The afternoon of [**5-26**] after bone marrow
biopsy and discussion of amyloid diagnosis, patient began having
crampy, intermittent lower quadrant abdominal pain following
three loose stools. Abdomen was soft, non-distended and tender
to deep palpation. Pain improved initially with low doses of
Morphine, then resolved. A KUB showed no dilated bowel loops
and no air-fluid levels. He was given simethicone and the
patient's pain resolved.
Medications on Admission:
Lisinopril 2.5 mg daily
Lasix 40 mg [**Hospital1 **]
KCon 20 mg daily
Discharge Medications:
1. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10
days: Discuss this medication with Dr. [**Last Name (STitle) **] at your next
appointment.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Cardiac amyloidosis, pleural effusions, worsened kidney
function (acute renal failure)
Secondary: Status-post nephrectomy
Discharge Condition:
Hemodynamically stable and afebrile.
Discharge Instructions:
You were admitted for low blood pressure after taking your new
blood pressure medicine, Lisinopril. You were given IV fluids
and your blood pressure returned to your prior low level of
systolic blood pressure 80-90.
You were also seen by hematology/oncology for evaluation and
further work-up of amyloidosis. This disease causes deposition
of abnormal proteins in organs including your heart. This
results in impaired relaxation and filling of the heart, and can
cause low blood pressures and decreased blood flow to your
organs.
You also underwent thoracentesis to remove extra fluid from the
space around your lungs. You will continue to see Dr. [**Last Name (STitle) 4507**] for
future treatment of this problem.
The following changes to your medications were made:
- STOP taking Lisinopril
- DECREASE your Lasix to 20 mg daily
Please seek medical attention if you develop fever, chills,
difficulty breathing, chest pain, redness around your biopsy
site or if you feel dizzy, lightheaded, faint or any other
symptoms that are concerning to you.
Followup Instructions:
You have been referred to a specialist for your disease. Thus,
you have an appointment at [**Hospital6 **] Amyloid
Program. Your appointment is Monday, [**2129-5-30**] at 7:45AM.
This is at the Moakley Building on the [**Location (un) **]. If you need
to contact the clinic, call [**Telephone/Fax (1) 83462**].
Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 6330**]
[**Last Name (NamePattern1) **].
Phone: [**Telephone/Fax (1) 18509**]
Date: Friday, [**2129-6-3**] at 11:45 AM
You have follow-up scheduled with Dr. [**Last Name (STitle) 4507**], your
Pulmonologist:
PULMONARY FUNCTION LAB
Phone:[**Telephone/Fax (1) 609**]
Date:[**2129-6-8**] at 3:10 PM
DR. [**First Name8 (NamePattern2) 3688**] [**Last Name (NamePattern1) **]
Phone: [**Telephone/Fax (1) 612**]
Date/Time: [**2129-6-8**] at 3:30 PM
You will need to have the stitches take out of the skin on your
abdomen in 2 weeks. This can be done by Dr. [**Last Name (STitle) 4507**] at your
appointment.
Completed by:[**2129-5-27**]
ICD9 Codes: 5849, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8657
} | Medical Text: Admission Date: [**2190-12-11**] Discharge Date: [**2190-12-20**]
Date of Birth: [**2156-4-7**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
[**2190-12-11**] Chest Tube Placement
History of Present Illness:
34 male s/p single vehicle accident. Per report the patient was
intoxicated and hit a stationary object and his head went
through the windshield. He did not recall the exact
circumstances surrounding the event.
Past Medical History:
-Hypertension
-Bradycardia
-Obstructive sleep apnea
b/l adrenalectomy
Social History:
SOCIAL HISTORY: Lives with mother and brother, occasional cigar,
no drugs, + ETOH
Family History:
noncontributory
Physical Exam:
Constitutional: Moderate respiratory distress, anxious
HEENT: Small abrasion to anterior frontal region
C. collar in place
Chest: Tachypneic with coarse breath sounds
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Pertinent Results:
[**2190-12-11**] 08:57PM GLUCOSE-130* UREA N-16 CREAT-1.2 SODIUM-139
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14
[**2190-12-11**] 08:57PM CALCIUM-8.7 PHOSPHATE-4.4# MAGNESIUM-2.4
[**2190-12-11**] 12:26PM GLUCOSE-67* UREA N-9 CREAT-0.5 SODIUM-138
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-14* ANION GAP-23*
[**2190-12-11**] 12:26PM CK(CPK)-328*
[**2190-12-11**] 12:26PM CK-MB-3 cTropnT-<0.01
[**2190-12-11**] 12:26PM CALCIUM-6.9* PHOSPHATE-1.8* MAGNESIUM-0.9*
[**2190-12-11**] 09:39AM TYPE-ART TIDAL VOL-600 PEEP-12 O2-100
PO2-298* PCO2-42 PH-7.36 TOTAL CO2-25 BASE XS--1 AADO2-381 REQ
O2-67 INTUBATED-INTUBATED VENT-CONTROLLED
[**2190-12-11**] 09:39AM HGB-15.0 calcHCT-45
[**2190-12-11**] 07:29AM LACTATE-1.4
[**2190-12-11**] 07:29AM LACTATE-1.4
[**2190-12-11**] 07:13AM URINE HOURS-RANDOM
[**2190-12-11**] 07:13AM URINE HOURS-RANDOM
[**2190-12-11**] 07:13AM URINE UHOLD-HOLD
[**2190-12-11**] 07:13AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2190-12-11**] 07:13AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.030
[**2190-12-11**] 07:13AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2190-12-11**] 07:13AM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2190-12-11**] 04:55AM GLUCOSE-120* UREA N-15 CREAT-1.3* SODIUM-142
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-25 ANION GAP-15
[**2190-12-11**] 04:55AM estGFR-Using this
[**2190-12-11**] 04:55AM CK(CPK)-480*
[**2190-12-11**] 04:55AM LIPASE-17
[**2190-12-11**] 04:55AM cTropnT-<0.01
[**2190-12-11**] 04:55AM ASA-NEG ETHANOL-249* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2190-12-11**] 04:55AM WBC-6.0 RBC-5.34 HGB-15.7 HCT-46.4 MCV-87
MCH-29.3 MCHC-33.7 RDW-13.1
[**2190-12-11**] 04:55AM PLT COUNT-227
[**2190-12-11**] 04:55AM PT-13.9* PTT-24.4 INR(PT)-1.2*
[**2190-12-11**] 04:55AM FIBRINOGE-281
Brief Hospital Course:
The patient was evaluated in the emergency room. Due to concern
for possible worsening respiratory capacity as well as
somnolence, the patient was intubated in the emergency room for
airway protection. After his intubation it was appreciated that
he had developed a pneumothorax, hence a right sided chest tube
was placed. He was admitted to the intensive care unit. He was
transferred to the floor on [**2190-12-12**] The chest tube was
maintained to suction and then brought to water seal. Serial
chest x-rays demonstrated gradual partial resolution of the
pneumothorax. A CTscan was performed on [**2190-12-16**] which
demonstrated that the tube was within the minor fissure and that
there was some inflammatory change in the lateral aspect of the
lung at the site of placement of the chest tube. The chest tube
was felt to be in suboptimal position within the minor fissure,
hence it was pulled on [**2190-12-16**]. The patient was maintained on
oxygent to promote reabsorption of the pneumothorax. Due to
continued shortness of breath, he underwent a CT-angiogram with
pulmonary embolism protocol on [**2190-12-17**] which demonstrated no
pulmonary embolism. He had purulent discharge from the chest
tube placement site hence he was started on broad spectrum
antibiotics and wound cultures were sent. Infectious diseases
was consutled. Wound cultures came back with mixed bacterial
flora, and eventually demonstrated MSSA, hence he was started on
PO augmentin per ID recommendations for MSSA coverage as well as
broad coverage for other bacterial contaminants of his wound.
He was discharged on [**2190-12-20**] in good condition.
Medications on Admission:
Included atenolol and prazosin
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
2. prazosin 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a
day).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
4. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
5. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain for 10 days.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Pneumothorax
Wound infection
Discharge Condition:
At the time of discharge, the patient was afebrile with vital
signs within normal limits. He was ambulating and voiding
without difficulty. He was tolerating a regular diet and his
pain was well controlled.
Discharge Instructions:
You were treated for a pneumothorax, which is air that collects
in the space between the lung and the chest wall and interferes
with breathing. You were treated for this condition with the
placement of a chest tube, which enables the air trapped between
the lung and the chest wall to be removed so that the lung can
function normally. After your chest tube was removed, you
developed an infection at the site of placement of your chest
tube, for which you are receiving antibiotics.
Please refrain from heavy exertion until cleared by a physician.
[**Name10 (NameIs) **] you smoke, it is important that you stop for your general
health, but particularly while recovering from this illness. It
is also important that you refrain from alcohol until cleared by
a physician.
[**Name10 (NameIs) 357**] do not drive while taking pain medications.
You will need to do dressing changes daily on your chest wound.
a visiting nurse will come initially to help with this.
Followup Instructions:
Please call the Acute Care Surgery clinic to make an appointment
to be seen in follow up in 2 weeks. The phone number for the
[**Hospital 2536**] clinic is ([**Telephone/Fax (1) 2537**]. Please get a chest x-ray before
coming to thsi appointment. You can do the chest x-ray on the
day of your appointment prior to meeting with the doctor. Please
call the number above to schedule the chest x- ray as well.
Completed by:[**2190-12-20**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8658
} | Medical Text: Admission Date: [**2124-1-19**] Discharge Date: [**2124-3-14**]
Date of Birth: [**2048-2-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Acute Pancreatitis
Major Surgical or Invasive Procedure:
Open Tracheostomy [**2124-2-4**]
Open G/J tube placement [**2124-2-11**]
History of Present Illness:
This is a 75 year old male admitted from [**Location (un) 14663**] with acute
pancreatitis, (amylase 2698, lipase 3327 at OSH). He reports no
ETOH, and imaging reveals no gallstones, his TG were 114.
A CT ([**1-17**] - OSH) abd/pelvis showed nonspecific inflammatory
changes in anterior pararenal space, extending from above
pancreas in pelvis and involving R retroconal fashion. Fatty
liver. Small amount ascites, borderline enlarged pelvic lymph
nodes. Gallbladder WNL. A RUQ U/S ([**1-17**] - OSH) showed CBD 4mm, no
gallstones. At the OSH, he was treated with ABX, NPO, IVF. His
repeat lipase/amylase showed a downward trend, but transferred
to [**Hospital1 18**]. He was admitted to ICU for tachycardia to low 100s,
tachypnea in 30s, PaO2 66 on 4L NC; also hypocalcemic.
Past Medical History:
PMH:CAD s/p MI [**30**] years ago; HTN, hyperlipidemia, obesity, OA,
BPH, duodenal ulcer
PSH:B TKR (most recent R TKR [**1-5**])
Social History:
Retired contractor, living with 2nd wife. [**Name (NI) **] a daughter and 4
sons. Quit smoking 15 yrs. ago. No history of alcohol and
IVDU.
Family History:
Parents - hypertension
Mom - CVA
Pertinent Results:
[**2124-1-20**] 12:22AM BLOOD WBC-21.5* RBC-3.02* Hgb-9.0* Hct-27.7*
MCV-92 MCH-29.8 MCHC-32.4 RDW-13.8 Plt Ct-334
[**2124-1-26**] 01:18AM BLOOD WBC-22.3* RBC-2.50* Hgb-7.3* Hct-23.9*
MCV-96 MCH-29.3 MCHC-30.7* RDW-14.5 Plt Ct-326
[**2124-1-20**] 04:56AM BLOOD Glucose-272* UreaN-60* Creat-1.6* Na-140
K-3.9 Cl-107 HCO3-22 AnGap-15
[**2124-1-26**] 01:18AM BLOOD Glucose-111* UreaN-39* Creat-1.6* Na-146*
K-4.4 Cl-117* HCO3-22 AnGap-11
[**2124-1-20**] 04:56AM BLOOD Lipase-225*
[**2124-1-26**] 01:18AM BLOOD Lipase-24
[**2124-1-26**] 01:18AM BLOOD Calcium-7.6* Phos-4.3 Mg-2.0
.
CT ABDOMEN W/CONTRAST [**2124-1-20**] 4:29 AM
IMPRESSIONS:
1. No evidence of pulmonary embolus.
2. Moderate-to-severe acute pancreatitis, with little to no
enhancement of the pancreatic neck and head, focal ileus and
moderate associated ascites. No evidence of associated vascular
compromise.
.
Cardiology Report ECG Study Date of [**2124-1-20**] 1:29:16 AM
Sinus tachycardia. Non-diagonstic repolarization abnormalities.
No previous tracing available for comparison.
Rate PR QRS QT/QTc P QRS T
107 160 100 356/438 30 -18 6
.
TTE (Complete) Done [**2124-1-21**] at 11:43:28 AM
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 70%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is moderately dilated. 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. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is no pericardial effusion.
.
CT ABDOMEN W/CONTRAST [**2124-1-23**] 11:57 AM
1. Diffuse peripancreatic edema/phlegmonous change. No
pseudocyst or abscess present at this time. Mild hypoenhancement
of the pancreatic head likely related to the acute inflammatory
process. Small amount of ascites.
2. Mildly dilated proximal small-bowel loops likely representing
focal localized ileus. No small-bowel obstruction. Inflammatory
thickening of the 2nd and 3rd portions of the duodenum as well
as the hepatic flexure.
3. Markedly enlarged prostate.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2124-1-24**] 9:17 AM
1. Limited exam. The liver is coarsened and echogenic consistent
with fatty infiltration. More advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded. No
focal hepatic lesion is identified.
2. No evidence of gallstone or intra/extrahepatic biliary
dilatation.
3. Ascites.
.
CHEST (PORTABLE AP) [**2124-1-25**] 8:52 AM
INDICATIONS: A 75-year-old man intubated, with increasing
leukocytosis and fever. Question pneumonia.
CHEST, AP PORTABLE SEMI-UPRIGHT: Comparison is made to the prior
day, also with limited review of a recent CT from [**2124-1-20**]. The
patient remains intubated. The endotracheal tube again
terminates at the carina. A nasogastric tube passes into the
stomach, although its distal course is not well visualized for
technical reasons. The lung volumes are low, and the film
lordotic in orientation. Persistent bibasilar opacities are
present, most suggestive of atelectasis. There is no
pneumothorax, definite effusion or pulmonary edema.
IMPRESSION: Endotracheal tube terminating at the carina.
Probable bibasilar atelectasis
R KNEE 2 VIEW PORTABLE [**2124-1-27**] 9:31 AM
History: 75-year-old male with erythema and pain. Evaluate for
fluid or
infection.
1. Large joint effusion.
2. Intact total knee arthroplasty without signs for loosening.
CT TORSO [**2124-1-28**] 1:43 PM
INDICATION: Pancreatitis, abdominal distention, and pain
1. Interval progression of changes of acute pancreatitis,
including hypoenhancement of the pancreatic head suspicious for
pancreatic necrosis.
2. Probable developing pseudocysts about the pancreas and
gastric fundus, but no walled-off collections suggestive of
abscess. Increased ascites.
3. Dilated small bowel loops with air-fluid levels are
suggestive of ileus.
4. Unchanged hepatic flexure colonic edema, likely reactive.
5. Bilateral pleural effusions, unchanged. Increased
atelectasis and patchy consolidation that could relate to
infectious or inflammatory process
6. Endotracheal tube terminating in proximal right main stem
bronchus.
Brief Hospital Course:
This is a 75 year old male transferred from [**Location (un) 14663**] with
acute pancreatitis, (amylase 2698, lipase 3327 at OSH). He
reportedly had no gallstones, no ETOH, and TG 114.
.
Neuro: While he was intubated with ETT, he received a
combination of propofol and midazolam for sedation. These were
weaned off [**1-29**] and Precedex was started. This was weaned off
on [**2-4**] after his tracheostomy. His pain was controlled with
intermittent fentanyl, toradol x3 days and dilaudid. As of [**2-6**]
he has been maintained on intermittent ativan and morphine for
sedation/pain control. He was transferred to the floor on
[**2124-3-6**] with tylenol, ibuprofen, and a clonidine patch for pain
control.
.
CV: On HD [**1-16**], he began having rapid Afib. He received Lopressor
IV and Diltiazem, but did not seem to be responding. Cardiology
was consulted and it was recommended he be cardioverted. An ECHO
was perfomed prior and cardioversion was attempted twice, but
was unsucessful. He was started on an heparin drip, amiodarone &
esmolol drips. He remained in Afib and converted to NSR on
[**2124-1-21**] after being placed on a procainamide drip. He continued
on Amio and Lopressor for rate control and heparin drip for
anticoagulation. On [**2-7**], he was transitioned to PO amiodarone.
He reconverted to Afib after his open G-tube on [**1-/2045**] and
required rebolusing of amiodarone. However, he eventually
converted back to NSR and was maintained on PO amiodarone.
Throughout his ICU course, he did require some low dose
neosynephrine for pressure control but was able to be weaned
off. He was transferred to the floor on PO amiodarone and
metoprolol and has remained in normal sinus rhythm. He was
transferred to ICU on [**2124-3-12**] for a-fib. He was started on
Diltiazem drip and converted to sinus rhythm. He is currently
sinus on PO Lopressor and PO Amiodarone.
.
Pulm: He was tachypnic and developed pulmonary effusions. He
received Lasix for diuresis. He was intubated for the
cardioversion. He was eventually extubated on [**1-26**]. CXR showed
bilateral atelectasis with decreased lung volumes. On [**1-28**] he
had progressive increased work of breathing and tachypnea. CXR
demonstrated even lower lung volumes and he was electively
re-intubated. He was initially requiring high ventilator
support but he was progressively weaned down. He received an
open tracheostomy on [**2124-2-4**] by the trauma surgery team. He was
able to be weaned to trach mask and is currently tolerated a
Passy-Muir valve. On the floor he was triggered twice on
[**2124-3-7**] for decreasing oxygen saturations. The first event
occurred after a vigorous bowel movement and he returned to
baseline within minutes. A CXR revealed bilateral pleural
effusions. The second trigger occurred after a coughing fit
caused an episode of emesis. Due to concerns for aspiration, a
repeat speech and swallow evaluation was ordered, which he
passed. He is receiving suctioning every 4 hours by the nurse
or MD.
.
GI: On admission he was made NPO, started on IVF resuscitation
and TPN (goals: 1.5gAA/kg, 25Kcal/kg). He was improving and NGT
was D/C'd on HD 9 and he was started on sips. However, his
abdominal distension increased and he was made NPO and an NGT
was replaced. KUB on [**1-28**] demonstrated dilated small bowel
loops consistent with an ileus. His NGT output gradually
decreased and he started to pass flatus. The NGT was removed on
[**2-5**]. On [**1-/2045**] an open GJ-tube was placed. During surgery ~2L
ascites were drained. He was started on Peptamen tube feeds the
next day and was eventually advanced to goal. He underwent
placement of percutaneous cholecystostomy tube and he continues
to have significant amount of bile draining from this tube. We
have been refeeding this bile through through his J-tube.
Please continue to do the same. He passed his speech and
swallow evaluation and is able to eat soft foods with thin
liquids.
.
Pancreatitis: His Amylase and Lipase trended down and his
abdominal pain resolved. A US on [**1-24**] showed no evidence of
gallstone or intra/extrahepatic biliary dilatation. CT abd on
[**1-28**] demonstrated: Interval progression of changes of acute
pancreatitis, including hypoenhancement of the pancreatic head
suspicious for pancreatic necrosis; probable developing
pseudocysts about the pancreas and gastric fundus, but no
walled-off collections suggestive of abscess; increased ascites;
dilated small bowel loops with air-fluid levels suggestive of
ileus. Repeat CT abd [**2124-2-16**] that showed marked interval
progression of peripancreatic fluid collections which now appear
much larger and more organized; one of these involves the
inferior right lobe of the liver and a distended gallbladder.
The peripancreatic fluid collection (below liver) and
gallbladder were percutaneously drained on [**2-17**], yielding ~500cc
serosanguinous fluid and 270cc sludgey bile, respectively. He
will need a follow up CT scan of pancrease 1 month from time of
discharge. He will need follow up with the result of CT.
.
FEN: He was maintained on bowel rest and TPN until resolution of
his acute pancreatitis. He was started on tube feeds 24 hours
after he received an open G-tube on [**1-/2045**]. He became
hypernatremic on [**2-10**] and this resolved with free water boluses.
.
Heme: As of [**2-13**], he was transfused a total of 4 units of blood
for anemia (i.e. Hct <22). He was maintained on a heparin drip
given his runs of Afib. Goal PTT was 60-80. He was eventually
bridged over to coumadin (first dose [**2-13**]).
.
ID: Since his admission, his WBC was elevated to ~20's with the
differential significant for mostly PMNs. He also had
intermittent fever spikes. He was initially started on empiric
antibiotics including vanco/zosyn/flagyl. The only cultures
that grew out were a BAL (1 out of 4) with MRSA on [**1-25**] and
sputum on [**1-30**] with rare yeast. For the presumed MRSA
pneumonia, he was treated with vancomycin for 8 days (ID service
was in agreement). He was started on meropenem [**1-28**] and there
was an associated significant decrease in his WBC. This was
stopped after ~2weeks of treatment. On [**2-12**], his WBC began to
climb once again. He was pancultured and lines were resited.
On [**3-8**] Vancomycin was restared for gram positives in sputum.
Final cultures showed MSSA and gram negative rods. Vancomycin
was discontinued and Nafcillin and Cipro was started on [**2124-3-10**].
He should continue w/ Nafcillin and Cipro until the [**2124-3-17**]. He
continues to have leukocytosis and we believe this is secondary
to his chronic pancreatitis.
.
Endo: He was on an Insulin drip for BG control. His HgA1C was
7.2 around the time of admission. He was eventually switched to
SQ insulin. Cushings work-up was negative.
.
MSK: He had question of warmth in R knee and given his history
of bilateral knee replacements, a xray and orthopedics consult
were obtained. The R Knee xray showed a large joint effusion
with ntact total knee arthroplasty without signs for loosening.
Ortho did not feel an infection was present and that any
intervention was required on [**2124-1-27**]. His knees were stable
ever since.
.
GU: Urine output was monitored with a Foley and it was
marginally adequate throughout his stay. A lasix drip was
started to aid in diuresis. His creatinine bumped up on [**2-13**]
from 1.0 to 1.4 and continued to increase. His lasix drip was
held. He has not required diuresis recently and has been
autodiuresing.
.
Micro (recent):
[**3-7**] BAL: MSSA and sparse GNR x 2.
[**3-8**] urine: NG
[**3-11**] Cdiff: neg
[**3-12**] blood: Pend
[**3-12**] urine: Pend
[**3-12**] sputum: Pend
.
Imaging:
[**1-17**] (OSH) CT abd/pelvis: nonspecific inflammatory changes in
anterior pararenal space, extending from above pancreas in
pelvis and involving R retroconal fashion. Fatty liver. Small
amount ascites, borderline enlarged pelvic lymph nodes.
Gallbladder WNL.
[**1-17**] (OSH) RUQ U/S: CBD 4mm, no gallstones
[**1-19**] CXR: low lung volumes, no PTX, no PNA, no effusions
[**1-19**] CTA: No PE, moderate-to-severe acute pancreatitis, with
little to no enhancement of pancreatic neck and head and a focal
ileus and moderate associated ascites. No evidence of associated
vascular compromise.
[**1-21**] ECHO EF 70%
2/11 RUQ U/S: No gallstones, CBD 5mm, +ascites.
[**3-11**] CT Chest/Abd/Pelv: 1. Extensive pancreatic necrosis and
inflammatory change, similar to the prior study. Multiple
peripancreatic fluid collections redemonstrated. The largest
collection along the inferior edge of the liver has a pigtail
catheter within it and is smaller in size. Other peripancreatic
collections are unchanged.
2. Decrease in volume of ascites.
3. No change in moderate bilateral pleural effusions and
atelectasis of the
dependent lower lobes.
Medications on Admission:
atenolol 25mg'; omeprazole 20 mg"; HCTZ 20 mg'; lisinopril 40
mg";finasteride 5 mg'; terazosin 10 mg'; simvastatin 20
mg';arixtra 2.5 mg'
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO Q6H (every
6 hours) as needed.
2. Bisacodyl 10 mg Suppository [**Month/Year (2) **]: One (1) Suppository Rectal
HS (at bedtime) as needed.
3. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed.
4. Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet [**Month/Year (2) **]:
1-2 Tablets PO TID (3 times a day).
5. Simvastatin 40 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO DAILY (Daily).
6. Olanzapine 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Paroxetine HCl 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
9. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours).
10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]:
One (1) Inhalation Q6H (every 6 hours).
11. Insulin NPH Human Recomb 100 unit/mL Suspension [**Last Name (STitle) **]: 35
Units Subcutaneous every twelve (12) hours.
12. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: Sliding
Scale Injection every six (6) hours: Insulin SC Sliding Scale
Q6H
Regular
Glucose Insulin Dose
0-60 mg/dL [**12-15**] amp D50
61-120 mg/dL 0 Units
121-160 mg/dL 3 Units
161-200 mg/dL 6 Units
201-240 mg/dL 9 Units
241-280 mg/dL 12 Units
281-320 mg/dL 15 Units
> 320 mg/dL Notify M.D.
.
13. Magnesium Hydroxide 400 mg/5 mL Suspension [**Month/Day (2) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
14. Ciprofloxacin 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
15. Nafcillin in D2.4W 2 gram/100 mL Piggyback [**Month/Day (2) **]: Two (2) gm
Intravenous Q6H (every 6 hours) for 5 days.
16. Amiodarone 200 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times
a day).
17. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: 1.5 Tablets PO TID (3
times a day).
18. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: One (1) PO BID (2
times a day).
19. Miconazole Nitrate 2 % Powder [**Month/Day (2) **]: One (1) Appl Topical QID
(4 times a day) as needed.
20. Zolpidem 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO HS (at bedtime).
21. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection TID (3 times a day).
22. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
[**Month/Day (2) **]: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day).
23. Phenazopyridine 100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID (3
times a day) for 3 days.
24. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Month/Day (2) **]: Two
(2) ML Intravenous DAILY (Daily) as needed.
25. Sodium Chloride 0.9 % 0.9 % Syringe [**Month/Day (2) **]: Three (3) ML
Injection DAILY (Daily) as needed.
26. Lorazepam 2 mg/mL Syringe [**Month/Day (2) **]: 0.25 mg Injection Q6H (every
6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Acute Pancreatitis
Rapid Atrial Fibrilation
Malnutrition
Deconditioning
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**9-27**] lbs) for 6 weeks.
* Monitor your incision for signs of infection
* You may shower and wash. No tub baths or swimming. Keep your
incision clean and dry.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2124-4-17**]
11:45
Please arrive for CT of Pancreas at 9:30am to [**Hospital Ward Name 23**] [**Location (un) **].
Completed by:[**2124-3-14**]
ICD9 Codes: 5849, 5990, 5119, 412, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8659
} | Medical Text: Admission Date: [**2138-5-9**] Discharge Date: [**2138-5-13**]
Date of Birth: [**2082-3-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Hydrocodone
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Angina
Major Surgical or Invasive Procedure:
[**2138-5-9**] Coronary artery bypass graft x3: Left internal mammary
artery to left anterior descending artery, and saphenous vein
grafts to obtuse marginal-1 and 2
History of Present Illness:
This is a 56 y.o English speaking Latino woman with a past
medical history of IDDM, poorly controlled hypertension,
hypercholesterolemia, and GERD, who first presented in [**2131**] with
angina and an abnormal stress test. She was taken to the cath
lab where she was found to have proximal and mid LAD lesions,
which were each treated with one Taxus DES. She has done well
over the past several years and is followed by [**Hospital **] Clinic.
She states he blood pressure has been difficulty to manage at
times. Approximately one month ago she developed shortness of
breath while climbing stairs. This usually resolves with rest.
She also experiences shortness of breath when walking long
distances on flat surfaces. Cardiac catheterization today
revealed multi-vessel disease and she was referred for surgery.
Past Medical History:
Coronary artery disease s/p stents 5 years ago
Lumbar Spine DJD s/p disc surgery [**57**] years ago
Osteoarthritis and Tenosynovitis s/p recent steroid injection to
the left volar third finger with improvement
Diabetes Mellitus c/b neuropathy
Hypertension
GERD
Iron Deficiency Anemia
Tonsillectomy
Hysterectomy (ovaries intact)
Social History:
Race:caucasian
Last Dental Exam:>2 years, edentulous
Lives with:She lives alone in [**Hospital1 8**] MA. She is legally
married but her husband lives in [**Name (NI) 26692**]. She uses a
cane
and a rolling walker. She has not had any recent falls and does
have lifeline in her home.
Occupation:She is currently disabled.
Tobacco:none
ETOH:none
Family History:
Brother past away from Leukemia and had "irregular heart rates".
Father past away in his 60's following an MI. Mother had
congestive heart failure and diabetes and died in her 60's. Her
daughter who is 36 also has leukemia. Many family members have
diabetes and Hypertension.
Physical Exam:
Pulse: 69 Resp:14 O2 sat: 99%
B/P 151/70
Height: 5 Ft 4 inches Weight:180 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]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact[x]
Pulses:
Femoral Right:1+ Left:1+
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:2+ Left:2+
Carotid Bruit Right:- Left:-
Pertinent Results:
[**2138-5-13**] 04:30AM BLOOD WBC-8.5 RBC-3.85* Hgb-10.7* Hct-32.3*
MCV-84 MCH-27.8 MCHC-33.2 RDW-14.1 Plt Ct-94*
[**2138-5-13**] 04:30AM BLOOD Glucose-106* UreaN-16 Creat-0.7 Na-137
K-4.4 Cl-99 HCO3-31 AnGap-11
[**2138-5-13**] 04:30AM BLOOD Mg-2.1
Conclusions
Prebypass
No spontaneous echo contrast is seen in the body of the left
atrium or left atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Right ventricular chamber size and free wall motion are
normal. The ascending, transverse and descending thoracic aorta
are normal in diameter and free of atherosclerotic plaque. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
Postbypass
Dr. [**Last Name (STitle) **] was notified in person of the results at the
time of the study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician
Brief Hospital Course:
Mrs. [**Known lastname **] was a same day admit and brought to the operating
room on [**5-9**] where she underwent a coronary artery bypass graft x
3. Please see operative report for surgical details. Following
surgery she was transferred to the CVICU for invasive monitoring
in stable condition. Later that day she was weaned from
sedation, awoke neurologically intact and extubated. She was
started on beta-blockers and diuretics and gently diuresed
towards her pre-op weight. On post-op day one she was
transferred to the step-down floor for further care. On post-op
day two her chest tubes and epicardial pacing wires were
removed. She continued to make good progress and worked with
physical therapy for strength and mobility. On post-op day #4
she was discharged to [**Location 1820**]/[**Hospital 1821**] rehab with the
appropriate medications and follow-up appointments.
Medications on Admission:
AMBIEN - 10MG Tablet - ONE PILL BY MOUTH AT BEDTIME
ATENOLOL - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime
CITALOPRAM - (Prescribed by Other Provider) - 10 mg Tablet - 1
(One) Tablet(s) by mouth once a day total dose is 50mg daily
CITALOPRAM [CELEXA] - 40 mg Tablet - 1 Tablet(s) by mouth once a
day plus add'l 10 mg for total of 50 mg per Dr [**Last Name (STitle) 16471**]
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other
Provider) - 50,000 unit Capsule - 1 (One) Capsule(s) by mouth
every other sunday
FLUTICASONE - 50 mcg Spray, Suspension - [**2-9**] spray(s) both
nostrils once a day
GABAPENTIN - (Prescribed by Other Provider) - 100 mg Capsule -
2
Capsule(s) by mouth in the morning, 3 pills at bedtime/PRN
INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider: [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] - 100 unit/mL Solution - Sliding Scale 4 x a day [**First Name8 (NamePattern2) **]
[**Hospital 387**] clinic
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - 2
Tablet(s) by mouth twice a day
NIACIN [NIASPAN EXTENDED-RELEASE] - 500 mg Tablet Extended
Release - 1 Tablet(s) by mouth twice a day
NYSTATIN-TRIAMCINOLONE - 100,000 unit/gram-0.1 % Cream - as
directed four times a day please dispense 30 gm tube
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s)
by mouth once a day
RISPERIDONE - 1 mg Tablet - 1 Tablet(s) by mouth once a day
SIMVASTATIN - 5 mg Tablet - 1 Tablet(s) by mouth once a day
TRAMADOL - 50 mg Tablet - 1 Tablet(s) by mouth twice a day as
needed for pain
Medications - OTC
ACETAMINOPHEN [TYLENOL] - 325 mg Tablet - as needed
ECASPIRIN - 325MG Tablet, Delayed Release (E.C.) - ONE BY MOUTH
EVERY DAY
LORATADINE - 10 mg Tablet - 1 tablet by mouth once a day
NPH INSULIN HUMAN RECOMB [HUMULIN N] - (Prescribed by Other
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]; Dose adjustment - no new Rx) - 100
unit/mL
Suspension - 30units in the morning 17 units at bedtime
Discharge Medications:
1. citalopram 20 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. potassium chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours): hold for K+ > 4.5.
6. niacin 500 mg Capsule, Extended Release Sig: One (1) Capsule,
Extended Release PO BID (2 times a day).
7. risperidone 0.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
11. metformin 500 mg Tablet Extended Release 24 hr Sig: Two (2)
Tablet Extended Release 24 hr PO DAILY (Daily): DO NOT CRUSH.
12. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
13. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. INSULIN ss and fixed dose ( see attached)
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Past medical history:
s/p stents 5 years ago
Lumbar Spine DJD s/p disc surgery [**57**] years ago
Osteoarthritis and Tenosynovitis s/p recent steroid injection to
the left volar third finger with improvement
Diabetes Mellitus c/b neuropathy
Hypertension
GERD
Iron Deficiency Anemia
Tonsillectomy
Hysterectomy (ovaries intact)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema -BLE 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 766**] [**6-9**] @ 1:15 pm
Cardiologist: Dr. [**Last Name (STitle) 911**] [**6-18**] @ 2:40 pm
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (STitle) 9006**] in [**5-13**] 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**
Provider: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2138-8-12**] 10:10
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3310**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2138-9-5**] 12:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2138-5-13**]
ICD9 Codes: 5180, 5119, 3572, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8660
} | Medical Text: Admission Date: [**2102-12-10**] Discharge Date: [**2102-12-16**]
Service: [**Hospital Ward Name 19217**]
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: This is an 80 year old woman
with chronic obstructive pulmonary disease on home O2 at a
basal rate of three liters per minute on nasal cannula
admitted for shortness of breath of a few days duration. The
patient was admitted to the Medical Intensive Care Unit for
hypercarbia and respiratory acidosis, intubated for two days,
and then extubated and started on steroids, bronchodilators
and Levofloxacin empirically for pneumonia/bronchitis.
Vital signs were stable, and the patient was transferred to
the ACOVE Service.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease. The patient was
intubated twice. She is normally on home O2 at three liters
per minute and has an FEV1 of 0.66 liters.
2. The patient also has history of hypertension.
3. History of partial deafness.
4. History of colon cancer; status post resection in [**2098**].
5. History of osteoarthritis.
6. History of a stroke.
OUTPATIENT MEDICATIONS:
1. Albuterol.
2. Atrovent.
3. Serevent.
4. Ranitidine 150 mg twice a day.
5. Clonidine 0.25 mg twice a day.
6. Ritalin.
ALLERGIES: Doxycycline.
HOSPITAL COURSE: After the patient was transferred from the
Unit, the goal was to bring her back to her baseline oxygen
requirement. Nebulizer treatments were continued and
gradually transitioned with the aide of respiratory therapy
with metered dose inhalers.
The patient was continued on the p.o. Levaquin antibiotic.
Over the next few days, the patient's course gradually
improved and oxygen requirement decreased so that she
returned to her baseline.
The patient was evaluated by Physical Therapy and any final
evaluation of rehabilitation potential versus home with
assistance. The patient will be discharged home on the
following medications.
DISCHARGE MEDICATIONS:
1. Prednisone 30 mg p.o. q. day for three days followed by
20 mg p.o. q. day times three days followed by 10 mg p.o. q.
day times three days, then 10 mg every other day for three
days, and then finally stopping.
2. Ipratropium two puffs inhaled three times a day.
3. Albuterol two puffs inhaled q. four to six hours.
4. Levofloxacin 250 mg p.o. q. day times ten days.
5. Insulin on regular sliding scale.
6. Clonazepam 0.25 mg p.o. twice a day.
7. Calcium carbonate, or TUMS, three tablets p.o. q. day.
8. Protonix 40 mg p.o. q. day.
9. Lorazepam 1 to 2 mg intravenous q. two to four hours
p.r.n. agitation.
10. Alendronate 5 mg p.o. q. day.
11. Vitamin D 400 International Units daily.
DISCHARGE INSTRUCTIONS:
1. Diet is regular soft diet.
2. No restrictions on activity as tolerated for weight
bearing.
3. Anticipated goal is to return the patient to maximum
semblance of independent activities of daily living.
DISCHARGE DIAGNOSES: Chronic obstructive pulmonary disease
exacerbation.
CONDITION ON DISCHARGE: Stable.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 8442**]
MEDQUIST36
D: [**2102-12-15**] 17:41
T: [**2102-12-15**] 18:45
JOB#: [**Job Number 19218**]
ICD9 Codes: 4589, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8661
} | Medical Text: Admission Date: [**2104-1-15**] Discharge Date: [**2104-2-19**]
Date of Birth: [**2046-1-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
58 year old white male s/p CABG in [**2099**] with TVR and multiple
hospitalizations for CHF over past 6 months.
Major Surgical or Invasive Procedure:
Tricuspid valve replacement with 33mm CE Thermafix Pericardial
valve [**2105-1-16**]
History of Present Illness:
58 year old white male s/p CABGx4 in [**2099**] with a 6 month history
of TR and CHF. He has had 3 admissions for CHF since [**Month (only) 216**] and
is treated with Torsemide. An echo [**7-21**] revealed an LVEF of
25%, diffuse hypokinesis, trace AI and severe TR. Cardiac cath
[**7-21**] showed an LVEF of 25%, 3 patent grafts, and a 50% lesion in
the PDA graft. He is now admitted for TVR.
Past Medical History:
s/p CABGx4 [**6-/2099**]
s/p MI
s/p bil. THR
s/p bil. detached retinal surgeries
s/p bil. cataract [**Doctor First Name **].
obesity
Afib
CHF
ischemic cardiomyopathy
HTN
GERD
RA
^chol.
CRI
Social History:
Lives with wife and daughter
Cigs: quit 15 years ago
ETOH: 3 glasses wine per day
Family History:
CAD
Physical Exam:
Gen: WDWN [**Male First Name (un) 4746**] in NAD
AVSS
HEENT: NC/AT, PERLA, EOMI, oropharynx has upper dentures, benign
Neck: supple, FROM, +JVD, no lymphadenopathy or thyromegaly,
carotids 2+=bilat. without bruits.
Lungs: CLear to A+P
CV: IRRR without R/G +M
Abd: obese, soft, nontender, without masses or
hepatosplenomegaly
Ext: without C/C/E, severe varicosities on bil. LE, well healed
surgical scars on leg and L radial site.
Neuro: nonfocal
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2104-2-18**] 10:55AM 8.9 3.67* 11.8* 34.8* 95 32.1* 33.8 16.0*
342#
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2104-2-18**] 10:55AM 71.9* 20.3 3.6 3.9 0.4
RED CELL MORPHOLOGY Hypochr Macrocy
[**2104-2-18**] 10:55AM 1+ 1+
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2104-2-18**] 10:55AM 342#
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2104-2-16**] 03:45PM 95 56* 1.8* 138 3.9 97 26 19
[**2104-2-19**] INR: 2.4
Brief Hospital Course:
The patient was admitted on [**2105-1-14**] for tricuspid valve
replacement and on [**2105-1-16**] he underwent a right thorocotomy and
tricuspid valve replacement with a 33mm CE Thermafix Pericardial
valve. Total bypass time was 97 mins. and patient was
transferred to the CSRU on Propofol, Milrinone, and Levophed in
stable condition. He had thick, copious secretions post op and
was bronched. He was hypoxic and hypotensive and required
^PEEP. The Milrininone was d/c'd on POD#3 as well as his chest
tubes. He continued to have thick, copious secretions with
frequent bronchs and required sedation. He was followed by the
heart failure service at this time as well. He had a R
pneumothorax on POD#5 and had a chest tube placed. He was
eventually evaluated by infectious disease as he ws spiking
temps to 105 without a clear source. He was continued on Vanco
and Zosyn. He only grew out E. coli in the sputum. He had a
full course of antibiotics and eventually defervessed and his
TEE was negative.
He developed a L gluteal necrotic area which has been packed
with duoderm gel and foam. He was eventually extubated on POD#15
and continued to require aggressive respiratory therapy and
diuresis. He was confused and his mental status waxed and
waned. He was evaluated by the electrophysiology service and
Dr. [**Last Name (STitle) **] wants the patient to go to rehab, and when he is
ready to be discharged from rehab to home, he wants him
readmitted to his service and evaluated for an ICD/Biventricular
pacer. He continued to slowly improve and was transferred to
the floor on POD#25. He was evaluated by psychiatry as he had
increased paranoid ideations and delerium and had a negative
head CT, MRI, and neurological workup. He was started on Haldol
and eventually cleared. [**2104-2-18**] he was diagnosed with an E.
Coli UTI which is resistant to most abx. and is being treated
with a course of Cefepime for 14 days. He was discharged to
rehab on POD#33 in stable condition.
Medications on Admission:
Lisinipril 20 mg PO daily
Carvedilol 6.25 mg PO BID
Prilosec 20 mg PO daily
Colace 100 mg PO daily
Flexeril 10 mg PO TID
Lipitor 10 mg PO daily
Ferrous sulfate 325 mg PO daily
Triazolam 0.25 mg PO daily
Percocet 1 PO BID
Torsemide 50 mg PO BID
MVI
Coumadin 3 mg PO daily
KCl 20 mEq PO daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Torsemide 100 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
11. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. Papain-Urea [**Telephone/Fax (3) 3335**] unit-mg/g Ointment Sig: One (1) Appl
Topical PRN (as needed).
14. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
15. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
18. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
19. Cefepime HCl 2 g Piggyback Sig: One (1) Intravenous once a
day for 14 days.
20. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): INR goal 2-2.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Tricuspid regurgitation
Prolonged intubation
HTN
E. Coli UTI
Delerium
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Make an appointment with Dr. [**First Name (STitle) **] when you are released from
rehab.
Make an appointment with Dr. [**First Name (STitle) **] when you are released from
rehab.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
When you are ready to be released from rehab, call Dr. [**Name (NI) 49475**] office to arrange to be readmitted for evaluation
for ICD/Biventricular pacer.
Completed by:[**2104-2-19**]
ICD9 Codes: 5990, 2875, 5185, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8662
} | Medical Text: Admission Date: [**2185-4-9**] Discharge Date: [**2185-4-21**]
Date of Birth: [**2099-4-27**] Sex: F
Service: SURGERY
Allergies:
Shellfish
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
[**2185-4-9**]: Exploratory laparotomy with duodenal [**Location (un) **] patch,
Hepatorrhaphy, Placement of jejunal feeding tube, Temporary
abdominal closure.
[**2185-4-11**]: Abdominal washout, temporary closure.
[**2185-4-14**]: Exploratory laparotomy, washout, and closure of abdomen
with internal drainage.
History of Present Illness:
Ms. [**Known lastname 105753**] is an 85F with chronic CLL, bladder cancer
s/p TURB, and retroperitoneal non-hodgkins lymphoma who presents
with abdominal pain s/p fall this afternoon. Patient was
recently admitted in early may with hyponatremia and dehydration
related to poor po intake, diuretic use, and possible RLL
pneumonia. At that time, CT showed interval increase in her RP
mass and she was
started on rituximab. Recent CT from [**2185-4-7**] showed a decrease
in the size of her mass and increased pleural effusions. Since
her CT, she has been at her baseline with continued poor po
intake. Today, she attempted to rise from a chair and fell over,
striking her abdomen on the coffee table. She did not hit her
head and denies LOC. She complained of severe abdominal pain
therafter
with 2 episodes of emesis. Since arrival in the ED, she has had
increasing tachypnea and hypoxia. A non-rebreather mask and
foley were placed. Her pain has worsened and she reports feeling
confused and overwhelmed
Past Medical History:
-Transitional cell bladder CA s/p TURB ([**2185-3-15**]), anticipating
radiation
-Non-hogkins retroperitoneal lymphoma on rituximab
-Chronic CLL
-Depression
-Anxiety
-Hypothyroidism
-Dyspepsia
-Herpes zoster
-Right bundle-branch block.
-HTN
-Hyperlipidemia
Past Surgical History:
-Lobular breast CA s/p resection [**2182**]
-Mechanical fall requiring R arm hardware
-Two spinal surgeries for scoliosis, s/p hysterectomy for
fibroid
Social History:
The patient is a widow from her first husband back in the [**2152**]
and married to her second husband for about 24 years. No
siblings. never smoked. denies drinking any alcohol. Denies any
illicit drug use.
Family History:
Denies any known family history of any blood disorders or cancer
that she is aware of
Physical Exam:
On admission:
Vital Signs: 97.8 90 154/69 16 98% 2L Nasal Cannula
General Appearance: Cahectic, appears uncomfortable with labored
breathing
Cardiovascular: RRR
Respiratory: Diminished breath sounds bilaterally, L>R, crackles
at b/l bases, wheezes intermittently, using accessory muscles
for
breathing
Abdomen: Soft, markedly distended, severely tender to palpation
and percussion throughout with rebound tenderness and guarding/
Extremities: Warm, thin, no edema
On discharge:
Vital Signs: T 98.0 BP 130/78 P 68 R 20 O2sat 97% RA
GEN: A&O, NAD
CV: RRR
PULM: Crackles to bilateral lung bases on auscultation, no use
of accessory muscles.
GI: Soft, appropriately tender at incision site, minimally
distended. Abdominal midline surgical incision well-approximated
with staples intact, no drainage, minimal errythema. RLQ old
drain sites with small amount serosang drainage. J tube site
c/d/i.
EXTR: 2+ edema to all 4 extremties. Warm, pink, well-perfused.
Pertinent Results:
[**2185-4-9**] 02:00PM BLOOD WBC-12.3* RBC-3.87* Hgb-11.9* Hct-38.3
MCV-99* MCH-30.7 MCHC-31.0 RDW-18.8* Plt Ct-668*
[**2185-4-9**] 02:00PM BLOOD Glucose-146* UreaN-36* Creat-1.0 Na-138
K-4.0 Cl-100 HCO3-29 AnGap-13
CT abdomen/pelvis:
1. New pneumoperitoneum and complex free fluid. In the absence
of recent
intervention, findings are highly concerning for a bowel
perforation, and
given the distribution and mechanism of injury, a duodenal
perforation is
suspected.
2. New heterogeneous hepatic hypodensities within segment IVb
of the liver concerning for hepatic lacerations and hematoma.
3. Ill-defined pancreatic head hypodensity is concerning for
additional
injury.
4. Cholelithiasis with gallbladder wall edema likely secondary
to the
intra-abdominal fluid.
5. Flattened IVC suggest a degree of volume depletion.
6. Unchanged appearance of extensive retroperitoneal mass
compatible with lymphoma.
7. Unchanged right moderate hydronephrosis.
8. Bladder mass at the right UVJ is not well delineated on the
current exam.
Labs at discharge:
[**2185-4-19**] 06:17AM BLOOD WBC-11.7* RBC-4.21 Hgb-12.7 Hct-40.9
MCV-97 MCH-30.1 MCHC-31.0 RDW-17.3* Plt Ct-391
[**2185-4-19**] 06:17AM BLOOD Glucose-149* UreaN-30* Creat-0.6 Na-144
K-4.1 Cl-104 HCO3-28 AnGap-16
[**2185-4-19**] 06:17AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.0
Brief Hospital Course:
After long discussions with the patient, her husband, her son,
her PCP, [**Name10 (NameIs) **] her oncologist, the consensus was to proceed with
surgery. Patient was taken emergently to the OR on [**2185-4-9**]. Due
to severe bowel distension, her abdomen could not be closed and
she was brought to the ICU intubated and sedated.
ICU Course:
Patient was initially hypotensive and required neosinephrine for
pressor support. She was resuscitated with crystalloid and PRBC
with improvement. She was taken back to the OR on [**4-11**] for wash
out and attempted closure, however her colon was still too
distended and came back to ICU intubated and sedated. A rectal
tube was placed for decompression with good effect. Tube feeds
were started via her Jtube. She was treated with vanco, cipro,
and flagyl for 48 hours postop. Once improved, she was diuresed
with a lasix drip. On [**4-14**], she returned to the OR for
definitive closure which she tolerated well. She was extubated
postop. On the night of [**4-14**], she developed afib with RVR
requiring an amio drip for rate control. She converted to sinus
rhythym within 12 hours. Her tube feeds were advanced to goal
and her amiodarone converted to po. She was transferred to the
floor on [**2185-4-15**].
Floor course:
On the floor her vital signs were routinely monitored and
remained stable. She was monitored on telemetry and remained in
NSR with occasional PVC's on the PO amiodarone. Diuresis was
continued with intermittent IV lasix. Her electrolytes were
monitored and repleted as needed. Tube feeds were continued at
goal via the J tube. She was kept NPO with an NG tube in place
until [**4-17**] when the NG tube was removed. Speech and swallow was
consulted on [**4-18**] to evaluate for dysphagia. She had difficulty
swallowing but ultimately the decision was made to keep her NPO
with tubefeeds for 10 more days after discharge to allow the
site of perforation time to heal. Plan was to re-evaluate
swallowing at rehab 10 days from discharge and advance diet if
appropriate at that time. A foley catheter had been placed on
admission and was removed on [**4-18**] at which time she was able to
void adequate amounts of urine without difficulty. She remained
on SC heparin for DVT prophylaxis.
Physical therapy was consulted to evaluate the patient's
mobility who recommended rehab when patient was medically
cleared.
The patient's oncologist Dr. [**Last Name (STitle) 105754**] was notified of her
hospitalization. The oncology service evaluated the patient and
agreed with the plan of care. Plan was to hold off on any
radiotherapeutic treatment of her bladder cancer until she has
recovered and reevaluate after the patient has recovered.
On [**4-20**] she remains afebrile and hemodynamically stable. She is
tolerating tube feeds at goal via J tube and diuresing
appropriately with lasix prn. She is being discharged to acute
rehab to continue her recovery.
Medications on Admission:
Acyclovir 400 mg TID, Amlodipine 5mg daily, Atorvastatin 10 mg
daily, Duloxetine 60 mg daily, Levothyroxine 100 mcg daily,
Lorazepam prn, Mirtazapine 7.5 mg qhs, Olmesartan 20mg daily,
Sertraline 20mg daily, Spironolocatone-HCTZ 25 mg daily, Aspirin
81mg daily, Calcium 250 mg daily, Vitamine D3 1000 U daily,
Colace 100 mg TID, Multivitamin
Discharge Medications:
1. mirtazapine 15 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO HS (at bedtime).
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
3. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
5. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. olmesartan 20 mg Tablet Sig: One (1) Tablet PO daily ().
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
13. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
14. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. sertraline 20 mg/mL Concentrate Sig: Five (5) mL PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
s/p fall
1. Hepatic laceration.
2. Traumatic perforation of duodenum.
3. sepsis
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 hospital after a fall and a perforation
in a portion of your gastrointestinal tract called your
duodenum. Your required an operation to fix the area of
perforation and a feeding tube was placed into the portion of
your small bowel below the area of perforation called the
jejunum. You are now receiving tubefeeds through the tube. You
should not eat or drink anything by mouth until your swallowing
has been re-evaluated at the rehab facility 10-14 days from now.
Please follow up in the Acute Care Surgery clinic at the
appointment scheduled for you below.
Because of the surgery, plans for any radiotherapeutic treatment
of your bladder cancer have been put on hold for now. Please
follow up with Dr. [**Last Name (STitle) 105754**] after you have left rehab to discuss
future treatment.
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
With Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: TUESDAY [**2185-5-10**] at 1:30 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2185-4-20**]
ICD9 Codes: 0389, 4589, 4019, 2449, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8663
} | Medical Text: Admission Date: [**2171-1-2**] Discharge Date: [**2171-1-6**]
Service: CCU
CHIEF COMPLAINT: Lethargy and inferior myocardial infarction
with complete heart block.
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname **] is a [**Age over 90 **]-year-old
woman with history of hypertension, who was transferred from
[**Hospital 1474**] Hospital. The patient was in her usual state of
health until one day prior to admission at which time she was
noted to be very lethargic and fatigued. Patient at that
time denied any chest pain or shortness of breath. She did
not experience syncope. Family called EMS in the afternoon,
who brought her to [**Hospital1 1474**] Emergency Department, where she
was noted to be extremely lethargic with a heart rate in the
20s and also to be diaphoretic and with cool on the
extremities. The patient was given atropine and Epinephrine,
and noted to be in respiratory distress for which she
required intubation. At that time, her arterial blood gas
was 7.11/32/275. The patient was then noted to be
ventricular tachycardia. She was given lidocaine and at the
same time, continued on Epinephrine and atropine x3. Then
she was started on dopamine which was titrated up to achieve
a blood pressure of 109/21 with a heart rate of 71. She was
also given normal saline bolus, and 100 mg of intravenous
Lasix for diuresis.
At this point, she was transferred to [**Hospital1 190**] for cardiac catheterization after diuresis.
The family requested aggressive regimen. At [**Hospital1 346**], cardiac catheterization was
performed which showed right atrium pressure of 24, RV 48/13,
P.A. 48/30. Cardiac output 5.9 and cardiac index of 4.0.
[**Hospital1 47348**] was placed. Also the right coronary artery was found to
have a total occlusion, and was therefore, treated with PTCA
which resulted in 40% residual occlusion.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Coronary artery disease.
MEDICATIONS:
1. Norvasc 10.
2. Atenolol 50.
3. Hydrochlorothiazide 50.
4. Doxazosin 8.
5. Urecholine 25.
ALLERGIES: Unknown.
SOCIAL HISTORY: Unknown.
PHYSICAL EXAMINATION AT PRESENTATION IN THE CCU: General
appearance: Intubated and sedated. Vent setting: AC 612,
100%, 5. HEENT: Pupils reactive, but sluggish. Nasogastric
tube in place. Neck: Jugular venous pressure approximately
10 cm of water, no bruits. Chest: Rales at bases
bilaterally. Heart: Regular rate, S1, S2 normal, no
murmurs. Abdomen: Bowel sounds positive, soft, nontender.
Extremities: Cool. Neurologic: Intubated, not following
commands, sedated.
LABORATORIES AT [**Hospital1 **]:
Complete blood count remarkable for a white blood cells of
22.8, hematocrit of 39.5. Chem-7 remarkable for a bicarb of
17, BUN of 54, creatinine of 2.5. CK 1161. Lactate 5.0.
Arterial blood gas: 7.26/33/180.
BRIEF HOSPITAL COURSE: Mrs. [**Known lastname **] is a [**Age over 90 **]-year-old woman
status post inferior-posterior myocardial infarction
complicated by complete heart block and hypertension status
post temporary pacer, [**Name (NI) 47348**], RCA PTCA, now admitted to CCU for
further management.
Cardiovascular: The patient was status inferior-posterior
myocardial infarction intervened on cardiac catheterization
with PTCA. She had an [**Name (NI) 47348**] placed. Her CK's were followed.
She was continued on aspirin and Plavix. Eventually, [**Name (NI) 47348**]
had to be removed because of ischemic toes. However, by that
time, the patient appeared to be perfusing well even without
the [**Name (NI) 47348**]; and she appeared to be euvolemic. An external
pacer was placed, and she remained paced.
Pulmonary: Patient has been admitted when she was intubated.
Arterial blood gases eventually showed that she was achieving
good ventilation and oxygenation before she was switched to
pressure support which she tolerated successfully, and she
was then extubated.
For her extremities, after the [**Name (NI) 47348**] insertion, she had
bilateral foot ischemia, which were addressed by starting
Lovenox subQ for anticoagulation in an attempt to improve toe
perfusion. At around 4 pm on [**2171-1-5**], she was noted to
develop sudden hypertension with a systolic blood pressure in
the 80s and decreased urine output. She was given normal
saline boluses without any improvement. She was then started
on Levophed and Dopamine also without any improvement.
An arterial blood gas was obtained which was 7.12/14/78 on
50% face mask. She was then reintubated. The family was
[**Name (NI) 653**], and they decided to switch her code status to DNR
at this point. A lactic acid was obtained, which was 7.9.
This was found to be secondary to rhabdomyolysis. Most
likely diagnosis was found to be metabolic acidosis, not
successfully compensating, most likely also complicated by
septic shock from sepsis. Vancomycin was started.
Ceftriaxone and Flagyl were also continued which had been
started in order to treat potential pneumonia or infection of
ischemic toes. The patient, however, continued to remain
unresponsive to the antibiotics or the pressors. She became
more and more hypertensive, and she expired at 3 am on
[**2171-1-6**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Last Name (NamePattern1) 6071**]
MEDQUIST36
D: [**2171-4-4**] 11:12
T: [**2171-4-5**] 05:42
JOB#: [**Job Number 47349**]
ICD9 Codes: 5070, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8664
} | Medical Text: Admission Date: [**2127-2-8**] Discharge Date: [**2127-2-23**]
Date of Birth: [**2047-9-1**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
evaulation if pulmonary infiltrates - transfer from [**Hospital 11373**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79 yo femal with PMH of RA treated with pred and MTX, CAD, long
h/o GERD, breat ca s/p left mastectomy and h/o pulm fibrosis
presents from OSH for further eval of hypoxia in the setting of
pregressice bilateral pulm infiltrates. In [**Month (only) **], the pat had
RUL PNA that responded to abx by exam and CXR. In early
[**Month (only) 1096**], she reported that she had weeks of fever around 101
associated with progressive SOB and cough, non-productive esp
severe DOE. +sweat and chills/ no PND, sleeps on [**5-13**] pillows.
Past Medical History:
HTN, GERD, Pulm fibois, RA, ?PMR/TA, hypothroid, depression and
anxiety, breast cancer s/p L mastectomy, OA, macular
degeneration, s/p B TKR, chronic pain syndrome
Social History:
Lives near son. Moved here from, Flordia in [**Month (only) 205**] to be closer to
children. Never smoked and rarely drinks ETOH. Able normally to
walk around with a walker
Family History:
NC
Physical Exam:
Vitals: T= 98.8, HR = 96, BP = 133/71, RR = 24, SaO2 = 93-95% on
5L NC.
General: Pleasant female, appears in slight distress. Speaks in
short full sentances. no accessory muscle use
HEENT: Normocephalic and atraumatic head, no nuchal rigity
though holds head tilted toraed right. anicteric sclera, moist
mucous membranes.
Neck: No thyromegaly, no lymphadenopathy, no carotid bruits.
Chest: Her chest rose and fell with equal size, shape and
symmetry, her lungs had bronchial breath sounds thoughout all
lung fields bilaterally.
CV: PMI appreciated in the fifth ICS in the midclavicular line
without heaves or thrills, RRR, normal S1 and S1 no murmurs rubs
or gallops.
Abd: Normoactive BS, NT, slightly distended. No masses or
organomegaly
Back: No spinal or CVA tenderness.
Ext: NO cyanosis, no clubbing, trace pedal edema with 2+
dorsalis pedis pulses bilaterally. lateral deviation of all toes
on both feet.
Integument: no rash
Neuro: CN II-XII symmetrically intact, PERRLA.
Pertinent Results:
Labs from OSH:
[**10-14**]>__ < 311
31
[**Age over 90 **]|101|42<165
3.9|24|1.5
BNP 152
CT and Xrays were sent with patient.
OSH CT of chest: bilateral upper lobe infiltrates, ground glass
opacities.
[**2127-2-9**] 06:02AM BLOOD WBC-8.7 RBC-3.10* Hgb-10.3* Hct-30.9*
MCV-100* MCH-33.2* MCHC-33.3 RDW-17.9* Plt Ct-271
[**2127-2-9**] 06:02AM BLOOD Plt Ct-271
[**2127-2-9**] 06:02AM BLOOD PT-13.1 PTT-20.9* INR(PT)-1.1
[**2127-2-9**] 06:02AM BLOOD Glucose-105 UreaN-42* Creat-1.4* Na-134
K-3.7 Cl-97 HCO3-26 AnGap-15
[**2127-2-9**] 06:02AM BLOOD ALT-43* AST-35 LD(LDH)-442* AlkPhos-84
TotBili-0.4
[**2127-2-9**] 06:02AM BLOOD Albumin-3.2* Calcium-8.9 Phos-3.7 Mg-1.9
[**2127-2-8**] 06:55PM BLOOD Type-ART O2 Flow-2 pO2-67* pCO2-33*
pH-7.49* calHCO3-26 Base XS-2 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
Chest CT [**2127-2-11**]: Severe patchy ground glass opacity,
reticulation, and traction bronchiectasis within both lungs,
predominantly involving both upper lobes. This finding is
non-specific in nature, but could represent atypical infection,
hypersensitivity pneumonitis, or Acute Interstitial Pneumonia.
Hand X-Ray [**2127-2-12**]: Findings most consistent with advanced
osteoarthritis, though the second MCP joint is narrowed as
described.
Foot X-Ray [**2127-2-12**]: There are no fractures. There is marked
medial subluxation of the second and third proximal phalanges on
the metatarsals, and marked lateral subluxation of the fourth
and fifth distal phalanges on the proximal phalanges. There are
no focal osteolytic or sclerotic lesions. There are no marginal
erosions. There is a posterior calcaneal spur. There is soft
tissue prominence in the region of the MTPs.
Chest CT [**2127-2-17**]: 1). Diffuse lung disease with upper lobe
predominance (left greater than right). The areas of
ground-glass opacity with traction bronchiectasis have increased
in density when compared to [**2127-2-11**], but are otherwise
unchanged. If the patient has a fever, these findings would
consistent with pneumocystis carinii pneumonia or other atypical
infectious processes. Other conditions that could be included on
the radiographic differential diagnosis include chronic
eosinophilic pneumonia, cryptogenic organizing pneumonia,
vasculitis, drug toxicity, or acute interstitial pneumonia.
CXR [**2127-2-21**]: Observed changes suggest improved aeration of the
areas with less degree of ground-glass densities but persistent
mostly interstitial infiltrates. No other significant interval
change since [**2-14**].
Brief Hospital Course:
79 yo f with PMH sig for RA treated with pred/MTX, CAD, long h/o
GERD, breast ca s/p left mastectomy presents from OSH for
further eval of hypoxia (85% on RA) in the setting bilateral
pulm infiltrates.
1.Pulm infiltrates. DDx includes PCP, [**Name10 (NameIs) **] other infectious cause
(atypical PNA), vs MTX lung (dx of exclusion). She had 3
negative sputum cultures for PCP. [**Name10 (NameIs) **] was on levoflox/vanco on
transfer from the OSH for CAP but they were d/c'd by they ICU
team. Because po allergy to bactrim, pt was started on
primaquine and clinda for a 3 week course for presumed PCP. [**Name10 (NameIs) **]
has been on high dose steroids since admission. She received 3
days of IV Solu-Medrol and is currently on 60 mg of po
Prednisone which she will continue until she is seen by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] in the pulmonary clinic in [**4-11**] weeks. She notes slight
subjective improvement in SOB with exertion since admission.
Bronch vs VATS were considered to get a tissue diagnosis given
her repeat CT after two weeks of PCP treatment with continued
ground glass opacities, however pulm/thoracics/cardiology felt
that these procedures were too high risk given underlying
cardiac disease (reversible defect on recent MIBI ([**10-12**])).
She will be treated with high-dose steroids empirically for
interstitial lung dz and followed closely by pulmonary. She will
complete a 21 day course of Abx for PCP [**Name Initial (PRE) **]. She was given
inhaled pentamidine for one month of PCP [**Name Initial (PRE) 1102**]. She had
baseline PFTs done on [**2127-2-21**]. The results are currently
pending. She will have a repeat CXR and PFT's in one month to
monitor her lung function once PCP treatment has finished.
She should have a CBC with diff checked in one week for concern
of granulocytopenia with primaquine and RA.
2. CV. Positive stress test with reversible defect in [**10-12**] w/o
intervention.
Cardiology saw pt for pre-op evaluation and felt she was at
moderate risk.
She was started on Metoprolol 75 [**Hospital1 **] and hydralazine with
adequate BP control.
She was continued on Isordil and [**Hospital1 **] daily. Her LFT's were WNL.
Her LDL was found to be 161, therefore she was started on 80 mg
of Lipitor.
3. RA normally on prednisone and MTX once weekly. Rheumatology
followed her during her stay. Her MTX was held. She is currently
on high dose steroids for lung issues which is also controlling
her RA. Alternative therapies may need to be considered once she
is off steroids (TNF-inhib, etc). Her pain is currently
controlled on a Fentanyl patch. She was continued on Ca/Vit D
supplements. Her Alendronate was increased to full strength.
4. GERD: She was continued on Protonix 40 [**Hospital1 **].
5. CRF. Cr at baseline of 1.5. She received Mucomyst and
hydration prior to CT scan. She is normally on EPO injections
for anemia. She did not receive EPO during her stay.
6. Hypothyroid: She was continued on Levoxyl.
7. Depression/Anxiety. She was continued on Effexor, trazodone
prn, and Zyprexa.
8. Dementia. She notes short term memory impairment and should
have an outpt evaluation.
9. PPX. She was on SC heparin during her stay.
10. Code Status. Full.
Medications on Admission:
Meds on transfer: advair, clinda, timentin, vanc, lovenox,
lactinex, primaquine, alphaquan, fosamax, levothyroxine, MIV,
[**Last Name (LF) 59392**], [**First Name3 (LF) **], nasonex, humibid, cardizem 120, duragesic patch,
zyprexa, trazadone, cal, vit D, effoxor XR, nystatin s and
swallow, solumedrol 30 QID, protonix, isordil 20 TID, [**Doctor First Name 130**]
180
outpatient: aranesp 200mcg every few weeks (last dose [**2127-1-23**])
Discharge Medications:
1. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
2. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for coughing.
4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO HS (at bedtime).
5. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomina.
6. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO BID (2 times a day).
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever, pain.
12. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
15. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
16. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Transdermal Q72H
(every 72 hours).
17. Senna 8.6 mg Tablet Sig: 1-5 Tablets PO BID (2 times a day)
as needed.
18. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day): Please hold for Blood Pressure < 110 and
Heart Rate < 60. .
19. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO QSUN
(every Sunday).
20. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-9**] Sprays Nasal
QID (4 times a day) as needed.
21. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
22. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
23. Hydralazine HCl 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours): Please hold for systolic blood pressure < 110.
.
24. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
25. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
26. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
27. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): While on high dose steroids. .
28. Primaquine Phosphate 26.3 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 6 days.
29. Clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO Q6H
(every 6 hours) for 6 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Likely Pneumocystis carinii pneumonia
Secondary Diagnoses:
Rheumatoid Arthritis
Coronary Artery Disease
Discharge Condition:
Stable
Discharge Instructions:
Please call your primary care physician or return to the
hospital if you experience worsening shortness of breath or any
other symptoms.
Please do not take Methotrexate as there is concern that it is
affecting your lungs. Please continue to take 60 mg of
Prednisone until you see Dr. [**First Name (STitle) **] in 3 - 4 weeks.
Followup Instructions:
1. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the Pulmonology
clinic in three to four weeks. Please call ([**Telephone/Fax (1) 513**] to
make an appointment.
2. Pleaase follow-up with your primary care physician in one to
two weeks.
3. Please follow-up with your rheumatologist in three to four
weeks. You are no longer taking Methotrexate as there is concern
that it is affecting your lungs.
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8665
} | Medical Text: Admission Date: [**2120-10-4**] Discharge Date: [**2120-10-10**]
Date of Birth: [**2068-2-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Toradol
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
LV lead placement via left thoracotomy/ICD generator change on
[**2120-10-4**]
History of Present Illness:
52 y/o male with Ischemic CM and class III heart failure.
Percutaneous attempt to place LV lead was unseccessful x 2. He
now presents for surgical placement. He remains symptomatic
despite medical therapy.
Past Medical History:
Ischemic Cardiomyopathy/Congestive Heart Failure w/ EF of 35%
Coronary Artery Disease s/p Myocardial Infarction [**2115**] s/p
thrombectomy and stent to OM1
Intraventricular Conduction Defects (IVCD) s/p Dual Chamber
pacer [**12-20**]
Hypertension
Hyperlipidemia
Cervical disc herniation s/p surgery x 2
s/p lumbar disc surgery x 2
s/p Cholecystectomy
s/p Left shoulder surgery
s/p Left total knee replacement
s/p pericarditis [**2115**]
Osteoarthritis
Social History:
Tobacco: 70pack/yr hx, IPPD currently
ETOH: denies
Family History:
Father w/ CABG at 57. Brother w/ Myocardial Infarction at 42.
Physical Exam:
VS: 154/98 63 6'8" 260#
General: WDWN male in NAD
Skin: Good turgor, well healed incisions
HEENT: PERRL, EOMI, Oropharynx benign
Neck: Supple, -JVD, -Bruit
Chest: CTAB -w/r/r
Heart: RRR, -c/r/m/g
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, -edema, left varicosities
Neuro: A&Ox3, CN 2-12 intact, MAE, FROM, 5/5 strength
Pulses: BFA 2+, BDP 1+, BPT 1+, BRA 2+
Pertinent Results:
[**2120-10-4**] 11:26AM BLOOD WBC-11.4* RBC-3.37* Hgb-11.8* Hct-34.8*
MCV-103* MCH-35.1* MCHC-34.0 RDW-13.1 Plt Ct-290
[**2120-10-9**] 06:10AM BLOOD WBC-11.9* RBC-2.91* Hgb-10.2* Hct-29.7*
MCV-102* MCH-35.1* MCHC-34.5 RDW-12.9 Plt Ct-273
[**2120-10-7**] 07:00AM BLOOD PT-13.6* PTT-23.4 INR(PT)-1.2
[**2120-10-8**] 06:30AM BLOOD PT-12.9 PTT-23.1 INR(PT)-1.1
[**2120-10-5**] 03:00AM BLOOD Glucose-122* UreaN-13 Creat-0.7 Na-139
K-3.7 Cl-102 HCO3-28 AnGap-13
[**2120-10-7**] 07:00AM BLOOD Glucose-101 UreaN-20 Creat-0.8 Na-141
K-4.1 Cl-101 HCO3-32 AnGap-12
Brief Hospital Course:
Pt. was a same day admit and was brought directly to the
operating room where he underwent an LV lead placement via left
anterior thoracotomy and ICD generator change. Pt. was brought
to the PACU in stable condition and was extubated without
incident. Later on operative day, patient had oxygen
desaturation along with incisional pain and labored breathing.
Oxygen was given via NRB and anesthesia was called. CXR was
obtained which revealed a small left apical pneumothorax,
collapse of the right upper lobe (raises the possibility of a
centrally obstructing mass, and an 1-cm linear density
projecting over the left glenoid. Pt. was eventually converted
to nasal cannula from NRB after better oxygen saturation. On POD
#1 a bronchoscopy was performed and large amount of secretions
was found and RUL plugs suctioned. On POD #2 repeat CXR revealed
changes consistant with the day before. A chest CT was performed
which showed soft tissue mass obstructing the right upper lobe
bronchus causing complete collapse of the right upper lobe with
mediastinal lymphadenopathy, atelectasis in the left lower lobe
likely secondary to secretions, and a very small left-sided
pneumothorax. Thoracic surgery was consulted and saw pt on POD
#3 (see chart for A/P). Recommended multiple radiology
studies(can be done as outpt) and a repeat bronchoscopy with
biopsies. Blood, urine and sputum cultures were taken secondary
to increased WBC. A repeat bronchoscopy was performed on POD #4.
This revealed patent RUL with no obstruction. A TBNA, washing,
and brushing from RUL was sent to cytology. Repeat CT also done
on this day revealed resolution of right upper lobe atelectasis,
with residual patchy ill-defined opacity, and an interval
increase in size of left-sided pneumothorax compared to the CT
scan of [**2120-10-5**]. After cytology results, Thoracic surgery noted
that RUL collapse was likely due to mucus plug and unlikely to
be a malignancy. On POD #5 chest tube was removed. Final CXR
before discharge revealed a small residual left-sided
pneumothorax and previously noted atelectatic changes in the
left lower lung zone and pleural thickening along the left chest
wall are unchanged. On POD #6 pt was doing well. He was
hemodynamically stable with good vital signs and stable labs. He
was discharged home with appropriate f/u appointments.
Medications on Admission:
1. Coreg 50mg [**Hospital1 **]
2. Diovan 160mg [**Hospital1 **]
3. Spirolactone 25mg [**Hospital1 **]
4. Hydralazine 25mg tid
5. Lasix 40mg [**Hospital1 **]
6. Protonix 40mg qd
7. Prilosec 40mg qd
8. ASA 325mg qd
9. Digoxin 0.125mg [**Hospital1 **]
10. Clonidine 0.1mg [**Hospital1 **]
11. Lipitor 40mg qd
Discharge Medications:
1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4*
3. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
5. Valsartan 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
8. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Failed percutaneous lead placement s/p LV lead placement via
Left Anterior Thoracotomy/ICD generator change
RUL collapse s/p bronchoscopy
Ischemic Cardiomyopathy/Congestive Heart Failure w/ EF of 35%
Coronary Artery Disease s/p Myocardial Infarction [**2115**] s/p
thrombectomy and stent to OM1
Intraventricular Conduction Defects (IVCD) s/p Dual Chamber
pacer [**12-20**]
Hypertension
Hyperlipidemia
Cervical disc herniation s/p surgery x 2
s/p lumbar disc surgery x 2
s/p Cholecystectomy
s/p Left shoulder surgery
s/p Left total knee replacement
s/p pericarditis [**2115**]
Osteoarthritis
Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fevers greater then 100.5
Followup Instructions:
with Dr. [**Last Name (STitle) 17107**] in [**12-17**] weeks
with Dr. [**Last Name (STitle) 17108**] in [**1-18**] weeks
with Dr. [**Last Name (STitle) 17109**] in 1 week ([**Telephone/Fax (1) 1504**]
Completed by:[**2120-10-10**]
ICD9 Codes: 4280, 5180, 4019, 2724, 412, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8666
} | Medical Text: Admission Date: [**2156-1-28**] Discharge Date: [**2156-2-4**]
Date of Birth: [**2079-5-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pressure
Major Surgical or Invasive Procedure:
[**2156-1-29**]
1. Coronary artery bypass grafting x4 with left internal
mammary to left anterior descending coronary artery;
reverse saphenous vein single graft from the aorta to
the first obtuse marginal coronary artery; reverse
saphenous vein single graft from the aorta to second
obtuse marginal coronary artery; reverse saphenous vein
single graft from the aorta to the distal right coronary
artery.
2. Limited concomitant Maze procedure with pulmonary vein
isolation using the AtriCure Synergy system and
resection of left atrial appendage.
3. Epiaortic duplex scanning
4. Endoscopic left greater saphenous vein harvesting.
History of Present Illness:
76 year old female with multiple
problems CAD w/ MI [**2148**] (medically managed), HTN,
Hyperlipidemia,
DM, paroxysmal AF on coumadin, and cerebrovascular disease s/p
CVA*2 who presented with nearly 24 hours of chest pressure.
She reports this pain started on the evening prior to
presentation when she noted substernal chest pressure radiating
down her left arm starting while she was cooking dinner. This
was
associated with dyspnea and some diaphoresis but the pain was
relatively mild so she managed to finish her dinner and go sit
down in front of the TV where she continued to have pain. She
reports she fell asleep with this pain so it is impossible to
assess just how long it lasted. She awoke the next morning pain
free but reports recurrent pain after walking back to the house
after trying to start her car. This was associated with dyspnea,
diaphoresis, and nausea and she reports vomiting once. All told
her symptoms lasted about 30 minutes. She then went into her
regularly scheduled PCP appointment and was sent directly to the
ED from there for further evaluation.
She had a cardaic cath on [**2156-1-22**] at [**Hospital1 18**] which revealed severe
CAD. She was referred for surgical revascularization. She has
undergone a coumadin washout and is admitted preoperatively for
heparin drip.
Past Medical History:
CAD, a-fib, s/p CABG, Maze [**2156-1-29**]
PMH:
1. Osteoarthritis
2. Gout
3. CVA [**2154**], left hearing loss and left sided weakness, walks
with walker and drags left leg
4. History of PMR
5. Elevated CPK
6. CAD s/p MI in [**2148**]
7. Hypertension
8. Hyperlipidemia
9. Type 2 DM
10. CKD
11. Paroxysmal atrial fibrillation on warfarin
12. LVH and dCHF
13. Elevated CPK
14. Hyperparathyroidism
15. OSA
16. Obesity
Surgical history:
s/p disc surgery
s/p appendectomy
s/p hysterectomy
s/p bilateral carpal tunnel repair
Social History:
The patient lives with her [**Age over 90 **] year old mother in senior housing.
She is widowed. Retired from working in a community center. She
stopped smoking 30 years ago. She denies EtOH or other drugs.
Family History:
Mother is alive at 94 and has HTN. Her father had [**Name (NI) 2320**]. One son
with CAD. One son died of liver Ca and another died after
transplant surgery.
Physical Exam:
Pulse:59 Resp:16 O2 sat:100/RA
B/P Right:133/92
Height:5'4" Weight:200 lbs
General: NAD, WGWN, appears stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x] cataracts
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema 1+
Varicosities: None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: NP Left: NP
Radial Right: 2+ pea size mobile cord from cath site
cannulation
Radial Left: 2+
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2156-2-3**] 05:17AM BLOOD WBC-11.0 RBC-3.27* Hgb-9.3* Hct-27.9*
MCV-85 MCH-28.5 MCHC-33.4 RDW-17.5* Plt Ct-220
[**2156-2-3**] 05:17AM BLOOD PT-18.7* INR(PT)-1.7*
[**2156-2-2**] 05:03AM BLOOD PT-14.7* INR(PT)-1.3*
[**2156-2-1**] 04:44AM BLOOD PT-14.2* INR(PT)-1.2*
[**2156-1-31**] 01:39AM BLOOD PT-13.8* PTT-34.0 INR(PT)-1.2*
[**2156-1-29**] 04:45PM BLOOD PT-16.5* PTT-53.1* INR(PT)-1.5*
[**2156-2-3**] 05:17AM BLOOD Glucose-46* UreaN-50* Creat-1.7* Na-135
K-4.3 Cl-101 HCO3-28 AnGap-10
[**2156-2-2**] 05:03AM BLOOD Glucose-56* UreaN-59* Creat-2.2* Na-135
K-4.5 Cl-101 HCO3-26 AnGap-13
Intra-op TEE [**2156-1-29**]
Conclusions
PRE-CPB:
The left atrium is moderately dilated. Mild spontaneous echo
contrast is seen in the body of the left atrium. Mild
spontaneous echo contrast is present in the left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s).
Overall left ventricular systolic function is normal (LVEF>55%).
There are no obvious wall motion abnormalities. The LV walls
appear to be thick, although this appearance may be secondary to
small chamber size.
Right ventricular chamber size and free wall motion are normal.
There are complex (>4mm) atheroma in the descending thoracic
aorta. No thoracic aortic dissection is seen.
The aortic valve leaflets (3) are mildly thickened with focal
calcifications but aortic stenosis is not present. The right
coronary cusp mobility appears mildly restricted. No aortic
regurgitation is seen.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is moderate MAC, most notably in
the posterior annulus.
POST-CPB:
The LV systolic function appears normal, estimated EF=55%. There
are no obvious wall motion abnormalities. The chamber size is
small, most likely reflective of relative hypovolemia. The walls
again appear thick.
RV systolic function appears normal. There is mild TR.
The LAA is no longer seen, c/w LAA ligation.
There is no evidence of aortic dissection.
Dr. [**Last Name (STitle) 914**] was notified in person of the results at time of
study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD, Interpreting physician [**Last Name (NamePattern4) **]
[**2156-1-29**] 16:46
Brief Hospital Course:
The patient was brought to the operating room on [**2156-1-29**] where
the patient underwent CABG x 4 with Dr. [**Last Name (STitle) 914**]. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. Creatinine trended up to 2.4, indicating acute
kidney injury without oliguria. Lasix was held, and creatinine
would trend down prior to discharge. The patient was evaluated
by the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 5 the patient was
ambulating with assistance, the wound was healing and pain was
controlled with oral analgesics. The patient was discharged to
[**Hospital3 41599**] and Rehab in [**Location 1268**] in good condition
with appropriate follow up instructions.
Medications on Admission:
AMLODIPINE 10 mg PO daily
-COLCHICINE 0.6 mg PO daily
-ERGOCALCIFEROL
-FLUTICASONE 100 mcg in each nostril once a day
-FUROSEMIDE 40 mg QAM, 20 mg QPM daily
-INSULIN LISPRO sliding scale
-METOPROLOL SUCCINATE 100 mg by mouth twice a day
-OMEPRAZOLE 20 mg by mouth once a day
-SPIRONOLACTONE 25 mg by mouth once a day
-VALSARTAN 320 mg by mouth once a day
-WARFARIN ****last dose [**2156-1-23**]- was on lovenox 100mg [**Hospital1 **] last
dose [**2156-1-28**]
-ASPIRIN 81 mg by mouth once a day
-INSULIN NPH & REGULAR HUMAN [70/30] 32 units QAM
-Insulin NPH 15 units with dinner daily
-Plavix 75mg Daily
ALLERGIES:Sulfa, PCN
Plavix - last dose: [**2156-1-21**] 75mg
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM as needed for afib: MD to dose daily for goal INR 2-2.5, dx:
afib.
7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, then
200mg daily until further instructed.
12. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
13. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
14. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
15. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: One (1) Subcutaneous twice a day: 32 units with breakfast,
7 units with dinner.
16. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection four times a day: Regular insulin per attached sliding
scale.
17. Outpatient Lab Work
Labs: PT/INR
Coumadin for a-fib
Goal INR 2-2.5
First draw [**2156-2-4**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr.
**Please arrange for coumadin/INR follow-up prior to discharge
from rehab**
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Nursing & Therapy Center - [**Location 1268**] ([**Location (un) 86**] Center
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
CAD, a-fib, s/p CABG, Maze [**2156-1-29**]
PMH:
1. Osteoarthritis
2. Gout
3. CVA [**2154**], left hearing loss and left sided weakness, walks
with walker and drags left leg
4. History of PMR
5. Elevated CPK
6. CAD s/p MI in [**2148**]
7. Hypertension
8. Hyperlipidemia
9. Type 2 DM
10. CKD
11. Paroxysmal atrial fibrillation on warfarin
12. LVH and dCHF
13. Elevated CPK
14. Hyperparathyroidism
15. OSA
16. Obesity
Surgical history:
s/p disc surgery
s/p appendectomy
s/p hysterectomy
s/p bilateral carpal tunnel repair
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
2+ LE edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2156-2-24**] 1:30
Cardiologist Dr. [**First Name (STitle) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2156-3-16**] 9:00
Primary Care Dr. [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 3819**], MD, MPH[**MD Number(3) 708**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2156-2-26**] 11:30
**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
Coumadin for a-fib
Goal INR 2-2.5
First draw [**2156-2-4**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr.
**Please arrange for coumadin/INR follow-up prior to discharge
from rehab**
Completed by:[**2156-2-3**]
ICD9 Codes: 5849, 2761, 2749, 412, 2724, 5859, 4280, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8667
} | Medical Text: Admission Date: [**2159-5-30**] Discharge Date: [**2159-6-27**]
Date of Birth: [**2159-5-30**] Sex: F
Service: Neonatology
(This is an interim discharge summary report, covering the
period of [**2159-5-30**] through [**2159-6-27**]).
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 28214**] [**Known lastname 52157**] is an
855 gram, former 26 and 6/7 weeks gestation infant, born to a
34 year old, Gravida IV, Para 1, now 2, mother with prenatal
screens as follows: A positive, antibody negative. Rubella
immune. RPR nonreactive. Hepatitis B surface antigen
negative. GBS unknown.
Pregnancy was complicated by preterm labor and prolonged
preterm rupture of membranes. Mother's membrane ruptured
approximately ten days prior to delivery. She was treated
with seven days of Clindamycin and Erythromycin. She had
received Betamethasone on [**5-21**] and [**5-22**]. No maternal
temperature noted.
Infant was delivered by normal spontaneous vaginal delivery
and had good response to routine care. Apgars were nine and
nine. She was admitted to the Neonatal Intensive Care Unit
for management of prematurity.
PHYSICAL EXAMINATION: Birth weight 855 grams; head
circumference 24 cms; anterior fontanel was open, flat and
soft. Ears were normally positioned. Regular rate and
rhythm. No murmurs, rubs or gallops. Decreased breath
sounds bilaterally. Abdomen was soft with minimal bowel
sounds. 2+ pulses. Full range of motion. Normal preemie
female genitalia. Nonfocal neurologic examination.
HOSPITAL COURSE: 1.) Respiratory: [**Known lastname 28214**] was a premature
infant with clinical symptoms of respiratory distress. She
was intubated in the Neonatal Intensive Care Unit and given
one dose of Surfactant with good response. She was extubated
to nasal C-pap soon after that, on day of life zero. She has
remained on C-pap since then, failing several trails of C-Pap
to nasal cannula. She was started on caffeine on day of life
one for apnea of prematurity, with her last spell on the day
of dictation. She is currently on C-pap of five, room air,
with a plan of trialing C-pap again in the next couple of
days, given her stable status on C-pap of five in the past
week.
2.) Cardiovascular: [**Known lastname 28214**] had remained cardiovascularly
stable throughout this interim period. No murmur was heard
on examination.
3.) Fluids, electrolytes and nutrition: [**Known lastname 28214**] was started on
parenteral nutrition on day of life zero with improvement of
her respiratory distress. She was started on enteral feeds
on day of life three and gradually advanced to full feeds.
She is currently on total fluids of 150 cc per kg per day,
taking breast milk 30 with Promod pg. Her birth weight was
855 grams. Her weight on the day of dictation, on day of life
28, was 1,165 grams.
4.) Gastrointestinal: [**Known lastname 28214**] had initial hyperbilirubinemia
with bilirubin of 4.2 on day of life one. At that time,
phototherapy was initiated and discontinued on day of life
size. Rebound bili showed subsequent progressive elevation of
bilirubin levels from 3.3 on day of life seven to 5.9 on day
of life nine, at which time phototherapy was restarted. On
day of life 11, bilirubin level decreased to 2.6 and
phototherapy was once again discontinued. A rebound bili on
day of life 12 was 2.6.
5.) Infectious disease: [**Known lastname 28214**] was started on antibiotics
Ampicillin and Gentamycin for a sepsis evaluation. Her
initial CBC revealed a white count of 26.4 thousand with 46
polys and 10 bands. Given this left shift, it was decided
that she should continue for a total of seven day antibiotic
course. A lumbar puncture was performed on day of life five
which revealed 325 white blood cells and 3,130 red blood
cells. Given pleocytosis, a concern of meningitis, it was
determined that [**Known lastname 28214**] should continue on antibiotics for a
total 21 day course. Also, at this time, she was switched
from Ampicillin and Gentamycin to Ampicillin and Cefotaxime
for better central nervous system penetration. A repeat
lumbar puncture was performed on day of life nine, revealing
white blood cells of 33, red blood cells of 7,500. She
completed the 21 day antibiotic course on [**6-19**] and there
are no infectious disease concerns at this point.
6.) Neurology: [**Known lastname 52158**] initial head ultrasound on day of
life one was negative. A repeat head ultrasound on day of
life five revealed a question of ventriculitis, which may be
consistent with her meningitis. A follow-up head ultrasound
was obtained on day of life nine which showed resolution of
signs consistent with ventriculitis. Her next follow-up head
ultrasound is scheduled for [**6-28**].
7.) Hematology: [**Known lastname 52158**] initial hematocrit was 43.1;
platelets were 360; maternal blood type was A positive and
[**Known lastname 52158**] blood type was 0 positive, Coombs negative. Her
hematocrit on day of life 20 was down to 22.4 with a
reticulocyte count of 1.7, at which time she was transfused
with directed donor packed red blood cells of 20 cc per kg.
8.) Sensory: Audiology, hearing screening is to be done
prior to discharge.
9.) Ophthalmology: The patient is due for first eye
examination on corrected gestational age of 32 to 33 weeks.
CONDITION AT THE TIME OF DICTATION: [**Known lastname 28214**] has been stable on
C-pap of five, room air, for the past week with minimal apnea
of prematurity on caffeine. She has been tolerating her full
feeds of breast milk 30 with Promod.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) 24592**] [**Last Name (NamePattern1) 1349**] in [**Location (un) **]
Port.
CARE RECOMMENDATIONS:
Current medications:
Caffeine at 8 mg per kg per day.
Vitamin E and iron.
Car seat position screening to be done prior to discharge.
State newborn screen sent.
IMMUNIZATIONS:
Will receive hepatitis B vaccination when [**Known lastname 28214**] reaches 2,000
grams or two months of age, whichever comes first.
DISCHARGE DIAGNOSES:
Prematurity at 26 and 6/7 weeks.
Respiratory distress syndrome.
Apnea of prematurity.
Meningitis.
Anemia of prematurity.
DR. [**First Name8 (NamePattern2) 37693**] [**Last Name (NamePattern1) 37692**] 50-454
Dictated By:[**Doctor Last Name 52159**]
MEDQUIST36
D: [**2159-6-27**] 12:38
T: [**2159-7-3**] 08:34
JOB#: [**Job Number 52160**]
ICD9 Codes: 769, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8668
} | Medical Text: Admission Date: [**2120-4-3**] Discharge Date: [**2120-4-13**]
Date of Birth: [**2045-8-30**] Sex: F
Service: [**Location (un) 259**]
DISCHARGE DIAGNOSIS:
1. Paroxysmal atrial fibrillation
2. Coronary artery disease
3. Congestive heart failure
4. Hypertension
5. Diabetes mellitus
6. Hypercholesterolemia
7. Obstructive and restrictive lung disease
8. Chronic renal insufficiency
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 34-year-old
Russian-speaking female who presented with the acute onset of
shortness of breath. The patient originally presented with
shortness of breath to her primary care physician at the
office of Dr. [**Last Name (STitle) 3357**], who diagnosed her with an asthma
exacerbation and sent her to the Emergency Room at [**Hospital1 1444**] for further medical
management. In the Emergency Room, the patient was thought
to have an asthma exacerbation. Peak flows were
approximately 250 to 300. Albuterol x 3 nebulizers were
given, with decreased shortness of breath and increased
oxygenation. Chest x-ray showed mild congestive heart
failure. The patient received intravenous lasix for
diuresis. The patient was also started on oral prednisone at
that time. Her oxygen saturations were 95% on room air, and
subsequently decreased to 89% with exercise on room air. The
patient denied any chest pain or any acute onset. The
patient does report stable, constant chest pain for the past
nine years, worse with exertion. No nausea, vomiting,
diaphoresis. The patient received 60 mg of oral prednisone
in the Emergency Room.
PAST MEDICAL HISTORY:
1. Asthma. In [**2118-6-14**], FEV-1 of 67% of predicted, 1.38
liters, FVC of 2.03 which was 70% of predicted.
2. Noninsulin dependent diabetes mellitus
3. Degenerative joint disease
4. Mild to moderate lumbar spinal stenosis
5. Hypertension
ALLERGIES: Hydrochlorothiazide with unknown reaction
MEDICATIONS ON ADMISSION: Combivent as needed two puffs
every four to six hours, Procardia XL 50 mg by mouth once
daily, Glucophage 500 mg by mouth twice a day, Serevent two
puffs twice a day, Neurontin 200 mg by mouth three times a
day, Percocet one to two tablets by mouth every six hours as
needed for pain, Azmacort four puffs by mouth twice a day,
Beconase two puffs twice a day, [**Last Name (un) **]-Dur 300 mg by mouth
twice a day, albuterol as needed, Vasotec 10 mg by mouth once
daily, Glynase 6 mg by mouth twice a day, Zantac 150 mg by
mouth twice a day.
PHYSICAL EXAMINATION: On presentation, temperature 98.2,
blood pressure 160/98, heart rate 92, respiratory rate 24,
oxygen saturation 95% on room air. Blood sugar 242. In
general, the patient was an elderly female, in no apparent
distress, alert and oriented x 3. Pulmonary examination
revealed bilateral expiratory wheezes throughout. Head,
eyes, ears, nose and throat examination: Pupils were equal,
round and reactive to light, extraocular movements intact,
mucous membranes moist, no oral lesions, no lymphadenopathy
was appreciated. The neck was supple. Cardiac examination:
Regular rate and rhythm, normal S1 and S2. Jugular venous
pressure was approximately 8 cm. Abdominal examination:
Nontender to palpation, normal active bowel sounds,
nondistended. Extremity examination: 1+ bilateral edema,
positive superficial venous stasis.
LABORATORY DATA: On presentation, white count 7,500,
hematocrit 40.6, platelets 298,000. 69% neutrophils, 20%
lymphocytes, 4% eosinophils. INR 1, PTT 27.6. Sodium 141,
potassium 3.8, chloride 103, bicarbonate 25, BUN 16,
creatinine 0.8, glucose 193. CK 111, troponin 0.4. Chest
x-ray revealed cardiomegaly, bilateral atelectasis vs.
scarring, left hilar prominence which may be the pulmonary
artery. Electrocardiogram revealed left bundle branch block.
Stress test performed in [**2110**] revealed low level exercise,
maximum heart rate 74%, normal Thallium images. Cardiac
echocardiogram performed in [**2110**]: Proximal septal
hypokinesis with trace aortic insufficiency.
HOSPITAL COURSE: 74-year-old female, admitted with mild
congestive heart failure and asthma exacerbation.
1. Cardiac. The patient was admitted to the Medicine
service and placed on telemetry for rule out myocardial
infarction protocol. The patient had serial CKs, which were
flat, and troponins which were negative. The patient ruled
out for myocardial infarction. The patient was started on a
low dose aspirin and low dose beta blocker. To further
evaluate the patient's coronary status, the patient had a
stress test, dobutamine MIBI, performed on [**4-8**], which
revealed global hypokinesis, left ventricular dilation with
stress, with resolution at rest. Essentially the entire
myocardium was reversible except for the lateral wall.
Given the patient's severe stress test, the patient was
brought to the cardiac catheterization laboratory, where
cardiac catheterization was performed. The left main was
normal, left anterior descending was 70%, and the stenosis in
the obtuse marginal I was 60% in the left circumflex. In the
diagonal, 50% stenosis in the posterior descending artery, a
wedge of 46, with 3+ mitral regurgitation.
The patient was continued on her aspirin and beta blocker.
The patient had no significant stenosis that was intervenable
upon. The patient was treated medically with afterload
reduction with Isordil and Hydralazine, as the patient did
not tolerate ACE inhibitor while given her chronic renal
insufficiency.
2. Atrial fibrillation. During the hospital course, the
patient had episodes of paroxysmal atrial fibrillation new
onset. The patient had a rapid ventricular rate, which was
controlled well with Lopressor. Given her low ejection
fraction of approximately 20%, the patient was chemically
cardioverted with procainamide, and the patient was
subsequently normal sinus rhythm. The patient was loaded
with Amiodarone during the hospital course, and remained in
normal sinus rhythm. The patient had a TSH which was normal,
and also pulmonary function tests performed as a baseline.
The patient is to follow up with her primary care provider
for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts evaluation.
3. Congestive heart failure. The patient had no history of
congestive heart failure, however, upon chest x-ray and
physical examination, the patient had evidence of failure. A
cardiac echocardiogram was performed, which revealed an
ejection fraction of approximately 20%, right atrium normal
size, left ventricle dilated, with global hypokinesis and a
focal akinesis. The patient was initiated on lasix therapy
with good urine output. However, the patient's creatinine
began to increase, and the patient had evidence of renal
insufficiency. Fractional secretion of sodium was sent off,
which revealed a FENA of less than 1%, which suggested a
prerenal etiology.
During cardiac catheterization, the patient had an episode of
flash pulmonary edema, and the patient required a stay in the
Intensive Care Unit, where she was aggressively diuresed and
subsequently improved well. The patient was initiated on
standing lasix regimen of approximately 40 mg by mouth twice
a day, for which she would be maintained and followed up by
her primary care provider and adjusted accordingly.
4. Hypertension. The patient has a history of hypertension,
which was relatively not controlled well during this hospital
course. The patient's blood pressure medications were
changed and increased. The patient's ACE inhibitor was
discontinued, as she was unable to tolerate this. Isordil
and Hydralazine were initiated as a second line of therapy,
and titrated up appropriately. Lopressor was also initiated,
and the patient tolerated this medication well.
5. Hyperlipidemia. Upon presentation, the patient's lipids
were checked, and the patient was found to have
hyperlipidemia with a total cholesterol of greater than 260.
The patient was initiated on Lipitor 10 mg by mouth daily at
bedtime, and her liver function tests were within normal
limits at initiation. Seven days after initiation, the
patient's liver function tests remained within normal limits.
6. Pulmonary. The patient has a history of asthma and was
kept on nebulizers and metered dose inhalers during this
admission. The patient was also placed on a prednisone
taper, which was rapidly tapered from 60 mg to off in a week.
During the hospital course, the patient had exacerbations of
her asthma, however, it was felt that the patient's asthma
was secondary to her congestive heart failure. After
aggressive diuresis, the patient no longer her asthma
exacerbation. Pulmonary function tests were performed,
however, post and pre-bronchodilator therapy could not be
performed, as the patient already received albuterol prior to
study. FVC of 52% of predicted, 1.47 liters. FEV-1 of 1.09
liters, 55% of predicted. FEV-1/FVC was 106% of predicted.
Total lung capacity of 89%. FRC of 100%. Diffusion DSV was
noted to be 62% of predicted.
7. Diabetes mellitus. The patient has a history of diabetes
mellitus in the past. Upon reviewing her chart, the patient
had hemoglobin A1c of up to 12 to 13 in the past. The
patient's finger stick glucoses during the hospitalization
were elevated, up to 500. The patient's Metformin was
discontinued secondary to her renal insufficiency and also
for cardiac catheterization. The patient was started on
70/30 regimen of insulin, which controlled her blood sugars
during the hospital course. The patient's high sugars were
thought to be attributed to her prednisone, which was rapidly
tapered off. At the time of discharge, the patient was sent
home with Glynase and to follow up with her primary care
physician for institution of her Metformin once her renal
function improves and her creatinine decreases to less than
1.4.
8. Anticoagulation. The patient will be anticoagulated
given her paroxysmal atrial fibrillation. The patient was
kept on heparin during the hospital course and, at the time
of discharge, the patient was switched over to Coumadin 5 mg
by mouth daily at bedtime. The patient should have an INR
checked at approximately one week after discharge by her
primary care physician or at an outside laboratory, and
results called in and faxed in to her primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 3357**].
9. Renal. At the time of admission, the patient's
creatinine was 0.8, however, during the hospital course, the
patient's creatinine began to increase with aggressive
diuresis for congestive heart failure. The patient's renal
function increased to 2.0, however, subsequently stabilized.
The patient's ACE inhibitor was discontinued as the etiology
of the patient's acute renal failure. After discontinuation
of the patient's ACE inhibitor, the patient's renal function
subsequently began to normalize. The patient's creatinine
function should be checked by her primary care physician
after being discharged. During the hospital course, the
patient was urinating and having good urine output.
DISCHARGE MEDICATIONS:
1. Isordil 20 mg by mouth three times a day
2. Hydralazine 20 mg by mouth four times a day
3. Amiodarone 400 mg by mouth twice a day
4. Coumadin 5 mg by mouth daily at bedtime
5. Albuterol two puffs four times a day metered dose inhaler
6. Atrovent metered dose inhaler two puffs four times a day
7. Neurontin 200 mg by mouth three times a day
8. [**Last Name (un) **]-Dur 200 mg by mouth twice a day
9. Glynase 6 mg by mouth twice a day
10. Flovent metered dose inhaler 110 mcg two puffs twice a
day
11. Lopressor 12.5 mg by mouth twice a day
12. Enteric coated aspirin 325 mg by mouth once daily,
13. Zantac 150 mg by mouth once daily
14. Lipitor 10 mg by mouth daily at bedtime
DISCHARGE CONDITION: At the time of discharge, the patient
was chest pain-free, without any wheezes or shortness of
breath.
DISCHARGE ACTIVITY: As tolerated.
DISCHARGE DIET: Low salt, cardiac.
DISCHARGE DISPOSITION: Home with [**Hospital6 407**]
services and home physical therapy.
FOLLOW UP: The patient is to follow up with her primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3357**], in one week for INR check and also
further management of her cardiac issues.
[**Doctor First Name **]. [**Name8 (MD) 7125**], M.D. [**MD Number(1) 7126**]
Dictated By:[**Last Name (NamePattern1) 5588**]
MEDQUIST36
D: [**2120-4-12**] 22:14
T: [**2120-4-13**] 00:02
JOB#: [**Job Number 95789**]
ICD9 Codes: 4280, 4254, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8669
} | Medical Text: Admission Date: [**2115-10-12**] Discharge Date: [**2115-10-25**]
Date of Birth: [**2061-4-2**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Right inguinal hernia, undescended testis on the right.
Major Surgical or Invasive Procedure:
[**2115-10-11**]: Right inguinal hernia repair with mesh, appendectomy,
right orchiectomy.
[**2115-10-17**]: Reclosure of abdomen with surgimend
History of Present Illness:
PeDr [**Month/Day/Year 4727**] note, this is a 54-year-old male with a history of
morbid obesity and bilateral inguinal hernia repairs as child.
He reports over the past 3
years, he has noticed a lump in his right groin that has been
increasing in size. Initially this lump was reducible; but over
the past year, it has become irreducible. He was seen in Dr
[**Last Name (STitle) 4727**] office and noted to have a giant right inguinal-scrotal
hernia that was chronically incarcerated and filled with small
bowel and sigmoid colon. He also has a history of an
undescended testis on the right side. Preoperative scrotal
ultrasound demonstrated the testis in the inguinal canal.
Past Medical History:
adult-onset diabetes type 2, obesity, history of left and right
inguinal hernias, arthritis, GERD, bronchitis, and varicose
veins.
PSH: bilateral inguinal hernia repair as a baby.
Social History:
He denies any history of alcohol. He has smoked less than one
pack a day for the past 42 years. He plans to quit smoking
prior to this operation. He works for the animal rescue of
[**Location (un) 86**]
Family History:
Father [**Name (NI) 90934**] CA and heart failure, mother, alive and well
Physical Exam:
VS: 98.8, 77, 121/71, 20, 95% 3L (Post Op)
Gen: AXO x 3, pain controlled with intermittent Morphine
Card: RRR
Lungs: No crackles or whezes, distant [**Last Name (un) **] sounds
Abd: OR dressing clean and intact, JPfrom R scrotum
serosanguinous
Extr: :Large amount edema bilateral lower extremities (present
prior to surgery)
At dischage:
Wound vac ~ 10cm ~7 cm black sponge in place, 125 mmHg. 3 JP
drains with serosang/serous fluid. Staples to groin incision.
Staples to upper midline incision.
Abd: No tender, non-distended
Ext: B/L lower ext edema improved from admission. B/L LE venous
statis changes
Pertinent Results:
Post OP Labs: [**2115-10-11**]
WBC-13.0*# RBC-4.95 Hgb-14.3 Hct-44.6 MCV-90 MCH-28.9 MCHC-32.1
RDW-14.3 Plt Ct-202
Glucose-154* UreaN-21* Creat-1.5* Na-138 K-4.8 Cl-104 HCO3-26
AnGap-13
Calcium-8.7 Phos-6.8* Mg-1.7
Brief Hospital Course:
54 y/o male admitted following Right inguinal hernia repair with
mesh, appendectomy, right orchiectomy with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. At
the time of exploration, the patient is noted to have a massive
indirect inguinal hernia, and a large, chronic, thick
hernia sac with small bowel, right colon and appendix in the
scrotum. Please see the operative note for surgical detail.
The patient was kept NPO and had an NG tube in place, and was
d/c'd on POD 2. Diet was slowly advanced and tolerated. On POD 3
the patient had a regular diet and tolerated without nausea or
vomiting. He was then started on oral pain meds with good relief
and tolerance. Some erythema was noticed on the lower portion of
his midline incision and ancef was continued.
On POD 5 an abdominal/pelvis CT scan was conducted for continued
drainage from the lower portion of the midline abdominal wound.
This showed a large fascial dehicence.
The patient was taken to the OR where abdominal closure with
sergimed was performed. There were no complications. 2 addition
JP drains were placed. Please see the separate operative note
for further details on the procedure. The patient was
transferred to the ICU for monitoring post operatively (patient
remained intubated overnight).
The patient did well post operatively and was extubated and
transferred on POD7/1. Patient was started on sips and bariatric
pneumo boots. On POD [**7-30**] the patient was advance to clears which
he tolerated well. POD [**8-31**] the patient was advanced to regular
diet and changed to PO pain medication. On POD [**11-2**] the patients
abdominal JP drains lost suction as a 1cm area in his lower
midline incision had opened. The wound was then opened and
explored. A vac dressing was placed over an ~10cm by ~7cm area
of the lower midline incision. The JP drains returned to holding
suction after vac placement. The patient tolerated vac placement
well. On POD 13/7 the vac dressing was changed. The wound was
healing well.
On POD 14/8 the patient was discharge home in good condition
with wound vac to lower midline incisional wound, 2 abdominal JP
drains in place, 1 scrotal JP drain in place. Patient was
tolerating regular diet, pain controlled with minimal PO pain
medication, amublating without assistance.
While hospitalized the patients blood sugars were controlled
with sliding scale insulin. His metformin was restarted POD13/7.
Medications on Admission:
metformin 500''
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain: Maximum 8 tablets daily.
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
6. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Right inguinal hernia, undescended testis on the right, wound
dehisence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-AllCare Visiting Nurse services have been arranged for Vac
dressing change
-Please call Dr[**Name (NI) 1369**] office at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, increased abdominal pain, swelling of
the abdomen, increased scrotal swelling, incisional redness,
drainage or bleeding.
-Please call the office if you are unable to tolerate food,
fluids or medications or if you are having diarrhea or
constipation.
-Do not strain when having a bowel movement. Take stool softener
and drink plently of fluids.
-Drain and record the JP drain output twice daily and as needed.
Keep a record of the output and bring a copy with you to your
clinic visit.
-No driving if taking narcotic pain medication
-No lifting of any objects greater than 10 pounds until notified
you may do so.
You may shower, no tub baths or swimming until notified you may
do so.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2115-10-30**] 10:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2115-10-25**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8670
} | Medical Text: Admission Date: [**2102-10-1**] Discharge Date: [**2102-10-3**]
Date of Birth: [**2019-8-6**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Quinolones
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
[**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] pacemaker placement
History of Present Illness:
83 yo male with history of hyperlipidema, hypertension,
bifascicular block on previous EKG presented to the ED with
syncope. The patient was feeling lightheaded this evening. He
called his daughter to discuss his symptoms. While he was on
the phone, the line went dead for approx 3min. He reports he
lost consciousness during that time. His daughter called EMS.
He denied falling during the episode of LOC. When EMS arrived,
he was found to be in complete heart block with a ventricular
rate in the 20s. He was given atropine en route to the ED.
.
In the ED, initial vitals were T99.0, HR 30, BP 140/60, RR18, o2
100% on NRB. He was found to be in third degree heart block
with a continued ventricular rate in the 30s. He was given
atropine again. He sustained a brief episode of asystole and a
temporary pacer wire was placed. He had appropriate capture and
was paced at a rate of 80bpm. He was intubated for airway
protection, given fentanyl and midazolam for sedation, then
changed to propofol prior to transfer.
.
Unable to obtain review of systems secondary to sedation.
Past Medical History:
1. CARDIAC RISK FACTORS: (+) Dyslipidemia, (+) Hypertension
2. CARDIAC HISTORY: left anterior fascicular block and right
bundle branch block on recent EKG
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- Obesity, central
- History of alcohol abuse.
- Status post ruptured rotator cuff: Injured shoulder 50 years
ago when he slipped on ice. Specialists have told him he needs
it replaced
- History of diverticulitis - s/p hemi-colectomy in [**5-16**]
Social History:
Lives at home with his wife. [**Name (NI) 1403**] in real estate part time with
son and son-in-law.
-Tobacco history: quit smoking 20+ years ago
-ETOH: Drinks roughly 12 alcoholic drinks per week,
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
GENERAL: intubated, sedated.
HEENT: NCAT. Sclera anicteric. Right pupil is tear drop shaped,
minimally reactive appears post surgical, left pupil is
reactive. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa. No xanthalesma.
NECK: Supple with flat JVP
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: midline scar, 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 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Pertinent Results:
[**2102-10-1**] 10:05PM BLOOD WBC-10.7 RBC-4.13* Hgb-11.9* Hct-37.7*
MCV-91 MCH-28.9 MCHC-31.6 RDW-16.5* Plt Ct-260
[**2102-10-3**] 07:00AM BLOOD WBC-6.9 RBC-3.87* Hgb-11.4* Hct-34.6*
MCV-90 MCH-29.6 MCHC-33.1 RDW-17.2* Plt Ct-206
[**2102-10-1**] 10:05PM BLOOD PT-12.9 PTT-24.2 INR(PT)-1.1
[**2102-10-1**] 10:05PM BLOOD Glucose-186* UreaN-29* Creat-1.0 Na-141
K-4.4 Cl-106 HCO3-22 AnGap-17
[**2102-10-3**] 07:00AM BLOOD Glucose-85 UreaN-19 Creat-0.8 Na-143
K-4.7 Cl-109* HCO3-25 AnGap-14
[**2102-10-1**] 10:05PM BLOOD CK(CPK)-40
[**2102-10-2**] 05:00AM BLOOD CK(CPK)-44
[**2102-10-1**] 10:05PM BLOOD cTropnT-0.02*
[**2102-10-2**] 05:00AM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2102-10-1**] 10:05PM BLOOD Calcium-8.3* Phos-5.8* Mg-2.1
[**2102-10-2**] 05:00AM BLOOD Triglyc-114 HDL-55 CHOL/HD-2.9 LDLcalc-82
EKG: On admission to the ED, third degree heart block with a
sinus rate of 110 bpm, and ventricular escape rhythm at 22bpm
with right bundle branch morphology, right-[**Hospital1 **] axis. On
admission to the CCU, pacer dependent at a rate of 80bpm.
ECG:
High degree A-V block. Again, given the inconsistent
relationship between
P waves and QRS complexes tracing is suggestive of complete
heart block with ventricular or aberrantly conducted nodal
escape rhythm. There is also a rightward axis deviation. Right
bundle-branch block and non-specific ST-T wave abnormalities.
Compared to the previous tracing #2 evidence for complete heart
block is more clearly seen.
TTE [**2102-10-3**]:
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded.
Overall left ventricular systolic function is normal (LVEF
60-70%). Right ventricular chamber size and free wall motion are
normal. The aortic root is mildly dilated at the sinus level.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The aortic valve is not well seen. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade.
Compared with the prior study (images reviewed) of [**2101-2-3**], no
major change is evident.
CXR:
FINDINGS: Left-sided dual-chamber pacemaker has been inserted,
with leads
intact and in standard positions, ending in the right atrium and
right
ventricle. There is no pneumothorax, focal consolidation,
pleural effusion or pulmonary edema. Degenerative changes are
noted in the thoracic spine.
IMPRESSION: New left-sided pacemaker with leads in standard
positions without evidence of pneumothorax.
Brief Hospital Course:
# Complete Heart Block: The patient had a know history of RBBB
and LAFB. His current presentation was likely degenerative
conduction disease, finally losing his posterior fasicle. He had
no evidence of active ischemia. A TTE showed no focal wall
motion abnormalities, cardiac biomarkers were flat, and ECGs
showed no signs of ischemia. He was initially emergently
intubated and tranvenously paced. He rapidly extubated and
eventually had a PPM placed with little complication. He
tolerated the procedure well and was discharged home on PO
clindamycin. He will follow up with EP and the device clinic. He
was started on 81mg of aspirin for primary prevention.
#HTN: Not previously on medical management and remained
normotensive in house. No medications started.
#Hyperlipidemia: Lipid profile at goal when checked in house. No
medications started.
#Prophylaxis: HSC
#Code: Full confirmed
COMM: [**Name (NI) 1404**] [**Name (NI) 14**] (Wife) [**Telephone/Fax (1) 1405**]
Medications on Admission:
Aspirin 81mg QAM
Pregabalin 75mg [**Hospital1 **]
Zyrtec 10mg QAM
Omeprazole 20mg QAM
Colace PRN
Senna PRN
Tylenol PRN
Percocet PRN
Discharge Medications:
1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
2. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 3 days.
Disp:*24 Capsule(s)* Refills:*0*
3. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Complete Heart Block
Discharge Condition:
stable.
Discharge Instructions:
You had a rhythm problem with your heart called complete heart
block. This was treated with a pacemaker that will regulate the
electrical system of your heart from now on. You did not have a
heart attack. Your echocardiogram showed no significant change
or abnormality. This is a preliminary [**Location (un) 1131**] and will be
reviewed by the attending cardiologist later in the day.
.
Medication changes:
1. Take a baby aspirin 81 mg daily.
2. Take Clindamycin for 3 days, this is an antibiotic that will
prevent an infection at the pacer site.
3. Vicodin: to take for pain at the pacer site or shoulders
.
No lifting more than 5 pounds with your left arm or lifting you
left arm over your head for 6 weeks. Keep the dressing dry, no
showers or baths for 1 week. Do not change the pacer dressing
unless it is damp.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2102-10-10**]
2:00.
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**]. [**Hospital Ward Name 516**], [**Hospital1 18**].
.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/time: [**11-10**]
at 3:20 pm.
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**]. [**Hospital Ward Name 516**], [**Hospital1 18**].
ICD9 Codes: 4275, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8671
} | Medical Text: Admission Date: [**2161-6-8**] Discharge Date: [**2161-6-18**]
Date of Birth: [**2108-10-2**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
[**2161-6-18**] ORIF left radius fracture
History of Present Illness:
52 y/o female s/p fall approx [**6-27**] steps today with multiple
injuries. No reported LOC. These injuries include a right
orbital wall fracture,
multiple rib fractures, and a possible left wrist fracture. She
was taken to an area hospital and then transferred to [**Hospital1 18**] for
further care.
Past Medical History:
Mental retardation
HTN
Hypothyroidism
Right hip dislocation s/p fall 4 years ago
Patellar dislocation and ORIF s/p fall
Social History:
Previously lived with her mother
Family History:
Noncontributory
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2161-6-18**] 07:20AM 9.7 2.97* 9.7* 28.9* 97 32.6* 33.5 14.8
262#
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2161-6-18**] 07:20AM 262#
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2161-6-18**] 07:20AM 78 26* 1.6* 138 5.2* 103 28 12
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2161-6-18**] 07:20AM
CT HEAD W/O CONTRAST [**2161-6-8**] 2:47 PM
IMPRESSION:
1. Right maxillary sinus, orbital floor, and zygomatic
fractures, with hemorrhage, and displacement of fracture
fragments into right maxillary antrum.
These fractures, particularly those of the orbital floor and
ZMC, are incompletely characterized, and might be further
evaluated with dedicated maxillofacial CT, with coronal and
sagittal reformations.
2. Laceration overlying left parietal bone, and soft tissue
contusion with subcutaneous gas overlying right maxillary
fracture.
3. No intracranial hemorrhage or other evidence of acute brain
parenchymal injury.
4. Chronic small vessel infarction.
RENAL U.S. [**2161-6-9**] 3:17 PM
RENAL U.S.
FINDINGS: The right kidney measures 9.6 cm. There is no
hydronephrosis and no stones or solid masses are identified in
the right kidney. Note is made that the patient was unable to
turn and therefore the left kidney was unable to be visualized
on this exam.
IMPRESSION: Unremarkable right kidney. Nonvisualization of the
left kidney as described above.
MR L SPINE W/O CONTRAST [**2161-6-12**] 4:43 PM
IMPRESSION: Limited study secondary to motion. Old appearing
compression injuries of T11 and T12 with minimal retropulsion
and indentation on the thecal sac. Mild multilevel degenerative
changes.
Brief Hospital Course:
She was admitted to the Trauma Service. Neurosurgery,
Orthopaedics, and Plastics were consulted because of her
injuries. Her spine injuries were managed non operatively; she
was placed on a pain regimen and will follow up in 8 weeks with
Dr. [**Last Name (STitle) **] for repeat spine imaging. Physical therapy was
consulted early on to facilitate mobility.
She was taken to the operating room on [**6-11**] by Orthopedics for
open reduction internal fixation of left distal radius
three-part fracture. A short cast was applied which patient
removed during an episode of agitation; it was later decided
that a long arm cast be applied. She will follow up in
[**Hospital 5498**] clinic in 2 weeks.
In the meantime she is to remain non weight bearing on her left
arm.
He orbital wall fracture was nonoperative; she was started on
Clindamycin and has completed a 7 day course. She will follow up
in [**Hospital 3595**] clinic in 2 weeks.
Her home medications were restarted; including her Olanzapine at
hs; standing doses of this were also initiated because of
several episodes of agitation. She was placed on 1:1 sitter for
safety reasons.
She will need to follow up with her primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]e from rehab regarding an incidental finding on renal
ultrasound.
She is being recommended for short term rehab following acute
hospitalization.
Medications on Admission:
Zyprexa 15 hs, Atenolol 50', Clonazepam 0.5', Imipramine 150hs,
Benztropine 1', Depakote 1000', Synthroid 100', Colace 100'
Discharge Medications:
1. Olanzapine 5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
2. Imipramine HCl 25 mg Tablet Sig: Six (6) Tablet PO HS (at
bedtime).
3. Benztropine 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-26**]
hours as needed for pain.
7. Divalproex 500 mg Tablet Sustained Release 24 hr Sig: Two (2)
Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) NEB Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
12. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for increased sedation.
13. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30)
ML's PO twice a day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
s/p Fall
INJURIES:
1) Left distal radius fracture - ORIF [**6-11**]
2) C7-T1 transverse process fx, T12/L1 compression fx
3) Right 5th rib fracture
4) Right orbital floor fracture
5) Scalp laceration
Discharge Condition:
Good
Followup Instructions:
Follow up in [**Hospital 5498**] Clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in 2
weeks, call [**Telephone/Fax (1) 1228**] for an appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) **] [**Last Name (STitle) 159**], for the left renal
mass; call [**Telephone/Fax (1) 921**] for an appointment.
Follow up in 8 weeks with Dr. [**Last Name (STitle) **], Neurosurgery for your
spine fractures. Call [**Telephone/Fax (1) 1669**] for an appointment. Inform
the office that you will need flex/ext films for this
appointment.
Completed by:[**2161-6-18**]
ICD9 Codes: 5849, 5859, 2449, 4240, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8672
} | Medical Text: Admission Date: [**2138-5-12**] Discharge Date: [**2138-5-16**]
Date of Birth: [**2055-8-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Dyspnea, fevers, mental status change
Major Surgical or Invasive Procedure:
Speech and swallow eval
History of Present Illness:
Ms. [**Known lastname **] is an 82 year old female with past medical history of
DM2, CAD who is admitted from [**Hospital **] Healthcare Center after
change in mental status. At baseline the patient is conversant
however today she was found to be less responsive than usual.
There was also note of some respiratory distress. She was
brought to [**Hospital1 18**] from the nursing home for further monitoring.
.
In the ED, the patient's vital signs were T 98.8, Tmax 102.2, BP
100/65, HR 118, RR 34, O2 sat 98% on NRB. On physical exam the
patient was unresponsive and did not withdraw to painful
stimuli. [**Hospital1 **] were notable for elevated WBC count 17.5, lactate
4.3, Na 164. CXR showed low lung volumes, with patchy airspace
process at the left lung base, which may be pneumonic
infiltrate. UA was positive for infection. She was given
Levofloxacin 750mg x1 and Ceftriaxone 1g x1, tylenol 500mg x1. A
head CT was done to work up the altered mental status. BP was
noted to be systolic 80s in the ED and she was given 3L NS. BP
responded to systolic 110s. She was also initially hypoxic to
84%, improved to 96% on NRB however remained tachypneic. She was
started on noninvasive ventilation and oxygen saturation
remained 95-99%. She is being admitted to the [**Hospital Unit Name 153**] for further
monitoring and treatment.
Past Medical History:
Diabetes Mellitus
Hypertension
Bipolar
Schizophrenia
Anemia
L1-L4 compression fracture
R hip revision
Osteoporosis
DVT in bilateral lower extremities
Tardive dyskinesia
.
Social History:
Lives at a nursing home. Unable to obtain remainder of social
history.
Family History:
non-contributory
Physical Exam:
VS: T 97.6, BP 108/49, HR 120, RR 16, 94 O2 sat .
GEN: Ill appearing elderly female in distress, rigoring.
Tachypneic.
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, MMM, Neck supple, no LAD, no carotid bruits
CV: RRR, nl s1, s2, no m/r/g
PULM: CTAB, no w/r/r with good air movement throughout
ABD: Soft, NT, ND, + BS, no HSM
EXT: warm, dry, +2 distal pulses BL, no femoral bruits
NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength
throughout. No sensory deficits to light touch appreciated. No
asterixis
Pertinent Results:
ADMISSION [**Hospital Unit Name **]:
===============
[**2138-5-12**] 10:28PM TYPE-ART PO2-112* PCO2-35 PH-7.45 TOTAL
CO2-25 BASE XS-0
[**2138-5-12**] 10:28PM LACTATE-4.3*
[**2138-5-12**] 07:29PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2138-5-12**] 07:29PM URINE RBC-[**10-23**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-[**2-5**]
[**2138-5-12**] 06:50PM GLUCOSE-239* UREA N-34* CREAT-1.1 SODIUM-164*
POTASSIUM-3.9 CHLORIDE-124* TOTAL CO2-28 ANION GAP-16
[**2138-5-12**] 06:50PM CK(CPK)-129
[**2138-5-12**] 06:50PM cTropnT-0.07*
[**2138-5-12**] 06:50PM CK-MB-2
[**2138-5-12**] 06:50PM WBC-17.5* RBC-4.68 HGB-13.2 HCT-43.0 MCV-92
MCH-28.1 MCHC-30.6* RDW-15.2
[**2138-5-12**] 06:50PM NEUTS-74.4* LYMPHS-22.7 MONOS-2.3 EOS-0.4
BASOS-0.3
[**2138-5-12**] 06:50PM PT-13.7* PTT-23.4 INR(PT)-1.2*
[**2138-5-12**] 06:50PM PLT COUNT-266
MICRO:
=====
[**2138-5-13**] 10:31 pm URINE Source: Catheter.
URINE CULTURE (Final [**2138-5-15**]): NO GROWTH.
[**2138-5-14**] 5:26 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
DISCHARGE [**Month/Day/Year **]:
==============
[**2138-5-16**] 06:30AM BLOOD WBC-10.2 RBC-3.46* Hgb-9.7* Hct-31.3*
MCV-91 MCH-28.1 MCHC-31.0 RDW-15.0 Plt Ct-265
[**2138-5-16**] 06:30AM BLOOD Glucose-110* UreaN-4* Creat-0.4 Na-147*
K-4.1 Cl-108 HCO3-29 AnGap-14
[**2138-5-13**] 05:09AM BLOOD ALT-39 AST-35 LD(LDH)-242 CK(CPK)-144*
AlkPhos-46 TotBili-0.4
[**2138-5-16**] 06:30AM BLOOD Calcium-7.8* Phos-2.8 Mg-2.1
[**2138-5-16**] 06:30AM BLOOD Valproa-30*
IMAGING:
========
Non-contrast head CT.
IMPRESSION:
1. Severe global atrophy with prominent sulci and dilated
ventricles.
2. No acute intracranial process.
CHEST (PORTABLE AP)
IMPRESSION: Low lung volumes, with patchy airspace process at
the left lung base, which may be pneumonic.
EKG
Sinus tachycardia
Atrial premature complex
Incomplete right bundle branch block
Left anterior fascicular block
No previous tracing available for comparison
Intervals Axes
Rate PR QRS QT/QTc P QRS T
121 136 112 344/450 73 -86 43
CHEST (PA & LAT)
IMPRESSION:
1. Aspiration and/or pneumonia at the lung bases.
2. Diffuse calcified atherosclerosis of the thoracic aorta.
3. Compression deformity of a mid thoracic vertebral body, age
indeterminate.
Brief Hospital Course:
82 year old female with history of DM, CAD who presented to the
ED with altered mental status admitted with AMS found to have
UTI, LLL PNA.
# Hypotension/fever: Patient presented with altered mental
status, hypotension, elevated WBC count concerning for presepsis
picture. Source was concerning for urine vs lung or both. She
was briefly hypotensive in the ED, BP improved with fluids.
She was covered broadly with Vanc/Cefepime as she is from
nursing home and may have resistant bacteria. She received
volume resuscitation with IV boluses. Her urine culture final
report was no growth but it was taken after start of IV abx, she
was transitioned to po levaquin for a total 7 day course.
- On discharge she is afebrile and BP is 136/86, hr 95 95% ra
# hypoxia: she received CPAP for tachypnea with improvement.
# Hypernatremia: Na 164 on admission. Differential is insensible
losses, GI losses, hypothalamic lesion, central/nephrogenic DI
vs intrinsic renal disease. CT head showed no acute intracranial
process. Free water deficit was figured at 5.1L with plan to
give half over first 24hrs, then second half over second 24
hours. Her Na continued to trend down and was 146 on discharge.
- She needs to increase her PO free water intake
- If she is on hospice, discuss with guardian whether [**Name2 (NI) **]
should continue to be drawn.
- Her lasix was held in the setting of dehyration. Monitor for
need to restart.
# delirium: she required prn haldol upon admission but on day of
discharge was much calmer, oriented to self, able to repeat a
few words and followed some commands. She was engaging in
conversation. Her remeron was stopped in the setting of her
delirium as all unnecessary medications were stopped in an
effort to clear her sensorium. Her PM valproic acid was
decreased to help with MS.
- d/c foley ASAP as wound care allows
- monitor mental status with decrease of valproic acid.
# LLL Pneumonia: Patient hypoxic on arrival to the ED. Her xray
revealed LLL pna and was treated with levaquin. She was also
seen by speech and swallow as there was concern for aspiration.
- Complete course of levaquin
# Swallowing eval: seen by speech pathologist. Did not exhibit
signs of overt aspiration. She did pocket her foods.
- Supervision with meals is suggested to ensure that she takes
small sips.
- recommendation is pureed diet with nectar thick liquids via
sip cup, aternating between bites and sips.
- clear her mouth prior to reclining in bed
- ensure pudding between meals
.
# Acute Renal Failure: her creatine was 1.1 on admission from a
baseline of 0.5. On discharge it is 0.4.
# Diabetes mellitus: Oral agents were held and she was placed on
an insulin sliding scale. Her blood sugars were well controlled.
Consider whether she needs oral agents.
# Schizophrenia: continued on risperdal and valproic acid (at
reduced dose).
# Wound Care: she was seen by our wound care team as well as
plastic surgery who felt ulcer was not infected. See wound care
recommendations. She was placed on ATC tylenol for pain control.
# hypothyroidism: her TSH was elevated at 5.38. No medications
were started. This should be reaccessed when she is out of her
acute illness.
.
# PPx: she received sc heparin for dvt prophylaxis, may
discontinue per primary team. Also was on bowel regimen.
#CODE: DNR/DNI per guardian. She does not have capacity to make
decisions. Spoke with hospice nurse who felt that a discussion
should be had with the guardian around possible do not
hospitalize orders. Due to her hospice status her fosomax was
not continued. Consider also stopping her atorvastatin.
Medications on Admission:
Lasix 20mg daily
Ascorbic acid 500mg daily
Glipizide 2.5mg daily
Fosamax 70mg weekly
Remeron 7.5mg daily
Lipitor 10mg daily
Valproic acid 250mg daily
Risperdal 0.5mg daily
Vicodin 5-500mg PRN
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Valproate Sodium 250 mg/5 mL Syrup Sig: One (1) PO QAM (once
a day (in the morning)).
9. Valproate Sodium 250 mg/5 mL Syrup Sig: One (1) PO QPM (once
a day (in the evening)).
10. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
11. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 7 days: First dose was [**5-14**], last dose
should be [**5-21**].
12. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in
Packet Sig: One (1) Powder in Packet PO TID (3 times a day) for
2 days.
13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO four
times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare-[**Location (un) 86**]
Discharge Diagnosis:
Sepsis
Aspiration pneumonia
Urinary Tract Infection
Hypernatremia
Delirium
Acute Renal Failure
Sacral decubitis stage III
Diabetes Mellitus
Schizophrenia
h/o DVT bilateral lower extremeties
Discharge Condition:
Fair
Discharge Instructions:
You were admitted with mental status change, low blood pressure
and low oxygen count. You had a fever and a presumed infection
in your lung and were treated with antibiotics and intravenous
fluids. You also had a high level of sodium in your blood and
this can be helped by drinking more water.
Followup Instructions:
1. Patient should resume hospice services and consider a DO NOT
HOSPITALIZE order to go with her DNR.
2. Encourage increased PO water intake
Completed by:[**2138-5-16**]
ICD9 Codes: 0389, 5070, 5990, 2760, 5849, 2449, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8673
} | Medical Text: Admission Date: [**2144-3-23**] Discharge Date: [**2144-3-28**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] yo M with HTN, PVD s/p fem-[**Doctor Last Name **] bypass, recurrent DVT on
Coumadin, Mobitz II s/p pacemaker, presenting with 1 day of
shortness of breath, cough and fever. Per the patient's care
assistant, he had some chest congestion yesterday, but was
otherwise well. Today, he had fatigue, malaise, fever, and
progressive shortness of breath, leading him to present the ED.
Of note, his Coumadin was held yesterday in preparation for a
dental procedure. He has had left lower extremity edema for the
past 3 weeks. He sometimes coughs after eating.
.
In the ED, initial vital signs were 99.4 90 142/69 34 90% 15L
Non-Rebreather. Lung exam was relatively clear per [**Name (NI) **] report.
EKG showed a venticularly-paced rhythm. Labs notable for WBC
24.9, INR 1.5, creatinine 1.4, lactate 2.8. U/A showed trace
leukocytes, trace blood, few bacteria. CXR showed no
consolidation. ABG 7.44/40/45 on bipap. He was treated with
levofloxacin, with a plan to also treat with vanc and cefepime,
although these were not given in the ED. He was started on bipap
with improvement in his respiratory status. Daughter is HCP
daughter [**Name (NI) **] [**Telephone/Fax (1) 39171**]. Son with [**Name2 (NI) 39172**]. Patient is full
code. Patient confused. Has 18-gauge for access. Vitals on
admission 128/104, 93, 20, 100% BIPAP FiO2 60%, [**6-6**].
.
On arrival to the ICU, the patient was on Bipap and was not able
to convey a history. Review of systems was unobtainable.
.
At baseline, the patient lives in an [**Hospital3 **] with
24-hour care. He receives assistance with eating, and with
transportation to bathroom. He is sometimes incontinent of urine
but not stool.
Past Medical History:
1. Hypertension.
2. high grade AV block s/p PPM
3. DVT, on Coumadin.
4. Hyperlipidemia.
5. Spinal stenosis.
6. Osteoporosis.
7. Several bowel obstructions.
8. Scoliosis.
9. Benign prostatic hypertrophy, followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 365**].
10. Gallstones seen on CAT scan of abdomen.
11. Renal cell carcinoma. A mass was seen on his left kidney
on
a CT scan in [**2138**].
12. Skin cancers. (BCC on nose and ear [**1-/2142**])
13. Gastritis.
14. Constipation.
15. Hearing loss.
16. Inguinal hernia.
17. Urinary incontinence.
18. Left hip fracture [**1-/2143**]
19. Right heel ulcer [**3-/2143**]
.
Past Surgical History:
1. TURP [**2118**].
2. Appendectomy [**2067**].
3. Arterial graft to left lower extremity [**2088**].
4. Skin cancers removed from left cheek [**2138**].
5. Status post pacemaker implant [**2140**].
6. ORIF left hip 12/[**2142**].
7. fem/[**Doctor Last Name **] bypass
Social History:
The patient is widowed. He had been living in [**State 792**]in
the summer and [**State 108**] in the winter, but now is residing in the
[**Location (un) 86**] area [**Street Address(1) 19131**]. He went to college for two years
and was an executive during his lifetime. His son and daughter
are involved in his care.
Family History:
Mother died of stroke age 75. Father had bowel infarction age
57.
Physical Exam:
Admission Physical Exam:
Vitals: 128/104, 93, 20, 100% BIPAP FiO2 60%, [**6-6**].
General: On Bipap. Unable to participate in conversation. No
acute distress.
HEENT: Sclera anicteric.
Neck: JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: foley in place
Ext: warm, well perfused, 1+ LLE edema with warm blanching
erythema tracking to the level of the buttocks
.
Discharge Physical Exam:
96.3, 148/68, 56, 20, 98ra
Breathing comfortably, NAD, speech is difficult to understand at
baseline
HEENT: Sclera anicteric.
Neck: JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley
EXT: warm, venous stasis changes bilaterally, assymetric pitting
edema (L), 1+ DP/PT pulses bilaterally. Erythema has receded
significantly compare to admission and is now centered around a
healing ulceration on the left anterior leg. No fluctuance or
tenderness.
Pertinent Results:
Admission Labs:
[**2144-3-23**] 01:20PM BLOOD WBC-24.9*# RBC-4.75 Hgb-14.8 Hct-41.8
MCV-88 MCH-31.2 MCHC-35.5* RDW-13.3 Plt Ct-301
[**2144-3-23**] 01:20PM BLOOD Neuts-80* Bands-5 Lymphs-14* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2144-3-23**] 01:20PM BLOOD PT-16.0* PTT-33.7 INR(PT)-1.5*
[**2144-3-23**] 01:20PM BLOOD Glucose-109* UreaN-27* Creat-1.4* Na-140
K-4.4 Cl-100 HCO3-24 AnGap-20
[**2144-3-23**] 02:39PM BLOOD Type-ART pO2-45* pCO2-40 pH-7.44
calTCO2-28 Base XS-2 Intubat-NOT INTUBA
[**2144-3-23**] 01:35PM BLOOD Lactate-2.8*
[**2144-3-24**] 01:55AM BLOOD WBC-14.8* RBC-3.74* Hgb-10.9*# Hct-32.5*
MCV-87 MCH-29.2 MCHC-33.7 RDW-13.6 Plt Ct-204
[**2144-3-24**] 01:55AM BLOOD PT-22.0* PTT-150* INR(PT)-2.1*
[**2144-3-24**] 01:55AM BLOOD Glucose-116* UreaN-27* Creat-1.2 Na-137
K-3.7 Cl-107 HCO3-21* AnGap-13
Urine:
[**2144-3-23**] 02:19PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2144-3-23**] 02:19PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2144-3-23**] 02:19PM URINE RBC-2 WBC-4 Bacteri-FEW Yeast-NONE Epi-0
Blood Cultures x2 ([**3-23**], [**3-24**]): NGTD
Urine Culture ([**3-23**]): NGTD
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2144-3-24**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2144-3-24**]):
Negative for Influenza B.
STUDIES:
CXR ([**3-23**]):
IMPRESSION:
Low lung volumes, without acute cardiopulmonary process.
.
LENI ([**3-23**]):
IMPRESSION:
1. Limited study, without left lower extremity DVT above the
knee.
2. Bilateral reactive inguinal nodes.
.
[**2144-3-25**] 07:45AM BLOOD WBC-9.9 RBC-3.80* Hgb-11.5* Hct-33.1*
MCV-87 MCH-30.3 MCHC-34.8 RDW-13.5 Plt Ct-217
[**2144-3-26**] 07:05AM BLOOD WBC-6.9 RBC-3.79* Hgb-11.5* Hct-32.9*
MCV-87 MCH-30.4 MCHC-35.0 RDW-13.4 Plt Ct-232
[**2144-3-27**] 07:29AM BLOOD WBC-6.2 RBC-3.55* Hgb-10.6* Hct-30.9*
MCV-87 MCH-29.7 MCHC-34.2 RDW-13.2 Plt Ct-260
[**2144-3-28**] 06:12AM BLOOD WBC-7.1 RBC-3.87* Hgb-11.6* Hct-32.9*
MCV-85 MCH-29.9 MCHC-35.2* RDW-13.2 Plt Ct-282
[**2144-3-27**] 07:29AM BLOOD PT-15.2* PTT-57.3* INR(PT)-1.4*
[**2144-3-27**] 04:00PM BLOOD PT-15.5* PTT-81.2* INR(PT)-1.5*
[**2144-3-27**] 09:36PM BLOOD PT-15.8* PTT-80.1* INR(PT)-1.5*
[**2144-3-28**] 06:12AM BLOOD PT-15.9* PTT-78.9* INR(PT)-1.5*
[**2144-3-26**] 07:05AM BLOOD Glucose-96 UreaN-15 Creat-1.1 Na-141
K-3.9 Cl-108 HCO3-29 AnGap-8
[**2144-3-27**] 07:29AM BLOOD Glucose-91 UreaN-15 Creat-1.0 Na-141
K-4.0 Cl-107 HCO3-29 AnGap-9
[**2144-3-28**] 06:12AM BLOOD Glucose-93 UreaN-14 Creat-1.0 Na-141
K-4.2 Cl-107 HCO3-29 AnGap-9
.
URINE CULTURE PENDING AT THE TIME OF DISCHARGE.
Brief Hospital Course:
.
Mr. [**Known lastname 9449**] is a [**Age over 90 **] yo M with HTN, PVD s/p fem-[**Doctor Last Name **] bypass,
recurrent DVTs on indefinite Coumadin, Mobitz II s/p pacemaker.
He presented with acute respiratory failure, high fevers, and
severe LLE cellulitis. He initially required BIPAP and 100% O2
via non-rebreather. His improvement was unusually rapid with
empiric coverage for HCAP, cellulitis, and PE. He was
transferred out of the MICU on room air less than 24 hours after
admission.
.
# Acute Respiratory Failure: His decompensation and recovery
from a respiratory point of view were both remarkably rapid. CXR
was unremarkable, but he was initially covered empirically for
HCAP with cefepime and vancomycin. He has a history of recurrent
aspiration and is on a modified diet, but we would have expected
some evidence of plugging/collapse or pneumonitis if this
picture was the consequence of an aspiration event. He was
also empirically treated for PE on admission given his history
of recurrent DVTs and recent pausing of coumadin for an elective
procedure. Cefepime was discontinued after transfer out of the
MICU and he was continued on vancomycin (for cellulitis) and
heparin drip. The speed of his recovery argues against
pneumonia or PE. In less than 24 hours, he progressed from
requiring a non-rebreather to being on room air. It is
conceivable that the increased metabolic demand (high fevers)
associated with his severe cellulitis was the cause of his acute
respiratory failure.
.
# LLL Cellulitis: Likely responsible for his acute
decompensation as above. LENIs were negative for persistent DVT.
He received vancomycin throughout this admission and was
transitioned to oral keflex/doxyclycine for 7 more days at the
time of discharge. Given that he presented in extremis because
of cellulitis, an argument for a full course of vancomycin could
be made, but the patient's family reported that he has a history
of pulling out catheters and lines. His infection will be
monitored by VNA and at his PCP's office (in four days).
Although he has a listed allergy to penicillins (rash), his
daughter [**Name (NI) **], his HCP, states that he has tolerated keflex
previously.
.
# h/o DVT: On coumadin chronically as an outpatient.
Subtherapeutic on admission and started on a heparin drip for
empiric coverage of PE. His family declined CTA as he has a
history of agitation associated with CTs. Because of his history
of DVT recurrence and possiblity of PE, he was discharged on a
lovenox bridge (1.5mg/kg daily) and 5mg coumadin daily. INR on
the day of discharge is 1.5. Arrangements were made for close
surveillance of his INR given the concomittant use of
anitbiotics (particularly doxycycline): he will have his INR
check on [**3-30**] by VNA and on [**3-/2061**] at his PCP's office.
.
# Anemia: He had a Hct drop after fluid resuscitation in the
MICU. He is guiaic negative and his Hct is trending up. It
should be re-checked when he follows-up in his PCPs office next
week.
.
# Nutrition: Coughing while trying to eat with nurse. He was
seen by speech and swallow. The patient declined a video swallow
and his diet was down-graded to ground solids with thickened
liquids. He should be supervised for all meals.
.
# Hypertension: His lisinopril was held on admission because of
hypotension and renal failure. It was not re-started as he
remained normotensive without it.
# BPH: Tamsulosin was continued.
.
He is DNR, but he and his family are comfortable with
intubation.
.
Medications on Admission:
lisinopril 2.5 mg daily
Nystatin creme
tamsulosin 0.4 mg QHS
warfarin
vitamin D 1000 units daily
colace 100 mg daily
senna 8.6 mg QHS
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
4. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
6. enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous
Q 24H (Every 24 Hours).
Disp:*4 syringes* Refills:*0*
7. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
8. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 7 days.
Disp:*14 Capsule(s)* Refills:*0*
9. Outpatient Lab Work
Please check INR on Monday [**3-30**] and fax to the office of Dr.
[**Last Name (STitle) **] at fax ([**Telephone/Fax (1) 39173**], tel ([**Telephone/Fax (1) 6846**].
Discharge Disposition:
Extended Care
Facility:
[**Street Address(1) 19127**] at [**First Name4 (NamePattern1) 3340**] [**Last Name (NamePattern1) 19128**] - [**Location (un) 583**]
Discharge Diagnosis:
Acute Respiratory Failure
Cellulitis
Chronic LE DVTs
Hypertension
BPH w/ urinary obstruction
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 9449**],
You were brought to the hospital with acute respiratory failure
which required ICU-level support. You improved very quickly
with the initiation of antibiotics and supplemental oxygen was
weaned over 2 days. A CXR did not demonstrate pneumonia. The
cause of your initial decompensation remains somewhat unclear:
it is possible that you had a pulmonary embolism as you had
paused coumadin, but this seems unlikely given the speed at
which you recovered. More likely, this was all due to the
severe infection (cellulitis) in your leg and high fevers.
You received antibiotics while you were in the hospital and will
need to continue oral antibiotics for one week following
discharge: you have received prescriptions for keflex and
doxycycline.
You will be prescribed lovenox injections until your INR is
therapeutic. You will have your INR checked on Monday by the VNA
and faxed to your PCPs office. You will receive instructions
from the VNA and your PCPs office regarding the duration of
lovenox.
You should hold lisinopril as we have not given it to you in the
hospital and your blood pressure has been within a reasonable
range.
Followup Instructions:
WE HAVE SCHEDULED AN APPOINTMENT WITH YOUR PCP FOR YOU.
Department: GERONTOLOGY
When: WEDNESDAY [**2144-4-1**] at 12:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
PREVIOUSLY SCHEDULE APPOINTMENT
Department: PODIATRY
When: THURSDAY [**2144-4-2**] at 1:40 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
Completed by:[**2144-3-29**]
ICD9 Codes: 0389, 5849, 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8674
} | Medical Text: Admission Date: [**2148-7-3**] Discharge Date: [**2148-7-8**]
Date of Birth: [**2077-5-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides) / Tegretol / Ciprofloxacin
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Right middle lobe nodule
Major Surgical or Invasive Procedure:
[**2148-7-3**] Right middle lobe video-assisted lobectomy.
History of Present Illness:
70 yo F with RML nodule (10 mm) that has slightly grown from 8
mm (seen in retrospect on an abdominal CT in [**4-12**]). Significant
history of asthma and shortness of breath that caused a
hospitalization a couple of weeks prior to visit which resulted
in a chest xray on which the nodule was noted. CT scan was done
that confirmed its presence. Patient is P.E.T. negative despite
history of adrenal nodule. Patient denies any new onset symptoms
though she still has shortness of breath and occasional
productive cough. No fevers, chills, weight loss of malaise.
Past Medical History:
HTN
hypercholesterolemia
panic attacks/anxiety
seasonal allergies
?asthma
chronic back pain
Social History:
distant smoking history, social alcohol [**12-8**] x per week, no
drugs. Lives in [**Location (un) **] [**Hospital3 **].
Family History:
Son w/depression.
No history of lung cancer.
Physical Exam:
Gen: GEN
CV: RRR, nl S1/S2
Resp: Wheezing with mild rhonchi bilaterally
Abd: soft, nt/nd
Ext: wwp, no edema
Neuro: nonfocal
Pertinent Results:
[**2148-7-4**] 05:15AM BLOOD WBC-8.0# RBC-3.51* Hgb-10.4* Hct-33.2*
MCV-94 MCH-29.7 MCHC-31.5 RDW-12.9 Plt Ct-241
[**2148-7-5**] 06:18AM BLOOD Glucose-89 UreaN-15 Creat-0.8 Na-123*
K-4.1 Cl-91* HCO3-25 AnGap-11
[**2148-7-5**] 06:18AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.5
CXR ([**2148-7-4**]): There is no evident pneumothorax. Extensive
subcutaneous emphysema of the right chest wall extending to the
neck is unchanged. There is worsening in volume loss on the
right lung with elevation of the right hemidiaphragm. Right
lower lung opacity is unchanged. Left lower lobe linear
atelectasis and small pleural effusion are stable. Right chest
tubes remain in place. The cardiomediastinum is slightly
deviated towards the right side.
CXR ([**2148-7-5**]): 1. Minimal improvement of extensive right-sided
subcutaneous emphysema.
2. Persistent right lower lobe atelectasis with associated small
pleural
effusion.
Brief Hospital Course:
Ms. [**Known lastname 98723**] had a video-assisted thoracoscopic right middle
lobectomy on [**2148-7-3**] under GETA without complications. She was
transfered to the floor with two chest tubes in the right chest
on suction. Her pain was initially controlled with a dilaudid
PCA then changed ultimately to tramadol with IV dilaudid for
breakthrough pain. Her pain was well controlled. On the floor
she did have subcutaneous air on the right chest that slowly
decreased during her hospital stay. The chest tubes were removed
on [**7-6**]. On [**7-6**] Ms. [**Known lastname 98723**] developed marked hyponatremia to 117
and was transfered to the ICU for monitoring. A renal consult
was obtained and they believed her hyponatremia was secondary to
stress response resulting in SIADH. Her hyponatremia resolved on
[**7-7**] with hypertonic saline and free water restriction. On [**7-7**]
she was transfered to the floor without issue. The patient was
discharged to _________ on 8/____ in stable condition.
Medications on Admission:
Tylenol-Codeine #3 300 mg-30'''' prn, Albuterol 90
(1-2 puffs)'' prn, Carvedilol 6.25', Diazepam 2''' prn,
Fluticasone 110 (2 puffs)'', Gabapentin 600', Meclizine 12.5''
prn, Prednisone taper, Simvastatin 20', Timolol (1 drop both
eyes [**Hospital1 **]), Diovan 160'
Discharge Medications:
Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours)
as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center
Discharge Diagnosis:
Right middle lobe nodule
Discharge Condition:
Vital signs stable. Pain well controlled.
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] [**Telephone/Fax (1) 4741**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Chest pain
-Incision develops drainage
-Chest tube site may drain fluid, so cover with a clean dressing
and change as needed to keep site clean and dry
-You may shower today. No tub bathing for swimming for 6 weeks
-No driving while taking narcotics
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] NPs [**7-16**] at 1:30pm in the [**Hospital Ward Name 121**]
Building Chest Diease Center [**Hospital1 **] I
Report to the [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiology
For a Chest X-Ray 45 minutes before your appointment
Follow-up with Dr. [**Last Name (STitle) 141**] your PCP
Completed by:[**2148-7-8**]
ICD9 Codes: 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8675
} | Medical Text: Admission Date: [**2101-4-27**] Discharge Date: [**2101-5-1**]
Date of Birth: [**2047-7-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 20473**] is a 53 year old gentleman with a PMH significant
for EtOH abuse admitted for hypotension and hypoxemia. The
patient is homeless and was found unresponsive by the police
with a vodka bottle in his hand. Per the patient, he does not
recall the events surrounding the event, but states that his
happens frequently since he "drinks a lot."
.
In the [**Hospital1 18**] ED, VS 97.7 88 86/? 20 88%RA -> 90% 4L nc ->
98%NRB. He received 3L IVF, including bananna bag, with
improvement in SBP to 100-110s. A CXR demonstrated possible
infiltrates and he was treated with ceftriaxone and
levofloxacin. While in the ED, the patient had a transient
episode of possible Torsades with a serum magnesium of 1.1 which
was repleted with 2gm IV. He was then transferred to the MICU
for further management.
.
Currently, the patient is resting comfortably without
complaints. Denies CP/SOB, f/c/s, n/v/d, abd pain, HA,
palpitations, constipation.
Past Medical History:
HTN
Crack cocaine and EtOH abuse
Hx of stab wound to abdomen with abdominal exploration
Hx of ankle fracture s/p ORIF
long-standing scrotal swelling, hydrocele vs spermatocele
Hematocele extraction [**2100-3-8**]
repeat scrotal exploration for fever [**2100-3-15**]
inguinal hernia repair
humerus fracture
Social History:
Homeless
Tob: occ cigarette, 1cig QD
EtOH: relates drinking 2 pints/day, has been drinking since he
was 13
Illicits: smokes crack cocaine currently, also history of
distant IVDU
Family History:
Brother with Diabetes
Father's side with hx of EtOH abuse
Physical Exam:
Vitals: afebrile, satting well on room air. elevated BP
General: Intoxicated
HEENT: Perrl, eomi, sclera anicteric, MMM, Poor dentition
Neck: supple, JVP flat. Acanthosis nigricans.
Lungs: Transmitted upper airway sounds. Mild rales at the bases
bilaterally.
CV: Distant heart sounds. Nl S1+S2.
Abdomen: S/NT/ND, +bs
GU: Scrotal edema, small superficial erosions.
Ext: 2+ pitting edema bilaterally. Bilateral skin breakdown over
feet.
Pertinent Results:
[**2101-4-27**] 02:40PM BLOOD WBC-3.8* RBC-3.63* Hgb-11.2* Hct-33.9*
MCV-94 MCH-30.9 MCHC-33.0 RDW-14.7 Plt Ct-131*#
[**2101-5-1**] 10:00AM BLOOD WBC-4.1 RBC-4.02* Hgb-12.5* Hct-37.5*
MCV-93 MCH-31.0 MCHC-33.3 RDW-14.4 Plt Ct-178
[**2101-4-27**] 02:40PM BLOOD Glucose-102 UreaN-17 Creat-1.4* Na-140
K-3.2* Cl-96 HCO3-26 AnGap-21*
[**2101-5-1**] 10:00AM BLOOD Glucose-140* UreaN-14 Creat-0.6 Na-138
K-3.8 Cl-100 HCO3-27 AnGap-15
[**2101-4-27**] 10:06PM BLOOD ALT-11 AST-39 LD(LDH)-283* CK(CPK)-326*
AlkPhos-106 TotBili-0.3
[**2101-4-28**] 03:16AM BLOOD CK(CPK)-322*
[**2101-4-27**] 02:40PM BLOOD Calcium-7.8* Phos-4.4 Mg-1.1*
[**2101-5-1**] 10:00AM BLOOD Calcium-8.4 Phos-4.0 Mg-1.4*
[**2101-4-28**] 03:16AM BLOOD %HbA1c-5.9
[**2101-4-27**] 02:40PM BLOOD ASA-NEG Ethanol-370* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2101-4-27**] 03:22PM BLOOD Lactate-2.2*
[**2101-4-27**] 11:16PM BLOOD Lactate-1.9
ECG:
Normal sinus rhythm, rate 86. Low voltage in the standard leads.
Compared to the previous tracing of [**2100-11-20**] no significant
change.
CXR:
IMPRESSION: Nodular opacity at the left base may represent
aspiration or
focal pneumonia, but a neoplastic process cannot be excluded.
Short interval radiographic followup is recommended to ensure
resolution. If nodular opacity persists, CT would be recommended
for further evaluation.
RUQ U/S:
IMPRESSION:
1. Fatty infiltration of the liver. Other forms of liver disease
and more
advanced liver disease including significant hepatic
fibrosis/cirrhosis cannot be excluded on this study. No focal
liver lesion identified.
2. No ascites identified.
Brief Hospital Course:
Mr. [**Known lastname 20473**] is a 53 year old gentleman with a PMH significant
for EtOH abuse admitted for hypotension and hypoxemia after
being found unresponsive.
.
# Hypoxemia: Likely secondary to aspiration pneumonia versus
pneumonitis. Improved with supplemental O2. Received
ceftriaxone, levaquin x 1 in ED. Initially covered with
Amp/sulbactam for aspiration pna coverage
.
# EtOH: Utox and Serum tox negative. Given valium for CIWA scale
>10. Given thiamine and folate. Seen by social work.
Unfortunately patient signed out AMA.
.
# BP: Trend hypotension. Likely secondary to intravascular
volume depletion resolved with IVF. Lactate improved with
fluids.
.
# Acute renal failure: Baseline Cr 0.8-1. On admission
creatinine 1.4. Resolved with fluids.
.
# Acid-base balance: Patient with anion gap of 18. Likely
secondary to EtOH intoxication. Resolved with fluids.
.
# Scrotal and peri-anal maggots: Patient has some minor
peri-anal and scrotal skin breakdown, but no signs of gangrene.
Patient may be diabetic given acanthosis nigricans on exam and
body habitus. HbA1c normal. Wound consult obtained. After
cleaning the wounds there were no large open wounds and no more
maggots were found.
.
# Hypomagnesemia: Mg 1.1 in ED. Per report, patient had
transient episode of Torsades on telemetry while hemodynamically
stable although question if artifact. Mg repleted. No repeat
episodes.
.
# Nodular opacity: Repeat CXR during admission to assess for
interval change. If persistent would consider non-contrast CT
chest to further evaluate given concern for potential
malignancy. Was unable to follow up as inpatient, will need
outpatient follow up.
Mr. [**Known lastname 20473**] left AMA on [**2101-5-1**].
Medications on Admission:
None
Discharge Medications:
Patient signed out AMA
Discharge Disposition:
Home
Discharge Diagnosis:
AMA
Discharge Condition:
AMA
Discharge Instructions:
AMA
Followup Instructions:
AMA
ICD9 Codes: 5070, 5849, 2875, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8676
} | Medical Text: Admission Date: [**2162-3-2**] Discharge Date: [**2162-3-7**]
Date of Birth: [**2096-12-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary Artery Bypass x5 [**2162-3-2**]
History of Present Illness:
This 65 year old male has had a 6month history of exertional
chest pain and shortness of breath. He had a +ETT on [**2162-2-26**] and
had a stress echo on [**2162-3-1**] which revealed diffuse 1-[**Street Address(2) 1766**]
depressions during recovery with
diffuse T wave inversions consistent with ischemia. He
underwent cardiac cath at [**Hospital **] Hospital which revealed a
tight LM stenosis, an ostial D1 stenosis, ostial LCX stenosis,
and the RCA is nondominant. He was transferred for for CABG.
Past Medical History:
Hypertension
GERD
Social History:
Lives with: wife
Occupation: Jet Blue flight attendant
Tobacco: never
ETOH: rare
Family History:
Unremarkable
Physical Exam:
Pulse: 55 Resp: 22 O2 sat: 98% on RA
B/P Right: 136/83 Left:
Height: Weight:
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
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: no Left: no
Pertinent Results:
[**2162-3-3**] Echo:
Prebypass
There is a PFO with left to right shunt. There is mild regional
left ventricular systolic dysfunction with hypokinesia of the
apex, apical and mid portions of the anterior septum. Overall
left ventricular systolic function is mildly depressed (LVEF= 45
%). Right ventricular chamber size and free wall motion are
normal. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results on [**2162-3-3**] at
1445 hrs.
Poor transgastric views
Post bypass
Patient is A paced and receiving an infusion of phenylephrine.
LVEF= 45%. Mild mitral regurgitation persists. Aorta is intact
post decannulation.
Poor transgastric views.
[**2162-3-6**] CXR: FINDINGS: The right IJ sheath has been removed.
There is no pneumothorax. Lung volumes are low. There is patchy
increased opacity at both bases, left greater than right that
could represent volume loss or early infiltrate. There are small
bilateral pleural effusions seen best on the lateral film
[**2162-3-2**] 07:15PM BLOOD WBC-10.2 RBC-4.64 Hgb-13.9* Hct-40.8
MCV-88 MCH-30.0 MCHC-34.1 RDW-13.3 Plt Ct-196
[**2162-3-6**] 06:20AM BLOOD WBC-12.4* RBC-3.66* Hgb-11.4* Hct-32.3*
MCV-88 MCH-31.2 MCHC-35.3* RDW-13.1 Plt Ct-130*
[**2162-3-2**] 07:15PM BLOOD PT-12.8 PTT-22.5 INR(PT)-1.1
[**2162-3-2**] 07:15PM BLOOD Plt Ct-196
[**2162-3-3**] 07:21PM BLOOD PT-14.3* PTT-32.6 INR(PT)-1.2*
[**2162-3-6**] 06:20AM BLOOD Plt Ct-130*
[**2162-3-2**] 07:15PM BLOOD Glucose-107* UreaN-19 Creat-1.2 Na-139
K-4.1 Cl-105 HCO3-24 AnGap-14
[**2162-3-5**] 04:25AM BLOOD Glucose-108* UreaN-15 Creat-1.1 Na-136
K-3.8 Cl-102 HCO3-25 AnGap-13
[**2162-3-2**] 07:15PM BLOOD %HbA1c-5.9 eAG-123
Brief Hospital Course:
The patient was brought to the operating room on [**2162-3-3**] where
the patient underwent coronary artery bypass x 5 (LIMA->LAD,
RSVG->[**Last Name (LF) **], [**First Name3 (LF) **]). Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 4 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged [**2162-3-7**] in good condition with
appropriate follow up instructions.
Medications on Admission:
ASA 81 mg PO daily
Atenolol 25 mg PO daily
Prilosec PRN
Discharge Medications:
1. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 5 days.
Disp:*10 Tablet, ER Particles/Crystals(s)* Refills:*0*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain for 10 days.
Disp:*75 Tablet(s)* Refills:*0*
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease
Hypertension
GERD
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr.[**Last Name (STitle) **] [**4-1**] 1:00p [**Telephone/Fax (1) 170**]
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**3-26**] 3:00p
Wound Check on [**Hospital Ward Name 121**] 6 Tues [**3-16**] OR Wed [**3-17**] @10am
Please call to schedule the following:
Primary Care Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**4-27**] 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:[**2162-3-7**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8677
} | Medical Text: Admission Date: [**2196-5-10**] Discharge Date: [**2196-5-18**]
Date of Birth: [**2133-10-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Nortriptyline
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
Increasing shortness of breath, found to have Left hemothorax
Major Surgical or Invasive Procedure:
Left thoractomy & decortication for fibrothorax
History of Present Illness:
62 male esrd [**2-10**] dm s/p crt [**9-8**] w/ baseline creatinine of 2.0,
s/p L thoractomy and decort for fibrothorax on [**5-12**]; transferred
from [**Hospital3 **] for recurrent hemothorax. Pt was admitted
[**2196-4-20**] for increasing dyspnea,s/p fall and found to have L
hemothorax and underwent thoracentesis w/ removal of 300cc blood
fluid. Patient discharged, then readmitted [**2196-4-29**] for
increasing dyspnea. Left CT placed, w/ 400-500 cc bloody fluid.
CT removed after 72 hours w/ oozing from CT site. CT scan
showed recurrent homothorax w/ possible empyema. Pt then became
'septic' and transferred to [**Hospital1 18**] for further care. INR >5.0 on
admission. Post-op oliguric atn with hyperkalemia now resolving.
Past Medical History:
s/p CRT [**9-8**], CAD,s/p CABG '[**94**], severe PVD (necesitating
anti-coagulation), Hypertension, gout, hyperlipidemia
Social History:
lives w/ wife in [**Name (NI) 26469**] RI, very supportive family.
Physical Exam:
General-NAD
HEENT-PERRLA, anicteric
REsp- Clear, crackles @ left base, Left thoracotomy incision
CV- RRR, no murmer, pulses intact, + CSM.
ABD- + BS x4, NT, ND.
Ext-+ pulses, well healed scars @ RLE, LLE; feet warm
Neuro- A&O x3, very cooperative and pleasant
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2196-5-15**] 04:45AM 7.7 3.15* 9.2* 27.5* 87 29.3 33.6 15.3
267
RCL
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2196-5-15**] 04:45AM 267
RCL
[**2196-5-15**] 04:45AM 15.0*1 26.4 1.5
RCL
1 NOTE NEW NORMAL RANGE AS OF 12 AM [**2196-5-7**]
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2196-5-15**] 04:45AM 116* 68* 1.5* 146* 4.4 114* 25 11
RCL
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2196-5-12**] 11:06AM 235*
[**2196-5-12**] 04:31AM 157
OTHER ENZYMES & BILIRUBINS Lipase
[**2196-5-11**] 12:01AM 17
CPK ISOENZYMES CK-MB cTropnT
[**2196-5-12**] 11:06AM 3 0.02*1
1 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
[**2196-5-12**] 04:31AM 3 <0.011
1 <0.01
RADIOLOGY Final Report
ART DUP EXT LO UNI;F/U [**2196-5-17**] 8:45 AM
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with Fem BK [**Doctor Last Name **] on R
REASON FOR THIS EXAMINATION:
please do graft surveillance of RLE
HISTORY: Graft surveillance for a fem below-the-knee popliteal
bypass on the right.
FINDINGS:
No prior studies at this institution for comparison. The peak
systolic velocity within native right common femoral artery is
161 cm per second and at the proximal graft anastomosis with
this vessel is 73 cm per second. Graft velocities range from a
minimum of 25 to a maximum of 62 cm per second. At the distal
graft anastomosis, the peak systolic velocity is 76 cm per
second and that within the native distal vessel is 94 cm per
second.
IMPRESSION:
Widely patent right fem-to-tibial bypass graft.
RADIOLOGY Preliminary Report
CHEST (PA & LAT) [**2196-5-17**] 9:18 AM
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with L thoractomy -chest tubes to water seal
REASON FOR THIS EXAMINATION:
assess hemothorax
INDICATION: Status post thoracotomy and removal of chest tube,
assess for pneumothorax.
PA AND LATERAL RADIOGRAPH. Comparison is made to one day
earlier.
FINDINGS: Two right-sided chest tubes have been removed. There
is a persistent loculated hydropneumothorax at the left apex,
which is unchanged from the prior studies. Skin staples are seen
overlying the left side of the chest. Patchy opacification is
again identified at the left lung base, which is stable in
appearance. The right lung remains essentially clear.
IMPRESSION:
Interval removal of left-sided chest tubes. No significant
change in appearance of loculated hydropneumothorax in the left
upper lobe.
Brief Hospital Course:
Pt admitted [**2196-5-10**] from [**Hospital **] Hospital for recurrent hemothorax
vs. empyema despite placement of chest tubes x2 and CT scan
showing recurrent fluid. Pt on anticoagulation for PMHx of PVD,
CRT ([**9-8**]).
Transplant nephrology, vascular surgery, and [**Hospital **] clinic were
consulted.
Patient underwent Left thoracotomy [**2196-5-12**], fibrosis consolidated
effusion, total Lung decortication, VATS. Findings> pleural
effusion consolidated into pockets of solid vs gelatinous
consistancy in L lung field. Thickened parietal pleura. 3 left
chest tubes in place to sx. Pt transferred to SICU post-op,
intubated, sedated, pain control w/ Fentanyl gtt, Insulin gtt;
on levoquin, flagyl and vancomycin for coverage; transfused w/
2u PRBC for hct 24, ^32 post transfusion; TF nepro started.
POD#1- Pt weaned and extubated at 11am w/ + gag, good sats
5lNC. Pain control w/ fentanyl patch w/ fentanyl gtt weaned to
off, no c/o of pain; OOB to chair; clear liqs tol well; I/O
adquate; Insulin gtt d/c @ dinner w/ NPH/Sliding scale; po meds
restarted.
POD#2 D/C to floor, BS decreased at left base, CT to sx ser/sang
fluid continues, no air leak, no crepitus, 4lNC, IS; tolerating
po intake, BSx4po pain medication; activity advanced as
tolerated/IS. Renal and [**Last Name (un) **] consults cont to follow, recs
appreciated.
POD#[**3-11**] Pt continues to improve, CT remain to sx; Flagyl, levo
and vanco cont; RISS cont w/NPH [**Hospital1 **]. Pain control w/ Fentanyl
patch and percocet po.
POD#5-CT placed to water seal, then d/c later in day w/o
complication. Thoracotomy dsg D&I, CT dsg site smal amt sang
drainage, dsg change prn. Episode of BS of 60, treated w/ OJ +
sugarx2. F/U bs 105, then dinner taken.Ambulatory. Pain control
cont as above
POD#6-BS crackles LUL, diminished LLL, IS cont to be encouraged
and done. RLE Graft surveillance done= patent. Pt to be d/c on
ASA 81 mg and plavix 75 mg qd; Po intake tolerated well. L
thoracotomy site D&I, CT site bruising/eccymosis present.
Ambulatiing ad lib.
POD#7- NO events overnight. Pt stable for d/c to home in company
of wife. Antibiotics changed to Dicloxacillin 500po qid x14
days. Patient will f/u w/ [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD, [**Location (un) **], MA.
Medications on Admission:
doxazosin, coumadin, prograf, prednisone, norvasc, synthroid,
labetolol, alprazolam, temazepam, neurontin, sulfamethoxazole,
lasix, liitor, zetia, primidone, clonidine, AASA, MVI, SSI,
allopurinol
Discharge Medications:
1. Doxazosin Mesylate 4 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
2. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
Disp:*120 Capsule(s)* Refills:*0*
3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Labetalol HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*0*
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) as needed. Tablet(s)
10. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Primidone 250 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Clonidine HCl 0.2 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Magnesium Citrate 1.745 g/30mL Solution Sig: One Hundred
Fifty (150) ML PO QHS (once a day (at bedtime)) as needed.
16. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
17. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
18. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
19. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*2*
20. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
21. Dicloxacillin Sodium 500 mg Capsule Sig: One (1) Capsule PO
four times a day for 14 days.
Disp:*56 Capsule(s)* Refills:*0*
22. medication
Insulin- NPH
Per previous regimen
23. medication
Insulin- Humalog
Per previous regimen
24. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO
twice a day.
Disp:*300 ML(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Left thoractomy & decortication for fibrothorax, recurrent
hemothorax
PMH: Cadaver Renal Transplant [**9-8**], Coronary Aartery Disease,
severe Peripheral Vascular Disease (necesitating
anti-coagulation), Hypertension, gout, hyperlipidemia
Discharge Condition:
good
Discharge Instructions:
Call Dr[**Last Name (STitle) 61679**] office ([**Telephone/Fax (1) 61680**] for: fever, chest pain,
shortness of breath, increased reddness or discharge from
incision site.
REsume all medications as previous to hospitalization.
TAke new medications as directed.
[**Month (only) 116**] shower in [**1-10**] days. No tub baths for 3-4 weeks.
Followup Instructions:
Call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office for appointment in [**1-10**] weeks-
[**Telephone/Fax (5) 61681**] [**Location (un) **] Dr, [**Location (un) 8973**], [**Numeric Identifier 17178**]
Completed by:[**2196-5-18**]
ICD9 Codes: 5845, 2767, 4439, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8678
} | Medical Text: Admission Date: [**2131-10-3**] Discharge Date: [**2131-10-12**]
Date of Birth: [**2065-10-3**] Sex: M
Service: MEDICINE
Allergies:
Atenolol / Ms Contin
Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
1. Was intubated while in ICU for worsening respiratory
distress
History of Present Illness:
This is a 65 y.o male with history of COPD, AAA, HTN who
presented to his PCP's office with 4 day history of dyspnea with
appearance of purse lipped breathing and tiring and an O2 Sat of
91%. He was sent from his PCP's office emergenty to the ED.
.
In the ED, initial V/S: T 97.9 P 86 BP 130/83 R 24 O2 sat. 100%
on non-rebreather. Patient was given azithromycin, ipratropium
and albuterol nebulizers and 125mg solu-medrol IV x 1. He was
transferred to the floor for further management.
.
Patient was admitted last night and was placed on Solumedrol
125mg q8h, Azithromycin 500mg PO daily, Albuterol and
Ipratropium nebs with minimal improvement today. Patient
continues with tachypnea. ABG done this afternoon 7.38/48/86.
Lactate was 3.4 so MICU was consulted for evaluation given
concern for need for BIPAP. Recommendation was for transfer to
ICU.
.
Currently, patient c/o +SOB but improved from this morning, +dry
cough x 5 days, +SOB x 5 day. Denies any recent fevers, chills,
myalgias, chest pain, nausea, vomiting, diarrhea or abdominal
pain.
.
Past Medical History:
COPD, admission to [**Hospital1 2177**] with COPD exacerbation last winter.
AAA
HTN
Hyperlipidemia
Gout
Osteoporosis, history of L1 burst fracture on chronic opioids
for pain relief, l3 compresion fracture
Social History:
History of EtOH abuse with beer, no history of illicit drug use.
Long history of smoking >40 years of 2 ppd, currently smoking
[**11-24**] pack per day. Lives by himself, is on disability.
Family History:
No history of CAD. Otherwise non-contributory.
Physical Exam:
Vitals: T: 96.7 BP: 133/98 P: 98 R: 27 O2: 97%
General: Mild Distress, cachectic, AAOx3
HEENT: cry MM, oropharynx clear
Neck: supple, no LAD
Lungs: +pursed lip breathin, +minimal expiratory wheezing
throughout, prolonged expiratory phase, poor inspiratory effort
CVS: +S1/S2, no M/R/G, RRR
ABD: soft, +BS, NT/ND, no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rashes
Pertinent Results:
CXR [**2131-10-4**]:
FINDINGS: In comparison with the study of [**10-3**], there is no
interval change. Again there is extensive evidence of chronic
pulmonary disease with calcification in the area of the carotid
bifurcations and upper lung fibrosis with upward retraction of
the hila consistent with old granulomatous disease. No evidence
of acute focal pneumonia.
.
[**2131-10-3**] 10:35AM BLOOD WBC-4.8# RBC-5.56 Hgb-16.8 Hct-50.2
MCV-90 MCH-30.2 MCHC-33.4 RDW-14.3 Plt Ct-161
[**2131-10-5**] 04:30AM BLOOD WBC-10.6# RBC-4.94 Hgb-15.3 Hct-43.9
MCV-89 MCH-31.0 MCHC-34.9 RDW-14.2 Plt Ct-198
[**2131-10-4**] 06:30AM BLOOD Neuts-78* Bands-3 Lymphs-15* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2131-10-3**] 10:35AM BLOOD Glucose-92 UreaN-14 Creat-0.9 Na-137
K-4.6 Cl-98 HCO3-24 AnGap-20
[**2131-10-4**] 06:30AM BLOOD Albumin-3.3* Calcium-9.1 Phos-1.3* Mg-1.9
[**2131-10-3**] 04:13PM BLOOD Type-ART pO2-108* pCO2-45 pH-7.32*
calTCO2-24 Base XS--3
[**2131-10-5**] 12:26AM BLOOD Type-ART pO2-92 pCO2-48* pH-7.40
calTCO2-31* Base XS-3
[**2131-10-5**] 12:26AM BLOOD Lactate-1.8
.
Respiratory Culture:
RESPIRATORY CULTURE (Final [**2131-10-10**]):
RARE GROWTH Commensal Respiratory Flora.
STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.
Note: For treatment of meningitis, penicillin G MIC
breakpoints
are <=0.06 ug/ml (S) and >=0.12 ug/ml (R).
Note: For treatment of meningitis, ceftriaxone MIC
breakpoints are
<=0.5 ug/ml (S), 1.0 ug/ml (I), and >=2.0 ug/ml (R).
For treatment with oral penicillin, the MIC break
points are
<=0.06 ug/ml (S), 0.12-1.0 (I) and >=2 ug/ml (R).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
CEFTRIAXONE-----------<=0.06 S
ERYTHROMYCIN---------- =>1 R
LEVOFLOXACIN---------- 1 S
PENICILLIN G---------- 0.25 S
TETRACYCLINE---------- =>16 R
TRIMETHOPRIM/SULFA---- 1 I
VANCOMYCIN------------ <=1 S
.
Chest X-ray: REASON FOR EXAMINATION: Followup of the patient
with respiratory failure. ([**10-8**])
Portable AP chest radiograph was compared to [**2131-10-7**].
There are bibasal opacities, new bibasal opacities compared to
the chest
radiograph from [**10-6**]. The evaluation of the chest CT from
[**2131-10-6**] demonstrate already present minimal opacities
in the lower lobes compatible with multifocal pneumonia that
appears to be worsening on chest radiograph, consistent with
progression of the disease.
.
CTA Chest:
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Stable appearance of the AAA, incompletely assessed in the
current study.
3. Multifocal patchy opacities in the lower lobes, compatible
multifocal
pneumonia.
Brief Hospital Course:
1. COPD Excaerbation: Mr [**Known lastname 13621**] was admitted with worsening
respiratory distress suggestive of COPD flare. He was
transferred from the floor to the ICU for worsening
desaturations which required intubation. While in the ICU, he
was started on 125 mg IV solumedrol q8 daily for X 4 days. He
was given ipratropium and albuterol nebulizers, and was started
on azithromycin. While in the ICU, a CTA was done to rule out
pulmonary embolism, which was negative. The CTA did reveal,
however, a superimposed multifocal pneumonia. He was initially
started on broad spectrum antibiotic coverage with vancomycin
and cefepime, but this coverage was narrowed once his sputum
grew out strep pneumococcus sensitive to levoquin. He was
started on a levoquin course which he should continue for a
total of a 9 day course (can be stopped after [**10-15**]). He
self-extubated in the ICU and thereafter had saturations between
95 - 100% on 3 L NC. He was then transferred to the floor where
he was weaned down to room air with continued saturations
between 95 - 100%. He was able to ambulate on room air without
desaturations. He was discharged home with services, with a
plan to continue inhaled steroids and long acting B agonist
(advair) and tiotropium daily, with albuterol nebs as necessary.
He was instructed to finish his steroid taper (got 4 days of IV
steroids, then 4 days of 60 mg of prednisone in the hospital.
At home, he will finish 3 days of 40 mg, and 3 days of 20 mg).
He will also finish 3 additional days of levaquin to finish a 9
day course. He was set up for follow up appointments with a
[**Hospital 1944**] clinic and pulmonary (Dr [**Last Name (STitle) **]. The
importance of compliance to both his medications and keeping his
appointments was emphasized.
.
2. Hyperlipidemia - was continued on lipitor
.
3. Gout - continued on allopurinol.
.
4. Osteoporosis - Continue vitamin D
.
5. Abdominal aortic aneurysm - Stable
.
6. Chronic back pain - continue percosets 1-2 tabs q8 as
necessary for pain
.
7. Disposition - To home with services; they will help instruct
him on use of nebulizers and inhaled steroids as above.
.
8. Hypophosphatemia - Found to be substantially hypophosphatemic
during this hospitalization and required phosphate repletion. He
will follow up in post discharge clinic for electrolyte check.
Medications on Admission:
Albuterol inh prn
tiotropium 18mcg daily
Risedronate [Actonel] 35 mg Tablet qweek
percocet 1-2 tabs qid prn pain
allopurinol 300mg [**Hospital1 **]
Ergocalciferol (Vitamin D2) [Vitamin D] 800mg daily
atorvastatin 10mg daily
Discharge Medications:
1. Nebulizer
Home Nebulizer.
2. Risedronate 35 mg Tablet Sig: One (1) Tablet PO once a week.
3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
4. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Vitamin D 400 unit Capsule Sig: Two (2) Capsule PO once a
day.
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day:
Continue until [**2131-10-15**].
Disp:*3 Tablet(s)* Refills:*0*
8. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day:
Take 40 mg on [**10-13**] and another 40 mg on [**10-14**]. .
Disp:*2 Tablet(s)* Refills:*0*
9. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day:
take 20 mg on [**11-25**], and [**10-17**].
Disp:*3 Tablet(s)* Refills:*0*
10. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
Disp:*1 1* Refills:*2*
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
Disp:*1 1* Refills:*2*
12. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization
Sig: [**11-24**] Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
Disp:*1 1* Refills:*0*
13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation once a day as needed for shortness of breath
or wheezing.
14. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*7 Patch 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1. COPD
2. Pneumonia
3. Hypertension
Discharge Condition:
Stable for home. Ambulating on room air. Saturations between
95 - 100% on room air.
Discharge Instructions:
You were admitted with worsening of your lung disease that we
call COPD (Chronic obstructive pulmonary disease). COPD can
cause you to feel short of breath and wheeze. When we admitted
you, we started you on steroid medications that help control the
disease. While you were hospitalized, we also found that you
had a pneumonia along with your COPD, which may have made it
particularly difficult for you to breathe. For these reasons,
you briefly required intensive care, requiring us to use a
breathing machine for a short term period. We started you on an
antibiotic to help treat your pneumonia. At the time of
discharge, your breathing had improved, and you were able to
breathe normally without us giving you additional oxygen.
.
It is really important that you continue to take inhaled
steroids daily through your inhaler as well as the albuterol and
Spiriva. Not taking these medications regularly can cause the
COPD to worsen. You should also continue to take your
antibiotics for another three days. These medication changes
are summarized below. You should be sure to follow up with both
your primary care doctor and a lung doctor. You have
appointments with both physicians set up below.
.
The medication changes we made during this admission are:
(1) You should take prednisone (a steroid) which helps treat
your COPD. You should take 2 pills (20 mg each) on [**10-13**] and
again on [**10-14**]. Thereafter, you should take 1 pill (20 mg) on
[**10-15**], another on [**10-16**], and the last one on [**10-17**]. After this,
you can stop taking the oral steroids.
(2) You should take inhaled steroids (Advair) 1 puff twice a
day. You should continue this medicine daily. This will help
keep your COPD controlled.
(3) You should take inhaled tiotropium daily. This will also
help your COPD.
(4) If you start to wheeze, you can use the albuterol nebulizer
as necessary. You do not need to take this daily, only as
needed when you feel short of breath or are wheezing. You can
also use the inhaler instead of the nebulizer.
(5) You should take levofloxacin (an antibiotic for your
pneumonia) for another 3 days (on [**12-24**], and [**10-15**]). You
can stop it after [**10-15**].
(6) You can continue to use your nicotine patch by applying one
patch daily. You should change this patch daily. Your primary
care doctor will help you adjust the dosage after you see him.
Stopping smoking will help control your COPD.
.
If you experience worsening shortness of breath or wheezing,
fevers, chills, worsening cough, or any other concerning
symptoms, please call your primary care doctor or return to the
emergency department.
Followup Instructions:
You have an appointment with Dr [**First Name (STitle) **] [**Name (STitle) **] at our Health Care
associated clinic on Monday, [**10-15**] at 8:50am. The clinic
is located at [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 895**], [**Location (un) 3387**], [**Location (un) 86**]
Phone number: [**Telephone/Fax (1) 250**]
Special instructions if applicable: This appointment is for
follow up to your hospitalization. You will then be connected
to your Primary Care provider after this visit.
.
You also have an appointment with a lung doctor, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]
on Monday, [**11-19**] at 4:00pm. This is located at [**Location (un) **], [**Hospital Ward Name 23**] Bldg [**Location (un) **], [**Location (un) 86**], MA. If you have
any questions or want to reschedule, please call ([**Telephone/Fax (1) 513**].
Please arrive to your appt at 3:40pm for pulmonary function
tests, which are a series of tests that help us figure out the
best treatment plan for you. You will then see Dr. [**Last Name (STitle) **] at
4:00pm
ICD9 Codes: 5990, 2749, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8679
} | Medical Text: Admission Date: [**2176-4-22**] Discharge Date: [**2176-4-27**]
Date of Birth: [**2118-8-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Coronary Artery Bypass x 3 (LIMA-LAD, SVG-OM, SVG-LPDA) [**2176-4-22**]
History of Present Illness:
57 year old male has a history of hypertension, hyperlipidemia
and insulin dependent diabetes. He has been fairly sedentary
over the past year and recently began to notice that he was
having dyspnea with activities that he previously could do
without problems, including climbing a flight of stairs or
walking up a slight incline. At times, this has been associated
with mild left sided chest discomfort. Recent stress echo
revealed ischemia c/w three vessel disease or LM disease. He was
referred for cardiac catheterization to further evaluate. He was
found to have multivessel disease and is now being referred to
cardiac surgery for revascularization.
Past Medical History:
Coronary Artery Disease
s/p Coronary artery Bypass x 3
PMH:
Hypertension
Hyperlipidemia
Insulin dependent diabetes
Hx of bladder cancer s/p laser surgery/cauterization
s/p Cholecystectomy
Umbilical hernia
Common bile duct stone s/p ERCP with sphincterotomy [**2175-3-20**]
Social History:
Lives with:Wife
Occupation:consultant for school systems
Tobacco:quit 27 years ago
ETOH: 1 drink per week
Family History:
Father had a stroke while having a cardiac
catheterization and CABG
Physical Exam:
Pulse:51 Resp:16 O2 sat: 99/Ra
B/P Right:162/77 Left:158/66
Height:5'6" Weight:212 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]
Extremities: Warm [x], well-perfused [] Edema Varicosities:
None
[x]
Neuro: Grossly intact[x]
Pulses:
Femoral Right: 1 Left:1
DP Right: 1 Left:1
PT [**Name (NI) 167**]: 1 Left:1
Radial Right: 1 Left:1
Carotid Bruit Right: - Left:-
Discharge
VS: 74-81 SR BP: 110-136/74 Sats: 98% RA Wt: 94.8 kg
General; 57 year-old male ambulating in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple, no lymphadenopathy
Card; RRR normal S1,S2 no murmur
Resp: decreased breath sounds on left 1/4 up otherwise clear
GI; bowel sounds positive, abdomen soft non-tender
Extr: warm no edema. DP's 2+
Incision: sternal and LLE incision c/d/i no erythema
Neuro: awake, alert oriented
Pertinent Results:
[**2176-4-26**] 04:23AM BLOOD WBC-12.1* RBC-3.87* Hgb-11.2* Hct-32.1*
MCV-83 MCH-29.0 MCHC-35.0 RDW-13.4 Plt Ct-216
[**2176-4-26**] 04:23AM BLOOD Glucose-160* UreaN-20 Creat-0.9 Na-138
K-3.9 Cl-101 HCO3-28 AnGap-13
[**2176-4-26**] 04:23AM BLOOD Mg-2.0
Intra-Op TEE [**2176-4-22**]
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is low normal (LVEF
50-55%). with mild global free wall hypokinesis. There are
simple atheroma in the descending thoracic aorta.
There is a minimally increased gradient (9mmHg) consistent with
minimal aortic valve stenosis. The left cusp is calcified and
hypomobile.
No aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. Trace mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is A-Paced and on no inotropes.
Preserved biventricular systolic fxn.
Trace MR, no AI. Aorta intact.
CXR
[**2176-4-26**]: IMPRESSION:
Interval progression of moderately large left pleural effusion
and left lower lobe atelectasis.
Brief Hospital Course:
The patient was brought to the operating room on [**2176-4-22**], where
the patient underwent CABG x 3 with Dr. [**Last Name (STitle) **]. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
[**Last Name (un) **] was consulted for assistance with diabetes management.
Blood glucose remained elevated, and he was briefly transferred
back to CVICU for IV insulin. When glucose came under control,
he was returned to the floor. Chest tubes and pacing wires were
discontinued without complication. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility.
By the time of discharge on POD 5 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to home in good
condition with appropriate follow up instructions.
Medications on Admission:
INSULIN DETEMIR [LEVEMIR] - (Prescribed by Other Provider) -
100
unit/mL Solution - 25 units twice a day
INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - 100
unit/mL Solution - sliding scale with meals (80-100 units per
day)
LISINOPRIL - (Prescribed by Other Provider) - 20 mg Tablet - 2
Tablet(s) by mouth every morning
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg
Tablet Extended Release 24 hr - 1 Tablet(s) by mouth every
morning
NITROGLYCERIN - (Prescribed by Other Provider) - 0.4 mg Tablet,
Sublingual - 1 Tablet(s) sublingually every five minutes for
chest discomfort. Call 911 if pain persists longer than 15
minutes
ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 20 mg
Tablet - 2 Tablet(s) by mouth every morning
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1
Tablet(s) by mouth once a day
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
6. Levemir 100 unit/mL Solution Sig: 25 units Subcutaneous
twice a day.
7. Humalog insulin sliding
Continue previous insulin sliding scale
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days:
take with lasix.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0*
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**4-24**]
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Coronary Artery Disease
s/p Coronary artery Bypass x 3
PMH:
Hypertension
Hyperlipidemia
Insulin dependent diabetes
Hx of bladder cancer s/p laser surgery/cauterization
s/p Cholecystectomy
Umbilical hernia
Common bile duct stone s/p ERCP with sphincterotomy [**2175-3-20**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Wound Check on [**Hospital Ward Name 121**] 6, [**2176-5-7**], 10am
Cardiac Surgery: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2176-5-16**] 1:00
Please call to schedule the following:
Cardiologist/PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**0-0-**]
**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:[**2176-4-27**]
ICD9 Codes: 5119, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8680
} | Medical Text: Admission Date: [**2185-11-13**] Discharge Date: [**2185-11-18**]
Date of Birth: [**2166-9-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
This is a 19 year-old Indian with no significant PMH but a
recent diagnosis of idiopathic dilated cardiomyopathy (EF 15%,
2D-Echo [**2185-11-15**]), presenting with acute-onset of shortness of
breath for 2-days.
.
Of note, the patient was recently admitted to the
[**Hospital1 1516**]-Cardiology service on [**2185-10-17**] when he presented with
palpitations, dyspnea, some URI symptoms, which was associated
with substernal chest pain, found to have evidence of volume
overload and peripheral edema consistent with decompensated
dilated cardiomyopathy. A 2D-Echo was performed and showed 3+
mitral regurgitation with an LVEF of 15-20%. He was started on a
Nitro gtt and aggressively diuresed, requiring a Lasix gtt with
conversion to PO Torsemide prior to discharge. His weight on
admission was 97 kg (dry weight estimated at 90 kg) and this
improved to 89.8 kg at discharge. In terms of cardiomyopathy
investigation - his HIV, Lyme antibody, CMV, EBV, hepatitis
serologies, TSH and [**Location (un) **] virus testing were all negative.
Of note, the patient has a strong family history of dilated
cardiomyopathy, with two uncles who expired in their 30s from
heart failure. Additions to his medication list at that time
included an ACEI, beta-blocker and spironolactone. He was also
loaded with Digoxin and was uptitrated to 375 mcg PO daily. He
was discharged on [**2185-10-26**]. The patient's 2D-Echo was repeated on
[**2185-10-31**] showed similar findings after initiation medical
therapies.
.
He now presented with shortness of breath while at his
rehabilitation facility the day prior to admission, [**2185-11-12**],
which was occurring at rest and worst with exertion. This was
associated with substernal chest pain that radiated to the right
scalp, worse with deep inspiration and relieved by leaning
forward. He has noted no unintentional weight gain, leg
swelling. He also denied fevers or chills, nausea, palpitations
and diaphoresis. He denies URI symptoms or productive cough or
abdominal pain.
.
In the ED, initial VS 98.1 105 137/79 15 100%RA. His exam was
notable for tachypnea, tachycardia, but no leg swelling or JVP
elevation. His WBC was 21.1 (N 82.9%, L 10.3%), pro-BNP 2968,
Troponin < 0.01. In the ED, his tachypnea progressed and he
required RSI (etomidate, succinylcholine) for airway protection
and increased work of breathing. Cardiology was consulted.
Cardiac U/S in the ED showed no evidence of pericardial
effusion, poor squeeze and a dilated left ventricle. CTA chest
showed small, LLL subsegmental pulmonary embolus with possible
right lung base PNA. Prior to transfer, VS 97.7 100 99/72 22
100% intubated (500/22/5/1.0).
.
In the MICU, patient was started on heparin gtt following bolus
for small, LLL subsegmental pulmonary embolus. They continued
Vancomycin, Cefepime and Levofloxacin for presumed
healthcare-associated pneumonia given CT findings of right lung
base consolidation. Cardiology recommended discontinuing
anti-hypertensives and continuing anticoagulation. He was
extubated on [**11-13**] and his heparin gtt was bridged to Coumadin
with some mild hemoptysis. He spiked a temperature to 101.5F,
developed tachycardia to the 120s and had a repeat 2D-Echo on
[**11-14**] showing right ventricular systolic function that was more
severely impaired when compared to the [**10-31**] study. He developed
intermittent abdominal pain with hyperbilirubinemia and a
moderate transaminitis concerning for cardiogenic hepatic
congestion. A RUQ ultrasound showed prominent hepatic veins,
mild distention of the gallbladder with mild wall thickening and
no gallstones. At this point, his outpatient Cardiologist, Dr.
[**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**], recommended transfer to the CCU for IV Lasix and
Milrinone therapy given his biventricular cardiac failure.
.
On arrival to CCU, has some nausea and on-going small volume
hemoptysis but he is without lightheadedness or dizziness. He
denies chest pain or trouble breathing.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, 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; see HPI for details.
.
Cardiac review of systems is notable for absence of chest pain.
It is notable for dyspnea on exertion, but no paroxysmal
nocturnal dyspnea. He did notes some orthopnea, but was without
ankle edema, palpitations, syncope or pre-syncope.
Past Medical History:
PAST MEDICAL HISTORY:
* CARDIAC RISK FACTORS: No dyslipidemia, hypertension or
diabetes
* CARDIAC HISTORY: Recently diagnosed with dilated
cardiomyopathy with 2D-Echo showing 3+ mitral regurgitation with
an LVEF of 15-20%
* CABG: None
* PERCUTANEOUS CORONARY INTERVENTIONS: None
* PACING/ICD: None
.
PAST MEDICAL & SURGICAL HISTORY:
1. Dilated cardiomyopathy (3+ mitral regurgitation with an LVEF
of 15-20%)
Social History:
Patient is a never-smoker. He notes drinking [**2-21**] alcoholic
beverages weekly, ocassionally up to 7-beers in one sitting (4
drinks on the Friday prior to presentation). Notes ocassional
marijuana use with no IVDU. He is student studying international
relations and economics; he has a girlfriend, and he is sexually
active with her monogamously. He denies history of SITs
(although never tested prior to presentation). Has traveled to
wooded areas within [**Location (un) 8447**], but does not recall ticks or
insect bites. Prior travel to both cities and rural areas of
[**Country 63412**], [**Country 11150**], [**Country 12602**]; was born in [**Country **], [**Country **], traveled to
the UK, UAE, and USA. Has not traveled to Latin or South
America.
Family History:
Mother's brother developed cardiomyopathy s/p and is cardiac
transplant. Father's brother died of cardiomyopathy around age
30 years; both of these cases were caused by an infectious
etiology. No other family history of heart disease, sudden
cardiac death, or dysrrhythmias.
Physical Exam:
PHYSICAL EXAM (on admission to CCU):
VITALS: 98.8 104 108/73 81 33 96%RA
GENERAL: Appears in no acute distress. Alert and interactive.
Robust-appearing male.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes dry with dry-blood at mouth edges. No
xanthalesma.
NECK: supple without lymphadenopathy. JVD 2-3 cm above the
clavile at 30-degrees.
CVS: PMI located in the 5th intercostal space, mid-clavicular
line. Sinus tachycardia with normal rhythm, with 2/6
holosystolic murmur, without rubs or gallops. S1 and S2 normal.
No S3 or S4.
RESP: Respirations unlabored, no accessory muscle use. Decreased
breath sounds bilaterally without adventitious sounds. No
wheezing, rhonchi or crackles. Stable inspiratory effort.
ABD: soft, mildly tender diffusely, non-distended, with
normoactive bowel sounds. No palpable masses or peritoneal
signs. Abdominal aorta not enlarged to palpation, no bruit. No
hepatomegaly noted.
EXTR: no cyanosis, clubbing; [**12-19**]+ non-pitting edema, 2+
peripheral pulses
DERM: No stasis dermatitis, ulcers, scars.
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally, sensation grossly intact. Gait
deferred.
PULSE EXAM:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2185-11-12**] 10:15PM BLOOD WBC-21.1*# RBC-5.03 Hgb-14.1 Hct-42.3
MCV-84 MCH-27.9 MCHC-33.2 RDW-13.7 Plt Ct-245
.
[**2185-11-17**] 06:45AM BLOOD WBC-9.2 RBC-4.25* Hgb-11.7* Hct-35.7*
MCV-84 MCH-27.4 MCHC-32.7 RDW-13.4 Plt Ct-245
.
[**2185-11-12**] 10:15PM BLOOD Neuts-82.9* Lymphs-10.3* Monos-5.7
Eos-0.7 Baso-0.4
.
[**2185-11-17**] 06:45AM BLOOD PT-33.8* PTT-33.5 INR(PT)-3.3*
.
[**2185-11-14**] 03:22AM BLOOD PT-16.9* PTT-74.5* INR(PT)-1.5*
.
[**2185-11-12**] 10:15PM BLOOD PT-16.1* PTT-26.9 INR(PT)-1.4*
.
[**2185-11-17**] 06:45AM BLOOD Glucose-99 UreaN-15 Creat-0.8 Na-132*
K-4.1 Cl-93* HCO3-32 AnGap-11
.
[**2185-11-12**] 10:15PM BLOOD Glucose-142* UreaN-15 Creat-0.9 Na-134
K-4.6 Cl-101 HCO3-22 AnGap-16
.
[**2185-11-17**] 06:45AM BLOOD ALT-160* AST-59* AlkPhos-59 TotBili-1.7*
.
[**2185-11-15**] 03:21PM BLOOD ALT-226* AST-244* AlkPhos-55 TotBili-2.0*
.
[**2185-11-13**] 05:20AM BLOOD ALT-24 AST-21 AlkPhos-50 TotBili-1.7*
.
[**2185-11-14**] 10:32AM BLOOD Lipase-62*
.
[**2185-11-13**] 05:20AM BLOOD cTropnT-<0.01
.
[**2185-11-12**] 10:15PM BLOOD cTropnT-<0.01 proBNP-2968*
.
[**2185-11-17**] 06:45AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.2
.
[**2185-11-16**] 04:55AM BLOOD Albumin-2.9* Calcium-8.1* Phos-2.0*
Mg-1.7 Iron-23*
.
[**2185-11-12**] 10:15PM BLOOD Calcium-9.3 Phos-3.0 Mg-2.1
.
[**2185-11-16**] 04:55AM BLOOD calTIBC-243* Ferritn-573* TRF-187*
.
[**2185-11-17**] 06:45AM BLOOD Vanco-12.2
.
[**2185-11-12**] 10:15PM BLOOD Digoxin-0.8*
.
CARDIAC CATH: None
.
MICROBIOLOGY DATA:
[**2185-11-12**] Urine culture - negative
[**2185-11-13**] Blood culture (x 2) - pending
[**2185-11-13**] MRSA screen - negative
[**2185-11-13**] Urine Legionella antigen - negative
[**2185-11-13**] Sputum culture - contaminated specimen
[**2185-11-14**] Sputum culture - contaminated specimen
[**2185-11-15**] Urine culture - pending
.
2D-ECHO ([**2185-10-31**]) - The left atrium is mildly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is severely dilated. There is severe global left
ventricular hypokinesis (LVEF = 15 %). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular free wall thickness is
normal. The right ventricular cavity is dilated with depressed
free wall contractility. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion. Significant augmentation of
contractile function of the left ventricle is seen during
postextrasystolic beats.
.
2D-ECHO ([**2185-11-15**]) - The left atrium is dilated. The right
atrium is markedly dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is severely dilated.
with severe global free wall hypokinesis. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. Mild to moderate ([**12-19**]+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. The main
pulmonary artery is dilated. There is a trivial/physiologic
pericardial effusion. Compared with the prior study (images
reviewed) of [**2185-10-31**], right ventricular systolic function is
now more severely impaired. The left ventricle is now more
dilated. Mitral regurgitation is now slightly less prominent.
.
[**2185-10-19**] CARDIAC MR IMAGING - Severely increased left ventricular
cavity size with severe global dysfunction. The LVEF was
severely decreased at 12%. The effective forward LVEF was
severely decreased at 8%. No CMR evidence of prior myocardial
scarring/infarction. These findings areconsistent with a
nonischemic cardiomyopathy. Mildly increased right ventricular
cavity size and severe global dysfunction. The RVEF was severely
decreased at 15%. No thrombus seen in the left ventricular
cavity. Moderate-to-severe mitral regurgitation. Mild pulmonic
regurgitation. The indexed diameters of the ascending and
descending thoracic aorta were normal. The main pulmonary artery
diameter index was normal. Mild biatrial enlargement. Normal
coronary artery origins with no evidence of anomalous coronary
arteries, and normal signal characteristics of all visualized
vessel segments. There is mild to moderate pulmonary edema.
Moderate bilateral simple pleural effusions (right greater than
left) and bibasilar consolidations, likely representing
atelectasis.
.
[**2185-11-12**] CTA CHEST W&W/O C&RECON - Pulmonary emboli within
subsegmental branches of the left and right lower lobe pulmonary
arteries. Small right pleural effusion, decreased from prior.
Non-enhancing consolidation in the right lung base which may
reflect pneumonia or aspiration in the appropriate clinical
circumstance. Stable mediastinal and right hilar
lymphadenopathy. Stable moderate cardiomegaly. No pericardial
effusion. Standard position of lines and tubes.
.
[**2185-11-15**] LIVER OR GALLBLADDER US - Right pleural effusion.
Prominent hepatic veins. Mild distension of the gallbladder
along with mild thickening of its wall, no stones identified.
Trace amount of pericholecystic fluid.
Brief Hospital Course:
19M with no significant PMH presents with likely famlial dilated
cardiomyopathy with recent hospitalization for acute failure who
responded to diuresis who now returns with shortness of breath
found to have pneumonia and subsegmental pulmonary embolus with
evidence of biventricular failure and volume overload.
.
# IDIOPATHIC DILATED CARDIOMYOPATHY - The patient presented on
[**2185-10-17**] in overt volume overload with evidence of congestive
heart failure. He was noted to have decompensated dilated
cardiomyopathy with a 2D-Echo showing 3+ mitral regurgitation
with an LVEF of 15-20%. He responded to aggressive Lasix gtt
with conversion to PO Torsemide with improvement in symptoms at
that time. Etiologies for his cardiomyopathy included: ischemic
(unlikely given age and no risk factors; no cardiac cath data)
vs. infectious (HIV, Lyme, viral, Chagas - last admission his
HIV, Lyme antibody, CMV, EBV, hepatitis serologies, TSH and
[**Location (un) **] virus testing were all negative) vs. toxic (alcohol,
cocaine, medications - unlikely given no prior medication; prior
toxicology screens negative, although moderate alcohol intake
was noted) vs. familial (most likely possibility given strong
family history noted above; genetic vs. autoimmunity-related).
He now returned with dyspnea on exertion and at while at rest
without overt volume overload symptoms, but was found to have a
subsegmental LLL pulmonary embolus requiring heparinization. A
repeat 2D-Echo ([**11-15**]) showed right ventricular systolic
dysfunction that was now more severely impaired. The left
ventricle was also more dilated. Overall it appeared to be
consistent with right ventricular failure and right atrial
dilatation occurring in the setting of subsegmental LLL
pulmonary embolus and infection (pneumonia) that had
precipitated [**Hospital1 **]-ventricular failure (his admission pro-BNP was
2968). He also had significant abdominal pain and transaminitis
which was attributed to cardiogenic-hepatic congestion or
congestive hepatopathy. He was admitted to the CCU after
transfer from the medical ICU, and was initiated on a Milrinone
infusion of 0.25 mcg/kg/min following an initial loading dose of
50 mcg/kg over 15-minutes. This was titrated to 0.375 mcg/kg/min
at one point, but he developed tachycardia, and this was
decreased to the 0.25 mcg/kg/min dosing with good tolerance.
Simultaneously, he was started on a continuous IV Lasix infusion
at 5-7 mg/hr and together with the inotropic effect of
Milrinone, he diuresed roughly 6-8L of fluid to a weight of 90.2
kg (95 kg on admission; dry weight 89.8 kg). He will continue on
Milrinone therapy and will be transferred to [**Hospital3 90505**] Center for Cardiac Transplant Surgery evaluation. We
trended his transaminitis and monitored his abdominal pain,
which both steadily improved with diuresis. His ACEI
(Lisinopril) and Spironolactone therapy were held in the setting
of acute heart failure, but his Metoprolol was titrated back at
12.5 mg by mouth twice daily; we also continued his Digoxin
therapy. We strictly monitored his in's and out's and optimized
his electrolytes; he was monitored via telemetry.
.
# PULMONARY EMBOLUS - The patient was found to have pulmonary
embolism in a segmental branch of the left lower lobe of the
pulmonary artery - initially presenting with worsening dyspnea.
He received heparin gtt and he was bridged to Coumadin. A
2D-Echo showed right ventricular failure and right atrial
dilatation with acute [**Hospital1 **]-ventricular failure; but it is unlikely
that a distal, subsegmental PE induced right ventricular
failure, but this should be considered. EKG was without evidence
of poor R-wave progression; and he maintained his oxygen
saturations. In light of his recent hospitalization, the risk of
thromboembolic disease should be noted. He was started on
Coumadin 5 mg PO daily and his dose was titrated to an INR of
[**1-20**].
.
# HEALTHCARE-ASSOCIATED PNEUMONIA - The patient presented with
right sided chest pain with tachypnea. He was found to have
right lower lobe consolidation on CT imaging. The patient was
recently discharged from the hospital and was in a rehab
facility. This was all associated with leukocytosis with a left
shift. The patient was afebrile in the ED. Nonetheless, he was
given IV Vancomycin, Cefepime, and Levofloxacin (started [**11-13**])
for healthcare associated pneumonia coverage. The patient was
initially intubated in the ED for airway protection and
increased work of breathing, but he was swiftly extubated
without desturations. He did have some evidence of hemoptysis,
likely from his infectious alveolar process and anticoagulation
needs. This steadily improved and he remained hemodynamically
stable without evidence of large volume bleeding. His U/A was
reassuring and blood, urine cultures were negative. He remained
afebrile and his leukocytosis improved. He will continue on
healthcare associated PNA coverage with Vancomycin, Cefepime,
Levofloxacin for a total of [**9-30**] days.
.
# CORONARIES - He has no evidence of ischemic cardiomyopathy or
coronary disease; no prior cardiac catheterizations; no HTN,
smoking history or strong atherosclerotic family history (only
familial NICM history) - presented with some atypical chest pain
symptoms - but now pain free - Troponin < 0.01 x 2-sets with
reassuring EKG showing only sinus tachycardia and no ST-changes
on admission. He has no indication for Aspirin - [**Location (un) 47**] risk
score calculates to 10-year risk of 1% - given HDL 44,
cholesterol 167, age < 20, male, no smoking history and no
indication for statin at this time. He was monitored with serial
EKGs.
.
# RHYTHM - No evidence of arrhythmia or history of dysrrhythmia.
.
TRANSITION OF CARE ISSUES:
1. The patient is being transferred to [**Hospital6 **]
Center for management of his acute biventricular heart failure
and will be evaluated by the Cardiac Transplantation Service.
2. Continue Lasix gtt at 5 mg/hr and titrate to adequate
diuresis.
3. Continue Vancomycin, Levaquin and Cefepime for 10-14 days for
coverage of healthcare-associated pneumonia; start date of
[**2185-11-13**].
4. Morphine IV for pain control.
5. His ACEI and Spironolactone were held while his acute
biventricular failure was managed.
Medications on Admission:
HOME MEDICATIONS (confirmed with patient)
1. Lisinopril 25 mg PO daily
2. Metoprolol succinate 25 mg XL PO daily
3. Spirinolactone 12.5 mg PO daily
4. Digoxin 325 mcg PO daily
Discharge Medications:
1. digoxin 125 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
3. 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.
4. Milrinone 0.25 mcg/kg/min IV INFUSION
Maximum dose: 0.5 mcg/min
5. furosemide 10 mg/mL Solution Sig: Five (5) mg/hour Injection
INFUSION (continuous infusion): titrate to UOP 100cc/hour.
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. morphine 5 mg/mL Solution Sig: 2-4 mg Injection Q3H (every 3
hours) as needed for pain.
8. levofloxacin in D5W 750 mg/150 mL Piggyback Sig: Seven
[**Age over 90 1230**]y (750) mg Intravenous Q24H (every 24 hours): day
1=[**11-14**].
9. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous
Q 8H (Every 8 Hours): day 1 [**11-13**].
10. cefepime 2 gram Recon Soln Sig: Two (2) g Injection Q8H
(every 8 hours): day 1=[**11-13**].
11. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for fever or pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3278**] Medical Center
Discharge Diagnosis:
Primary Diagnoses:
1. Acute biventricular heart failure
2. Dilated cardiomyopathy
3. Pulmonary embolism
4. Healthcare-associated pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Patient Discharge Instructions:
.
You were admitted to the Cardiac Intensive Care Unit (CCU) at
[**Hospital1 69**] on CC7 regarding management
of your severe heart failure and pulmonary embolism with
pneumonia. You were treated with an IV inotropic (promotes heart
contractility) [**Doctor Last Name 360**] with IV diuretics to promote better heart
function with promotion of fluid removal. You tolerated this
therapy in the ICU well and diuresed to near-baseline weight.
You were also anticoagulated for your pulmonary clot. You were
treated with IV antibiotics for presumed healthcare associated
pneumonia. Your abdominal pain, volume status and shortness of
breath improved prior to your transfer to [**Hospital3 90505**] Center. The cardiac transplant team will continue your
management and care.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED:
You are being TRANSFERRED ON: Milrinone 0.25 mcg/kg/min IV
continuous infusion (maximum dosing 0.5 mcg/min); lasix drip
titrated to urine output 100cc/hour; cefepime, vancomycin and
levofloxacin.
Monitor your INR and restart warfarin when your INR is no longer
supratherapeutic at 3.3 (ideal range is [**1-20**]).
We CHANGED: Metoprolol succiante 25 mg XL daily to Metoprolol
tartrate 12.5 mg by mouth twice daily.
.
* The following medications were DISCONTINUED on admission and
you should NOT resume:
DISCONTINUE: Spironolactone
DISCONTINUE: Lisinopril
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2185-12-5**] at 2:00 PM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: MONDAY [**2185-12-5**] at 3:00 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 486, 4254, 4280, 4240, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8681
} | Medical Text: Admission Date: [**2177-8-19**] Discharge Date: [**2177-8-25**]
Date of Birth: [**2101-6-24**] Sex: M
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: This is a 76-year-old patient
who was referred to [**Hospital6 256**] for
cardiac catheterization due to a history of worsening angina
and a history of positive exercise treadmill test. Cardiac
catheterization showed three-vessel coronary artery disease
and a normal left ventricular function. The patient was
admitted to [**Hospital6 256**] on [**8-19**]
for surgery with Dr. [**Last Name (STitle) **].
PAST MEDICAL HISTORY: 1. Hypertension. 2. Elevated
cholesterol. 3. Coronary artery disease. 4. History of
Parkinson's disease. 5. Status post tonsillectomy.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
PREOPERATIVE MEDICATIONS: Aspirin 325 mg p.o. q.d.,
Lopressor 50 mg p.o. b.i.d., Lipitor 10 mg p.o. q.d.,
Cogentin 1 mg p.o. q.i.d.
PREOPERATIVE PHYSICAL EXAMINATION: General: The patient is
a 76-year-old gentleman in no apparent distress. He was
alert and oriented times three. Neurological: Grossly
intact. Chest: Clear to auscultation bilaterally.
Cardiovascular: Regular, rate and rhythm. S1 and S2.
Within normal limits. Electrocardiogram normal sinus rhythm.
LABORATORY DATA: CBC with a white blood cell count of 6.8,
hematocrit 39.1, platelet count 185,000; sodium 141,
potassium 4.4, chloride 102, bicarb 30, BUN 27, creatinine
1.0.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2177-8-19**], by Dr. [**Last Name (STitle) **], for a coronary artery
bypass grafting times four, LIMA to diagonal, saphenous vein
graft to left anterior descending, saphenous vein graft to
OM1, saphenous vein graft to posterior descending artery;
please see operative note of that day for further details.
The patient was transferred to the Intensive Care Unit in
stable condition. In the Intensive Care Unit, the patient
required FFP, Protamine, and blood transfusions for elevated
chest tube drainage which subsequently resolved. The patient
was weaned from mechanical ventilation that evening and
extubated without problem. The patient remained
hemodynamically stable. The patient was transferred out of
the Intensive Care Unit on postoperative day #1 in stable
condition.
The patient's chest tubes and pacing wires were removed on
postoperative day #3. The patient remained tachycardiac on
increasing doses of Lopressor. The patient was noted to have
a hematocrit of 23.9 which had been stable. The patient was
given a blood transfusion for tachycardia and orthostasis.
Repeat hematocrit after transfusion was 25.3. The patient
experienced some confusion on postoperative day #4 which
resolved spontaneously. The patient's Foley catheter was
removed on the evening of postoperative day #4. The patient
had a postvoid residual checked which was greater than 300
cc. The Foley catheter was inserted at that time. The Foley
catheter was subsequently removed several hours later, and
the patient once again was unable to void, and a Foley was
reinserted. Urinalysis on that day was negative for signs of
infection.
On postoperative day #5, the patient was also noted to have
left upper extremity IV site that was erythematous and
indurated. The patient was placed on intravenous Kefzol.
Ultrasound was obtained to rule out deep venous thrombosis.
Ultrasound was positive for basilic vein thrombosis, negative
for deep venous thrombosis. The patient was continued on
antibiotics, and it was determined that there was no need for
anticoagulation at that time.
The patient is ambulating with Physical Therapy 340 feet on
postoperative day #6 with several rest periods. The patient
was screened for [**Hospital 3058**] rehabilitation placement and was
accepted and was cleared for discharge on [**2177-8-25**].
CONDITION ON DISCHARGE: Vital signs: T-max 100.7??????, pulse 98
in sinus rhythm, blood pressure 125/84, respirations 20, room
air oxygen saturation 94%. General: The patient was alert
and oriented times three with a right upper extremity tremor,
worsening with activity, which the patient reported was the
same as preoperatively secondary to Parkinson's disease.
Cardiovascular: Regular, rate and rhythm. Without rub or
murmur. Respiratory: Lungs clear to auscultation
bilaterally. No wheezes, rhonchi, or rales. GI: Positive
bowel sounds. Soft, nontender, nondistended. The patient is
tolerating a regular diet without nausea or vomiting. GU:
The patient had a Foley catheter in place, draining clear,
yellow urine. Chest: Sternal incision with staples intact
without erythema or drainage. Sternum is stable.
Extremities: Right lower extremity saphenectomy site clean
and dry without erythema or drainage. Left upper extremity
basilic vein with a palpable cord. No erythema. No purulent
drainage.
DISCHARGE LABORATORY VALUES: Urinalysis from [**8-24**] was
negative. Electrolytes from [**8-21**] revealed a sodium of
137, potassium 4.2, chloride 101, bicarbonate 24, BUN 24,
creatinine 1.1, glucose 106. CBC from [**8-23**] with a white
blood cell count of 11.2, hematocrit 25.3, platelet count
111,000.
DISPOSITION: The patient is to be discharged to
rehabilitation in stable condition.
DISCHARGE DIAGNOSIS:
1. Status post coronary artery bypass grafting.
2. Hypertension.
3. Elevated cholesterol.
4. Benign prostatic hypertrophy with urinary retention.
5. History of Parkinson's disease.
6. Left basilic vein thrombosis.
7. Status post tonsillectomy.
DISCHARGE MEDICATIONS: Lopressor 100 mg p.o. b.i.d.,
Cogentin 2 mg p.o. b.i.d., Lasix 20 mg p.o. b.i.d. x 7 days,
KCl 20 mEq p.o. b.i.d. x 7 days, Colace 100 mg p.o. b.i.d.,
Aspirin 81 mg p.o. q.d., Lipitor 10 mg p.o. q.h.s., Keflex
500 mg p.o. q.i.d. x 7 days, Ibuprofen 600 mg p.o. q.4-6
hours p.r.n.
DISCHARGE INSTRUCTIONS: The patient is to be discharged to
rehabilitation with Foley catheter in place. The patient is
to make an appointment with his urologist, Dr. [**Last Name (STitle) 35380**], in
[**Location (un) 620**], phone [**Telephone/Fax (1) 35381**], upon discharge from
rehabilitation for monitoring and management of benign
prostatic hypertrophy and Foley catheter.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 35382**]
MEDQUIST36
D: [**2177-8-25**] 12:27
T: [**2177-8-25**] 13:20
JOB#: [**Job Number 35383**]
ICD9 Codes: 2930, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8682
} | Medical Text: Admission Date: [**2130-1-17**] Discharge Date: [**2130-1-23**]
Date of Birth: [**2052-7-23**] Sex: M
Service: MEDICINE
Allergies:
Antihistamines
Attending:[**First Name3 (LF) 19193**]
Chief Complaint:
elevated BGs, and chest pain
Major Surgical or Invasive Procedure:
Central Line Placement
History of Present Illness:
77 yoM with CLL, DM type I with insulin pump, HTN, afib who p/w
SOB, R sided pleuritic chest and shoulder pain, and elevated
BGs. History obtained from patient's son as patient is not able
to answer questions upon arrival to MICU. By report, patient has
been feeling fatigued over the last week. He was seen by his
outpatient Oncologist just after [**Holiday 1451**] and had bloodwork
performed which showed an elevated WBC count. He had been
scheduled to start Chlorambucil 8 days ago. However, as he and
his family were travelling to [**Location (un) 26833**] over the weekend, he did
not want to start the medication. He was in [**Location (un) 26833**] from
Fri-Mon and returned yesterday. He spent much of the flight on
his feet due to chronic pain in his knees. Yesterday evening,
patient ate dinner with his son and was still doing well. He
fell into [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] but this was a witnessed fall and had no head
trauma or LOC. This am, patient called his son at 8 am stating
that he was aching all over and felt SOB w/ pleuritic R sided
chest and shoulder pain. He also noted to his son that his blood
sugars had been in the 300s and 400s which was unusual for him.
His son then brought him to his [**Name (NI) 6435**] office who brought him to
the ED.
.
In the ED, T, 99.0, BP 116/40, HR 85, RR 16, O2 96% RA. He was
found to have elevated leukocytosis compared to prior values in
our system. CXR showed e/o RLL pna w/ a R sided effusion. He was
given ceftriaxone and azithromycin. EKG with ST depressions in
inferior and lat leads, worse than prior. His first set of
cardiac enzymes were negative. He received 1 SL NTG which had no
effect on chest pain but led to hypotension w/ SBP to 70s. He
received 1 LNS w/ SBPs to 80s. Given persistent hypotension, he
was started on the sepsis protocol and a R IJ CVL was placed.
Around the same time, he developed severe abdominal pain. He
complained of [**11-16**] epigastric abdominal pain and reportedly had
a distended, firm abdomen. He received 1 percocet, 2 mg of
morphine, and 2 mg of dilaudid with improved abdominal and chest
pain but worse mental status. He received a abdominal XR and an
abdominal CT without contrast which showed no acute
abnormalities. His SBP rose to 110s after 4 L of NS. His abdomen
once again was soft and his abdominal pain did not return.
Past Medical History:
CLL x 5-6 years
DM1 w/ insulin pump x 50 years
htn
Afib on anticoagulation
osteoarthritis
s/p B shoulder surgeries
s/p knee arthroplasty
s/p prostate surgery
Social History:
Lives in [**Location 620**] with his wife. Independent with ADLs. Former
pipe and cigar smoker. Quit 8 years ago. Never smoked
cigarettes. Social EtOH. Swimmer and tennis player.
Family History:
Mother died of MI in 90s. Further fam hx unknown
Physical Exam:
T: 97.8 BP: 106/78 HR: 85 RR: 32 O2 99% 15L FM
Gen: Awake but confused, restless in bed, responsive to voice
HEENT: PERRL. No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No JVD. No thyromegaly.
CV: irreg irreg. No murmurs
LUNGS: Diffuse insp and exp wheezes. Bibasilar crackles, R>L w/
decreased BS at bases bilat, R>L
ABD: Decreased BS. Soft, ND. + splenomegaly. Insulin pump in
place
EXT: WWP, 1+ LE edema bilat. 2+ DP pulses BL. Scars over
bilateral shoulders
SKIN: No rashes or ecchymoses
NEURO: Restless. Responds to voice. Cannot answer questions or
follow commands. Pupils equal and minimally reactive. CN 2-12
grossly intact. Moving all extremities.
Pertinent Results:
[**2130-1-23**] 04:18AM BLOOD WBC-219.8* RBC-3.10* Hgb-9.0* Hct-27.5*
MCV-89 MCH-29.1 MCHC-32.8 RDW-17.3* Plt Ct-83*
[**2130-1-17**] 11:33AM BLOOD WBC-205.9*# RBC-3.66* Hgb-11.1* Hct-34.3*
MCV-94 MCH-30.3 MCHC-32.4 RDW-18.5* Plt Ct-145*
[**2130-1-20**] 05:07AM BLOOD Neuts-5* Bands-0 Lymphs-92* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2130-1-17**] 11:33AM BLOOD Neuts-1* Bands-0 Lymphs-92* Monos-0 Eos-0
Baso-0 Atyps-7* Metas-0 Myelos-0
[**2130-1-23**] 04:18AM BLOOD PT-24.7* PTT-31.5 INR(PT)-2.4*
[**2130-1-19**] 04:27AM BLOOD PT-58.1* PTT-50.1* INR(PT)-7.1*
[**2130-1-17**] 11:33AM BLOOD PT-29.2* PTT-34.4 INR(PT)-3.0*
[**2130-1-19**] 04:27AM BLOOD Fibrino-730*
[**2130-1-18**] 03:17PM BLOOD Fibrino-632*# D-Dimer-1253*
[**2130-1-18**] 03:17PM BLOOD FDP-0-10
[**2130-1-23**] 04:18AM BLOOD Glucose-338* UreaN-65* Creat-1.8* Na-132*
K-4.5 Cl-102 HCO3-17* AnGap-18
[**2130-1-17**] 11:33AM BLOOD Glucose-420* UreaN-56* Creat-2.3* Na-135
K-5.0 Cl-100 HCO3-22 AnGap-18
[**2130-1-19**] 04:27AM BLOOD LD(LDH)-331* TotBili-2.1* DirBili-0.4*
IndBili-1.7
[**2130-1-17**] 02:00PM BLOOD ALT-13 AST-22 LD(LDH)-432* AlkPhos-72
Amylase-13 TotBili-2.7*
[**2130-1-18**] 03:06AM BLOOD CK(CPK)-83
[**2130-1-17**] 07:13PM BLOOD CK(CPK)-75 DirBili-0.4*
[**2130-1-17**] 11:33AM BLOOD CK(CPK)-69
[**2130-1-17**] 02:00PM BLOOD Lipase-8
[**2130-1-18**] 03:06AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2130-1-17**] 07:13PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2130-1-17**] 11:33AM BLOOD cTropnT-<0.01
[**2130-1-21**] 05:34AM BLOOD Calcium-8.6 Phos-4.3 Mg-2.1
[**2130-1-19**] 04:27AM BLOOD Hapto-191
[**2130-1-17**] 10:00PM BLOOD Cortsol-60.2*
[**2130-1-17**] 02:00PM BLOOD IgG-260* IgA-13* IgM-35*
[**2130-1-18**] 03:06AM BLOOD Digoxin-1.1
[**2130-1-18**] 04:45PM BLOOD Lactate-1.6
[**2130-1-17**] 11:43AM BLOOD Lactate-2.8*
[**2130-1-17**] 06:10PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.021
[**2130-1-17**] 06:10PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2130-1-17**] 06:10PM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2130-1-17**] 09:32PM URINE Hours-RANDOM UreaN-818 Creat-144 Na-21
K-76 Cl-48
.
.
CULTURE DATA:
Blood Culture, Routine (Final [**2130-1-19**]):
STREPTOCOCCUS PNEUMONIAE. FINAL SENSITIVITIES.
MEROPENEM Sensitivity testing performed by Etest.
Penicillin PRESUMPTIVE RESISTANCE CONFIRMED BY MIC.
REFER TO MIC
RESULTS.
Note: For treatment of meningitis, ceftriaxone MIC
breakpoints are
<=0.5 ug/ml (S), 1.0 ug/ml (I), and >= 2.0 ug/ml (R).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
CEFTRIAXONE----------- 2 I
LEVOFLOXACIN---------- 1 S
MEROPENEM------------- 1 R
PENICILLIN------------ =>2 R
TETRACYCLINE---------- =>16 R
TRIMETHOPRIM/SULFA---- 8 R
VANCOMYCIN------------ <=1 S
.
URINE CULTURE (Final [**2130-1-18**]): NO GROWTH.
.
Legionella Urinary Antigen (Final [**2130-1-18**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
.
Blood Cultures [**2130-1-18**] and [**2130-1-19**]- No Growth To Date- PENDING
.
.
IMAGING:
[**2130-1-17**] CXR
IMPRESSION: Right lower lobe pneumonia with likely small right
parapneumonic effusion.
.
[**2130-1-17**] Abdominal XRAY
IMPRESSION: Normal bowel. Infiltrates at both bases. DJD in
the lumbar
spine. Metallic device lateral to the left hip.
.
[**2130-1-17**] ABDOMINAL/PELVIS CT
IMPRESSION:
1. No acute intra-abdominal process to explain the patient's
pain.
2. Severe splenomegaly and marked lymphadenopathy,
predominantly in the
mesenteric nodal station. No evidence of splenic rupture. Lack
of IV
contrast limits evaluation for splenic infarcts.
3. Extensive right lower lobe pneumonia and a smaller
consolidation in the left lower lobe, which may represent an
additional focus of infection.
4. Moderate left hydronephrosis of uncertain etiology, but
possibly due to congenital UPJ obstruction. Comparison with
prior outside studies would be helpful to evaluate chronicity of
this process.
.
[**2130-1-19**] CXR
IMPRESSION:
1. Gradual increase in right pleural effusion in a patient
with right lower lobe consolidation.
2. Increased vascular engorgement which may be related to
volume
overload/mild congestive heart failure.
.
.
STUDIES
[**2130-1-17**]: ECG
Atrial fibrillation. Non-specific low amplitude T waves in leads
I, II, aVF with non-specific ST segment depressions in leads
V5-V6. No previous tracing available for comparison.
.
[**2130-1-18**] ECHO:
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is10-20mmHg.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) There is no ventricular
septal defect. The right ventricular cavity is mildly dilated.
Right ventricular systolic function is normal. 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. Mild to moderate ([**2-8**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is mild to moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
Brief Hospital Course:
A/P: 77 yoM with CLL, DM type I with insulin pump, HTN, afib who
p/w SOB and pleuritic CP found to have elevated WBC count, RLL
pna, hypoxia, and hypotension now being called out of MICU on
Levo for PNA and BP stable
.
# RLL PNA: Initally, the patient met SIRS criteria with RLL PNA
on CXR. Found to have s.pneumo bacteremia in [**5-11**] bottles, and
was started on Levofloxacin. He was initially treated with
Vanc/Cefipime, then ceftriaxone. The patient's BP was initially
low, and he was on pressors, but quickly improved with
treatment. His mental status was initially deteriorated due to
his sepsis, but prior to discharge had signficantly improved
with medical therapy. His urine culture was negative and
legionella antigen negative. He was unable to produce sputum
for culture. At discharge, his respiratory status had
significantly improved and he was satting >95% on room air. He
was afebrile and able to ambulate without difficulty. He will
continue his Levofloxacin as an outpatient.
.
# Hypoxia: The patient initially hypoxic at presentation likely
due to his PNA. He had a TTE which showed an EF of 60%. With
antibiotics and nebs, the patient's respiratory status
significantly improved, and at discharge he was on room air.
.
# Acidosis: Initially, the patient had AG acidosis, likely
secondary to lactate. It then became non gap in setting of IVF
and renal failure. During his hospitalization, the patient's
blood sugars were very elevated, and he was initially on an
insulin gtt in the ICU. He is on an insulin pump at home, but
he was being covered with humulog and HISS. While the patient
was on the floor, his blood sugars were uncontrolled requiring
increased doses of humulog to cover the elevated blood glucose,
but he did not develop DKA. At the time of discharge, he blood
sugars were better controlled, and the plan was for him to start
his insulin pump once he was at home with close f/u with his
PCP.
.
# chest pain: Initially, the CP was pleuritic and radiating to R
shoulder. It was likely secondary to pneumonia and diaphragmatic
irritation. He had worsened ST depressions on ECG but <1 mm. Per
discussions w/ Heme/Onc and transfusion medicine, leukostasis
causing hyperviscosity extremely unlikely and there was no need
to plasmapherese. His CEs negative x 3. At discharge, his ST
depressions had resolved, and he was CP free.
.
# CLL: Per Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 26834**]) he generally starts
2mg Chlorambucil for 21 days when the patient's WBC >130,000 and
then comes off. The patient usually requires tx every [**5-13**]
months. Pt was asked to start 1 wk ago, but hadn't started yet.
Per Heme/Onc, they would not start chemotherapy in the setting
of infection. As above, Heme/Onc and Transfusion medicine not
concerned about leukostasis and no need for plasmaphoresis.
During his hospitalization, the patient's WBC continued to
climb. After discussion with heme/onc, it was still felt that
treatment was not yet necessary given his infection. He was
given a dose of IVIG in the ICU per heme-onc recommendations.
At the time of discharge, the patient had followup with Dr. [**Last Name (STitle) **]
who would determine if chemo was necessary. His platelets
remained low, but stable, and he did not have any active
bleeding.
.
# Acute Kidney Injury: Per outpt PCP, [**Name10 (NameIs) 5348**] creatinine 1.3.
He was admitted at 2.3. This was likely secondary to hypotension
given concern for sepsis. At the time of discharge, his
creatinine was trending down and was 1.7 at discharge.
.
# Coagulopathy: The patient's INR was 3 on admission, and peaked
at 7.1. On coumadin as an outpt. It was likely elevated
secondary to oral anticoagulation and sepsis. He was given vit
K for INR 7.1 and it decreased to 1.8. He was restarted on
coumadin INR therapeutic at time of discharge.
.
# Afib: The patient is on coumadin as outpt. He was rate
controlled with digoxin alone. His INR was supratherapeutic on
admission. At discharge, his INR was therapeutic and he was
rate controlled on digoxin.
.
# DM: The patient was hyperglycemic initially. This was likely
in setting of infection. His insulin pump was stopped and he was
initially on insulin gtt. He was then switched to NPH [**Hospital1 **] and
ISS. His FS were elevated on the floor requiring increased
humulog doses. At disharge, the patient's gluocose levels were
better controlled, and he was instructed to restart his insulin
pump at discharge. He will f/u with his PCP.
.
# HTN: now normotensive
- cont metoprolol for now
- will review patient's medications in AM to ensure he is on all
proper medications
.
# COMM: wife/HCP [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 26835**]
.
# DISP: The patient wanted to be discharge given that he was
feeling better and on satting well on room air. He will
continue his abx regimen, and f/u with his PCP and hematologist
after discharge. The patient was instructed to restart his
insulin pump once he got home since he did not have all of the
supplies necessary to restart it at the hospital and he did not
want to stay longer for his wife to bring the supplies in.
Medications on Admission:
Coumadin 2.5 mg daily
Enalapril 5 mg daily
Spironolactone/HCTZ 25/25 mg daily
Digoxin 250 mcg every other day
Allopurinol 300 mg daily
Finasteride 5 mg daily
Dexamethasone 0.1% OP 2 drops in each eye [**Hospital1 **]
Discharge Medications:
1. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every other
day for 9 days: last dose [**2130-2-1**].
Disp:*4 Tablet(s)* Refills:*0*
2. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
3. Spironolacton-Hydrochlorothiaz 25-25 mg Tablet Sig: One (1)
Tablet PO once a day.
4. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO once a
day.
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Insulin Pump Cartridge Cartridge Sig: AS DIRECTED units
Subcutaneous daily: use insulin pump as directed by your PCP.
7. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
8. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO every other
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Pneumonia
Sepsis
Secondary Diagnosis:
Diabetes Mellitus Type 1
Atrial Fibrillation
Chronic Lymphocytic Leukemia
Hypertension
Discharge Condition:
Good, afebrile, breathing room air
Discharge Instructions:
You were admitted for high blood sugers and a pneumonia. You
were initially in the ICU due to low blood pressures and high
blood sugars. You were started on antibiotics and you improved
significantly. You will need to complete a 14 day course of
antibiotics.
.
Please take all medications as prescribed. Please keep all
scheduled appointments.
.
If you develop any of the following concerning symptoms, please
call your PCP or go to the ED: shortness of breath, chest pains,
fevers, elevated/uncontrolled blood sugars, headaches, altered
mental status, or abdominal pain.
Followup Instructions:
Appointment with Dr. [**Last Name (STitle) 16258**] [**Telephone/Fax (1) 19196**]: [**2130-2-1**] at 9:45 AM
.
Appointment with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 26836**]: [**2130-2-6**] at 1:30 PM
ICD9 Codes: 5849, 2762, 4019, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8683
} | Medical Text: Admission Date: [**2152-6-30**] Discharge Date: [**2152-7-5**]
Date of Birth: [**2070-4-10**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Reglan
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pressure
Major Surgical or Invasive Procedure:
[**2152-6-30**] Aortic valve replacement ([**First Name8 (NamePattern2) 6158**] [**Male First Name (un) 923**] Epic) coronary
artery bypass graft x1 (saphenous vein graft > obtuse marginal)
History of Present Illness:
82 year old female with longstanding history of aortic valve
stenosis followed by serial echocardiograms. Recently she has
noted anterior chest pressure with exertion and intermittant
lightheadedness. An echocardiogram demonstrated normal left
ventricular size and function and moderate to severe aortic
stenosis. Cardiac catheterization confirmed the echo findings
and revealed a 50% first obtuse marginal artery lesion. Given
the severity of her disease, she was seen by Dr. [**Last Name (STitle) **] in
clinic last month. She returns today for her preadmission
testing prior to her scheduled surgery on [**2152-6-30**]. As she
was previously MSSA positive and treated, she will need to be
rescreened today.
Past Medical History:
- Aortic valve stenosis
- Coronary artery disease
- Hyperlipidema
- Hypertension
- Type II diabetes mellitus
- Overactive bladder
- Hypothyroid
- Carcinoma of the larynx in [**2129**] - partial laryngectomy
following radiation and chemotherapy by Dr. [**First Name (STitle) 3311**]
- GERD
- Carotid artery stenosis
- Depression
- Osteoarthritis
- Macular degeneration
- Hemochromatosis gene carrier
- Diverticulitis (pt unsure)
- Recurrent urinary tract infections
- Cholecystectomy
- Partial laryngectomy [**2129**]
- Hysterectomy
- Appendectomy
- Squamous cell cancer excision (pt denies)
Social History:
Lives: Alone. Widowed
Occupation: Retired
Tobacco: Never
ETOH: None
Family History:
Family History: Father passed at 59 of cerebral hemorrhage.
Mother passed of CVA at 75. 2 brothers with hemochromatosis.
Physical Exam:
Pulse: 73 Resp: 18 O2 sat: 99%
B/P Right: 151/72 Left: 145/80
Height: 5'4" Weight: 138 lb
General: Well-developed elderly female in no acute distress.
Skin: Warm [X] Dry [X] Intact [X]
HEENT: NCAT [X] PERRLA [X] EOMI [X]
Neck: Supple [X] slighltly limited ROM with scar/radiation
effects to neck following laryngeal surgery. Voice muffled but
understandable.
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur III/VI SEM
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema -
Varicosities: Bilateral very superficial. Legs very thin. GSV
palpable in bilateral thighs.
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 Bilateral bruit vs transmitted murmur
Brief Hospital Course:
Admitted same day surgery and was brought to the operating room
for aortic valve replacement and coronary artery bypass graft
surgery. See operative report for further details. She
received vancomycin for perioperative antibiotics and was
transferred to the intensive care unit for post operative
management. In the first twenty four hours she was weaned from
sedation, awoke neurologically intact and was extubated without
complications. She continued to progress and on post operative
day two was transferred to the floor. Speech therapy was
consulted due to history of dysphagia preoperatively, including
video swallow which revealed aspiration. the findings were
discussed with her and her daughters at length regarding
alternate means of nutrition and she declines feeding tube at
this time and understands risk of aspiration. The findings were
also communicated with Dr. [**First Name (STitle) 3311**] [**Telephone/Fax (1) 40829**] at the [**Company 2860**] who
was in agreement with the findings of the speech and swallow
evaluation. She was placed on a pureed diet and thin liquids and
instrcuetd regarding techiniques to improve swallowing and
decrease aspiration. Physical therapy worked with her on
strength and mobility. She continued to progress and was ready
for discharge to rehab [**Hospital1 599**] [**Location 40830**] in
[**Hospital1 789**] RI on post operative day #5.
Medications on Admission:
Enalapril 10mg [**Hospital1 **]
Folic Acid 1mg daily
Glipizide 20mg daily
Macrodantin 50mg daily
Prilosec 20mg daily
Simvastatin 20mg daily
Effexor XR 150mg daily plus 37.5 mg
Aspirin 81mg daily
Synthroid 75mcg daily
Vitamin B-12
Ocuvite daily
Omega-3 fatty acids 1,000mg daily
Aleve prn
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
6. enalapril maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
9. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Two (2)
Capsule, Ext Release 24 hr PO DAILY (Daily).
11. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. nitrofurantoin macrocrystal 50 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
13. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
15. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
16. venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
18. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO DAILY (Daily).
19. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
20. potassium chloride 20 mEq Packet Sig: Two (2) PO once a day
for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] seniorhealthcare
Discharge Diagnosis:
Aortic valve stenosis s/p AVR
Coronary artery disease s/p CABG
Hyperlipidema
Hypertension
Diabetes mellitus type 2
Overactive bladder
Hypothyroid
Carcinoma of the larynx
Gastric esophageal reflux disease
Carotid artery stenosis
Depression
Osteoarthritis
Macular degeneration
Hemochromatosis gene carrier
Diverticulitis
Recurrent urinary tract infections
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2152-7-27**] 1:15
Cardiologist: Dr [**Last Name (STitle) 2912**] - [**8-10**] at 2:30pm
VASCULAR LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2153-4-2**] 10:30
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2153-4-2**]
11:00
Please call to schedule appointments with your
Primary Care Dr [**First Name (STitle) 2505**] - [**Telephone/Fax (1) 40831**] in [**5-2**] weeks
Dr. [**First Name (STitle) 3311**] regarding your swallowing issues
**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:[**2152-7-8**]
ICD9 Codes: 4241, 2724, 4019, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8684
} | Medical Text: Admission Date: [**2139-11-27**] Discharge Date: [**2139-12-6**]
Date of Birth: [**2087-10-4**] Sex: M
Service: [**Location (un) **]
CHIEF COMPLAINT: Hypotension.
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
male with a past medical history significant for type 2
diabetes mellitus, hypertension, and tobacco use who
presented to the Emergency Department with a 7-day history of
worsening dyspnea on exertion, a cough productive of yellow
sputum, fevers, chills, as well as left-sided pleuritic chest
pain.
The patient had presented to his primary care physician with
similar symptoms in [**Month (only) **] and [**2139-9-18**] and was
treated with a course of azithromycin for presumed
bronchitis; reportedly without symptomatic improvement.
The patient denied recent travel, sick contacts, headaches,
abdominal pain, nausea, vomiting, diarrhea, as well as
urinary symptoms.
Of note, the patient had recently changed primary care
physicians and had been informed that his diabetes was well
controlled. Based on this conversation, the patient assumed
his diabetic medication was unnecessary and discontinued the
medication approximately six week prior to admission.
In the Emergency Department, the patient was found with a
temperature of 102.2, heart rate was 137, blood pressure was
123/64, and oxygen saturation was 96% on room air, and
respiratory rate was 28. The patient was noted to using
accessory muscles with coarse breath sounds throughout.
The initial chest x-ray was without evidence of infiltrate;
however, a computed tomography angiogram was obtained given
the patient's complaint of primary care physician and
evidence of sinus tachycardia. The computed tomography
angiogram demonstrated a left lingular infiltrate, and the
patient was started on levofloxacin and nebulizer treatments.
Shortly thereafter, the patient became progressively
hypertensive with systolic blood pressures in the 80s with
worsening shortness of breath. The patient was electively
intubated for hypercarbic respiratory failure with an
arterial blood gas of 7.22/50/407 on assist-control, tidal
volume of 700, respiratory rate of 12, and FIO2 of 100%.
While in the Emergency Department, the patient received a
total of 8 liters of normal saline without significant blood
pressure response, and the patient was subsequently started
on blood pressure support.
The patient's initial laboratories were notable for a white
blood cell count of 18.8 (with 12% bands), a blood glucose of
412, with trace ketonuria, and an anion gap of 13. The
patient was admitted to the Medical Intensive Care Unit for
further monitoring and evaluation.
PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus.
2. Hypertension.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Atenolol 50 mg p.o. q.d.
2. Metformin 500 mg p.o. b.i.d. (discontinued by the patient
six weeks prior to admission).
ALLERGIES:
SOCIAL HISTORY: The patient is an emigrant from [**Country 3587**]
in [**2117**]. The patient lives with his wife and daughter. [**Name (NI) **]
works in a candy factory. The patient reports a one pack per
day tobacco history of 18 years (currently using) with social
alcohol. No intravenous drug use.
FAMILY HISTORY: Family history was unknown.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed temperature was 101.2, blood pressure
was 102/68, pulse was 128, respiratory rate was 24, oxygen
saturation was 96% on 2 liters nasal cannula. In general,
the patient was found awake and alert. Spoke in full
sentences with frequent coughing. In mild distress. Head,
eyes, ears, nose, and throat examination revealed
normocephalic and atraumatic. Pupils were equal, round, and
reactive to light and accommodation. Arcus senilis
bilaterally. Extraocular movements were intact bilaterally.
Mucous membranes were dry. The oropharynx was erythematous
with no exudate. The neck was supple. No lymphadenopathy or
jugular venous distention noted. Cardiovascular examination
revealed a regular rate and rhythm with no extra heart sounds
appreciated. Pulmonary examination revealed diffusely
scattered wheezes and rhonchi anteriorly and posteriorly.
Abdominal examination revealed soft, nontender, and
nondistended. Normal active bowel sounds. No masses were
appreciated. Extremity examination revealed no clubbing,
cyanosis, or edema. Warm and well perfused.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
and studies on admission revealed complete blood count with a
white blood cell count of 18.8, hematocrit was 43.6, and
platelets were 195. White blood cell differential revealed
75% neutrophils, 12% bands, 4% lymphocytes, and 2% monocytes.
Chemistry-7 revealed sodium was 132, potassium was 4,
chloride was 95, bicarbonate was 23, blood urea nitrogen was
19, creatinine was 0.9, and blood glucose was 412, with an
anion gap of 14. Urinalysis was notable for greater than
1000 glucose, greater than 80 ketones, with 0 white blood
cells and 0 red blood cells. Microbiologic studies notable
during this admission included a sputum culture from [**2139-11-27**] with moderate streptococcal pneumococci.
RADIOLOGY/IMAGING: Radiologic studies of note included a
chest computed tomography on admission which was notable for
left lingular infiltrate with no evidence for pleural
effusion of pericardial effusion, and no evidence
intraluminal filling defects to suggest pulmonary embolus.
A repeat chest computed tomography on hospital day six (on
[**2139-12-2**]) demonstrated ground-glass opacification and
consolidation in the lung apices with additional patchy areas
of opacification in the periphery of the right middle lobe
and lingua. Small right and moderate left pleural effusions,
and several small pathologic mediastinal lymph nodes.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. INFECTIOUS DISEASE ISSUES: The patient was initially
treated with levofloxacin, ceftriaxone, and vancomycin a
multilobar pneumonia with a septic physiology.
The vancomycin was discontinued after one day, and following
the results of a sputum culture from admission with evidence
of moderate pneumococci, the Levaquin was discontinued after
completion of five days. The patient was continued on
ceftriaxone for the duration of the hospitalization.
For the first eight days of the hospitalization, the patient
demonstrated a persistently elevated white blood cell count
with bandemia (maximum white blood cell count was 16.6 with
26% bands) and persistent fever (ranging from 100 to 103).
All blood cultures were without growth including multiple
catheter tip cultures.
The persistent fever was concerning for a line infection, and
vancomycin was restarted on [**12-3**]. Clostridium
difficile colitis (given several days of diarrhea) as well as
empyema (given small bilateral pleural effusions) were also
of concern. However, the patient defervesced without the
addition of new therapy. Clostridium difficile toxin results
were negative, and after imaging, the effusions were too
small to tap.
2. PULMONARY SYSTEM: The patient was intubated for
multilobar pneumococcal pneumonia secondary to hypercarbic
respiratory failure. The patient required frequent
suctioning for copious secretions as well as frequent
albuterol nebulizer treatments for bronchospasms.
As the patient was being weaned from sedation and
ventilation, the patient self-extubated on [**12-1**]. The
patient maintained adequate oxygenation and ventilation for
the remainder of the hospitalization.
Serial chest x-rays demonstrated improving multilobar
pneumonia with development of very small bilateral pleural
effusions.
3. CARDIOVASCULAR SYSTEM: The patient initially required
blood pressure support for hypotension in the setting of
sepsis. After hospital day one, the patient continued off of
blood pressure support with systolic blood pressures ranging
from 130 to 160.
3. ENDOCRINE SYSTEM: The patient has a known diagnosis of
type 2 diabetes mellitus and presented with hyperglycemia and
mild diabetic ketoacidosis. The patient required an insulin
drip while in the Medical Intensive Care Unit for poorly
controlled blood glucoses. On hospital day nine, metformin
was restarted at outpatient doses.
4. NEUROLOGIC ISSUES: The patient was noted to be
significantly lethargic with episodes of physical agitation
following extubation. While intubated, the patient had
received significant sedation for suctioning.
The patient underwent a diagnostic head computed tomography
without evidence of pathology. The patient's mental status
improved with time off of sedatives.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE DIAGNOSES:
1. Multilobar pneumococcal pneumonia.
2. Type 2 diabetes mellitus.
3. Hypertension.
MEDICATIONS ON DISCHARGE:
1. Metformin 500 mg p.o. b.i.d.
2. Levaquin 500 mg p.o. q.d. (changed from ceftriaxone to
Levaquin to complete a total 14-day course of antibiotics).
3. Atenolol 50 mg p.o. q.d.
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed
to follow up with his primary care physician in two weeks
status post discharge.
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**]
Dictated By:[**Name8 (MD) 4935**]
MEDQUIST36
D: [**2139-12-16**] 18:52
T: [**2139-12-17**] 11:54
JOB#: [**Job Number 45030**]
ICD9 Codes: 2765, 5119, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8685
} | Medical Text: Admission Date: [**2123-12-19**] Discharge Date: [**2124-1-4**]
Date of Birth: [**2078-6-20**] Sex: F
Service: CARDIOTHORACIC
CHIEF COMPLAINT: Sternal hematoma.
HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old
woman status post aortic root replacement for aortic ectasia
in [**2123-1-23**]. The patient has had multiple hospitalizations
since that time for wound debridement and superficial sternal
infections.
The patient was recently involved in a motor vehicle
accident, [**2123-12-4**], as an unrestrained driver with
airbag deployment, head-on into a truck at approximately
50-60 mph. The patient sustained facial and nasal fractures,
bruises to chest and knees. She was evaluated at [**Hospital6 10443**] and was also found to have a T12-L1 compression
spine fracture.
He was transferred to [**Hospital3 12564**] Facility on
[**12-17**], when the patient noticed a lump on her chest at
the top of her sternum. The patient stated that it started
approximately one inch and reported that it increased in size
steadily since that time. The patient stated that it was
very tender to touch.
She had no complaints of fever, chills, drainage,
palpitations, or radiation of pain.
MEDICATIONS ON ADMISSION: OxyContin 30 mg b.i.d., Vioxx 25
mg q.d., Colace 100 mg b.i.d., Prevacid 30 mg q.d., Senokot 2
mg q.d., Dulcolax 1 q.d., Vancomycin 1 g b.i.d., Dilaudid 2-6
mg q.4-6 hours p.r.n., Milk of Magnesia 30 q.d. p.r.n.,
Ativan 0.5 mg q.d.
PAST MEDICAL HISTORY: Aortic ectasia status post aortic root
replacement in [**2123-1-23**]. Sternal wound debridement in
[**2123-6-25**]; further sternal wound debridement in [**2123-9-25**]. Zenker's diverticulum. Gastroesophageal reflux
disease. Hypertension. Nephrolithiasis. Depression.
Anxiety. Cholecystectomy. Appendectomy. Total abdominal
hysterectomy. Exploratory laparotomy. Lysis of adhesions.
ALLERGIES: CODEINE, ERYTHROMYCIN, SULFA, PREDNISONE,
TETRACYCLINE, BACTRIM, AMPICILLIN, AMOXICILLIN, ALBUTEROL,
ATROVENT.
PHYSICAL EXAMINATION: Vital signs: On admission the patient
was afebrile, heart rate 96, blood pressure 170/70,
respirations 20. General: The patient was alert and
oriented times three. She was in no acute distress. She was
slightly anxious. HEENT: Pupils equal, round and reactive
to light. Moist mucous membranes. No jugular venous
distention. Cardiovascular: Regular, rate and rhythm. No
murmurs, rubs, or gallops. Positive swelling in the
suprasternal region, 5 x 5 cm area, with erythema. Chest:
Breath sounds even and unlabored. Clear to auscultation
bilaterally. Abdomen: Soft, nontender, nondistended.
Extremities: No erythema or edema.
HOSPITAL COURSE: The patient was admitted to Cardiothoracic
Surgery and scheduled for CAT scan of her chest. This showed
a collection of the anterior to the manubrium, with an
enlarged pseudoaneurysm measuring 3.3 x 5.6.
On [**12-22**], the patient was brought to the Operating Room
at which time she underwent an aortic root replacement and
coronary artery bypass grafting times one. Please see the
operative report for full details.
In summary the patient had an aortic root replacement and
coronary artery bypass grafting times one with saphenous vein
graft to the right coronary artery and an intra-aortic
balloon placement at that time.
She was transferred from the Operating Room to the
Cardiothoracic Intensive Care Unit.
At the time of transfer, the patient had an intra-aortic
balloon pump at 1:1, Milrinone 0.5 mcg/kg/min, Dobutamine 5
mcg/kg/min, and Levophed, Propofol, and .................
Upon arrival in the Cardiothoracic Intensive Care Unit, the
Levophed was weaned to off, and the patient was started on
Nitroglycerin which was gradually increased to 2.5
mcg/kg/min.
Additionally, the patient arrived in the Cardiothoracic
Intensive Care Unit with an open chest, and paralytics were
initiated at that time.
Following her arrival in the Intensive Care Unit setting, the
Plastic Surgery Service, as well as Infectious Disease
Service were consulted.
On postoperative day #1, the patient remained with an open
chest, continued on paralytics. Her Dobutamine was weaned to
off. Her Milrinone was weaned to 0.1 mcg/kg/min. She
tolerated these procedures and remained hemodynamically
stable.
On postoperative day #2, the patient remained hemodynamically
stable. Her cardioactive drips were weaned as tolerated.
On postoperative day #3, the patient returned to the
Operating Room at which time she underwent a clean-out of her
chest and primary closure of her chest. She tolerated that
procedure well and was again transferred to the
Cardiothoracic Intensive Care Unit.
At the time of transfer, the patient had the intra-aortic
balloon pump at 1:1 and Milrinone at 0.25 mcg/kg/min.
Following her return to the Cardiothoracic Intensive Care
Unit, the patient's paralytics were discontinued. Her
sedation was discontinued. She was allowed to awaken and was
weaned on the ventilator to pressure support ventilation.
On the following morning, the patient's intra-aortic balloon
pump was weaned and successfully removed. The patient's
Milrinone was weaned to off, and her PA line was removed.
Following removal of the intra-aortic balloon pump, the
patient was further weaned from her ventilator and
successfully extubated.
Over the next several days, the patient had an uneventful
Intensive Care Unit stay. She remained in the Cardiothoracic
Intensive Care Unit to evaluation her hemodynamically and
from a respiratory standpoint, and furthermore, until her MRI
of the spine could be completed to additionally evaluate her
reported compression fractures and assess her neurological
status.
On postoperative day #8, the patient was transferred from the
Cardiothoracic Intensive Care Unit to .................. for
continuing postoperative care and cardiac rehabilitation.
She continued to be followed by not only the Cardiothoracic
Service but also by the Infectious Disease Service, as well
as the Neurosurgery Service.
It was their recommendation following MRI to continue the
patient in a brace for up to three months and to have
follow-up with her outside hospital neurosurgeon, as the MRI
showed no obvious cord compression, and only a slight bulge
at L1 with no compromise.
The patient's stay on ............ was relatively uneventful.
Her activity level was advanced with the assistance of the
nursing staff and Physical Therapy Service.
On postoperative day #14, it was decided that the patient was
stable and ready to be transferred to rehabilitation.
DISCHARGE PHYSICAL EXAMINATION: Vital signs: Temperature
98.5??????, heart rate 96 in sinus rhythm, blood pressure 110/70,
respirations 20, oxygen saturation 94% on room air. Weight
preoperatively was 80 kg, discharge 90 kg. General: The
patient was alert and oriented times three. She moves all
extremities and follows commands. Chest: Clear to
auscultation bilaterally. Cardiovascular: Regular, rate and
rhythm. S1 and S2. Incision with Steri-Strips, open to air,
clean and dry. Abdomen: Soft, nontender, nondistended.
Positive bowel sounds. Extremities: Warm and well perfused
with no edema. Left saphenous vein graft site with
Steri-Strips and open to air, clean and dry.
DISCHARGE LABORATORY DATA: Sodium 135, potassium 4.0,
chloride 97, CO2 26, BUN 13, creatinine 0.5, glucose 121;
white count 11, hematocrit 37.6, platelet count 649.
DISCHARGE MEDICATIONS: Vancomycin 1 g b.i.d., stop date of
[**1-30**], Rifampin 300 mg q.8 hours, to be continued
indefinitely, Gentamicin 100 mg q.8 hours, stop date of
[**1-8**]. Following completion of Gentamicin course, the
patient is to start on Levofloxacin 500 mg q.d., and this is
to continue indefinitely. Aspirin 325 mg q.d., Lansoprazole
30 mg q.d., Lorazepam 1 mg q.h.s., Heparin 5000 U t.i.d.,
Colace 100 mg b.i.d., Metoprolol 75 mg b.i.d., Hydromorphone
2-4 mg q.4-6 hours p.r.n., Ibuprofen 400 mg q.6 hours p.r.n.,
Simethicone 40-80 mg q.i.d. p.r.n., Cyclobenzaprine 10 mg
t.i.d. p.r.n.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSIS:
1. Status post aortic root replacement.
2. Coronary artery bypass grafting times one with saphenous
vein graft to right coronary artery.
3. Zenker's diverticulum.
4. Gastroesophageal reflux disease.
5. Hypertension.
6. Nephrolithiasis.
7. Depression.
8. Anxiety.
9. Status post cholecystectomy.
10. Status post appendectomy.
11. Status post total abdominal hysterectomy.
12. Status post exploratory laparotomy and lysis of
adhesions.
DISCHARGE STATUS: The patient is to be discharged to
rehabilitation.
FOLLOW-UP: She is to have follow-up with Dr. [**Last Name (STitle) 1140**] from
[**Hospital3 **] Neurosurgery Department in one month.
Follow-up with Infectious Disease Clinic, Dr. [**First Name (STitle) **], [**First Name3 (LF) **] 5,
10 a.m. Follow-up with Dr. [**Last Name (STitle) 1537**] in one month.
Additionally, the patient is to have a CBC, BUN, creatinine,
LFTs, and Vancomycin trough checked on a weekly basis with
the results faxed to Dr.[**Name (NI) 103853**] office in the Infectious
Disease Clinic, [**Telephone/Fax (1) 1419**].
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2124-1-4**] 13:18
T: [**2124-1-4**] 13:26
JOB#: [**Job Number 103854**]
ICD9 Codes: 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8686
} | Medical Text: Admission Date: [**2129-10-17**] Discharge Date: [**2129-10-21**]
Service: MEDICINE
Allergies:
Tetracyclines
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Mental status changes
Major Surgical or Invasive Procedure:
intubation [**2129-10-19**]
extubation [**2129-10-21**]
History of Present Illness:
[**Age over 90 **] year old woman admitted for MS changes on [**10-17**]. In the
[**Hospital1 18**] ED she was found to have a infiltrate on CXR and dirty UA
therefore started on levofloxacin and flagyl. Lactate was 1.0.
She was given levoquin, flagyl and kayexalate for her high
potassium (5.7). Also in the ED, SW spoke with the [**Hospital1 9168**] who went
into the patient's home who reported that home showed evidence
of hoarding with hallways and stairs filled with boxes of food.
[**Hospital1 9168**] reports that there was no trash or dirt among the items and
that the home was clean. Pt lives with her daughter who was home
at the time of [**Name (NI) 9168**] visit.
Daughter, [**Name (NI) 714**], reports that she is the pts primary
caretaker in the home with the only assistnce being 5 hours of
PCA through Family Services and ETHOS, and once a week visits
from her sister who lives in [**Name (NI) 3307**]. She states that she
started to increase her mothers Haldol and tylenol and codeine
as of Friday in order to help her sleep at approximately 3 times
her baseline doses. Has held her Lasix and Glyburide. Pt had
decreased PO intake at home. Daughter has been in contact with
ETHOS and with the patient's PCP, [**Name10 (NameIs) 1023**] came to house this morning
in reponse to an email from daughter. Daughter states very
clearly that she is having a hard time caring for her mother at
home, and is interested in pursuing placement for her mother
from the hospital. Daughter is also concerned about $300 copay
required by insurance if pt is admitted. SW provided support to
daughter and discussed anticipated course of care if pt is
hospitalized. Daughter is aware that keeping pt at home is no
longer working and is willing to explore options for placement.
Daughther is expressing indicators of caregiver burnout and is
aware of this and actively seeking help and support from
available services.
.
Past Medical History:
CHF
HTN
Hypothyroid
NIDDM
s/p surgery for diverticulitis
s/p CCY
s/p Appy
Multi-infart dementia
'heart murmur'
Social History:
lives with daughter at home ([**Name (NI) 714**] [**Name (NI) 4223**] [**Telephone/Fax (1) 38562**]).
No tobacco or alcohol.
Family History:
Non-contributory
Physical Exam:
PE
T 94 BP 115/58 HR 65 RR 22 92% 4L O2sats
Gen: Awake, NAD
HEENT: PERRL, EOMI, clear OP, anicteric, mmm
Neck: No LAD, JVD
Lungs: Decr BS RLL, no wheezes, crackles, rhonchi
Heart: RRR no m/r/g
Abd: Soft, NT, ND +BS
Ext: 1+ edema in ankles, trace edema in legs bilat (diffuse
below knee), 2+ DP/PT
Neuro: A&O times 2 (not time), no focal deficits, CN II-XII
intact
Pertinent Results:
[**2129-10-17**] 08:14PM URINE HOURS-RANDOM UREA N-826 CREAT-155
SODIUM-30
[**2129-10-17**] 08:14PM URINE OSMOLAL-576
[**2129-10-17**] 08:00PM GLUCOSE-113* UREA N-37* CREAT-1.6*
SODIUM-132* POTASSIUM-5.3* CHLORIDE-95* TOTAL CO2-28 ANION
GAP-14
[**2129-10-17**] 08:00PM OSMOLAL-281
[**2129-10-17**] 08:00PM PT-31.4* PTT-47.5* INR(PT)-7.4
[**2129-10-17**] 01:50PM LACTATE-1.0
[**2129-10-17**] 01:30PM GLUCOSE-98 UREA N-35* CREAT-1.3* SODIUM-131*
POTASSIUM-5.7* CHLORIDE-92* TOTAL CO2-28 ANION GAP-17
[**2129-10-17**] 01:30PM CK(CPK)-156*
[**2129-10-17**] 01:30PM CK-MB-9 cTropnT-<0.01
[**2129-10-17**] 01:30PM NEUTS-88.0* BANDS-0 LYMPHS-5.9* MONOS-4.5
EOS-1.5 BASOS-0.1
[**2129-10-17**] 01:30PM WBC-10.4 RBC-3.89* HGB-11.4* HCT-32.8* MCV-84
MCH-29.2 MCHC-34.6 RDW-13.9
[**2129-10-17**] 01:30PM PLT COUNT-164
[**2129-10-17**] 12:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2129-10-17**] 12:30PM URINE RBC-0-2 WBC-[**4-29**]* BACTERIA-MOD
YEAST-NONE EPI-0
.
[**10-17**] CXR IMPRESSION: AP chest compared to [**2128-9-16**]:
There is extensive multifocal consolidation in the lungs, most
marked in the right apex but also in the right and left lower
lung zones most consistent with multifocal pneumonia. Small
left pleural effusion is new. Moderate
cardiomegaly is chronic. Findings were discussed with Dr.
[**Last Name (STitle) 6633**] by
telephone at the time of dictation.
.
[**10-17**] CT head IMPRESSION:
1. No evidence of intracranial hemorrhage.
2. Evidence of age-related atrophic changes.
3. Findings suggestive of bilateral chronic small vessel
ischemic infarcts in
the cerebral white matter, as well as lacunar infarcts.
4. Right maxillary sinus disease.
.
[**10-18**] CT head IMPRESSION: No evidence of intracranial
hemorrhage or other acute abnormality. Please see the prior
report for findings consistent with chronic bilateral infarcts
and right maxillary sinus disease. No significant change since
the prior day.
.
[**10-19**] CXR IMPRESSION: New pulmonary edema, worsening multifocal
pneumonia, enlarging bilateral effusions
.
[**10-20**] CXR IMPRESSION: AP chest compared to [**10-17**] and
30th: Moderately severe pulmonary edema has improved slightly
since [**10-19**] at 10:02 p.m., but multifocal pneumonia is
unchanged. There is a component of atelectasis in the right
upper lobe where simple pneumonia was demonstrated on [**10-17**] and the same is probably true in the left upper lobe.
Moderate cardiomegaly is stable and a moderate-sized left
pleural effusion which developed since [**10-17**] is stable
subsequently. ET tube is in standard placement, nasogastric
tube passes below the diaphragm and out of view. Tip of the
left jugular line projects over the left brachiocephalic vein.
No pneumothorax.
Brief Hospital Course:
Assessment [**Age over 90 **] year old woman admitted for MS changes with U/A
consistent with UTI and CXR consistent with multifocal PNA.
.
## Pneumonia. As per CXR on admission, patient had extensive
multifocal consolidation in the lungs. She was started on
Flagyl and Levoquin for atypical and community aquired PNA
coverage. The patient had intermittent fevers throughout the
hospital course. We repeated CXRs daily and her PNA progressed
despite antibiotic coverage, and she was switched to
Vancomycin/Zosyn on [**10-19**]. Ongoing discussion with her daughter
involved goals of care and whether or not to intubate if that
became necessary. On the morning of [**10-19**], she became short of
breath with desaturations into the 70s and was transferred to
the MICU, initially for non-invasive ventilation. Patient's ABG
was notable for respiratory acidosis 7.29/78/71 repeat
7.21/78/71 on 4L face mask. Repeat CXR showed persistent
multilobar PNA with new LUL infiltrate, no overt evidence of
CHF. Patient received nebulizer treatment, Lasix, and
antibiotics were switched to Zosyn, Flagyl, and Vancomycin.
Daughter (HCP) was made aware of the situation by housetaff and
confirmed DNR/DNI status. Later on the day of transfer to the
ICU, the patient had increasing respiratory distress while on
non-invasive ventilation, and her daughter requested that she be
intubated. Anesthesia was called, and she was intubated without
complications. The patient's code status at that time remained
DNR (no CPR or shocks, pressors were acceptable). Over the next
1-2 days she became more hypotensive and displayed septic
physiology, ultimately requiring pressors to maintain her blood
pressure. On [**10-21**] the patietn's daughter and family made the
decision to withdraw care. Morphine was given for comfort, the
patient was extubated, and all other medications were stopped.
The patient died on [**2129-10-21**] at 9:55pm.
.
## UTI. UA had 6-10 WBCs and Pos nitrite and mod bacteria on
admission. Her Urine culture eventually grew pansensitive
e.coli. She was originally placed on Levoquin for UTI. Urine
was negative for Legionella on HD #3.
.
## Hyperkalemia/Hyponatremia. Patient was thought to be
dehydrated on admission given poor PO intake at home. SIADH was
also a possible etiology of hyponatremia. She was given
kayexalate in ED. We free water restricted her to 1.5L and used
NS for volume expansion. Nutrition was consulted. Urine
electrolytes were not revealing for SIADH.
.
## Coagulopathy. INR was probably high due to Warfarin so this
was held upon admission and INR was followed daily. INR
reversed with Vit K and FFP. LFTs were also slightly elevated
at that time and trended down.
.
## MS Changes. As noted above, this was probably multifactorial
with PNA (and resulting hypoxia and hypercarbia), UTI and poor
nutrition contributing. In addition, Tylenol with Codeine at 3x
baseline dose probably contributed. Narcotics, benadryl, and
other sedating meds were held.
.
## CHF/Afib. On admission there was moderate volume overload on
exam and CXR. Lasix was given prn to keep I/O even to negative.
Coumadin was held as above.
.
## Anemia. At baseline HCT (32) on admission. Patient received
1U PRBCs [**10-21**] for anemia and low UOP.
.
## CKD- Baseline creatinine 1.2-1.5. Steadily trended up during
hospital course. We renally dosed meds (Cr Clearance <30) and
avoided nephrotoxic meds.
.
## DM. Stable BS on admission was increasingly labile
throughout admission. Pt was covered by SSI.
.
## Hypothyroid. Continued synthroid at outpatient dose.
Medications on Admission:
Metoprolol 50 TID
Lisinopril 2.5 Daily
Amiodarone 200 Daily
Gylburide 1.25 [**Hospital1 **]
Levothyroxine 125 mcg Daily
Lasix 20 Daily
Haldol 0.5 qhs increased to tid on Fri
Warfarin 2.5 QIW
T&C #3 tid
Timolol OU
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnoses:
hypercarbic and hypoxemic respiratory failure secondary to
multifocal pneumonia
E. coli urinary tract infection
Secondary Diagnoses:
congestive heart failure
hypertension
Hypothyroidism
type II diabetes
Multi-infart dementia
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
ICD9 Codes: 486, 4280, 5859, 5849, 5990, 2767, 0389, 2761, 4019, 2449, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8687
} | Medical Text: Admission Date: [**2125-1-16**] Discharge Date: [**2125-1-23**]
Date of Birth: [**2060-3-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
abnormal stress test
Major Surgical or Invasive Procedure:
[**2125-1-16**] Coronary artery disease times four vessels (LIMA to
LAD, SVG to DIAG, SVG to OM, SVG to PDA)
History of Present Illness:
Mr. [**Known firstname 1528**] [**Known lastname **] is a 64 year old gentleman who recently was
found to have an abnormal stress test. Subsequent cardiac
catheterization revealed 30% LM, 40%LAD, 95% prox. diag 1, 95%
prox. diag 2, 95% CX, prox. RCA 100%. Referred for surgical
revascularization.
Past Medical History:
Diabetes mellitus
hypercholesterolemia
kidney stones 3 years ago
cataract surgery bilaterally
Social History:
Mr. [**Known lastname **] is a certified public accountant. he denies tobacoo
or alcohol use. He lives with his wife.
Family History:
Mr. [**Known lastname 26971**] family medical history is non-contributory to his
cardiac condition.
Physical Exam:
pre-op 5'6 [**1-2**] " 202#
NAD
skin/HEENT unremarkable
nek supple with full ROM and no bruits
CTAB
[**Last Name (un) **], no murmur
soft, NT, ND, +BS
warm, well-perfused, trace BLE edema
no varicosities
neuro grossly intact
2+ bil. fem/ radials
1+ bil. DP/PTs
At the time of discharge, Mr. [**Known lastname **] was in no acute distress.
He was awake, alert, and oriented times three. Upon
auscultation of his chest his heart was of regular rate and
rhythm and his lungs were slightly decreased throughout. No
drainage or erythema was noted at his mediastinal incision and
his sternum was stable. His abdomen was soft, non-tender, and
non-distended. His extremities were warm and trace upper
extremity edema was noted. His left sided endovascular harvest
site was clean, dry, and intact.
Pertinent Results:
[**2125-1-19**] 08:10AM BLOOD Hct-23.3*
[**2125-1-19**] 08:10AM BLOOD K-3.4
[**2125-1-22**] 01:05PM BLOOD WBC-11.3* RBC-3.18*# Hgb-9.8*# Hct-28.4*
MCV-89 MCH-30.9 MCHC-34.6 RDW-15.6* Plt Ct-224#
[**2125-1-22**] 01:05PM BLOOD Plt Ct-224#
[**2125-1-22**] 01:05PM BLOOD Glucose-162* UreaN-16 Creat-0.9 Na-139
K-4.7 Cl-98 HCO3-32 AnGap-14
[**2125-1-19**] 12:40PM BLOOD ALT-13 AST-19 AlkPhos-43 TotBili-0.9
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 55171**] (Complete)
Done [**2125-1-16**] at 10:24:56 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2060-3-28**]
Age (years): 64 M Hgt (in): 65
BP (mm Hg): 142/84 Wgt (lb): 200
HR (bpm): 82 BSA (m2): 1.98 m2
Indication: Left ventricular function. Intra-op TEE for CABG
ICD-9 Codes: 440.0
Test Information
Date/Time: [**2125-1-16**] at 10:24 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2007AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.4 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% >= 55%
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: 3.0 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aorta - Arch: 2.7 cm <= 3.0 cm
Aorta - Descending Thoracic: *2.6 cm <= 2.5 cm
Aortic Valve - LVOT diam: 2.2 cm
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 1.00
Mitral Valve - E Wave deceleration time: *270 ms 140-250 ms
Findings
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast is seen in the LAA. Good (>20 cm/s) LAA ejection
velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Low normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta. Normal aortic arch
diameter. Simple atheroma in aortic arch. Mildly dilated
descending aorta. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. No MS. Trivial MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Significant PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications. The patient was under
general anesthesia throughout the procedure. The patient appears
to be in sinus rhythm. Frequent ventricular premature beats.
patient. See Conclusions for post-bypass data
Conclusions
PRE-BYPASS:
1. The left atrium is moderately dilated. No spontaneous echo
contrast is seen in the left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. There are simple atheroma in the aortic arch. The descending
thoracic aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta.
6. There are three aortic valve leaflets. There is no aortic
valve stenosis. No aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
8. Significant pulmonic regurgitation is seen.
POST-BYPASS: Pt is being A paced and is on an infusion of
phehylephrine
1. Biventricular systolic function is normal
2. Aorta is intact post decannulation
3. Other Findings are unchanged
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician
?????? [**2121**] CareGroup IS. All rights reserved.
Brief Hospital Course:
On [**2125-1-16**] Mr. [**Known firstname 1528**] [**Known lastname **] underwent a coronary artery
bypass graft times four (LIMA to LAD, SVG to DIAG, SVG to OM,
SVG to PDA). This procedure was performed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
MD. He tolerated the procedure well and was transferred in
critical but stable condition to the surgical intensive care
unit.
In the surgical intensive care unit, Mr. [**Known lastname **] [**Last Name (Titles) 27836**] well.
He was extubated and weaned from his pressors. His home
diabetes medications were begun. By post-operative day two he
was ready for transfer to the surgical step down floor.
On the surgical step down floor, Mr. [**Known firstname 55172**] chest tubes and
epicardial wires were removed. He was transfused with red blood
cells for a decreased hematocrit. His blood pressure regimen
was maximized and diuresis increased. He was seen in
consultation by the diabetes service and the physical therapy
service. By post operative day #7 he was ready for discharge to
home. Pt. to make all follow-up appts. as per discharge
instructions.
Medications on Admission:
lisinopril 10 mg, toprol XL 25 mg, lipitor 10 mg, niacin ER
5000, aspirin 325 mg, metformin 1000 mg [**Hospital1 **], Avandia 4 mg [**Hospital1 **],
lantus 20 units in the am and 30 units in the pm, multivitamin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
6. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
7. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
8. Niacin 500 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO at bedtime.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed.
Disp:*60 Tablet(s)* Refills:*0*
10. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous QAM.
Disp:*1 month supply* Refills:*2*
11. Insulin Lispro (Human) 100 unit/mL Solution Sig: see sliding
scale units Subcutaneous four times a day: Please take as
directed according to sliding scale.
Disp:*1 month supply* Refills:*2*
12. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
Disp:*1 month supply* Refills:*2*
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days: Take for 7 days, then discontinue. Please
take with KCL.
Disp:*14 Tablet(s)* Refills:*0*
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days: Please take with Lasix.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
Coronary artery disease - s/p CABG
DM - Insulin dependent
Hypercholesterolemia
History of Kidney stones
s/p BL cataract surgery
Discharge Condition:
good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, lotions, or powders on wounds.
Call our office for temp>101.5, sternal drainage.
Followup Instructions:
Please see your PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17567**] ([**Telephone/Fax (1) 55173**] in [**1-2**] weeks.
Please see your cardiologist Dr. [**Last Name (STitle) 1295**] in [**1-2**] weeks.
Please see your surgeon [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**4-6**] weeks.
Completed by:[**2125-2-7**]
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8688
} | Medical Text: Admission Date: [**2158-11-21**] Discharge Date: [**2158-12-19**]
Date of Birth: [**2118-3-25**] Sex: M
Service: SURGERY
Allergies:
Codeine
Attending:[**Known firstname 371**]
Chief Complaint:
Trauma s/p fall
Major Surgical or Invasive Procedure:
1. T8-L2 fusion and T11-12 laminectomy on [**2158-11-25**]
2. Anterior cervical diskectomy and fusion C5-6 on [**2158-11-27**]
3. IVC filter placement on [**2158-11-28**]
4. Open gastrostomy tube placement on [**2158-12-12**]
2. Open tracheostomy [**2158-12-13**]
History of Present Illness:
HPI: The patient is a 40 yo male with unknown previous medical
history who was brought to the ED after a fall.
This evening the patient was drunk. While sitting on the rail at
[**Location (un) **] T-station, he fell backwards, about 15 feet down, onto
a
cement floor. He was found with blood on the back of his head.
In
the field he was able to say his name and address, moved his
arms
on both sides, but no movement was seen in his lower
extremities.
Per report he did not have sensation in his legs. GCS 14. A
bottle of valium was found (prescription).
Upon arrival in the ED, his breathing was shallow and he was
intubated for airway protection. He was able to follow simple
commands, but a history could not be obtained.
Past Medical History:
unknown
Social History:
unknown
Family History:
unknown
Physical Exam:
T afebrile BP:105/60 HR88 sO298% RR16
Gen: NAD
HEENT: NC/AT. Anicteric. MMM. some blood in his mouth. Blood on
back head.
Neck: Collar
Cardiac: RRR. S1/S2. no murmur
Lungs: intubated; CTA-bilaterally
Abd: Soft, NT, ND, +NABS. No rebound or guarding. Scars midline
(explorative lap?; scars side of chest)
Extrem: No C/C/E.
Pertinent Results:
[**2158-11-21**] 10:42PM TYPE-ART PO2-260* PCO2-53* PH-7.32* TOTAL
CO2-29 BASE XS-0
[**2158-11-21**] 10:42PM HGB-12.8* calcHCT-38 O2 SAT-93 CARBOXYHB-6*
[**2158-11-21**] 10:35PM WBC-10.4 RBC-4.19* HGB-13.6* HCT-38.5* MCV-92
MCH-32.5* MCHC-35.3* RDW-14.0
[**2158-11-21**] 10:35PM PLT COUNT-524*
[**2158-11-21**] 10:35PM PT-12.0 PTT-22.9 INR(PT)-1.0
[**2158-11-21**] 10:35PM FIBRINOGE-287
[**2158-11-21**] 10:42PM GLUCOSE-114* LACTATE-2.3* NA+-148 K+-3.7
CL--106
[**2158-11-21**] 10:35PM UREA N-10 CREAT-0.8
[**2158-11-21**] 10:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2158-11-21**] 10:35PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2158-11-21**] 10:35PM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2158-11-21**] 10:35PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2158-11-21**] 10:35PM ASA-NEG ETHANOL-341* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2158-11-21**] 10:35PM AMYLASE-47
Brief Hospital Course:
Patient admitted to the trauma ICU. Remained with flaccid
paralysis at bilateral lower extremities throughout
hospitalization.
Transferred to floor on [**11-21**] in stable condition. Returned to
the SICU [**3-8**] respiratory concerns. Transferred to the floor on
[**12-8**] again in stable condition but returned to SICU on [**2158-12-11**]
[**3-8**] respiratory concerns. He was intubated for respiratory
distress. A percutaneous tracheostomy was attempted but
unsuccessful, so an open tracheostomy was placed in the OR. A
PEG tube was subsequently placed. Continued to have elevated
WBC up to 24.5 with temp 101.4, Restarted on linazolid,
flucanazole, and zosyn.
Transferred to step-down unit on [**12-18**]. Continued to have
copious secretions well-controlled with suctioning.
Fever and elevated WBC resolved. Fluconazole and zosyn
discontinued. Had 14 day course of linazolid, discontinued on
discharge to rehabilitation.
He was seen throughout his stay by physical and occupational
therapists.
He failed speech and swallow evaluations on [**12-4**], and
[**12-11**].
Pt is discharged in stable condition and should follow-up with
the trauma surgery clinic as directed.
Medications on Admission:
unknown
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose
Injection ASDIR (AS DIRECTED): Per flowsheet.
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Subarachnoid hemorrhage (frontal)
2. Occipital fracture
3. Rib fracture (4th right)
4. Twelfth thoracic vertebrae fracture with spinal cord
compression
5. Eleventh and twelfth thoracic vertebrae facet fractures
6. Scalp laceration
Discharge Condition:
stable
Discharge Instructions:
1. physical and occupational rehabilitation
2. wound care/prevention of pressure ulcers and contractures
3. pulmonary toilet
Take all medications as prescribed. Keep all followup
appointments.
Call your doctor or go to the ER for:
-chest pain, shortness of breath
-fevers, chills
-worsening neurologic status
Followup Instructions:
Call ([**Telephone/Fax (1) 29931**] upon discharge for a follow-up appointment
with the Trauma Clinic in one week.
Call ([**Telephone/Fax (1) 11061**] upon discharge for a follow-up appointment
with Dr. [**Last Name (STitle) 363**] (spine surgeon).
ICD9 Codes: 5185, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8689
} | Medical Text: Admission Date: [**2182-8-17**] Discharge Date: [**2182-8-22**]
Date of Birth: [**2120-5-7**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
UGIB
Major Surgical or Invasive Procedure:
Upper Endoscopy with epinephrine injections
History of Present Illness:
62 yo F w/ PMH of progressive GBM p/w massive upper GI bleed, on
dex for GBM, taking motrin daily. HCT 22 at OSH. Taking 1.5mg
daily dex and daily ibuprofen. Tx from [**Hospital3 **]. Found on
toilet w/ BRB in toilet by husband, Hit back of head on sink. BP
55/palp in the field. [**Hospital3 **] CT head/neck negative. Got one
unit uncrossed blood at [**Hospital3 **] and was getting second on way
up from ED. has 2 18gs and one 20g PIV. BPs 105-115 in ED. Pulse
around 90. A/Ox2 (baseline). PPI bolus 80mg and drip started in
ED. GI and surgery were consulted.
Past Medical History:
Past Oncologic History:
# Right parietal glioblastoma multiforme, s/p
(1) a gross total surgical resection of a right parietal
glioblastoma by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. on [**2181-3-26**],
(2) s/p involved-field cranial irradiation to 6,000 cGy from
[**2181-4-16**] to [**2181-5-28**],
(3) s/p 1 cycle of adjuvant temozolomide, and
(4) started XL-184 on [**2181-10-2**] and has had 7 cycles so far.
Other Past Medical History:
(1) Insomnia
(2) Low back pain
(3) HSV oral ulcerations
(4) Cognitive impairment related to GBM
Social History:
She is married and she lives with husband. She smokes [**Date range (1) 61126**]
PPD. She reports drinking 2 small glasses wine per week, but
her brother reports that she drinks daily. Her husband
primarily caregiver. [**Name (NI) **] brother expressed concern that patient
may be neglected.
Family History:
Non-contributory; denies familial history of brain [**Name (NI) **] or
cancer.
Physical Exam:
On admission to ICU:
Vitals: T: 96.5 BP: 113/74 P: 95 R: 18 O2: 98% 2L
General: Alert, oriented x2, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. Chapped lips and
scaling of skin on L side of face
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, tender in epigastrium, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2182-8-17**] 07:47PM TYPE-[**Last Name (un) **] TEMP-35.9 PH-7.31*
[**2182-8-17**] 07:47PM freeCa-1.05*
[**2182-8-17**] 07:20PM GLUCOSE-172* UREA N-31* CREAT-0.3* SODIUM-136
POTASSIUM-3.2* CHLORIDE-109* TOTAL CO2-21* ANION GAP-9
[**2182-8-17**] 07:20PM CALCIUM-6.7* PHOSPHATE-2.6* MAGNESIUM-1.3*
[**2182-8-17**] 07:20PM WBC-8.0 RBC-3.90*# HGB-12.2# HCT-35.1* MCV-90
MCH-31.3 MCHC-34.9 RDW-17.2*
[**2182-8-17**] 07:20PM PLT COUNT-221
[**2182-8-17**] 07:20PM PT-15.6* PTT-23.6 INR(PT)-1.4*
[**2182-8-17**] 03:06PM TYPE-[**Last Name (un) **] TEMP-36.3 PH-7.26* COMMENTS-GREEN
TOP
[**2182-8-17**] 03:06PM LACTATE-2.0
[**2182-8-17**] 03:06PM freeCa-1.07*
[**2182-8-17**] 02:39PM HCT-30.6*
[**2182-8-17**] 02:39PM PLT COUNT-257
[**2182-8-17**] 02:39PM PT-15.1* PTT-26.1 INR(PT)-1.3*
[**2182-8-17**] 10:10AM LACTATE-2.6*
[**2182-8-17**] 10:00AM GLUCOSE-95 UREA N-35* CREAT-0.4 SODIUM-136
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-24 ANION GAP-11
[**2182-8-17**] 10:00AM estGFR-Using this
[**2182-8-17**] 10:00AM ALT(SGPT)-46* AST(SGOT)-30 ALK PHOS-63 TOT
BILI-0.3
[**2182-8-17**] 10:00AM LIPASE-27
[**2182-8-17**] 10:00AM ALBUMIN-2.6*
[**2182-8-17**] 10:00AM WBC-10.0 RBC-2.88* HGB-9.1*# HCT-27.6* MCV-96
MCH-31.6 MCHC-33.0 RDW-17.6*
[**2182-8-17**] 10:00AM NEUTS-80.4* LYMPHS-17.4* MONOS-1.7* EOS-0.2
BASOS-0.3
[**2182-8-17**] 10:00AM PLT COUNT-370
[**2182-8-17**] 10:00AM PT-15.5* PTT-25.8 INR(PT)-1.4*
Brief Hospital Course:
Upper GI [**Last Name (un) **]: Patient was given Blood(1 at OSH, 1 at ED, 2 on
the floor). She underwent upper endoscopy, found large ulcer in
Anterior duodenal bulb, that did not bleed on Upper endoscopy,
but pt continued to bleed post procedure. Patient was subjected
to another endoscopy found more bleeding ulcers, epi injected
into multiple sites. Found a diverticulum that was bleeding near
the ampulla, epi injected as well.
After the procedure overnight patient continued to have melena,
and had a large hematoma on the scalp.Hematomal bleeding was
well controlled and patient did not rebleed from that site,
which was likely a result of her fall while on the toilet with
the massive bleed via GI tract. Overnight after the procedures
she has been tachycardic (high 120s) and hypotensive (low 90's).
After discussion with the family it was felt that patient would
be better served with no more transfusions and no angio
intervention to control the bleeding if it recurs. DNR/DNI
status was confirmed with the Healthcare proxy.
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
ICD9 Codes: 2851, 4589, 2449, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8690
} | Medical Text: Admission Date: [**2151-12-28**] Discharge Date: [**2152-1-3**]
Date of Birth: [**2069-3-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain, shortness of breath
Major Surgical or Invasive Procedure:
coronary artery bypass x 2, mitral valve repair, repair of right
femoral artery [**2151-12-28**]
History of Present Illness:
The patient is an 82 year old male who developed chest pain
while snow-blowing and called 911. He presented to the [**Hospital1 18**],
[**Location (un) 620**] and was transferred to [**Location (un) 86**] for catheterization. He
ruled in for non-ST elevation myocardial infarction.
Past Medical History:
coronary artery disease
hypertension
benign prostatic hyperplasia
hyperlipidemia
polyps of vocal cords
Social History:
semi-retired
lives with wife
denies tobacco
drinks red wine daily
denies recreational drugs
Family History:
no history of premature coronary disease
Physical Exam:
Admission:
VS: 116/56, 80, 23
Gen: NAD
HEENT: unremarkable
Neck: supple, full ROM
Chest: lungs CTAB
Heart: RRR
Abd: +BS, soft, non-tender, non-distended
Ext: warm, well-perfused, no edema
Neuro: grossly intact
Pertinent Results:
[**2152-1-3**] 06:40AM BLOOD WBC-8.0 RBC-3.17* Hgb-9.6* Hct-27.6*
MCV-87 MCH-30.2 MCHC-34.7 RDW-14.0 Plt Ct-390#
[**2152-1-3**] 06:40AM BLOOD Glucose-125* UreaN-39* Creat-1.1 Na-142
K-4.4 Cl-105 HCO3-30 AnGap-11
[**2152-1-2**] 06:45AM BLOOD Mg-2.9*
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 93124**] (Complete)
Done [**2151-12-28**] at 6:09:50 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2069-3-11**]
Age (years): 82 M Hgt (in): 68
BP (mm Hg): / Wgt (lb): 180
HR (bpm): BSA (m2): 1.96 m2
Indication: Chest pain. Coronary artery disease. Left
ventricular function. Right ventricular function. Valvular heart
disease.
ICD-9 Codes: 410.91, 440.0, 413.9, 414.8, 424.1, 424.0
Test Information
Date/Time: [**2151-12-28**] at 18:09 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Last Name (NamePattern5) 9958**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW0-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.7 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Sinus Level: *3.8 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.3 cm <= 3.0 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Arch: 2.1 cm <= 3.0 cm
Aorta - Descending Thoracic: *2.6 cm <= 2.5 cm
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - Pressure Half Time: 58 ms
Mitral Valve - MVA (P [**12-10**] T): 3.8 cm2
Mitral Valve - [**Last Name (un) **]: 0.38 cm2
Mitral Valve - Regurgitation Volume: 55 ml
Pulmonic Valve - Peak Velocity: 0.7 m/sec <= 1.5 m/sec
Pericardium - Effusion Size: 1.0 cm
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Top
normal/borderline dilated LV cavity size. Normal regional LV
systolic function. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. Mildly dilated aortic sinus. Normal ascending aorta
diameter. Normal aortic arch diameter. Mildly dilated descending
aorta. Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Mild to
moderate ([**12-10**]+) AR.
MITRAL VALVE: Partial mitral leaflet flail. Eccentric MR jet.
Moderate to severe (3+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: Small to moderate pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE-BYPASS: The left atrium is mildly dilated. 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. Regional left ventricular wall motion
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The diameters of ascending aorta and arrch levels
are normal. The aortic root is mildly dilated at the sinus
level. The descending thoracic aorta is mildly dilated. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Mild to moderate ([**12-10**]+) aortic
regurgitation is seen. There appears to be flail of the P3
leaflet of the mitral valve. An eccentric jet of moderate to
severe (3+) mitral regurgitation is seen. There is a small to
moderate sized pericardial effusion.
POST BYPASS: The patient is AV paced and on an infusion of
phenylephrine. Left and right ventricular function is preserved.
The aorta is intact. A mitral valve repair has been performed
and an annuloplasty band placed. There is now no MR. Mild to
moderate AR persists. The remainder of the examination is
unchanged.
Dr. [**Last Name (STitle) **] was notified in person of the results in the
operating room.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2151-12-29**] 09:51
?????? [**2145**] CareGroup IS. All rights reserved.
Brief Hospital Course:
The patient was brought to the operating room emergently due to
bleeding in the right groin at the site of the intraortic
balloon pump. He underwent CABG x 2, mitral valve repair with
28mm [**Doctor Last Name **] [**Last Name (un) 3843**] Band and repair of the right femoral
artery (by Dr. [**Last Name (STitle) 1391**]. Please see operative report for
further details. Overall the patient tolerated the procedure
well and was transferred to the CVICU post operatively for
further monitoring. On POD 1 the patient remained intubated and
hemodynamics were supported with phenylephrine, norepinephrine
and epinephrine. Within 24 hours of surgery, the patient was
extubated and the balloon pump was discontinued. Vasoactive
drips were weaned off. The patient was transferred to the
telemetry floor on POD 3. Chest tubes and pacing wires were
discontinued without complication. The patient was gently
diuresed toward his preoperative weight. Social work consult
was obtained for family's concern of patient's history of
emotional/verbal abuse towards family members, including wife
who recently had a stroke. Additionally, geriatrics consult was
obtained for further management of this issue. The geriatrics
team will continue to follow the patient when he is discharged
to rehab. The patient made reasonable progress
post-operatively. He was discharged to the [**Hospital 100**] Rehab on POD
6.
Medications on Admission:
sertraline 50mg daily
lisinopril 2.5mg daily
simvastatin 20mg daily
diovan 80mg daily
doxazosin
lipitor 10mg daily
clonazepam
finasteride 5mg daily
glucosamine chondroitin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours) as needed.
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
12. Ayr Saline Gel Spray, Non-Aerosol Sig: One (1) Nasal
once a day.
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours).
17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
coronary artery disease
PMH:
hypertension
benign prostatic hyperplasia
vocal cord polyps
hyperlipidemia
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 1 week
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1728**] in [**1-11**] weeks [**Telephone/Fax (1) 14148**]
Please call for appointments
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2152-1-3**]
ICD9 Codes: 4111, 2762, 2930, 4240, 4019, 2724, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8691
} | Medical Text: Admission Date: [**2159-4-25**] Discharge Date: [**2159-4-30**]
Date of Birth: [**2094-9-7**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
Hypotension.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
History of Present Illness: 64-year-old man with pancreatic
cancer s/p recent Whipple ([**2159-1-31**]) now on adjuvant
chemotherapy (last dose per patient was two weeks prior to
this), diabetes type II, sCHF with EF 30%, CAD s/p MI, and
atrial fibrillation on coumadin who presented to the ED from
home with progressive lower extremity swelling and "not feeling
well." Family members at home, furthermore, felt that he did not
look right and decided to bring him to the emergency room. Of
note, patient was recently discharged from [**Hospital3 3583**] to
home with diagnosis of pneumonia. It is not clear what
antibiotics he was treated with - patient cannot remember.
.
In the ED, initial vital signs were T 97.6, HR 111, BP 86/56, RR
12, satting 94% RA. Labs notable for hct 29 (at baseline), trop
of 0.21 with normal CK (in setting of acute on chronic renal
failure with creatinine 2.0 from baseline ~1.3), and glucose of
38. Lactate was 1.6. EKG showed atrial fibrillation (rate of
107) with RBBB and RAD. There were no significant changes from a
preoperative EKG in [**Month (only) 958**]. CXR showed RLL infiltrate consistent
with pneumonia. UA was negative. Blood and urine cultures were
sent. Patient was given aspirin 325 mg, levofloxacin 750 mg,
vancomycin 1gm, and one amp of D50. He was given 1.5L NS (given
h/o sCHF) and admitted to the intensive care unit for persistant
hypotension.
.
Review of Systems: currently patient denies pain, shortness of
breath, chest pain or pressure, headache, nausea or vomiting
Past Medical History:
Past Medical History:
- Type II DM
- CHF with an EF of 30%
- CAD s/p MI
- h/o atrial fibrillation on Coumadin
- Chronic Renal Insufficiency (baseline creatinine 1.3)
- Adenocarcinoma of the pancreas s/p Whipple in [**Month (only) **]/[**2158**] with
positive margins, currently undergoing adjuvant chemotherapy
with gemcitabine (about three cycles in); most recent
chemotherapy was two weeks ago, per patient
.
Past Surgical History:
- sinus surgery
- (L)LE bypass for nonhealing toe ulcer
- ERCP with stent placement
- Whipple procedure as above
Social History:
Lives with his wife. Laid off from computer analyst position.
No tobacco. Occasional ETOH.
Family History:
Non-contributory.
Physical Exam:
Vitals: SBP 90s, HR 100-110, sat mid 90s on RA
General: pale-appearing elderly gentleman in no acute distress
HEENT: PERRLA, non-icteric sclera
Neck: JVP to ear lobe at 30 degrees
Cardiovascular: irregularly irregular
Pulmonary: bilateral crackles half way up lung fields
Abdominal: soft, non-tender, normal bowel sounds
Extremities: cold distally, non-diaphoretic, 2+ pitting edema to
above the knees bilaterally
Neurological: AAOx3, moving all extremities
Pertinent Results:
[**2159-4-25**] 01:18AM BLOOD WBC-10.0 RBC-3.26* Hgb-9.6* Hct-29.0*
MCV-89 MCH-29.5# MCHC-33.2 RDW-21.6* Plt Ct-359#
[**2159-4-25**] 09:05AM BLOOD WBC-11.8* RBC-3.20* Hgb-9.4* Hct-29.5*
MCV-92 MCH-29.4 MCHC-31.8 RDW-21.7* Plt Ct-347
[**2159-4-26**] 04:15AM BLOOD WBC-11.2* RBC-3.32* Hgb-9.6* Hct-29.6*
MCV-89 MCH-28.8 MCHC-32.3 RDW-21.4* Plt Ct-475*
[**2159-4-27**] 05:20AM BLOOD WBC-11.8* RBC-3.28* Hgb-9.6* Hct-29.2*
MCV-89 MCH-29.1 MCHC-32.7 RDW-21.4* Plt Ct-476*
[**2159-4-25**] 01:18AM BLOOD Neuts-79.2* Lymphs-12.2* Monos-6.9
Eos-1.4 Baso-0.2
[**2159-4-25**] 09:10AM BLOOD PT-35.7* PTT-51.0* INR(PT)-3.7*
[**2159-4-26**] 04:15AM BLOOD PT-27.4* PTT-42.7* INR(PT)-2.7*
[**2159-4-27**] 05:20AM BLOOD PT-25.3* PTT-42.0* INR(PT)-2.4*
[**2159-4-28**] 06:10AM BLOOD PT-28.2* PTT-42.0* INR(PT)-2.8*
[**2159-4-25**] 01:18AM BLOOD Glucose-39* UreaN-41* Creat-2.0* Na-143
K-3.9 Cl-108 HCO3-25 AnGap-14
[**2159-4-25**] 12:15PM BLOOD Glucose-94 UreaN-35* Creat-1.8* Na-144
K-3.6 Cl-110* HCO3-24 AnGap-14
[**2159-4-25**] 09:30PM BLOOD Glucose-177* UreaN-38* Creat-2.1* Na-141
K-4.0 Cl-107 HCO3-26 AnGap-12
[**2159-4-26**] 04:15AM BLOOD Glucose-182* UreaN-38* Creat-1.9* Na-141
K-4.1 Cl-107 HCO3-25 AnGap-13
[**2159-4-26**] 05:05PM BLOOD Creat-2.0* Na-138 K-4.2 Cl-105
[**2159-4-27**] 05:20AM BLOOD Glucose-137* UreaN-38* Creat-1.9* Na-140
K-3.7 Cl-105 HCO3-27 AnGap-12
[**2159-4-28**] 06:10AM BLOOD Glucose-97 UreaN-31* Creat-1.6* Na-140
K-3.8 Cl-105 HCO3-29 AnGap-10
[**2159-4-25**] 12:15PM BLOOD ALT-22 AST-35 LD(LDH)-269* CK(CPK)-101
AlkPhos-114 TotBili-0.8
[**2159-4-25**] 01:18AM BLOOD cTropnT-0.21*
[**2159-4-25**] 09:10AM BLOOD CK-MB-2 cTropnT-0.05*
[**2159-4-25**] 12:15PM BLOOD CK-MB-3 cTropnT-0.14*
[**2159-4-25**] 01:18AM BLOOD CK-MB-4 proBNP-[**Numeric Identifier 24733**]*
[**2159-4-25**] 01:18AM BLOOD CK(CPK)-142
[**2159-4-25**] 12:15PM BLOOD Albumin-2.2* Calcium-6.5* Phos-3.3
Mg-1.3*
[**2159-4-25**] 09:30PM BLOOD Calcium-7.4* Phos-3.6 Mg-1.8
[**2159-4-26**] 04:15AM BLOOD Calcium-7.6* Phos-3.7 Mg-1.7
[**2159-4-27**] 05:20AM BLOOD Calcium-7.8* Phos-2.9 Mg-1.8
[**2159-4-28**] 06:10AM BLOOD Calcium-7.5* Phos-2.5* Mg-1.8
[**2159-4-25**] 09:10AM BLOOD Digoxin-<0.2*
[**2159-4-25**] 12:15PM BLOOD Digoxin-0.3*
[**2159-4-26**] 04:15AM BLOOD Digoxin-0.3*
[**2159-4-25**] 02:39AM BLOOD Lactate-1.6
[**2159-4-25**] 10:11AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2159-4-25**] 04:25AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2159-4-25**] 10:11AM URINE Blood-TR Nitrite-NEG Protein-25
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2159-4-25**] 04:25AM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2159-4-25**] 10:11AM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2159-4-25**] 04:25AM URINE RBC-0 WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0-2
[**2159-4-25**] 10:11AM URINE CastHy-[**1-26**]*
[**2159-4-25**] 10:11AM URINE Hours-RANDOM UreaN-831 Creat-116 Na-20
TTE [**2159-4-25**]:
The left atrium is mildly dilated. The right atrium is
moderately dilated. The right atrial pressure is indeterminate.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is severe
regional left ventricular systolic dysfunction with akinesis of
the inferior and inferolateral walls and apex and hypokinesis of
the basal and mid anterior, anterolateral, and inferoseptal
segments. Overall left ventricular systolic function is severely
depressed (LVEF= 25-30 %). Right ventricular chamber size is
dilated and free wall motion is normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate to severe (3+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is at least moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Severely depressed left ventricular systolic
function with akinesis of the inferior and inferolateral walls
and apex and hypokinesis of the basal and mid anterior,
anterolateral, and inferoseptal segments. Mild aortic root and
ascending aortic diliatation. Moderate to severe mitral
regurgitation. Moderate to severe tricuspid regurgitation.
Moderate pulmonary artery systolic hypertension.
Compared with the report of the prior study (images unavailable
for review) of [**2147-12-19**], the left ventricular ejection fraction
appears similar. The severity of mitral and tricuspid
regurgitation has increased.
ECG [**2159-5-2**]:
Atrial fibrillation with ventricular rate of 107. Complete right
bundle-branch block with QRS duration of 136 milliseconds. Q
waves in leads II, III and aVF. Poor R wave progression
laterally. Right axis deviation at plus 117 degrees. Compared to
the previous tracing of [**2159-2-6**] no diagnostic interval change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
107 0 136 348/430 0 117 -18
CXR:
Cardiac size is top normal. There has been reaccumulation of
bilateral
pleural effusions , more conspicuous in the current exam could
be due to
difference in positioning of the patient. Bibasilar
consolidations are
grossly unchanged. Right Port-A-Cath remains in place in
standard position.
There is no evidence of pneumothorax.
Brief Hospital Course:
64-year-old man with history of pancreatic cancer s/p Whipple on
chemotherapy, DM II, CAD, PVD, and sCHF now presents with
hypotension, and progressive lower extremity edema.
.
# Hypotension: Likely secondary to decompensated heart failure
with unclear trigger. [**Month (only) 116**] also have been secondary to poorly
controlled atrial fibrillation with RVR as patient had not been
taking his digoxin. Required short course of pressors and IV
fluids. Losartan was held. Digoxin and metoprolol were
initially held, but with stabilization of blood pressures,
digoxin was loaded and metoprolol was added on [**4-27**] with good
rate control. Now symptomatically improved with stable vital
signs.
.
# Acute on chronic sCHF: Likely secondary to ischemic
cardiomyopathy. On admission, patient had 3+ lower extremity
edema to the hip, and a BNP > [**Numeric Identifier 15362**]. His weight on admission
was 200#, up from his dry weight of 180#. He was intially
treated with lasix gtt with good urine output. On discharge he
was transitioned to furosemide 40mg IV bid. Weight on discharge
was 192#. He had improved, but persistent LE edema on
discharge. He will require continued diuresis and monitoring of
his edema. He was continued on aspirin, beta-blocker, statin.
.
# Acute on chronic renal failure: likely prerenal azotemia -
unclear if secondary to hypovolemia versus poor forward flow
from decompensated CHF. His creatinine gradually improved.
.
# Atrial fibrillation: Loaded with digoxin and restarted
metoprolol at 12.5mcg PO BID. He remained in atrial
fibrillation. He was continued on his home coumadin, and INR was
checked daily.
.
# Pneumonia: Treated at OSH. Afebrile while here with no new
respiratory complaints. Antibiotics were discontinued on [**4-25**].
Urine legionella negative.
.
# Pancreatic cancer s/p Whipple: patient is currently undergoing
adjuvant chemotherapy and work-up for possible cyberknife
therapy, both at outside centers closer to his home. Spoke with
Dr. [**First Name (STitle) 3443**] ([**Hospital3 **] Oncology), she will see him in clinic next
week to further plan his cancer treatment.
.
# Anemia: Stable and at recent baseline. Normal MCV suggests
anemia of chronic inflammation.
.
# Type II diabetes: on insulin as outpatient. His long-acting
insulin was held given renal failure and low sugars in ED. He
was covered with a humalog sliding scale, and restarted on his
home lantus 15 units PO daily on discharge.
Medications on Admission:
- toprol XL 50mg QD
- cozaar
- losartan 50mg PO daily
- lasix 20mg PO daily
- ecotrin 80mg PO daily
- lipitor 40mg PO daily
- protonix 30mg PO daily
- lantus 15 units qam
- levaquin 500mg PO daily X 5 days (just finished)
- coumadin 3mg PO 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).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Lipase-Protease-Amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
6. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for stomach pain.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection
twice a day.
14. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)
units Subcutaneous once a day.
15. Furosemide
Patient's dry weight is 180 lbs, weight on discharge 192 lbs.
Please perform daily weights. Obtain serum Na, K, Cl,
Bicarbonate, BUN, Creatinine, Glucose twice weekly and send to
rehab MD. Titrate down furosemide dose as lower extremity edema
resolves, and patient approaches dry weight. Goal dose of
furosemide is 40mg PO bid.
16. Electrolytes
Please replete K to 4.0, magnesium to 2.0.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Acute on Chronic Systolic Heart Failure
Pancreatic Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for worsening of your heart failure. You were
treated with the diuretic furosemide, and your urine output
increased. You were restarted on digoxin for your atrial
fibrillation.
The following changes were made in your medications:
Your dose of furosemide was increased, and will be slowly
decreased while in rehab.
We stopped your Cozaar (losartan).
We restarted digoxin.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please arrange to see your PCP [**Name Initial (PRE) 176**] 1-2 weeks of discharge
from rehab.
Dr. [**First Name (STitle) 3443**]
[**Hospital3 **] Oncology
Tuesday [**2159-5-8**] 12:00 pm
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
ICD9 Codes: 5849, 5859, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8692
} | Medical Text: Admission Date: [**2192-12-28**] Discharge Date: [**2193-1-4**]
Date of Birth: [**2170-4-12**] Sex: M
Service: HEPATOBILIARY (BLUE) SURGERY SERVICE
HISTORY OF PRESENT ILLNESS: The patient is a 22 year-old
male who began having abdominal pain, nausea, vomiting and
high fever in [**2192-10-13**]. He was seen at a community
hospital near [**Location (un) 52794**]and underwent a CT scan of
the abdomen that apparently was interpreted as gas collecting
in the left lower lobe of the liver. An MRCP demonstrated
dilated peripheral hepatic ducts with a possible stricture.
An endoscopic retrograde cholangiopancreatography showed
normal common bile duct and distal hepatic ducts. The
peripheral ducts were not filled in the area of the CT and
MRCP abnormality. He was treated with intravenous
antibiotics for cholangitis and his fever resolved. He was
discharged on Ciprofloxacin 500 mg po b.i.d. and he was seen
by Dr. [**First Name (STitle) **] [**Name (STitle) 8551**] on [**2192-11-27**] and underwent a CT
scan of the abdomen on [**12-8**]. This was read as showing
persistent pneumobilia on the left lobe of the liver that was
unchanged from [**Month (only) **]. No abscess was seen. The
peripheral left hepatic bile ducts were dilated and no other
abnormalities were found. He denies any history of jaundice,
but he does have a long standing history of intermittent
gastrointestinal distress. He has lost 25 pounds during this
illness secondary to anorexia. He denies any history of
diarrhea or constipation. He underwent an endoscopic
retrograde cholangiopancreatography at [**Hospital1 190**] on [**12-25**] that demonstrated common bile
duct, common hepatic duct, cystic duct and gallbladder were
normal. The distal pancreatic duct was filled with contrast
and well visualized. There were no abnormalities. He had an
area of stricture in the left hepatic duct with proximal
marked dilatation consistent with primary sclerosing
cholangitis, focal Caroli's disease or cholangiocarcinoma.
He is now referred for consideration of left hepatic
lobectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS: Levaquin 500 mg po q.d.
DIET: He has a regular diet.
SOCIAL HISTORY: He has one or two social alcoholic beverages
per month. He smokes five cigarettes per day. He has no
history of intravenous drug use, marijuana use, blood
transfusions, hepatitis or piercing. He has a college
education and is a graduate student at [**Location (un) 35240**] [**Location (un) **].
He is single and has no children.
FAMILY HISTORY: Mother ahs heart disease. There is no
family history of liver disease.
PAST MEDICAL HISTORY: Stomach pain since [**2173**].
PAST SURGICAL HISTORY: No prior surgeries.
PHYSICAL EXAMINATION: Vital signs on admission blood
pressure 116/86. Pulse 76. Respirations 16. Temperature
96.8 and height 6', weight 227 pounds. On physical
examination he was an alert male in no acute distress. Skin
was normal with no evidence of spider angiomata or palmar
erythema. He had no scleral icterus. Neck with no
lymphadenopathy or thyromegaly. Lungs were clear to
auscultation. Cardiac examination showed normal S1 and S2.
No S3 or S4, murmurs or rubs. Regular rate and rhythm.
Abdominal examination benign. No hepatosplenomegaly, masses
or tenderness. No ascites. Extremities were with no
peripheral edema. Neurological grossly intact.
LABORATORY STUDIES: On [**12-19**] hemoglobin 14.3, hematocrit
41, white blood cell count 10.4, AST 28, ALT 21, alkaline
phosphatase 81, T bili .3. Amylase 66, lipase 26, INR 1, CEA
of 2, CA19 was pending at the time. On [**12-25**], his AST
was 21, ALT 48, alkaline phosphatase 88, and T bili .3.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2192-12-28**] for left hepatic lobectomy and cholecystectomy.
The patient's pain was controlled with a Dilaudid epidural at
20 with 1.1% Bupivacaine at 10 cc an hour. The patient was
alert and oriented times three and complaining of abdominal
tenderness. Postoperative laboratories showed a white blood
cell count of 17.3, hematocrit 33.5 and platelets of 298 with
a PT of 13.8, PTT 29.6 and INR of 1.3. Chemistries showed
sodium 139, potassium 4.3, chloride 109, bicarb 23, BUN 18,
creatinine .6 and glucose 150 with calcium, magnesium and
phos at 8.1, 1.4 and 3.5. ALT 24, AST 216, alkaline
phosphatase 59, T bili .9. Pain Service was consulted for
epidural management. On postoperative day one the patient
had a fever of 102.2 and continued to complain of mild pain.
On postoperative day two the patient continued to have fever,
which was thought likely due to atelectasis. The patient was
not cultured. On postoperative day two the patient had a
hematocrit drop to 24.5 from a postoperative hematocrit of
33.5 and was transferred to the unit for a rule out bleed.
The patient also had a fever of 102.5 at that time. The
patient was transfused 2 units of packed red blood cells and
continued NPO. He was also given 1 unit of fresh frozen
platelets. The patient's hematocrit trended down from 32.1
to 28.2 to 28.1 and 24.5. After 2 units the patient's
hematocrit came back to 31 and was stable and was transferred
to the floor on postoperative day three.
On postoperative day four the patient complained of gas pain
with three watery loose stools. C-diff was sent and the
patient was found to be C-diff positive and started on Flagyl
po. The patient was continue [**Male First Name (un) **] Zosyn that was started on
postoperative day number two for increasing fevers. The
patient was controlled on po Dilaudid from postoperative day
two after epidural was discontinued. Diarrhea improved by
postoperative day six. The patient began tolerating a po
diet. The patient was encouraged to get out of bed and on
postoperative day number seven [**1-4**] the patient was
discharged to home in good condition with discharge
greater then 101.4, persistent nausea, vomiting, constipation
or diarrhea and to please call for persistent abdominal pain
or redness and swelling around incision site.
FINAL DIAGNOSIS:
Caroli's disease status post hepatic lobectomy.
FOLLOW UP: Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2193-1-8**] at
phone number [**Telephone/Fax (1) 673**].
MAJOR SURGICAL PROCEDURE: Left hepatic lobectomy.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: To home with VNA for JP drain care.
DISCHARGE MEDICATIONS:
1. Flagyl 500 mg tablet one po t.i.d.
2. Dilaudid 4 mg tablet one tablet po q 2 to 4 hours as
needed.
3. Colace 100 mg capsule one po b.i.d. for three weeks,
please only take after diarrhea resolves.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,PH.D.[**MD Number(3) 48821**]
Dictated By:[**Last Name (NamePattern4) 7013**]
MEDQUIST36
D: [**2193-1-4**] 11:10
T: [**2193-1-4**] 11:13
JOB#: [**Job Number 52795**]
ICD9 Codes: 5180, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8693
} | Medical Text: Unit No: [**Numeric Identifier 68590**]
Admission Date: [**2191-12-3**]
Discharge Date: [**2191-12-3**]
Date of Birth: [**2191-12-3**]
Sex: F
Service: Neonatology
HISTORY: The infant is the 2.795 kg product of a 34-6/7 week
gestation, born to a 23-year-old G2, P1, now 2 mother.
Prenatal screens were A positive, antibody negative,
hepatitis surface antigen negative, RPR nonreactive, rubella
immune, GBS unknown. This pregnancy was complicated by a
sacrococcygeal teratoma, duplex left kidney, ureterocele and
polyhydramnios. At 19 weeks gestation, fetal survey revealed
left-sided hydronephrosis and then mother experienced
abdominal distention at approximately 31+ weeks gestation and
a follow-up fetal ultrasound revealed a left duplex kidney
with dilated upper pole and a sacrococcygeal teratoma. Fetal
MRI and ultrasound at [**Hospital3 **] revealed a duplex left
kidney with obstructed upper pole, normal right kidney and a
normal lower pole of left kidney, ureterocele in bladder,
sacrococcygeal teratoma, [**3-18**] external and [**2-15**] internal,
measuring at that time 6 x 6 x 5 cm in pelvis with a little
extension above the pelvic floor, polyhydramnios, heart at
the upper limits of normal size, no fetal hydrops. Family was
involved with the Advanced [**Hospital **] Care Center at [**Hospital3 18242**] with surgical consultation being provided by Dr.
[**First Name8 (NamePattern2) 44092**] [**Name (STitle) 37080**]. Prior OB history included a previous delivery
by C-section of male newborn, now 3 years old and healthy.
Social reveals a stay-at-home mom and father is [**Initials (NamePattern4) **] [**Name (NI) 68591**]
mechanic. Decision was made to deliver infant due to fetal
decelerations, delivery by repeat cesarean section. Apgars
were 9 and 9. The infant urinated in delivery room.
PHYSICAL EXAMINATION ON ADMISSION: Weight was 2.795 kg,
length 45 cm, head circumference 33.5 cm, non dysmorphic,
pink, in no acute distress. Anterior fontanelle was soft and
flat. Red reflex was present bilaterally. Ears were normal
set without anomalies. Neck was supple, intact clavicles,
intact palate. Lungs - fair aeration, positive grunting and
retractions. Cardiovascular - regular rate and rhythm, no
murmur, 2+ femoral pulses. Abdomen - soft, positive bowel
sounds, liver edge soft and just above the umbilical level,
rounded left mass palpable. GU - normal preterm female,
positive sacral mass involving perineum, rectum, lower
sacrum, right-sided greater than left-sided, measures 9 x 9 x
7 cm. Anus was open, positive anal wink.
PLAN: The plan is to transfer the infant to [**Hospital3 18242**] for further surgical management. In preparation for
transfer, the infant was intubated for management of
respiratory distress syndrome, received 1 dose of surfactant.
She was NPO on 60 cc/kg/day of D10W via peripheral IV. A UVC
was attempted and was not obtained. An UAC was in place with
half normal saline, running at 1 cc an hour. The infant had
CBC and blood culture obtained. The CBC had a white blood
cell count of 8.6, 18 neut's, zero bands, 64 lymphs, 10
nucleated red blood cells and hematocrit was 40.5 with a
platelet count of 283. Blood culture was obtained via UAC and
infant was started on ampicillin and cefotaxime.
DELIVERING OBSTETRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.
OBSTETRICIAN: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
PEDIATRICIAN: [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 933**], M.D.
The infant was transferred to [**Hospital3 1810**] for further
management. The parents are updated and involved.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2191-12-4**] 03:27:41
T: [**2191-12-4**] 09:49:18
Job#: [**Job Number 68592**]
ICD9 Codes: 769, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8694
} | Medical Text: Admission Date: [**2168-7-13**] Discharge Date: [**2168-7-19**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
cold L foot
Major Surgical or Invasive Procedure:
[**2168-7-19**] Left popliteal anterior tibial and posterior
tibial artery embolectomy and saphenous vein patch
angioplasty.
History of Present Illness:
[**Age over 90 **]F w acute onset of L foot pain approx 3 hours ago. No
prior history of claudication but remote history of afib after
surgery. She states she noticed sudden onset of numbness,
coolness, and pain of her L foot this afternoon. She was
referred to the ED for further work-up. She has never had pain
w
walking. She denies CP, SOB, N/V, abd pain, or other
complaints.
Past Medical History:
PMH: afib, HTN, hypothyroid, PNA
.
PSH: hysterectomy, L neck melanoma excision
Social History:
SH: no tobacco, no EtOH, no drug use
lives at [**Hospital3 **] apartment
Physical Exam:
Admission PE
PE: 98.3 90 156/115 16 94%RA
Gen: NAD, A+Ox3
Chest: CTAB
CV: RRR, - MRG
Abd: soft, NT, ND, no pulsatile mass
Ext: cool, blue plantar surface of distal L foot, loss of
sensation of the left foot, + motor function
Pulses:
fem [**Doctor Last Name **] PT DP
R palp palp dop palp
L palp palp - -
[**2168-7-14**] PHYSICAL EXAMINATION
The blood pressure was 130/80 mmHg supine. The pulse was 85
bpm.
The respiratory rate was 12. The patient was afebrile. The
weight was 107. Generally the patient appeared to be well
developed, well nourished and well groomed. The patient was
oriented to person, place and time. The patient's mood and
affect
were not inappropriate.
There was no xanthalesma and conjunctiva were pink with no
pallor
or cyanosis of the oral mucosa. The neck was supple with JVP of
5 cm water. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities. The
respirations were not labored and there were no use of accessory
muscles. The lungs were clear to ascultation bilaterally with
normal breath sounds and no adventitial sounds or rubs.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line.
There were no thrills, lifts or palpable S3 or S4.
The heart sounds revealed a normal S1 and physiologically split
S2. There were no rubs, clicks or gallops. The rate was
irregularily irregular. She had a [**12-15**] SM at the LLSB.
The abdominal aorta was not enlarged by palpation. There was no
organomegaly or tenderness.
The extremities had no pallor, cyanosis, clubbing or edema.
However the left leg was wrapped in gauze. I did not remove the
bandage. There were no abdominal, femoral. There was a very
soft right carotid bruits. She had a scar over her right neck
which was due to melanoma removal.
Inspection and/or palpation of skin and subcutaneous tissue
showed no stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal + DP 2+ PT +
Left: Carotid 2+ Femoral 2+ Popliteal + DP + PT +
EKG demonstrated atrial fibrillation with unspecific ST-T wave
changes. There is no prior comparison.
TELEMETRY: Atrial fibrillation with occasional polymorphic VPCs
max 3 beats.
Discharge PE
98.3, 140/60, 90, 20 94%RA
GEN: NAD
Cardiac: irreg, afib
Lungs: CTA
ABD: soft, NT
Pulses: B/L fem palp, B/L DP dop, RT PT palp, LT PT faint dop
Pertinent Results:
[**2168-7-19**] 05:25AM BLOOD WBC-17.8* RBC-3.25* Hgb-9.1* Hct-28.2*
MCV-87 MCH-28.0 MCHC-32.3 RDW-13.5 Plt Ct-266
[**2168-7-19**] 05:25AM BLOOD Plt Ct-266
[**2168-7-19**] 05:25AM BLOOD PT-34.1* PTT-44.7* INR(PT)-3.5*
[**2168-7-18**] 06:10AM BLOOD PT-34.0* PTT-88.6* INR(PT)-3.5*
[**2168-7-17**] 06:50AM BLOOD PT-21.0* PTT-74.1* INR(PT)-2.0*
Brief Hospital Course:
[**2168-7-13**] [**Age over 90 **]F w acute onset of L foot pain approx 3 hours ago. No
prior history of claudication but remote history of afib after
surgery. She states she noticed sudden onset of numbness,
coolness, and pain of her L foot this afternoon. She was
referred to the ED for further work-up. She has never had pain
w
walking. She denies CP, SOB, N/V, abd pain, or other
complaints.
Dx Left popliteal and proximal tibial
artery embolus. Taken to OR and underwent Left popliteal
anterior tibial and posterior tibial artery embolectomy and
saphenous vein patch
angioplasty.
[**2168-7-14**] Afib overnight. B/L DP/PT pulses palpable. Cardilogy/Dr.
[**Last Name (STitle) **] consulted for afib. Coumadin and Lopressor started. n
heparin gtt, titrated to maintain ptt 60-80.
[**Date range (1) 94275**] VSS. Afib continues. Cardiology titrating
Lopressor dose. Echo performed-Normal global and regional
biventricular systolic function. Moderate tricuspid
regurgitation. Mild pulmonary hypertension. Mildly dilated
ascending aorta.
[**2168-7-18**] VSS. No events. LLE swelling improved with ace wrap and
elevation. INR 3.5. Coumadin held X 1 day and dose decreased to
1mg. INR goal [**1-12**]. Cardiology following, rcommending starting
Toprol XL 150mg in am.
[**2168-7-19**] VSS. Started on 5 day course Flagyl for elevated WBC and
diarreah (also given laxative). Follow up scheduled with Dr.
[**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] (Cardiology). Per cardiology fellow-
Asymptomatic HR of 90-120 is acceptable. PCP- [**Last Name (NamePattern4) **]. [**Last Name (STitle) 81807**]
[**Name (NI) 653**] and his office will monitor coumadin/anticoagulation
once she is discharged back to her [**Hospital3 **] apartment.
Medications on Admission:
nifedipine, synthroid
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
4. Doxepin 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
5. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
7. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q 12H
(Every 12 Hours) as needed for glaucoma: 1 DROP BOTH EYES Q 12H
glaucoma .
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO BID (2 times a
day) as needed for constipation.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for mild pain .
12. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily):
Hold HR<60, if held, recheck and give when HR >60 and check with
MD or Dr.[**Name (NI) 8996**] office.
13. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Goal INR [**1-12**].
14. Outpatient Lab Work
INR 2x week/prn per Dr. [**Last Name (STitle) 81807**] phone [**Telephone/Fax (1) 71193**]/fax
[**Telephone/Fax (1) 94276**]. He will manage your anticoagulation once you are
back at your independent living facility.
15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 5 days: X 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 25112**]
Discharge Diagnosis:
[**Age over 90 **]F w cold L foot now s/p left [**Doctor Last Name **] embolectomy, vein patch
angioplasty
PMH: afib (isolated event 18 years ago after hysterectomy), HTN,
hypothyroid, PNA
.
PSH: hysterectomy, L neck melanoma excision
Discharge Condition:
Stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-12**]
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
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? 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:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over 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
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 3121**]
Date/Time:[**2168-8-1**] 2:20
[**Last Name (NamePattern1) 439**]-5B, [**Location (un) 86**] [**Numeric Identifier 718**] ([**Hospital Unit Name **])
Cardiology: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 2037**] [**2168-8-25**] 8am [**Hospital Ward Name 23**] [**Location (un) **] [**Hospital Ward Name 516**]
Your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 81807**] [**Telephone/Fax (1) 71193**]/fax [**Telephone/Fax (1) 94276**] will manage
your anticoagulation once you are back at your independent
living facility. The nursing home/rehab part of Rennasance
Gardens will manage your anticoagulation/coumadin while you are
inpatient.
Completed by:[**2168-7-19**]
ICD9 Codes: 4168, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8695
} | Medical Text: Admission Date: [**2160-4-10**] Discharge Date: [**2160-4-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Rectal bleeding
Major Surgical or Invasive Procedure:
Colonoscopy
Esophagogastroduodenoscopy
History of Present Illness:
87 yo F with h/o CAD, A fib on coumadin, HTN, hyperchol,
hypothyroidism p/w melena. Pt notes that for the past 2.5 weeks
she has been "run down with the flu," principally with symptoms
of malaise and poor appetite. Two days ago the pt noted the new
onset of black stools, described as "clots", passed with large
amounts of flatus. She was concerned that this was blood and
went to her PCP's office today. He did a rectal exam and in turn
referred her to the ED. Other than the melena, she denies any
frank blood. She had one episode of NB/NB vomitous one week but
no hematemesis. She denies CP/SOB/f/c/urinary sxs. Of note, pt
has had recent changes in her coumadin dose over the past 2
weeks though is unsure of doses.
.
In the ED, vitals: 97.6, hr 77, 181/64, rr 18, 95% ra. Hct 32
(baseline 38). wbc 16.9. INR 7.2. lactate 1.3. Lytes nml. U/A
6-10 wbcs. ekg: nsr@77bpm, LAD, no ishcemic changes. Pt given
vit K 10 mg po x 1, zosyn 4.5 grams iv, flagyl 500 grams iv. Pt
transferred to MICU for further management.
.
In the MICU, the patient received 2units FFP, HCTs remained
stable. GI evaluated and felt that an EGD was non-urgent and
will be done on Monday.
Past Medical History:
CAD: stress MIBI '[**56**]: IMPRESSION: At the level of exercise
achieved, there is a mild, partially reversible inferior wall
defect. MIBI in [**3-21**] without evidence of ischemia.
hypothyroidism
HTN
hypercholesterolemia
A fib
Social History:
widow, no tob, etoh, illicits, lives alone
Family History:
Three sisters with CAD after age 65 but all still living (ages
95, 81, 77). Mother had h/o CAD.
Physical Exam:
Temp 98.8
BP 136/63
Pulse 75
Resp 18
O2 sat 95 % ra
Gen - comfortbale, alert, no acute distress
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes dry
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd - Soft, nontender, nmildly distended, with normoactive bowel
sounds
Extr - No edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3,
Skin - No rash
rectal: guaiac pos in the ED
Pertinent Results:
[**2160-4-10**] 10:07PM BLOOD Hct-27.1*
[**2160-4-11**] 03:01PM BLOOD Hct-28.6*
[**2160-4-13**] 03:00PM BLOOD Hct-30.3*
[**2160-4-15**] 05:15AM BLOOD WBC-11.0 RBC-3.15* Hgb-9.2* Hct-28.2*
MCV-90 MCH-29.3 MCHC-32.7 RDW-14.0 Plt Ct-390
[**2160-4-16**] 05:28AM BLOOD WBC-11.1* RBC-3.09* Hgb-9.0* Hct-27.8*
MCV-90 MCH-29.1 MCHC-32.4 RDW-13.7 Plt Ct-355
[**2160-4-10**] 01:18PM BLOOD PT-60.6* PTT-58.5* INR(PT)-7.2*
[**2160-4-11**] 04:47AM BLOOD PT-20.1* PTT-34.1 INR(PT)-1.9*
[**2160-4-16**] 05:28AM BLOOD PT-15.0* PTT-27.7 INR(PT)-1.3*
[**2160-4-16**] 05:28AM BLOOD Glucose-111* UreaN-7 Creat-0.8 Na-141
K-4.0 Cl-106 HCO3-24 AnGap-15
[**2160-4-10**] 01:18PM BLOOD Glucose-96 UreaN-12 Creat-1.0 Na-142
K-3.5 Cl-105 HCO3-28 AnGap-13
[**2160-4-10**] 01:18PM BLOOD Calcium-8.8 Phos-3.0 Mg-1.8
[**2160-4-10**] 05:56PM BLOOD Lactate-1.3
[**2160-4-10**] 06:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008
[**2160-4-10**] 06:00PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-7.0 Leuks-TR
[**2160-4-10**] 06:00PM URINE RBC-0-2 WBC-[**6-24**]* Bacteri-OCC Yeast-NONE
Epi-0-2
CXR:
The heart size is normal. The aorta is tortuous and there is
calcification within the aortic knob. Ill-defined densities
noted within the right lung base. Questinable nodular densities
are scattered through out both lungs. The left retrocardiac
density corresponds to the hiatal hernia and appears unchanged
compared to the prior study. No pleural effusion or pneumothorax
is detected. The soft tissue and osseous structures are
unremarkable.
IMPRESSION:
Right basilar infiltrate is suggestive of peumonia.
Equivocal densities scattered through out both lungs need
further evaluation by nonurgent chest CT.
CT Abd/Pelvis:
Innumerable nodules measuring up to 13 mm in diameter are seen
in the imaged portion of the lung bases. The imaged portion of
the heart and pericardium appear unremarkable. Several enlarged
lymph nodes, some with hypodense centers, are seen in the
pericardial fat measuring up to 15 mm in diameter. Several
peripherally located heterogeneously hypodense lesions are seen
about the right and left lobes of the liver in subserosal
location consistent with metastases. The largest of these, in
the right lobe (2:14), measures 2.6 cm in diameter. Numerous
additional nodular and irregular foci involve the peripheral
aspects of segments V, VI, IVb and [**Doctor First Name 690**].
At the gastric fundus, a heterogeneous mass measures 3.4 x 2.6
cm and protrudes into the lumen (2:18).
Numerous enlarged lymph nodes and mesenteric masses are seen
throughout the entire abdomen. Two confluent omental masses
anteriorly (2:44) measure up to 6.1 cm in diameter. Numerous
additional mesenteric lymph nodes as well as retroperitoneal
nodes along the celiac axis and in aortocaval and paraaortic
location have hypodense centers consistent with central
necrosis. These are located in the omentum anteriorly (2:27), in
the lesser sac (2:27), adjacent to the spleen and along the left
lateral peritoneum (2:27, 21), and throughout the mesenteric
root (2:45). The pancreatic duct is nondilated and no definite
pancreatic masses are identified. The adrenal glands are mildly
nodular appearing although no definite masses are identified.
Bilateral hypodense renal lesions are too small to characterize.
There is no hydronephrosis. The aorta is normal in caliber with
mural calcification consistent with atheromatous disease. A
serosal mass involving the descending colon (2:60) measures 3.5
x 3.3 cm. The colon is displaced in multiple other locations by
multiple omental and serosal masses. There is no evidence of
bowel obstruction.
CT PELVIS WITH INTRAVENOUS CONTRAST: A heterogeneous centrally
hypodense mass spans the width of the lower abdomen and pelvis,
tethering the terminal ileum and cecum as well as the sigmoid
colon, and is contiguous with the uterus and adnexa. Overall,
this mass measures up to 14 cm in greatest transaxial dimension.
The sigmoid colon is extensively encased. The bladder contains
gas, and the dome of the bladder just touches the confluent
pelvic mass. Additional nodular implants are seen in the
rectovaginal cul-de-sac (2:78).
BONE WINDOWS: No definite lesions worrisome for osseous
metastatic disease are identified. There is lumbar scoliosis and
degenerative change.
IMPRESSION:
1. Innumerable omental and peritoneal masses throughout the
abdomen and pelvis, with the largest confluent mass in the deep
pelvis.
2. 3.4 x 2.6 cm gastric fundal mass.
3. Pulmonary metastases.
4. Serosal hepatic metastases.
5. Encasement of the uterus and sigmoid colon, and questionable
involvement of the bladder, by the conglomerate pelvic mass. No
evidence of bowel obstruction.
6. Air within the bladder. Please correlate with any possible
history of recent Foley catheterization.
Possible etiologies for the extensive metastatic disease could
include gastric cancer with metastases, versus other
gastrointestinal primary with metastases, or ovarian cancer.
Clinical correlation is recommended.
COLON BIOPSIES:
Proximal sigmoid colon mass, biopsy:
Colonic mucosa with chronic active inflammation.
No neoplasm seen.
Multiple levels have been examined.
Note: Possible causes include compression from an external
lesion or an intrinsic chronic colitis.
EGD:
Normal mucosa within the esophagus, stomach and duoenum. No sign
of gastric mass.
Colonoscopy:
Partially obstructing mass noted in the proximal sigmoid colon
(40cm) covered by normal appearing mucosa. Unable to pass scope
further.
Brief Hospital Course:
GI bleed: The patient intitially presented with a GI bleed.
Based on the presentation of more maroon stool than melena, it
was felt to be consitent with a lower GI bleed. Her INR was
significantly elevated at presentation, which was felt to be
contributing significantly to her bleeding. Her INR was reversed
with 2 units of FFP and 10mg of Vitamin K. She was initially
monitored in the ICU but remained hemodynamically stable and
required no blood transfusions with a stable hematocrit after
INR reversal. She was transferred to the floor and underwent a
colonoscopy after an uneventful prep. The colonoscopy found a
partially obstructing mass in the proximal sigmoid colon with
normal appearing mucosa. It was unclear if this was an
instrinsic vs. an extrinsic colonic mass pressing in so she
underwent a CT of her abd/pelvis. This found what is likely
diffuse metastatic disease, further discussed below. Her
coumadin has been stopped secondary to her increased bleeding
risk with her abdominal malignancy and for improved quality of
life. Her hematocrit remained stable througout her admission
with no further bleeding
Abdominal malignancy: As noted above, the patient was found to
have what appears to be diffuse metastatic disease throughout
her abdomen and lower lungs. The spread was consistent with a
gastric primary. Initial biopsies from the colonoscopy returned
as normal tissue, not surprising given the mass was only
extrinsically compressing the colon. An EGD was performed which
was entirely normal, indicating that the gastric mass seen on CT
was likely extraluminal. In discussion with the patient, she did
not desire any further work up including any other biopsies. She
does not desire any surgery or chemotherapy. A palliative care
consult was called and discussed hopsice options with the
patient. Fortunately, the patient was asymptomatic in regards to
her cancer. She was without pain, N/V, able to eat normally and
have normal bowel movement. Home hospice was set up and she was
discharged with close follow up with her PCP. [**Name10 (NameIs) **] was also set
up with an appointment with Dr. [**Last Name (STitle) **] in GI oncology to allow her
to ask further questions or discuss further options. She was
discharged with a prescription for stool softeners.
Pneumonia/UTI: The patient initially had a leukocytosis and a
positive U/A for a UTI. She also have a RLL infiltrate seen on
CXR. These were both treated with IV ceftriaxone and
transitioned to PO cefpodoxime, to finish a brief course at
home.
HTN: Initially her HTN meds were held in the setting of the GI
bleed. After she stabilized, they were restarted at lower doses
with good effect. She will be discharged on these lower doses
and follow up with her PCP.
A.fib: The patient remain rate controlled on her beta-blocker.
Her coumadin was stopped as above. She was continued on her low
dose aspirin.
Hypothyroidism: Continued on her home dose of Synthroid with
good effect.
Code status: DNR/DNI
Medications on Admission:
cozaar 100 mg daily
asa 81 mg daily
new thyroid medication X 2.5 weeks
coumadin (changed multiple times recently, pt unsure of dose)
toprol dose unknown
lipitor 10 mg daily
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 2 days.
Disp:*8 Tablet(s)* Refills:*0*
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
9. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hospice of the [**Hospital3 **]
Discharge Diagnosis:
Likely metastatic abdominal cancer, primary unknown
Lower gastrointestinal bleed
HTN
Atrial fibrillation
Coronary Artery Disease
Discharge Condition:
All vital signs stable, pain free, tolerating POs.
Discharge Instructions:
You were admitted with a GI bleed, likely from your lower
abdominal tract. This was likely caused by your elevated
coumadin level. During the work up for this, it was discovered
that you likely have metastatic cancer throughout your abdomen,
including pushing on your lower colon. As we discussed with you
and your family, we will not pursue any aggressive diagnosis,
including further biopsies. We will also not pursue chemotherapy
or surgery at this time. You will follow up with Dr. [**Last Name (STitle) **] and
we will set up a follow up appointment with one of our abdominal
cancer doctors to discuss [**Name5 (PTitle) 691**] further questions you may have.
We have stopped your coumadin as the risk from bleeding is
greater due to your cancer than the risk of stroke. We have also
decreased your blood pressure medications slightly as you did
not require as much while you were in hospital.
You were also diagnosed with a mild case of pneumonia and a
urinary tract infection while here. You were initially treated
with an IV antibiotic to treat both. This was changed to an oral
antibiotic that you will finish taking at home.
In discussion with you and your family, we have arranged for you
to go home with hospice assistance for further care.
Please call your doctor or the hospice nurses if you experience
abdominal pain, bleeding, nausea/vomitting, constipation,
difficulty urinating or any other symptoms that concern you.
Followup Instructions:
Please call Dr.[**Name (NI) 692**] office at [**Telephone/Fax (1) 693**] to schedule a
follow up appointment in the next 2-4 weeks.
You have an appointment with Dr. [**Last Name (STitle) **] (abdominal cancer doctor)
on [**5-2**] at 2pm. Please call ([**Telephone/Fax (1) 694**] to reschedule.
ICD9 Codes: 486, 5789, 5990, 4019, 2720, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8696
} | Medical Text: Admission Date: [**2189-8-20**] Discharge Date: [**2189-8-24**]
Date of Birth: [**2133-11-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Perirectal abscess/ pain x 7 days.
Major Surgical or Invasive Procedure:
I and D of abscess
History of Present Illness:
55 year old cantonese speaking male , PMH of ESRD on tri weekly
dialysis, DM, HTN, who presents with perirectal pain and
perirectal mass x 7 days.
Past Medical History:
-- HTN: difficult to control, multiple agents used
-- DM: with retinopathy, nephropathy
-- ESRD due to IgA nephropathy/DM
-- diabetic retinopathy- Blindness
-- R subclavian Thrombus [**2187**] - stopped anticoagulation in [**2187**]
-- Anemia of chronic disease
-- Hyperlipidemia
-- CAD - not an intervetional or CABG candidate. Cardiac
catheterization from [**2188-2-4**] showed 3VD with a 30% left
main, a diffusely diseased LAD with 80% mid stenosis, 90%
diagonal, 60% second diagonal, and 90% OM1. None suitable for
PCI or CABG. EF 60-70% TTE [**2188-10-14**]
Social History:
Cantonese/Mandarin speaking, limited English, immigrated to the
US 10 yrs ago, currently lives with wife and 3 children, has
been blind for approx 3 years, has not worked recently; No
history of tobacco use, alcohol, or illicit drug use. Wife
injects insulin.
Family History:
No family history of DM, CAD, Stroke, HTN, or Renal Disease
Physical Exam:
per surgery team
VS
Gen: Drowsy, hard to keep awake ( per wife is baseline state ).
Chest: Left dialysis catheter in Left subclavian vein.
CVS: RRR II/Vi Harsh systolic murmur at LSB and L 5th
intercostal space midclavicualr. No carotid bruits.
Pulm: CTAB no w/r/r
Abd: Soft NT/ ND + BS
Ext: No C/E bl
.
per icu team a day later:
VS: T 96.2; HR 68; BP 205/68; RR 22; SpO2 100% 3L NC
GEN: NAD, dyskinesia of mouth (lip smacking, tongue thrusting)
HEENT: mmm, poor dentition, small lesion on L side tongue, no
LAD, neck supple, no masses, blind, L eye: cloudy bloody cornea
no discernible pupil, R eye: small fixed pupil, injected
conjunctiva
CV: RRR, no M/R/G
LUNGS: CTA B, 100% 3L NC, episodes of panting
ABD: decreased bs, soft, ntnd
EXT: warm, dry, 2+ pedal and radial pulses, no edema or cyanosis
Perirectal area: packing is saturated with blood, edema
surrounding I/D site, very tender
Pertinent Results:
138 96 19
-------------< 79
3.4 29 6.0
Ca: 8.6 Mg: 1.6 P: 2.4 D
.
WBC: 11.4
HCT: 36.2
PLT: 198
.
PT: 14.3 PTT: 33.9 INR: 1.2
.
CXR: FINDINGS: In comparison with the study of [**5-11**], there is
again enlargement of the cardiac silhouette, although less
prominent than on the previous study. There is again
engorgement of the pulmonary vessels consistent with substantial
elevation of pulmonary venous pressure. The costophrenic angles
have cleared, consistent with decreased pleural effusion
Brief Hospital Course:
Mr. [**Known lastname 724**] is a 55 year old man with a PMH significant for ESRD on
MWF HD, CAD, DM, anemia, poorly controlled HTN, and anemia
transferred from the surgical service for monitoring s/p
perirectal I/D.
1. Perirectal Abscess: The patient was admitted for a perirectal
abscess status post I/D on [**8-19**]. Mr. [**Known lastname 724**] was initially treated
with ciprofloxacin and flagyl. After wound culture speciated out
as MRSA, vancomycin was added to the patient's antibiotic
therapy. Per Dr. [**Last Name (STitle) **] of surgery, antibiotic therapy will
need to be continued for 14 days (stop on [**9-5**]). The patient was
treated with oxycodone PRN for pain control, which he did not
require in the 48 hours prior to discharge. A follow-up
appointment was scheduled for the patient with Dr. [**Last Name (STitle) **] in
outpatient clinic in 2 weeks.
2. HTN: After the patient's I/D procedure, he became
hypertensive with SBP >200 and was transferred to the [**Hospital Ward Name 332**] ICU
for closer monitoring. His home medications were continued and
he was also placed on a nitroglycerin drip which was continued
until his hemodialysis on [**8-21**], at which point he became
hypotensive and the nitroglycerin was discontinued. Upon
transfer to the medicine floor, his blood pressure remained
stable. At discharge, patient was continued on his home regimen
of labetolol, minoxidil, clonidine, imdur, and amlodipine.
3. CAD: Patient's ASA and plavix was held for the I/D procedure.
At discharge, patient was resumed on all home medications
including ASA, plavix, losartan, labetolol, lisinopril.
4. DM 2: Patient continued on 70/30 and RISS Q6H during his
hospital course.
5. Hyperlipidemia: Patient continued on home statin therapy.
6. ESRD: Patient on MWF hemodialysis, which was continued during
his hospital course. Last HD was on day of discharge ([**Month/Year (2) 766**]).
Nephrocaps continued during hospital course. The patient will
need vancomycin dosed per HD protocol.
7. Anemia of chronic disease: On discharge, patient's HCT stable
and at baseline.
Medications on Admission:
Allergies: NKDA
Home meds (per OMR):
Atorvastatin 40mg po daily
Aspirin 325mg po daily
Clonidine patch
Epogen (2xper wk)
Hydralazine 50mg po daily
Insulin (NPH 10 units [**Hospital1 **])
Lisinopril 40mg daily
Losartan 100mg daily
Metoprolol tartrate 150mg po bid
Minoxidil 2.5mb po bid
Amlodipine 10mg daily
Nephrocaps
Calcium 500mg po tid
Plavix 75mg po daily
Protonix 40mg po daily
Reglan 5mg q8h IV
Fluticasone 2 puffs IH [**Hospital1 **]
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY
(Daily) as needed for constipation.
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
7. Minoxidil 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
10. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO Before every
meal.
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
13. Fluticasone 50 mcg/Actuation Disk with Device Sig: Two (2)
puffs Inhalation twice a day.
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day) as needed.
15. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
Sig: 8 units in the morning and 6 units at night . Subcutaneous
daily.
16. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
17. Metronidazole 250 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 12 days: Stop on [**9-5**].
Disp:*36 Tablet(s)* Refills:*0*
18. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 12 days: STOP ON [**9-5**].
Disp:*12 Tablet(s)* Refills:*0*
19. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous HD PROTOCOL (HD Protochol) for 12 days: STOP ON
[**9-5**]. gram
20. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
Sig: 8 units in the AM and 6 units in the PM Subcutaneous twice
a day.
21. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
22. Outpatient Lab Work
Vancomycin trough to be drawn on Friday ([**8-28**]) prior to
hemodialysis.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Primary
1. Perirectal abscess
2. Hypertension
Secondary
Diabetes
ESRD qMWF due to IgA nephropathy/DM
Diabetic retinopathy
R subclavian Thrombus [**2187**] - stopped anticoagulation in [**2187**]
Anemia of chronic disease
Hyperlipidemia
CAD
Discharge Condition:
Patient was discharged in stable condition.
Discharge Instructions:
1. You were admitted for a perirectal abscess, which was
surgically drained. You will need to take antibiotics for a
total of 14 days (STOP ON [**9-5**]). Your antibiotic regimen is:
Vancomycin 1000mg per HD protocol
Flagyl 250mg po TID (to be given after hemodialysis)
Ciprofloxacin 500 mg by mouth every 24 hours (to be given after
hemodialysis)
2. You will need to have a blood test (vancomycin trough) drawn
on Friday (8/285) prior to hemodialysis.
3. You should resume all of your home medications as prior to
admission. It is important that you take all of your medications
as prescribed.
4. You have a follow-up appointment with the surgeon as listed
below. It is very important that you make all of your doctors
[**Name5 (PTitle) 4314**].
5. If you develop a fever, chest pain, shortness of breath, or
other concerning symptoms, you should contact your PCP or go to
the local Emergency Department immediately.
Followup Instructions:
You are scheduled for a follow-up appointment with Dr. [**Last Name (STitle) **]
of surgery on [**2189-9-3**] at 4pm at [**Street Address(2) 1126**] in [**Location (un) **],
MA.
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-4**]
weeks. You can [**Month/Day (2) **] an appointment by calling ([**Telephone/Fax (1) 58911**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12902**], MD Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2189-11-19**] 10:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2190-4-6**] 11:20
Completed by:[**2189-8-24**]
ICD9 Codes: 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8697
} | Medical Text: Admission Date: [**2174-11-30**] Discharge Date: [**2174-12-6**]
Date of Birth: [**2116-8-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2174-11-30**] Three Vessel Coronary artery bypass grafting utilizing
the left internal mammary to left anterior descending, vein
grafts to obtuse marginal and posterior descending artery
[**2174-11-30**] Cardiac Catheterization with Placement of an IABP
History of Present Illness:
This is a 58 year old male who presented to the [**Hospital1 18**] with 4
hours of chest pain that was described as 10 out of 10. The EKG
was remarkable for [**Street Address(2) 2914**] elevation in the inferior
leads. He was started on Integrilin and Heparin and urgently
taken to the cardiac cath lab. CKMB on admission was 20 with a
troponin T of 0.05.
Past Medical History:
Coronary Artery Disease, Hypertension, Hypercholesterolemia,
non-insulin dependent Diabetes Mellitus, inferior MI
Social History:
Unavailable
Family History:
Unavailable
Physical Exam:
Vitals: BP 108/64, HR 87, RR 10 with 100% saturations
General: well developed male in mild distress
HEENT: oropharynx benign
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2174-12-5**] 07:40AM BLOOD WBC-6.4 RBC-3.05* Hgb-9.1* Hct-26.3*
MCV-86 MCH-29.8 MCHC-34.5 RDW-13.6 Plt Ct-217
[**2174-11-30**] 09:45AM BLOOD WBC-5.9 RBC-4.16* Hgb-12.5* Hct-35.7*
MCV-86 MCH-30.1 MCHC-35.0 RDW-13.1 Plt Ct-185
[**2174-12-5**] 07:10AM BLOOD Glucose-121* UreaN-14 Creat-0.9 Na-135
K-4.0 Cl-100 HCO3-23 AnGap-16
[**2174-11-30**] 09:45AM BLOOD Glucose-145* UreaN-12 Creat-0.8 Na-135
K-4.2 Cl-104 HCO3-22 AnGap-13
[**2174-11-30**] 09:45AM BLOOD CK-MB-20* cTropnT-0.05*
[**2174-12-4**] 10:35AM BLOOD Calcium-8.4 Phos-4.9* Mg-2.0
[**2174-11-30**] 09:45AM BLOOD ALT-70* AST-58* AlkPhos-59 Amylase-50
TotBili-0.4
[**2174-11-30**] 09:45AM BLOOD Triglyc-144 HDL-39 CHOL/HD-4.6
LDLcalc-112
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent emergent cardiac
catheterization which revealed severe three vessel coronary
disease. He remained hemodynamically stable throughout the
procedure but due to the severity of his coronary anatomy, an
IABP was placed. Coronary angiography revealed a right dominant
system. The LAD had a long 70% mid lesion; the first diagonal
had a 90% stenosis; the distal circumflex had a 99% lesion while
the proximal RCA and PDA both had a 90% stenoses. Left
ventriculogram showed no mitral regurgitation and a LVEF of 65%.
Following the procedure, he was taken directly to the operating
room for surgical revascularization, and three vessel coronary
artery bypass grafting was performed. The operation was
uneventful and he was brought to the CSRU in stable condition.
Despite revascularization, his preoperative inferior ST
elevations persisted. Repeat cardiac catheterization was done,
showing a patent LIMA and vein grafts. The LIMA was noted to
have evidence of diffuse spasm while the vein grafts had slow
flow related to large size mismatch in vessel caliber. He was
subsequently started on Plavix in addition to Aspirin. While in
the CSRU, he was noted to have short frequent runs of
non-sustained ventricular tachycardia. K and Mg levels were
monitored and repleted per protocol while Amiodarone therapy was
initiated. Beta blockade was concomitantly resumed. He
maintained stable hemodynamics with improvement in ventricular
ectopy. The IABP was gradually weaned and removed without
complication. He awoke neurologically intact and was extubated
without incident. His CSRU course was otherwise uneventful and
he transferred to the floor on postoperative day three. Pacing
wires were removed on POD #4. He started iron and vitamin C on
POD #5. Hct was 26.3. CXR showed a stable small left apical
pneumothorax. He developed some constipation and was given a
fleets enema and discharged to home on POD #6.
T 98.9 HR 80 NSR RR 22 114/67 91% RA sat.
Medications on Admission:
? avandia
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*30 Tablet(s)* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. Ferrous Sulfate 325 (65) mg Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day.
Disp:*30 Capsule, Sustained Release(s)* Refills:*0*
10. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
12. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO
DAILY (Daily) for 5 days.
Disp:*5 Packet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
Coronary Artery Disease, Acute MI, s/p Coronary Artery Bypass
Grafting
Hypertension
Hypercholesterolemia
Diabetes Mellitus
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] in [**4-19**] weeks
PCP [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**Last Name (STitle) 66153**] - in [**2-17**] weeks
Local cardiologist - *** - in [**2-17**] weeks
Completed by:[**2174-12-26**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8698
} | Medical Text: Admission Date: [**2183-10-3**] Discharge Date: [**2183-10-10**]
Date of Birth: [**2108-2-14**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: A 75-year-old gentleman who had
been worked up for back surgery. As part of the workup,
patient had a history of angina and underwent cardiac
catheterization. Cardiac catheterization showed significant
left main disease and three vessel coronary artery disease.
Patient was transferred from [**Hospital6 **] to [**Hospital1 1444**] for further evaluation and
treatment.
PAST MEDICAL HISTORY: Sleep apnea for which he uses a CPAP
machine at night.
Coronary artery disease status post myocardial infarction in
[**2152**].
Benign prostatic hypertrophy.
GERD.
Hypertension.
Spinal stenosis.
Status post left shoulder surgery.
Status post melanoma removal from his back.
Status post fusion of his lumbar vertebrae.
Status post bilateral total knee replacements.
Status post right shoulder replacement.
SOCIAL HISTORY: Patient has a 50-pack-year tobacco history,
quit smoking in [**2166**]. He admits to drinking [**2-18**] alcoholic
drinks per day.
ALLERGIES: Rifampin.
Sulfa.
Ancef.
PREOPERATIVE MEDICATIONS:
1. Lisinopril 10 mg by mouth every day.
2. Aspirin 81 mg by mouth every day.
3. Pravachol 20 mg by mouth every day.
4. Mobic 7.5 mg by mouth every day.
5. Nitro paste 1" every six hours.
6. Mirapex 0.5 mg by mouth every day.
7. Flomax 0.4 mg by mouth every day.
8. Protonix 40 mg by mouth every day.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**]. Upon evaluation of his
catheterization films and evaluation of the patient, it was
determined patient had ongoing angina. An intra-aortic
balloon pump, which was placed, did not result in resolution
of angina. Patient was taken urgently to the operating room
with Dr. [**Last Name (STitle) **] on [**10-3**] for a CABG x2, LIMA to LAD, and
saphenous vein graft to OM, total cardiopulmonary bypass time
42 minutes, cross-clamp time 32 minutes. Patient was
transferred to the Intensive Care Unit in stable condition.
Patient's intraoperative transesophageal echocardiogram
showed an ejection fraction of greater than 55 percent.
Patient had his intra-aortic balloon pump removed on
postoperative day number one. He remained intubated on
postoperative day number one due to episode of rapid atrial
fibrillation to the 140s, which required multiple attempts at
cardioversion and treatment with amiodarone. Patient had
hypotension associated with the event. Patient had moderate
amount of agitation while he was off sedation. Patient was
started on Precedex.
Patient was weaned and extubated from mechanical ventilation
on postoperative day number two. Patient converted into
sinus rhythm spontaneously. Prior to extubation, patient
continued to required Levophed to maintain adequate systolic
blood pressure. The Levophed was weaned to off and on
postoperative day number three, the patient was transferred
from the Intensive Care Unit to the regular part of the
hospital. Patient had been begun on Ativan due to his
history of EtOH intake and agitation and aggressive behavior.
Patient was transfused 1 unit of packed red blood cells on
postoperative day number three. Patient's chest tubes and
pacing wires were removed without incident. Patient began
ambulating with Physical Therapy, and it was decided that the
patient should be anticoagulated due to his multiple episodes
of postoperative atrial fibrillation. Patient was started on
Heparin drip and given Coumadin.
By postoperative day number six, patient had cleared level 5
with Physical Therapy. His INR had reached therapeutic level
and he was cleared for discharge home. On postoperative day
seven, he was discharged to home in stable condition.
CONDITION ON DISCHARGE: Temperature 99, pulse 62 in sinus
rhythm, blood pressure 119/59, respiratory rate 15, room air
oxygen saturation 93 percent. Patient's weight on [**10-10**] is
81 kg, preoperatively, the patient weighed 79 kg.
Neurologically: He is awake, alert, anxious, and oriented x3
and nonfocal. Heart is regular rate and rhythm without rub
or murmur. Patient's last episode of atrial fibrillation was
greater than 48 hours ago. Respiratory: Breath sounds are
clear and decreased at the left base. Chest x-ray on [**10-10**]
showed bilateral atelectasis, no significant effusion or
consolidation, no pneumothorax. Abdomen has positive bowel
sounds, soft, nontender, nondistended. Extremities had 1
plus edema in the left lower extremity, which is the site of
the vein harvest. Trace edema in the right lower extremity
and left lower extremity Steri-Strips are intact. There is
no erythema or drainage. Sternum: Steri-Strips are intact.
There is no erythema or drainage. The sternum is stable.
Potassium 4.2, BUN 23, creatinine 1.1. [**Name (NI) **] PT is 19.4,
INR is 2.4.
DISCHARGE CONDITION: The patient is to be discharged to home
in stable condition.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg by mouth twice a day.
2. Colace 100 mg by mouth twice a day.
3. Enteric coated aspirin 81 mg by mouth every day.
4. Protonix 40 mg by mouth every day.
5. Pravastatin 20 mg by mouth every day.
6. Flomax 0.4 mg by mouth every day.
7. Mirapex 0.5 mg by mouth every day.
8. Amiodarone 200 mg by mouth every day.
9. Lorazepam 0.5 mg by mouth every evening as needed.
10. Ibuprofen 600 mg by mouth every six hours.
11. Tylenol with codeine number three 1-2 tablets by
mouth every four to six hours as needed.
12. Lasix 40 mg by mouth every day x7 days.
13. Potassium chloride 20 mEq by mouth every day x7
days.
14. Coumadin. The patient is to receive 2.5 mg of
Coumadin on [**9-5**], and [**10-12**]. He is to have his
PT/INR checked by the visiting nurse on [**10-3**] with results
called to his cardiologist, Dr.[**Name (NI) 33126**] office. Dr.
[**Name (NI) 33126**] office is to adjust his Coumadin for a goal INR of
[**2-17**].5.
DISCHARGE DIAGNOSES: Coronary artery disease.
Status post coronary artery bypass graft.
Postoperative atrial fibrillation.
Benign prostatic hypertrophy.
Hypertension.
Sleep apnea.
Spinal stenosis.
DISCHARGE CONDITION: The patient is to be discharged to home
in stable condition.
FOLLOW-UP INSTRUCTIONS: He is to followup with Dr. [**Last Name (STitle) 9751**] by
phone number [**10-13**] for his INR results and Coumadin dosing.
He is to followup with Dr. [**Last Name (STitle) 9751**] in the office on [**10-23**]
at 2 p.m. Follow up with Dr. [**Last Name (STitle) **] in [**2-18**] weeks. He is to
followup with Dr. [**Last Name (STitle) **] in [**3-20**] weeks.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern4) 8524**]
MEDQUIST36
D: [**2183-10-10**] 19:28:35
T: [**2183-10-11**] 05:30:21
Job#: [**Job Number **]
ICD9 Codes: 4111, 9971, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8699
} | Medical Text: Admission Date: [**2155-12-22**] Discharge Date: [**2155-12-29**]
Date of Birth: [**2101-1-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides) / Morphine / Lactose-Free
Food
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
Recurrent Tracheobronchomalaciae
Major Surgical or Invasive Procedure:
Cervical tracheal resection and tracheoplasty ([**2155-12-22**])
History of Present Illness:
54yo F w/ a PMHx significant for prior tracheoplasty/bilateral
mainstem bronchioplasty w/ mesh ([**2152-12-19**]) represented with
recurrent symptoms of cough and SOB over a 6 month history.
This was quite debilitating for her and she elected to
re-explore a work-up for its etiology. Work-up revealed
recurrent tracheobronchomalacia and the patient elected to
undergo a primary cervical tracheal resection in an attempt to
palliate the dynamic upper airway collapse that she manifested
(while knowing that the lower airways still have collapse
occuring but that a re-thoracotomy and dissection of the
bronchi/mediastinal trachea with the incorporated mesh was too
risky, etc).
Past Medical History:
1- tracheobronchomalacia
2- Diabetes Mellitus (controlled)
3- Hypertension
4- Hyperlipidemia
5- H/o Staphylococcal and pseudomonal PNA
6- Depression/Anxiety
7- Obstructive Sleep Apnea
8- Migraines
9- Asthma/Bronchitis
Social History:
Denies tobacco, +occasional EtOH, married, lives in [**State 12000**]
Family History:
Non-contributory (no malignancy/tracheomalacia/Collagen Vascular
Disease)
Physical Exam:
VS: T= 97.0 HR 72 (SR) BP 110/75 RR 20 SpO2 98%RA
HEENT- anicteric, MMM, no cervical LAD, no JVD/thyromegaly, OP
negative
Cor- Reg S1S2 no m/r/g
Pulm- CTA x w/ some mild exp wheeze/cough
Abd- soft, NT, ND, no HSM, no mass/hernia
Ext- no c/c/e/ct, palp pedal pulses
Pertinent Results:
[**2155-12-22**] 12:00PM UREA N-17 CREAT-0.9 SODIUM-138 CHLORIDE-101
TOTAL CO2-27
[**2155-12-22**] 12:00PM WBC-10.5 RBC-3.57* HGB-9.6* HCT-28.0* MCV-78*
MCH-27.0 MCHC-34.4 RDW-14.8
Brief Hospital Course:
The patient underwent a primary repair of her trachea after a
2.5cm segment of cervical trachea was resected and
re-anastamosed (no mesh, interrupted vicryl utilized).
Post-peratively, the patient did very well. Her diet was serial
advanced, pulmonary toilet was administered. She complained of
intermittent cough (non-productive) and headache. Bedside
bronchoscopy x2 showed an intact anastamosis and minimal
secretions. A sty suture was removed from her chin by POD#5 and
she was dismissed home on POD#7 with instructions not to stretch
her neck and limit her ROM. She was afebrile, with adequate
oral analgesia and with no evidence of a wound
hematoma/cellutitis. The patient additionally completed a one
week course of Clindamycin to cover for upper respiratory track
pathogens in the wound bed. On the day of dismissal, a
bronchoscopy was completed that showed no evidence of necrosis,
ischemia or dehiscence with minimal secretions.
Medications on Admission:
Metformin 1000 [**Hospital1 **], Welbutrin 300mg QD, Lexapro daily, [**Doctor First Name **]
180mg QD, Singulair 10mg QD, Zocor 20mg QD, Trazodone 50mg HS,
Prevacid 15mg QD
Discharge Medications:
1. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO QD ().
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO daily ().
5. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Bupropion 150 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO QAM (once a day (in the morning)).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
11. Metformin 250mg po BID
Discharge Disposition:
Home
Discharge Diagnosis:
tracheobronchomalacia (recurrent) s/p tracheoplasty
Discharge Condition:
Good
Discharge Instructions:
Take all new prescriptions as directed. Do not drive while
taking narcotic pain medications.
You may resume your regular diabetic diet. Please resume any
previously taken medications as directed.
Please call Dr.[**Name (NI) 1816**] office [**Telephone/Fax (1) 170**] or return to the ER
if you experience:
- Fever (>101)
- Increased pain
- Worsening shortness of breath or chest pain
- Purulent discharge from your wound
- Other symptoms concerning to you
She should follow-up with her PCP when she returns to home (to
go over her medications and titrate her metformin dose back to
baseline once she is taking adequate po intake)
Followup Instructions:
Do not eat after midnight on wednesday.
Arrive at daycare [**Hospital Ward Name 121**] 8 at 9am for a broncoscopy with Dr.
[**Name (NI) **] and Dr. [**Last Name (STitle) 952**]
Completed by:[**0-0-0**]
ICD9 Codes: 2724, 4019 |
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