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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8700
} | Medical Text: Admission Date: [**2163-7-17**] Discharge Date: [**2163-7-23**]
Date of Birth: [**2116-7-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Transfer from [**Hospital6 5016**] after trauma in which patient
inpaled with sawblade in chest
Major Surgical or Invasive Procedure:
mediastinal exploration and removal of foreign body/ repair
right upper lobe [**7-17**]
History of Present Illness:
46yoM working at home, fell and landed on saw. Saw blade
imbedded in right chest. Chest tube placed at OSH then patient
transferred here for mediastinal exploration.
Past Medical History:
HTN
^ lipids
Fx Rt heel
M&T rt ear
Social History:
Lives with wife
[**Name (NI) 15068**] officer
Remote [**Name (NI) 79620**] quit many years ago
ETOH- daily(several drinks)
Family History:
noncontributory
Physical Exam:
Admission
VS T HR 85 BP 137/73 RR 12 O2sat 100%
Gen intubated
Neuro chemically paralyzed
Pulm diminished rt
CV RRR
Abdm soft, NT/ND
Ext warm, no edema. no varicosities. 2+ pulses throughout
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 79621**] (Complete)
Done [**2163-7-17**] at 10:22:26 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
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: [**2116-7-22**]
Age (years): 46 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Hypertension.
ICD-9 Codes: 402.90, 440.0
Test Information
Date/Time: [**2163-7-17**] at 22:22 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2008AW1-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 50% to 60% >= 55%
Findings
LEFT ATRIUM: Normal LA size. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal
LV wall thickness. Normal LV cavity size. Normal regional LV
systolic function.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque. Normal aortic diameter at
the sinus level. Simple atheroma in aortic root. Normal
ascending aorta diameter. Simple atheroma in ascending aorta.
Normal aortic arch diameter. Simple atheroma in aortic arch.
Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
TEE performed for saw blade trauma to right chest.
1. The left atrium is normal in size. No thrombus is seen in the
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal.
3. Right ventricular chamber size and free wall motion are
normal.
4. The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque. There are
simple atheroma in the aortic root. There are simple atheroma in
the ascending aorta. There are simple atheroma in the aortic
arch. There are simple atheroma in the descending thoracic
aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
7. There is a trivial/physiologic pericardial effusion.
8. There is no pleural effusion seen. The SVC is intact from the
RA to 4 cm above the RA.
Dr. [**Last Name (STitle) **] was notified in person of the results.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2163-7-17**] 22:29
Brief Hospital Course:
He was taken to the operating room where he underwent a
mediastinal exploration, removal of foreign body and repair of
RUL. He was transferred to the ICU in stable condition. He
received a dose of IV gentamicin for additional antibiotic
coverage given his penetrating wound. He was extubated on POD
#1. C-spine was cleared. He was started on a 10 days course of
ancef, which was changed to cefpodoxime. He was transferred to
the floor in stable condition. There was some question whether
or not he had RLL collapse vs pleural effusion, so he underwent
ultrasound by interventional pulmonology which merely showed
atelectasis. Chest tubes were DC'd, and he was discharged home
on [**2163-7-23**] in stable condition.
Medications on Admission:
Simvastatin, Atenolol, Lisinopril
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Cefpodoxime 100 mg Tablet Sig: Four (4) Tablet PO Q12H (every
12 hours) for 6 days.
Disp:*48 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
penetrating trauma s/p mediastinal exploration and removal of
foreign body/ repair right upper lobe [**7-17**]
PMH: HTN, ^lipids, rt heel fx, R&T rt ear
Discharge Condition:
good
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds.
Followup Instructions:
Chest Xray on [**2163-7-29**], return to floor for wound check.
[**Hospital 409**] clinic in 2 weeks
Dr [**Last Name (STitle) 7772**] in 4 weeks
Dr. [**Last Name (STitle) 55164**] in 2 weeks [**Telephone/Fax (1) 55136**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2163-7-23**]
ICD9 Codes: 5180, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8701
} | Medical Text: Admission Date: [**2146-6-15**] Discharge Date: [**2146-6-25**]
Date of Birth: [**2092-8-6**] Sex: M
Service: SURGERY
Allergies:
Zestril / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
end-stage renal disease
Major Surgical or Invasive Procedure:
living unrelated renal transplant4/28/10
History of Present Illness:
53-year-old gentleman with end-stage renal disease and multiple
medical problems including obesity and coronary artery disease
who presents for consideration of kidney transplantation.
Past Medical History:
CAD, s/p stent ([**12-19**] at [**Hospital1 1774**]), s/p CABG [**2145-9-15**] ongoing angina
Hypertension, h/o hypertensive urgency
Respiratory arrest [**2-/2145**] with resuscitation
Chronic diastolic heart failure
Chronic renal failure, secondary to ATN and diabetes
Angina pectoris
Diabetes
Obesity, s/p laparoscopic banding ([**Doctor Last Name **], [**12-25**]), with
subsequent removal of band after prolonged hospitalization in
[**10/2144**]
Hypercholesterolemia
OSA; has not used CPAP/BIPAP for years but does use 2L NC at
night
Psoriasis; Psoriatic arthritis
Chronic anemia
h/o TIA without residual symptoms
Motorcycle trauma ([**2144-11-8**]) with BL open Monteggia fractures,
R
knee degloving injury, hypotension, facial laceration s/p
ex-lap, and s/p cervical fusion with bone graft. ORIF R and L
elbows with hardware still in place, trach and peg
h/o hypernatremia
Social History:
Lives with wife, 3 children. On disability, former truck driver.
Tobacco: Former smoker, quit [**9-/2143**] after 80 pack-year history.
ETOH: Former heavy drinker, currently only has one drink on
occasion. Illicits: does endorse very remote history of cocaine
use, no history of any drug use in many years.
Family History:
Father - Leukemia, [**Name2 (NI) 32071**] heart disease
Mother - Diabetes [**Name2 (NI) **] type 2
Sister - Diabetes [**Name2 (NI) **] type 2
Physical Exam:
PE from preop office visit
Appears well.
Lungs are clear bilaterally.
Heart is regular.
Abdomen is soft, nontender, and nondistended, but obese.
He has multiple ventral hernias from his previous surgeries.
His groin pulses are 2+ throughout.
There is minimal peripheral edema.
Pertinent Results:
[**Name2 (NI) 1326**] kidney US [**6-15**]: Transplanted kidney with appropriate
arterial waveforms and resistive indices. No hydronephrosis or
perirenal fluid collection. Apparent slow flow within the renal
vein but it appears patent.
[**Month/Year (2) 1326**] kidney US [**6-16**]: 1. No hydronephrosis and no
perinephric collection. 2. Elevated resistive indices in the
intraparenchymal renal arteries.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Known lastname 1326**] Surgery Service and
underwent Living Unrelated Donor Kidney [**Known lastname 1326**]. The kidney
came from his wife. His post-operative course is summarized
below by system.
Neuro: Post-operatively pain was controlled on a morphine PCA
and was transitioned to PO pain meds.
Renal/[**Known lastname 1326**]/Immunosuppression: Mr. [**Known lastname 51792**] [**Known lastname **] was
complicated by delayed graft function requiring dialysis on [**6-20**].
His CBC and chemistries were monitored daily and more often as
indicated. He completed the typical post-operative course of
immunosuppression except that, due to low platelet counts, his
dose of ATG was given over more days in doses of 75. On [**6-21**]/5th the patient began to have increased urine output with an
associated drop in creatinine, seen the day before. This
continued up until his discharge with good urine output.
F/E/N: In general the patient did well with regard to fluids.
Because of the delayed graft function, he required dialysis on
[**6-20**]. After this, however, his graft function picked up and he
was able to handle his own excretory needs. On the day prior to
discharge, his potassium was elevated on his AM labs, follow up
showed an increasing potassium level to 6.1. This was treated
with dextrose, insulin, and IV lasix with moderate response,
thus he was also given kayexelate on the day of discharge after
his potassium had begun trending down. There were no associated
EKG changes. He will have labs checked on Monday in clinic.
During his hospitalization, he had an HD line present on right,
which served as IV access during the hospitalization. This will
be removed in office during followup.
Heme: In the context of the operation and the immediate
post-operative period he required transfusion of 2 pRBCs on
[**6-15**] FFP on [**6-16**] plt on [**6-16**]. He also had low platelets
intermittently in response to the ATG, thus the dose was given
at 75 a day.
Physical Therapy: The patient was seen in house by physical
therapy and considered able to go home with home PT. He was
encouraged to ambulate early and often.
Mr. [**Known lastname **] was discharged on POD 10 afebrile, with normal
hemodynamics, making good urine, tolerating a regular diet with
pain controlled on oral medications. He will follow up for lab
work on Monday [**6-27**].
Medications on Admission:
lipitor 80 daily, zetia 10 daily, carvedilol 25 [**Hospital1 **], citalopram
20 daily, asa 81 daily, plavix 75 daily, embrel 50 qweekly,
pepcid 20 daily, folate 1 daily, thiamine 100 daily, lantus 14
qAM 20 qhs, novolog SS, synthroid 50 dialy, renagel, epogen
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
s/p living unrelated renal [**Company **]
Hypertension
wound drainage
delayed graft function
hyperkalemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Please call the [**Name8 (MD) 1326**] Office [**Telephone/Fax (1) 673**] if you experience
any of the warning signs listed
You will need to have lab work drawn every Monday and Thursday
Visiting Nurse Agency has been arranged to assist you at home.
They will call you to arrange a home visit in the next day or so
Followup Instructions:
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2146-7-1**] 8:20
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name11 (NameIs) **] SOCIAL WORK
Date/Time:[**2146-7-1**] 9:00
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2146-7-7**] 10:20
ICD9 Codes: 5856, 4280, 2720, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8702
} | Medical Text: Admission Date: [**2123-8-23**] Discharge Date: [**2123-8-26**]
Date of Birth: [**2080-8-12**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
43 year-old female with history of ESRD on HD and HIV/AIDS CD
count 36 [**6-24**]), VL (106,986 copies/ml [**6-24**])
not on HAART who presented to ED from HD today (1.2L removed)
with right sided headache. Patient had shingles with eye
involvement in [**2117**], and has had neuralgia since. She has
previously been on gabapentin 100mg daily, and in the setting of
worsening pain, she had self titrated up to to 300mg once a day
over the last 6 weeks with bilateral blurry vision. Saturday She
became light headed and unsteady on her feet, and on looking up
the side effects of gabapentin, her son had her stop gabapentin
that day. Pain became persistent, [**9-22**] limited to the right
forehead. Felt lightheaded, unsteady on feet and son looked up
side effects of gabapentin and she stopped the drug a day or two
ago. ROS positive for chronic right eye swelling, which remains
unchanged. Denies phono or photophobia, fevers, chills or neck
rigidity.
.
Initial ED VS were T: 97.9 HR:92 BP:86/54 RR:18 02 100% RA
In the ED she was noted to have diffuse injection over her right
eye sclera. Fluorescein exam by ED physicians did not reveal
dendritic lesions. Diffuse erythematous lesions with small
ulcerations were noted over right zygoma. She declined LP. non
contrast head CT was remarkable only for exuberant
calcifications of falx and tentorium cerebelli, likely related
to patient's known ESRD and CXR and EKG unremarkable. Leukopenic
at 2.4 with 12% eos, Cr 5.8, gas of 7.37/47/34/28 with lactate
2.2. Blood cx sent. She received 750cc of NS with further
decline in BP to 74/34. Another 2.25L of fluid was given with BP
to 93/53. During fluid bolus patient developed "a funny chest in
her feeling ,HR 117 with repeat EKG now showing atrial
fibrillation. Troponin sent. She received percocet for pain and
cefepime/vanco (?cellulitis/line infection). Also started on
Acyclovir.Patient was sent to the ICU for further management.
On arrival to the MICU, VSS. Pt with 24 and 22 guage needles for
access. Right forehead pain is [**3-23**]. The "funny feeling" in her
chest has resolved.
Past Medical History:
# ESRD DUE TO: HIV nephropathy. Does not make urine.
# ON RENAL REPLACEMENT SINCE: [**2109**]
# ACCESS HISTORY AND COMPLICATIONS:
- multiple failed AVFs, most recently with femoral tunneled line
1. HIV. Diagnosed [**2105**] (heterosexual intercourse with HIV
positive partner). Hx PCP [**Name Initial (PRE) 11091**] x3 (last >10y ago). Last CD4 41.
Noncompliant w/HAART many times in past. Never restarted in [**Month (only) **]
[**2122**].
2. Varicella zoster [**2117**] right scalp and V1 distribution
complicated by loss of vision R eye + postherpetic neuralgia (on
Neurontin in the past without relief). Takes percocet with good
relief.
3. HIV associated ESRD on HD since [**2109**].
4. Cervical dysplasia.
5. Fibroids s/p ablation.
6. Post-HD presyncope and hypotension [**2121**] (diltiazem stopped).
7. Coag-negative staph bacteremia/HD line infection [**2121**].
8. Secondary hyperparathyroidism
9. Atrial fibrillation
Social History:
She lives at home with her 17-year-old daughter; sister also
lives in [**Name (NI) 86**]. Originally from [**Location (un) 4708**]. Unemployed, on
welfare. She denies alcohol, illicits or tobacco.
Family History:
Sister- DM, other sister - [**Name (NI) 27141**] in 50s
Physical Exam:
On admission:
Vitals: T: 97.4 BP: 102/64 P:98 R: 18 O2: 97% RA
General: Alert, oriented, no acute distress
HEENT: erythematous plaques in background of hyperpigmentation
and scarring with scattered circular erosions limited to right
face and forehead. Excoriated papules on scalp. Sclera
anicteric, MMM, oropharynx clear, sluggish right pupil, PERRL
Neck: supple, JVP not elevated, no LAD
CV: regularly irregular normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly. Left groin HD line with site clean, dry and
intact.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Skin: hyperpigmented follicular papules scattered over extensor
surfaces of upper and lower extremities, chest and abdomen with
associated excoriations, largely sparing back.
ON DISCHARGE
98.3, 98/53, P-83, RR-18, 97RA
General: Alert, oriented, no acute distress
HEENT: erythematous plaques in background of hyperpigmentation
and scarring with scattered circular erosions limited to right
face and forehead. Excoriated papules on scalp. Sclera
anicteric, MMM, oropharynx clear, sluggish right pupil, PERRL
Neck: supple, JVP not elevated, no LAD
CV: regular normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly. Left groin HD line with site clean, dry and
intact.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Skin: hyperpigmented follicular papules (prurigo) scattered over
extensor surfaces of upper and lower extremities, chest and
abdomen with associated excoriations, largely sparing back.
Pertinent Results:
On admission:
[**2123-8-23**] 02:20PM BLOOD WBC-2.4* RBC-3.95*# Hgb-12.6# Hct-40.6#
MCV-103* MCH-31.9 MCHC-31.0 RDW-14.7 Plt Ct-102*
[**2123-8-23**] 02:20PM BLOOD Neuts-64 Bands-1 Lymphs-12* Monos-8
Eos-12* Baso-1 Atyps-1* Metas-1* Myelos-0
[**2123-8-23**] 02:20PM BLOOD PT-9.9 PTT-32.8 INR(PT)-0.9
[**2123-8-24**] 04:39AM BLOOD WBC-2.5* Lymph-19 Abs [**Last Name (un) **]-475 CD3%-91
Abs CD3-432* CD4%-1 Abs CD4-6* CD8%-84 Abs CD8-399 CD4/CD8-0.0*
[**2123-8-23**] 02:20PM BLOOD Glucose-85 UreaN-27* Creat-5.8* Na-135
K-4.4 Cl-98 HCO3-24 AnGap-17
[**2123-8-23**] 02:20PM BLOOD CK-MB-4 cTropnT-0.26*
[**2123-8-24**] 04:39AM BLOOD CK-MB-4 cTropnT-0.24*
[**2123-8-23**] 02:20PM BLOOD CK(CPK)-102
[**2123-8-24**] 04:39AM BLOOD CK(CPK)-106
[**2123-8-24**] 04:39AM BLOOD Calcium-8.4 Phos-4.9* Mg-1.8
[**2123-8-24**] 04:39AM BLOOD Cortsol-7.4
[**2123-8-23**] 02:28PM BLOOD Type-[**Last Name (un) **] pO2-34* pCO2-47* pH-7.37
calTCO2-28 Base XS-0 Comment-GREEN TOP
[**2123-8-23**] 02:28PM BLOOD Lactate-2.2*
Imaging
CT Head
1. No acute intracranial process. If clinical suspicion for a
mass or an
acute infarction is high, MRI is the recommended study of
choice.
2. Again noted is exuberant calcification of the falx and
tentorium
cerebelli, likely related to patient's known underlying
end-stage renal
disease.
CXR- IMPRESSION: No acute intrathoracic process.
ECG [**2123-8-23**]
Atrial fibrillation. Borderline rapid ventricular response.
Since the
previous tracing atrial fibrillation is new. Clinical
correlation is
suggested.
ECG [**2123-8-25**]
Sinus rhythm. The tracing is within normal limits. Compared to
the previous
tracing of [**2123-8-23**] sinus rhythm has replaced atrial
fibrillation.
Brief Hospital Course:
43 year old F with history of AIDS (last CD4 count 6), ESRD on
HD, herpes zoster ophthalmicus c/b post-herpetic neuralgia
presenting with worsening right facial pain with blurry vision,
dizziness, and hypotension.
# Hypotension and dizziness: She was initially admitted to the
ICU with relative hypotension (baseline SBPs 90s) and
tachycardia with leukopenia, thereby meeting SIRS criteria.
Since it was unclear if her hypotension was secondary to a
septic process, she was covered broadly with Vancomycin and
Cefepime to cover a ?line infection vs. CNS infection and
acyclovir to prophylactically cover a reactivation of herpes
zoster of her face. She seemed to respond to 3L NS, maintaining
SBPs in low 90s-100s, with occasional dips into the 80s without
symptoms. Given her eosinophilia, her cortisol level was
checked to rule out adrenal insufficiency and it was low/normal.
Subsequent stim test showed no adrenal disease. She was seen by
the Renal team and it was decided to stop all antibiotics given
that her BPs were close to her baseline. It was felt that her
increased dose of gabapention may have contributed to her
feeling unwell. She was then transferred to the medical floor.
BP's were stable on the floor, but dropped to 60's-70's systolic
while on dialysis. Patient was asymptomatic and BP's recovered
with 200cc NS bolus. Patient was discharged with normal baseline
systolic BP in 80's-90's.
# Headache with facial itching and blurry vision/Post-herpetic
Neuralgia: She presented with an acute on chronic headache with
acute worsening in the setting of discontinuation of gabapentin.
Although there was a negative fluorescein exam in the ED, we
also asked the Ophthalmology team to evaluate her vision given
her prior history of eye involvement. They did not feel that
there were any acute concerns. Patient was prescribed
fexofenadine for her prurtitis. She also has a presumed
diagnosis of post-herpetic neuralgia. She was represcribed
amytriptiline which she reported has worked for her in the past.
# Rash: Clinically suspicious for eosinophilic folliculiits in
setting of HIV. No vesicular lesions noted, without concern for
disseminated herpes zoster. Primarily has post inflammatory
hyperpigmentation to trunk and extremities, although ? some
active lesions on scalp. Given proximity to facial lesions, with
? herpes zoster reactivation, her pruritus was managed with
fexofenadine 180mg qam, downtitrated to 60mg [**Hospital1 **] on transfer to
the floor. She was discharged with a prescription for this dose.
# ESRD on dialysis: ESRD [**1-14**] HIV on [**Month/Day (2) 12075**] dialysis. She was
continued on sevalemer and cinacalcet.
# Atrial fibrillation: She had one episode of afib during fluid
bolus in ED. Continued management with [**Month/Day (2) **] 325mg daily, without
rate controllers.
# AIDS: CD4 count of 6, off HAART in setting of non compliance.
Her risk for increased frequency herpes zoster reactivation off
HAART is certainly elevated. She had stopped her TMP-SMX and
azithromycin prophylaxis, so we restarted it on admission. She
was given Rx for these meds at discharge.
Transitional Issues
-The patient has FU appointments with her PMD Dr [**Last Name (STitle) **] and
Dermatology.
-She will also continue her prior dialysis schedule of [**Last Name (STitle) 12075**]
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Cinacalcet 60 mg PO DAILY
2. HydrOXYzine 25 mg PO TID:PRN itching
3. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
do not drive, operate machinery, or take sedating medications
while on this [**Last Name (STitle) 4085**]
4. Gabapentin 300 mg PO DAILY
5. Aspirin 325 mg PO DAILY
6. sevelamer CARBONATE 3200 mg PO TID W/MEALS
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Cinacalcet 60 mg PO DAILY
3. sevelamer CARBONATE 3200 mg PO TID W/MEALS
4. Amitriptyline 25 mg PO HS
RX *amitriptyline 25 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Azithromycin 1200 mg PO 1X/WEEK (TU)
RX *azithromycin 600 mg 2 tablet(s) by mouth once a week Disp
#*8 Tablet Refills:*0
6. Fexofenadine 60 mg PO BID
RX *fexofenadine 60 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
do not drive, operate machinery, or take sedating medications
while on this [**Last Name (STitle) 4085**]
8. HydrOXYzine 25 mg PO TID:PRN itching
9. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours as
needed Disp #*90 Tablet Refills:*0
10. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (MO,WE,FR)
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth three times per week (Mon, Wed, Fri) Disp
#*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Herpes Zoster Opthalmicus
HIV/AIDS
Eosinophilic Folliculitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital with headache and dizziness. This was
likely from your chronic shingles infection at your R eye. After
careful examination, it did not appear that you had an
infection. You also had significant itchiness that we have
controlled with a [**Last Name (STitle) 4085**] called fexofenadine. You have been
restarted on a [**Last Name (STitle) 4085**] called amitryptiline to help you with
your eye pain.
Your CD4 count was rechecked in the hospital. The level is 6.
This is dangerously low and puts you at risk for
life-threatening infection. This could be improved if you decide
to start anti-retroviral therapy. There are antibiotic
[**Last Name (STitle) 4085**] that you can take to help prevent these infections
called Bactrim and Azithromycin. You have started these
medications while you were in the hospital. You should continue
to take these medications at home.
You have follow-up appointments with all of your doctors listed
below.
It was a pleasure taking care of you, Ms [**Known lastname **].
Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2123-9-1**] at 8:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DERMATOLOGY
When: WEDNESDAY [**2123-9-1**] at 10:30 AM
With: [**Doctor Last Name 3833**] [**Telephone/Fax (1) 1971**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: OBSTETRICS AND GYNECOLOGY
When: WEDNESDAY [**2123-9-22**] at 2:30 PM
With: [**Hospital 14201**] CLINIC [**Telephone/Fax (1) 2664**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 1935**] CENTER
When: WEDNESDAY [**2123-12-15**] at 1 PM
With: [**Name6 (MD) 6131**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8703
} | Medical Text: Admission Date: [**2168-12-14**] Discharge Date: [**2168-12-19**]
Date of Birth: [**2114-1-5**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 28989**] is a pleasant,
54-year-old male with a known history of coronary artery
disease with a catheterization in [**Month (only) 205**] of this year which
showed 3-vessel coronary artery disease. However, the
patient was ultimately referred to outpatient medical therapy
because he denied permission for a coronary artery bypass
graft. His symptoms persisted with angina on exertion and
had a positive stress test approximately one month ago.
Ultimately, he agreed to a coronary artery bypass graft and
was transferred from the [**Hospital3 15174**] where he
was recently admitted for substernal chest pressure and a
rule out myocardial infarction protocol.
PAST MEDICAL HISTORY: The patient's past medical history is
significant for cardiac risk factors of hypercholesterolemia,
positive family history, as well as hypertension. He did
have a non-Q-wave myocardial infarction in [**2168-7-10**]. He
has had low back pain chronically requiring narcotics to
treat. He did fracture his right foot 10 years ago.
PAST SURGICAL HISTORY: His past surgical history included
tonsillectomy. He has had a lymph node removed from his neck
35 years ago, and a hair implant 20 years ago.
REVIEW OF SYSTEMS: Review of systems was notable just for
exertional substernal chest pain relived with nitroglycerin.
He had no respiratory complaints.
MEDICATIONS ON ADMISSION: His medications on admission were
atenolol 12.5 mg p.o. q.d., aspirin, Lipitor, nitroglycerin.
ALLERGIES: He has no known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: His examination was
notable for a blood pressure of 100/70, heart rate of 60, in
no acute distress. His head, ears, nose, eyes and throat
examination revealed pupils were equal, round, and reactive
to light and accommodation. Mucous membranes were moist.
His trachea was midline. No bruit. Heart had a regular rate
and rhythm with no murmurs. Lungs were clear to auscultation
bilaterally. His abdomen was soft, nontender, and
nondistended, with no bruit. His extremities were normal.
There were normal palpable posterior tibialis and dorsalis
pedis pulses bilaterally.
LABORATORY DATA ON PRESENTATION: His admission laboratories
were notable for white blood cell count [**Pager number **], hematocrit 39,
platelets 84,000. Chemistries were sodium of 137,
potassium 4.4, chloride 100, bicarbonate 27, blood urea
nitrogen 18, creatinine 1.2, glucose 101. PT and INR were
within normal limits.
HOSPITAL COURSE: He was therefore admitted on [**12-14**] to
the Cardiothoracic Surgery Service to have his coronary
artery bypass graft to be completed on [**2168-12-16**].
Additional information about the admission workup included a
chest x-ray that was negative. A urinalysis that was also
negative.
The patient went to the operating theater on [**2168-12-16**]
with Dr. [**Last Name (STitle) 1537**], where he underwent a 4-vessel coronary artery
bypass graft. He received grafts including left internal
mammary artery to the left anterior descending artery, left
radial graft to the PL, as well as saphenous vein graft to
the first obtuse marginal, sequential to the diagonal.
Postoperatively, he was transferred to the Intensive Care
Unit where he was on nitroglycerin, propofol, and
Neo-Synephrine.
On postoperative day one the patient was taken off of
Pressonex. His Neo-Synephrine was weaned to off. He was
placed on a cardiac diet. He was started on Lopressor,
Lasix, and aspirin. His postoperative hematocrit was 26,
white count of 15,000. Platelets were 319. Blood urea
nitrogen and creatinine of 15 and 0.8.
Ultimately, he was transferred to the floor on postoperative
day one. His postoperative course was complicated only by
high pain requirement. The patient ultimately had an Acute
Pain consultation and was placed on oxycodone 10 mg to 20 mg
p.o. q.4h. p.r.n. as well as Tylenol 650 mg p.o. q.4-6h.
p.r.n.
On postoperative day three, his temperature was noted to
be 101.5. He was cultured times two. Additionally, he got a
chest x-ray that showed a new left retrocardiac density since
surgery which was suspicious for a possible pneumonia.
Urinalysis was negative. Blood cultures did not grow out
anything during his hospital course. He was empirically
started on Levaquin and Flagyl to treat presumed pneumonia.
His temperature curve quickly defervesced once he was started
on the empiric therapy. His pain was well controlled. He
was ambulating and voiding spontaneously. Portable chest
x-ray showed no evidence of pneumothorax, just small
bilateral effusions, right greater than left. Additionally,
the aforementioned retrocardiac densities were present on the
left side.
By postoperative day four, the patient was ambulating a level
V and had completed stairs. His discharge laboratories were
notable for a hematocrit of 23, a white blood cell count
of 13,000, as well as blood urea nitrogen of 16, and
creatinine of 0.8. His discharge examination was notable for
a temperature of 98, pulse 87, blood pressure 115/70,
respiratory rate 20, 92% on 2 liters, in no acute distress.
His sternum was stable. There was no drainage. No was no
erythema. The staples were intact. His heart was regular
with no murmur. His lungs were clear to auscultation except
for decreased breath sounds, left greater than right. No
crackles were present, however. His abdomen was benign. His
lower extremities were warm and well perfused with palpable
dorsalis pedis and posterior tibialis pulses bilaterally.
MEDICATIONS ON DISCHARGE: (The patient's discharged
medications included the following)
1. Lopressor 25 mg p.o. b.i.d.
2. Lasix 20 mg p.o. q.d. times seven days.
3. K-Dur 20 mEq p.o. q.d. times seven days.
4. Colace 100 mg p.o. b.i.d. while he is taking oxycodone.
5. Oxycodone 10 mg to 20 mg p.o. q.4h. p.r.n.
6. Zantac 150 mg p.o. b.i.d.
7. Aspirin 325 mg p.o. q.d.
8. Tylenol 650 mg p.o. q.4-6h. p.r.n.
9. Levaquin 500 mg p.o. q.d. for a total course of seven
days (to be completed by [**2168-12-26**]).
10. Flagyl 500 mg p.o. t.i.d. (to be completed by
[**2168-12-26**]).
DISCHARGE FOLLOWUP: The patient's follow up will include
being seen by Dr. [**Last Name (STitle) 1537**] in one month from the time of
discharge. He will require no home services with [**Hospital6 3429**]. He was to be seen in the Wound Care
Clinic one week from the time of this discharge.
DISCHARGE STATUS: The patient's disposition was to home.
CONDITION AT DISCHARGE: Condition on discharge was stable,
afebrile.
DISCHARGE DIAGNOSES: Status post 4-vessel coronary artery
bypass graft for unstable angina.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2168-12-20**] 17:27
T: [**2168-12-20**] 16:54
JOB#: [**Job Number 35452**]
ICD9 Codes: 486, 2720, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8704
} | Medical Text: Admission Date: [**2161-7-28**] Discharge Date: [**2161-8-17**]
Date of Birth: [**2117-2-1**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: This is a 44-year-old gentleman
who developed sudden onset substernal chest pain on [**4-21**] of
this year. He presented to an outside hospital where he was
found to have EKG changes positive for ischemia, and a slight
troponin elevation. A CAT scan was obtained at the outside
hospital which showed a dilated ascending aorta without any
evidence of dissection. The patient was transferred to [**Hospital1 **] for further work-up.
Upon arrival to [**Hospital1 **], again the CT scan
films were reviewed, and it was decided that the patient had
no evidence of dissection or aortic hematoma. The patient
underwent cardiac catheterization at that time which showed
severe aortic regurgitation, no aortic dissection, no
coronary artery disease. The patient also had a
transesophageal echocardiogram which showed aortic
insufficiency and an ejection fraction of 25-30%, again with
a dilated ascending aorta. Both the echocardiogram and
cardiac catheterization showed elevated filling pressures,
and the patient was admitted and treated for his volume
overload.
During the patient's hospitalization, an RPR was sent which
was positive, and it was determined that the patient had an
aortic aneurysm due to syphilitic aortitis. The patient was
referred to Dr. [**Last Name (STitle) **] for treatment of his syphilitic
aortitis, as well as to Dr. [**Last Name (STitle) 70**] for surgery. The
patient was treated with penicillin for 10 days, and was
subsequently scheduled with Dr. [**Last Name (STitle) 70**] for repair of his
ascending aortic aneurysm.
The patient's preoperative work-up showed that the patient
had mildly elevated liver enzymes, as well as an elevated
prothrombin time. The patient was admitted preoperatively
for further work-up.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Syphilitic aortitis with ascending aortic aneurysm.
3. Positive tobacco; the patient smokes 2 packs per day.
SOCIAL HISTORY: The patient denies IV drug abuse or
excessive alcohol consumption.
ALLERGIES: NKDA.
PREOPERATIVE MEDICATIONS:
1. Lisinopril 20 mg po qd.
2. Lasix 10 mg po qd.
3. Ativan 0.5 mg prn.
ADMISSION PHYSICAL EXAM: Pulse 62, sinus rhythm, blood
pressure 128/63, room air oxygen saturation 96%.
Neurologically, the patient was awake, alert, neurologically
nonfocal. Heart has regular rate and rhythm, no rubs, a
[**Last Name (STitle) 1105**]/VI systolic ejection murmur. Abdomen was obese, positive
bowel sounds, soft, nontender, nondistended.
HOSPITAL COURSE: Upon admission to the hospital, the patient
had preoperative labs drawn which showed an elevated PTT,
which was consistent with his previous lab studies which had
been in the mid-40s to low 50s. The hematology service was
consulted. They felt that most likely cause was a lupus
anticoagulant, and the patient had test for lupus
anticoagulant, as well as anticardiolipin antibody, and full
coagulation panel sent. The results subsequently were found
that the only positive lab value in all of those tests was a
positive lupus anticoagulant.
The patient also had mildly elevated LFTs with an ALT 139,
AST 75, alk phos 143, with a total bili of 0.4. A medicine
consult was obtained to help sort out the etiology of the
elevated liver function tests. A liver ultrasound was
obtained which showed the liver was diffusely increased in
echotexture, no gross abnormalities of the pancreas,
gallbladder without stones or wall thickening, no biliary
ductal dilatation. The [**Location (un) 1131**] of the ultrasound was that
the highly echogenic liver was consistent with fatty
infiltration. It was not able to be determined the cause of
this. However, it was recommended that the patient have
follow-up as an outpatient, and both hematology and medicine
consult determined that these findings would not prohibit
patient from going for an operation.
The patient was taken to the operating room on [**2161-7-30**]
with Dr. [**Last Name (STitle) 70**]. While the patient was being prepped in
the operating room, the hematology service consulted cardiac
surgery team and discussed the further finding that one of
the two tests for lupus anticoagulant had been negative,
while the other test had been positive. It was decided by
Dr. [**Last Name (STitle) 70**], in discussion with further members of the
hematology service and the cardiac surgery service, that the
patient's surgery should be postponed until definitive
diagnosis could be made. The patient was intubated at the
time. The patient was brought from the Intensive Care Unit
to the Cardiac Surgery Recovery Unit where the patient was
weaned and extubated from mechanical ventilation.
Further hematology work-up was undertaken, and all of the
laboratory data was repeated. In the repeat hematology
work-up, it was shown that the original test for lupus
anticoagulant was again positive. However, the lupus
anticoagulant inhibitor screen was negative, while it should
have been positive with a positive lupus anticoagulant. It
was determined that the patient did not have a factor
deficiency, and it was decided that no clinically important
inhibitor deficiency was found, and the patient was not at
increased risk for bleeding, and the patient was cleared for
surgery definitively by the hematology service.
An official hepatology consult was obtained during this time,
as the patient's preoperative ultrasound of his liver showed
fatty infiltrates. The hepatologist felt that the fatty
infiltrates of his liver were likely NASH with no evidence of
cirrhosis, but again reiterated that a liver biopsy would be
necessary for absolute confirmation, but the hepatologist
felt that the patient was clear for surgery.
The patient was taken to the operating room on [**2161-7-31**] with Dr. [**Last Name (STitle) 70**] for replacement of the ascending
aortic root and aortic valve with a 28 mm homograft, and
replacement of the transverse arch due to an ascending aortic
aneurysm. The patient tolerated the procedure well and was
transferred to the Intensive Care Unit in stable condition on
a low-dose milrinone infusion. The patient did not have
excessive bleeding postoperatively and was started on
Precedex.
On the morning of postoperative day #1, the patient became
increasingly oliguric. It was decided to obtain a
transesophageal echocardiogram which showed no pericardial
effusion, no evidence of aortic dissection, normal left
ventricular function. The patient's liver function tests
were checked, and it was noted that all of the liver function
tests were significantly elevated with an ALT 7,000, AST
13,000, CK 14,000 and bilirubin 2.6. The patient had an
ultrasound of his liver and kidneys done at this time. The
ultrasound of the liver and kidneys showed no evidence of
hydronephrosis; the vascular supply to the liver and kidney
were within normal limits; and the diffusely echogenic liver
was unchanged from the previous study.
The hepatology service was reconsulted, and had no specific
explanation for the patient's postop acute hepatitis.
Recommended discontinuing any hepatotoxins, which had
previously been done, and to monitor the INR and liver
function tests q 6 h, which was done.
A renal consult was obtained due to the patient's continued
oliguria. The patient was started on IV fluids. It was felt
by the renal service that the patient had acute tubular
necrosis. However, the patient's renal function continued to
deteriorate, and the patient became progressively more
acidotic, and subsequently required the initiation of CVVH.
On postoperative day #2, a transplant was also obtained due
to patient's severe acute hepatitis in the event that the
patient would proceed to liver failure. The transplant
service recommended close follow-up, and it was recommended
that an isoflurane antibody be sent, the results of which are
still pending at this time. The patient's liver enzymes
continues to rise on his first postoperative day into his
second postoperative day, and slowly began to decrease.
However, the patient's creatinine continued to rise. During
this time, the patient was weaned off of milrinone due to
profound hypotension and continued on Neo-Synephrine infusion
to maintain adequate perfusion pressure. Neo-Synephrine was
weaned off on postoperative day #2. The patient continued to
be intubated and requiring mechanical ventilation during this
time due to significant volume overload, and the patient's
tenuous clinical status. Once CVVH was initiated, the
patient again required Neo-Synephrine infusion to maintain
adequate blood pressure. During this time, the patient's
cardiac output remained excellent. Since liver function
tests continued to decrease, the patient continued on CVVH,
and in spite of this therapy continued to have a rising BUN
and creatinine. The patient required intermittent blood
transfusions.
On postoperative day #4, the patient had a triglyceride level
that was greater than 2,000. The patient had been on
propofol since immediately postoperatively. This was
discontinued, and the triglyceride level continued to trend
down after that. The patient also had a sputum sample on the
26 that had gram-negative rods on the Gram stain. The
patient was started on Levofloxacin empirically, and
subsequent sputum culture was negative. The patient
completed a 10-day course of antibiotics. The patient
required bicarb replacement for continued acidosis thought to
be due to his kidneys.
On postoperative day #4, as the patient had multiple problems
with clotting his CVVH filter, hematology service agreed with
starting a low-dose heparin infusion, and following activated
clotting times to monitor anticoagulation. They felt that
there was no contraindication to this. Heparin drip was
started for a goal ACT of 150-160. The patient tolerated
this well without any evidence of bleeding.
The patient continued to have volume removal through the CVVH
with negligible urine output during this time. The patient
was weaned and extubated from mechanical ventilation on
postoperative day #4, requiring aggressive pulmonary toilet.
The patient continued to be lethargic. However, he was
following commands and was neurologically nonfocal. The
patient had significant hypertension upon extubation and was
started on Lopressor and hydralazine.
The patient was started on a labetalol infusion on the
evening of postoperative day #5, and several hours after that
the patient's hypertension came under control with the
bolused medications of Lopressor and hydralazine, and the
labetalol infusion was discontinued. The patient's CVVH was
discontinued on postoperative day #6, and the patient was
given a lasix challenge with minimal response. The renal
service scheduled the patient to start hemodialysis
treatments on postoperative day #8. On postoperative day #7,
with the patient liver function tests continuing to decrease,
the transplant service signed-off and felt that there was no
need for transplant work-up at that time.
On postoperative day #8, the patient underwent his first
hemodialysis treatment for removal of 2 kg, which he
tolerated well. The patient was continued on lasix and
Zaroxolyn with minimal to moderate urine output. The patient
had periods of agitation and confusion, for which he was
started on Haldol low-dose. This seemed to provide the
patient significant improvement in his mental status after a
couple of doses, and this was subsequently weaned off after
several days.
On postoperative day #10, by patient's urinalysis and urine
electrolytes, the renal service felt that the patient was
intravascularly depleted and recommended holding diuretic
treatment and starting the patient on IV fluids. The patient
was started on some IV fluids with out significant
improvement in his urine output or his BUN and creatinine.
BUN and creatinine continued to rise, and the patient had
hemodialysis on postoperative day #11 for no removal of
fluid, but ultrafiltration for clearance of solute.
The patient began working with physical therapy, getting out
of bed and sitting in a chair, and performing his own
activities of daily living. On postoperative day #12, the
patient was transferred from the Intensive Care Unit to the
floor. The renal service felt that his need for dialysis
would only be temporary, however would not be clear for the
next several weeks to months. It was recommended that the
patient have a Perma-Cath placed for dialysis access. The
patient began to have increasing urine output over the next
several days, and the renal service recommended again
starting the patient on diuretics which was done. The
patient was started on lasix with improvement in his urine
output and subsequent decrease in his BUN and creatinine.
The patient was taken to the operating room on [**2161-8-14**] for
placement of a Perma-Cath by Dr. [**Last Name (STitle) 952**]. The patient
tolerated the procedure without difficulty. The patient had
hemodialysis on the [**8-15**] for removal of 2 kg of
fluid and ultrafiltration. The patient continued to have
moderate urine output with adequate clearance of potassium.
On [**2161-8-15**], after working with physical therapy,
the patient was able to walk 500' and climb one flight of
stairs without difficulty, without requiring oxygen, and
remaining hemodynamically stable. On [**8-17**], the
patient was cleared for discharge to home.
DISCHARGE DIAGNOSES:
1. Syphilitic aortitis.
2. Ascending and transverse aortic arch aneurysm.
3. Bicuspid aortic valve.
4. Aortic insufficiency.
5. Status post replacement of transverse aortic arch.
6. Status post replacement of ascending aortic arch and
aortic valve with a 28 mm homograft.
7. Postoperative acute tubular necrosis.
8. Postoperative acute renal failure requiring dialysis.
9. Postoperative acute hepatitis.
10.Positive lupus anticoagulant.
11.Fatty liver by ultrasound, possibly nonalcoholic
steatohepatitis (NASH).
12.Status post Perma-Cath placement.
CONDITION AT DISCHARGE: T-max 99, pulse 87, sinus rhythm,
blood pressure 119/59, respiratory rate 18, oxygen saturation
94% on room air. The patient is neurologically awake, alert,
oriented x 3, nonfocal, ambulating in the halls without
difficulty and without assistance. Strength in upper and
lower extremities is equal bilaterally. Lugs are clear to
auscultation without wheezes, rhonchi or rales. Heart is
regular rate and rhythm with a soft I-II/VI systolic murmur.
Extremities are warm and well-perfused. The patient has
trace to 1+ pitting edema of distal lower extremities.
Abdomen is large, positive bowel sounds, soft, nontender,
nondistended. The patient is tolerating a regular diet and
having regular bowel movements. Sternal incision is clean,
dry and intact without erythema or drainage. The patient's
right subclavian Perma-Cath site is clean and dry, covered
with a Tegaderm. There is no erythema of the site. The
patient's groin incision is clean and dry. Steri-Strips are
intact. There is no erythema or drainage.
Chest x-ray after placement of his Perma-Cath showed mild
pulmonary edema and left lower lobe collapse and
consolidation. A repeat chest x-ray from [**8-17**] is
pending. The patient had blood cultures drawn after the
Perma-Cath was placed on [**8-14**], which are negative to
date. The patient's laboratory data from [**8-17**] is
pending. However, laboratory data from [**8-16**] with
white count 11.0, hematocrit 25.9, platelet count 594, sodium
135, potassium 3.8, chloride 95, bicarb 25, BUN 56,
creatinine 4.3, glucose 141.
DISCHARGE FOLLOW-UP:
1. The patient should follow-up with Dr. [**First Name (STitle) **], his
primary care physician, [**Last Name (NamePattern4) **] 1 week.
2. The patient should follow-up with Dr.[**Name (NI) 27686**] office
in [**1-12**] weeks.
3. The patient will have nephrology and dialysis follow-up
determined prior to discharge, and an addendum to this
dictation will be completed at that time.
DISCHARGE MEDICATIONS:
1. Colace 100 mg po bid.
2. Enteric-coated aspirin 325 mg po qd.
3. Protonix 40 mg po qd.
4. Niferex 150 mg po qd.
5. Multivitamin 1 po qd.
6. Dilaudid 2-4 mg po q 4 h prn.
7. Lopressor 75 mg po tid.
8. Epogen 5,000 U subcu three times a week--this will be
administered by the nephrologist.
9. Lasix 80 mg po bid.
The patient is to be discharged to home in stable condition.
The patient should follow-up with his physicians as directed.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 43187**]
MEDQUIST36
D: [**2161-8-17**] 10:10
T: [**2161-8-17**] 09:11
JOB#: [**Job Number 48554**]
ICD9 Codes: 5845 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8705
} | Medical Text: Admission Date: [**2144-7-14**] Discharge Date:
Date of Birth: [**2085-10-3**] Sex: F
Service: Coronary Care Unit
HISTORY OF PRESENT ILLNESS: The patient is a 59 year old
woman with a five day history of inspiratory chest pressure,
which increased over the last three days to shortness of
breath at rest, orthopnea and paroxysmal nocturnal dyspnea.
The patient went to see her primary care physician, [**Name10 (NameIs) 1023**]
discovered a new systolic murmur associated with a low grade
fever. The patient was noted to have a white blood cell
count of 14,000 and was admitted to [**Hospital3 3834**]. A
transthoracic echocardiogram at that point showed severe
mitral regurgitation which was previously unknown, inferior
hypokinesis but no vegetations. Blood cultures were drawn at
that time and the patient was prophylactically begun on
vancomycin, ciprofloxacin and gentamicin.
Cardiac enzymes were cycled and CK came back at 78 and
troponin 0.231. The patient's shortness of breath worsened
throughout her hospital course and a CT scan of the chest was
performed to rule out dissection, which was negative.
Electrocardiogram showed ST elevation in inferior leads and
the patient was transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **]
[**Last Name (Titles) **] for a cardiac catheterization.
Upon admission to the catheterization laboratory, the patient
was noted to be in severe respiratory distress. She was
intubated and had transient hypotension requiring Dopamine
for blood pressure support. Cardiac catheterization showed
40% eccentric left main stenosis, and 95% mid-right coronary
artery, which was stented and had 0% residual. The patient
was then transferred to the Coronary Care Unit for
hemodynamic monitor and stabilization while on an
intra-aortic balloon pump.
PAST MEDICAL HISTORY: 1. Rheumatoid arthritis. 2. Severe
trigeminal neuralgia. 3. Porphyria cutanea tarda. 4.
Raynaud's syndrome. 5. Chronic pain syndrome. 6.
Depression. 7. Migraines.
PAST SURGICAL HISTORY: Left eye enucleation.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient does not use alcohol but has a
smoking history.
ALLERGIES: Sulfa, Valium, erythromycin and barbiturates.
MEDICATIONS ON TRANSFER: Lovenox 40 mg s.c.b.i.d., fentanyl
patch 100 mcg q.3 days, vitamin E, vitamin B12, Lopressor
12.5 mg p.o.q.6h., Protonix 40 mg p.o.b.i.d., ibuprofen 1,600
mg p.o.q.d.
PHYSICAL EXAMINATION: On physical examination on admission
to the Coronary Care Unit, the patient had a temperature of
97, blood pressure 131/69, heart rate 119, respiratory rate
15; ventilator settings, tidal volume 600, respiratory rate
15, PEEP 5, FiO2 100%. General: Patient intubated and
sedated but occasionally responsive to sternal rub. Head,
eyes, ears, nose and throat: Non-elevated jugular venous
pressure, right pupil reactive, left eye prosthesis, neck
supple, no lymphadenopathy. Cardiovascular: Tachycardia,
III/VI early peaking systolic murmur, no rubs or gallops.
Chest: Clear to auscultation bilaterally. Abdomen: Soft,
nontender, nondistended, positive bowel sounds. Extremities:
1+ dorsalis pedis and 2+ posterior tibialis pulses
bilaterally, no lower extremity edema, no bruits appreciated
over catheterization site. Neurologic: Patient moved all
four extremities spontaneously.
LABORATORY DATA: Admission white blood cell count was 14.1,
hemoglobin 9.7, hematocrit 28, platelet count 295,000, sodium
136, potassium 3.2, chloride 101, bicarbonate 20, BUN 16,
creatinine 0.7, glucose 213, calcium 7.3, phosphorous 4.7 and
magnesium 1.7. Electrocardiogram status post catheterization
showed normalization of ST changes in inferior leads, with
mild diffuse ST changes in the septal and lateral leads with
a left atrial abnormality, patient was in sinus rhythm.
CORONARY CARE UNIT COURSE: 1. Coronary artery disease: The
patient was stabilized in the catheterization laboratory and
sent up to the floor on an Integrilin drip which was
continued for 18 hours, aspirin and Plavix for an inferior
myocardial infarction. Please see history of present illness
section for the complete cardiac catheterization report.
The intra-aortic balloon pump was pulled on hospital day
number one with no complications. The patient was started on
Captopril which was titrated up to 50 mg three times a day
and metoprolol which her blood pressure did not tolerated, so
this was not continued. Natrecor and intravenous
nitroglycerin were used to maintain a systolic blood pressure
around 110. Nipride was transiently used for additional
blood pressure control.
2. Valvular dysfunction: The patient was admitted with new
onset severe mitral regurgitation, which was noted at the
outside hospital. It is assumed that the mitral
regurgitation was due to an ischemic event. An
echocardiogram performed at [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **]
[**Last Name (Titles) **] showed 3+ mitral regurgitation, no aortic
insufficiency, inferior hypokinesis, akinesis and a left
ventricular ejection fraction of 45%.
The patient was aggressively diuresed with Lasix as needed,
with Natrecor and intravenous nitroglycerin for preload
control while in the Coronary Care Unit. Despite medical
management, her mitral regurgitation persisted and there
seemed to be no improvement with revascularization.
Therefore, the patient was taken to the Operating Room on
[**2144-7-28**] for a mitral valve replacement and coronary
artery bypass grafting.
3. Infectious disease: The patient was admitted to the
outside hospital with a low grade fever in the setting of a
new onset systolic murmur. She was pancultured and started
on empiric antibiotics. Blood cultures were negative for any
organisms. Upon transfer to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **]
[**Last Name (Titles) **], the patient was febrile throughout her Coronary Care
Unit course, with temperature spikes to 102 to 103.
The patient defervesced only briefly on hospital day number
two. Her white blood cell count was elevated for a majority
of the time, with the high reaching 18,000. The patient was
blood cultured times ten, with no growth on any sample.
Sputum culture on [**2144-7-15**] showed E. coli which was
pansensitive. The patient was treated with aspiration
pneumonia with a course of Levaquin and ceftazidime for seven
days.
A transesophageal echocardiogram was performed to rule out
the possibility of endocarditis as fevers remained elevated
for the first two weeks of hospitalization, which showed no
vegetations but was consistent with 3+ mitral regurgitation.
Upon discontinuation of ceftazidime and Levaquin, the
patient's fever defervesced, her white blood cell count fell
and her differential count was noted to have 5% eosinophils.
Therefore, it was assumed that the patient elevated fever was
related to a drug reaction to ceftazidime. Of note, after
discontinuation of the medications, a rash appeared on both
the trunk and the arms. The rash was much improved on
transfer.
4. Hematology: The patient had a falling hematocrit status
post her coronary artery bypass grafting. Given her history
of coronary disease, the patient was transfused on three
occasions of two units, for a total of six units. She has
stabilized at a hematocrit of 35. Concerning her porphyria
cutanea tarda, her primary hematologist, Dr. [**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) 14714**],
was contact[**Name (NI) **] and indicated no acute intervention for the
disease at this point. He also stated that there was no
contraindication for the cardiothoracic surgical procedure
and there was no reason the patient could not be started on
warfarin post procedure.
5. Pulmonary: The patient was extubated on hospital day
number two. She continued to have an oxygen requirement of
five liters via nasal cannula throughout her Coronary Care
Unit course. This was thought to be secondary to pulmonary
edema from pulmonary congestion from her mitral regurgitation
as well as a left lower lobe aspiration pneumonia, which was
treated.
6. Disposition: The patient was transferred to the
cardiothoracic surgery service on [**2144-7-26**] for mitral
valve replacement with coronary artery bypass grafting. An
additional discharge summary will be dictated upon discharge
from the surgery service.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 6240**]
MEDQUIST36
D: [**2144-7-31**] 11:44
T: [**2144-8-3**] 07:40
JOB#: [**Job Number **]
ICD9 Codes: 4240, 5070, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8706
} | Medical Text: Admission Date: Discharge Date: [**2144-9-21**]
Date of Birth: [**2074-2-10**] Sex: M
Service: CSU
.
HISTORY: Mr. [**Known lastname **] is a direct admission to the operating room
for coronary artery bypass grafting. He was seen in
preadmission testing prior to his scheduled admission to the
operating room. At the time of preadmission testing, the
patient's physical exam is as follows.
HISTORY OF PRESENT ILLNESS: 70-year-old Vietnamese speaking
man, with a history of coronary artery disease, presented to
an outside hospital one month ago, status post a syncopal
episode. He returned home and complained of fatigue and
chest pain with shortness of breath. On [**8-9**], the
patient had vomiting, lightheadedness and diaphoresis. He
then went to the emergency room via an ambulance. An EKG at
that time showed ST elevations in II, III and F with ST
depressions in V1 through V3 and V5 and six. The patient was
also found to be in complete heart block. Cath done at that
time. A transvenous pacing wire was placed and the
catheterization showed three-vessel coronary artery disease.
He had a stent to his RCA and was referred for coronary
artery bypass grafting.
PAST MEDICAL HISTORY: Significant for hypertension,
tuberculosis, treated over 20 years ago and angina. The
patient had a cath done on [**8-9**]. The cath at that
time showed a 70% mid RCA lesion and a stent was placed; 60
percent left main lesion and left circumflex, obtuse marginal
one and two diffusely diseased. An echo done also at that
time showed a mildly dilated RA with an ejection fraction of
55 percent and a mildly dilated descending aorta measuring
3.6 cm. The patient states no known drug allergies.
MEDS AT HOME:
1. Aspirin 81 mg every day.
2. Hydrochlorothiazide 50 every day.
3. Lisinopril 5 every day.
When seen in PAT, the patient was on aspirin 325 mg every
day, Plavix 75 every day, Colace 100 b.i.d., Lipitor 80 every
day, Captopril 12.5 t.i.d.
SOCIAL HISTORY: Lives with his daughter in [**Name (NI) 47**].
Fairly active man with current tobacco use, approximately
half pack per day times 60 years and occasional alcohol use,
a couple of drinks per week.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAM: General: Sitting in bed, in no acute
distress. Neurologic: Alert and oriented x3. Moves all
extremities. Follows commands. Nonfocal exam. During this
period, the daughter was acting as an interpreter.
Respiratory: Clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm, S1-S2. Abdomen is
soft, nontender, nondistended with normoactive bowel sounds.
Extremities: Warm, well-perfused with no edema and no
varicosities. Pulses radial two plus bilaterally. Dorsalis
pedis two plus bilaterally. Posterior tibial two plus
bilaterally. Carotids without bruits.
LABORATORY DATA: White count 6.2; hematocrit of 38.1,
platelets 191, PT 11.9, PTT 29.2, INR 0.9, sodium 141,
potassium 4.1, chloride 106, CO2 28, BUN 13, creatinine 0.6,
glucose 94, ALT 28, AST 32, LDH 38, alk phos 23, total bili
0.5. UA was negative.
Chest x-ray no acute cardiopulmonary processes.
HOSPITAL COURSE: As stated previously, the patient was a
direct admission to the operating room on [**9-17**]. Please
see the OR report for full details. In summary, the patient
had coronary artery bypass grafting times three with LIMA to
the LAD, saphenous vein graft to the diagonal and saphenous
vein graft to OM. His bypass time was 59 minutes with a
cross clamp time of 46 minutes. He was transferred from the
operating room to the cardiothoracic intensive care unit. At
the time of transfer, the patient was AV paced at 87 beats
per minute with a mean arterial pressure of 62 and a CVP of
five. He had Propofol at 20 mcg/kg per minute and Neo-
Synephrine at 0.5 mcg/kg per minute. The patient did well in
the immediate postoperative period. His anesthesia was
reversed. He was weaned from the ventilator and successfully
extubated. On postoperative day one, the patient continued
to be hemodynamically stable. He was begun on beta blockers
as well as diuretics. His chest tubes remained in because of
a fair amount of serosanguinous drainage and he was
transferred to the floor for continuing postoperative care
and cardiac rehabilitation. Once on the floor with the
assistance of the nursing staff and the Physical Therapy
staff, the patient's activity level was gradually increased
on postoperative day number two. He continued to be
hemodynamically stable. At that time, his Foley catheter was
removed as were his chest tubes and temporary pacing wires.
Over the next 2 days, the patient's activity level was
increased. He remained hemodynamically stable throughout
that period. On postoperative day four, it was decided that
the patient was stable and ready to be discharged to home.
At the time of this dictation, the patient's physical exam is
as follows. Temperature 99, heart rate 71 sinus rhythm.
Blood pressure of 108/70. Respiratory rate of 18. Oxygen
saturation 97 percent on room air. Patient's weight on the
day of discharge is 54.9 kg. Preoperatively, weight was 51
kg.
LABORATORY DATA: White count 7.9, hematocrit 27.3, platelets
153, sodium 139, potassium 3.8, chloride 104, CO2 26, BUN 12,
creatinine 0.6, glucose 112.
PHYSICAL EXAM: Alert and oriented. Moves all extremities.
Follows commands with family acting as interpreters.
Pulmonary lungs clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm, S1-S2. Sternum is
stable. Incision with staples open to air, clean and dry.
Abdomen is soft, nontender, nondistended with normoactive
bowel sounds. Extremities are warm and well-perfused with no
edema. Left saphenous vein graft harvest site incision is
clean and dry with Steri-Strips.
CONDITION AT DISCHARGE: Stable.
DISCHARGE INSTRUCTIONS: He is to be discharged to home with
visiting nurses.
He is to have follow-up with Dr. [**Last Name (STitle) **] in two to three weeks.
Follow-up with Dr. [**Last Name (STitle) 911**] in two to three weeks.
Follow-up with Dr. [**Last Name (STitle) **] in one month.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg every day times two weeks.
2. Potassium chloride 20 mEq every day times 2 weeks.
3. Colace 100 mg b.i.d.
4. Aspirin 325 every day.
5. Plavix 75 every day.
6. Lopressor 25 mg b.i.d.
7. Hydrocodone acetaminophen 5/500, one to two tablets every
four to six hours prn as needed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2144-9-22**] 17:29:10
T: [**2144-9-23**] 08:49:51
Job#: [**Job Number 58194**]
ICD9 Codes: 4111, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8707
} | Medical Text: Admission Date: [**2126-2-15**] Discharge Date: [**2126-3-2**]
Date of Birth: [**2077-9-15**] Sex: F
Service: Oncology Bone Marrow Transplant
REASON FOR ADMISSION: Matched unrelated donor allogenic bone
marrow transplant for ALL.
HISTORY OF PRESENT ILLNESS: This is a 48-year-old female
with a pre-B cell ALL diagnosed in [**June 2125**] following a
workup of diffuse myalgias and low-grade fevers. She was
induced with APO per ECOG protocol and consolidated with
hyper-CVAD for three cycles. Her course has been complicated
by a perirectal abscess, multiple line infections, a deep
venous thrombosis in her right upper extremity and internal
jugular vein as well as an episode of cholestasis and
hepatitis secondary to the use of Augmentin. She presents
for MUD allo-BMT.
PAST MEDICAL HISTORY:
1. ALL diagnosed in [**2125-6-3**] of the pre-B cell type with
the translocation of 4:11 status post hyper-CVAD x3, status
post APO induction.
2. Hepatitis B diagnosed in [**2117**], specific serology is
unknown.
3. History of zoster infection greater than 20 years ago.
4. History of Port-A-Cath infection date unknown.
5. Gastroesophageal reflux disease.
6. History of anal fissure.
7. Right upper extremity DVT.
8. Anxiety disorder.
ALLERGIES: Penicillin induces a rash. Augmentin leads to
cholestasis. Platelet transfusions have caused a rash in the
past.
MEDICATIONS AT TIME OF ADMISSION:
1. Diflucan 200 mg p.o. q.d.
2. Celexa 20 mg p.o. q.d.
3. Acyclovir 400 mg p.o. q.d.
4. Protonix 40 mg p.o. q.d.
5. Ativan 1 mg q.h.s.
6. Bupropion 100 mg p.o. q.d.
7. Prednisone 20 mg p.o. q.d.
8. Oxycodone prn.
9. Zyrtec 10 mg q.h.s.
SOCIAL HISTORY: The patient lives with her husband. She has
three cats. She worked as the owner of a commercial laundry
company. She has one daughter. She has 35-pack year history
and quit smoking in [**2125-9-3**]. No alcohol or IV drug
use.
FAMILY HISTORY: Mother had a CVA. Father prostate cancer at
age 68.
PHYSICAL EXAM AT THE TIME OF ADMISSION: Vital signs: Not
indicated on admission. General: Flat affect in no apparent
distress. HEENT: Pupils are equal, round, and reactive to
light and accommodation. Neck: No lymphadenopathy. Lungs:
Coarse breath sounds, no crackles or wheezes.
Cardiovascular: Regular rate and rhythm, no murmurs, rubs,
clicks, or gallops. Abdomen: Positive bowel sounds, soft,
obese, and nontender. Extremities: No cyanosis, clubbing,
or edema.
LABORATORY AND DATA POINTS AT THE TIME OF ADMISSION: White
blood cell count 18.6 compared to a baseline of 5.1 in
[**2126-2-3**]. Differential: 34% neutrophils, 18% bands,
10% lymphocytes, 1% monocytes, 4% metas, 1% myelos, 32%
atypicals. The hematocrit is 27.8, platelets 99. Chem-7 is
sodium 137, potassium 4.0, chloride 99, bicarb 25, BUN 10,
creatinine 0.5, glucose 133. The ALT is 32. The AST is 21.
The alkaline phosphatase is 96, total bilirubin 0.2, LDH 477.
The INR is 1.0. Calcium, magnesium, and phosphorus 9.5, 2.0,
and 3.2. Uric acid 6.4. Bone marrow biopsy demonstrates
persistent acute lymphoblastic leukemia.
BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE:
1. Leukemia: The patient presented with relapsed ALL. She
underwent cytoxan as well as total body irradiation with a
conventional allogenic bone marrow transplant. She was found
to have peripheral blasts and an 11q23 cytogenic abnormality.
She was re-induced with cytoxan, vincristine, and prednisone
and obtained partial response. However, a bone marrow on
[**2126-2-9**] demonstrated residual blasts with an elevated LDH.
The bone marrow transplant that she received was a single
antigen mismatched unrelated donor transplant. The date of
the stem cell transplant was [**2126-2-21**]. It was proceeded by
b.i.d. total body irradiation for four-day period.
On the day of stem cell transplant, the patient had an ANC of
50 with a uric acid level of 1.8 at that time. The
Allopurinol, which she had previously been placed on was
discontinued. She received methotrexate on days 0, 3, 6, and
11 with the dose on day 0 being 30 mg and the dose on the
rest of the days being 20 mg. At the time of dictation on
day plus 9, the patient was still neutropenic with an ANC of
20. She appeared to be developing a slight rash on her
shoulders, which could be suggestive of early acute GVH,
although she had no signs of engraftment at the time of
dictation making this unlikely.
She did have marked mucositis. See pain below. Patient was
continued on cyclosporin at a dose of 3 mg/kg IV continuous
infusion. Levels were checked and the dose was titrated as
needed.
2. Hematology: Patient did have several episodes of
questionable transfusion reaction. She received multiple
units of packed red cells approximately one per day.
Throughout her hospital course, she received multiple bags of
platelets approximately 1-2 per day. All investigations of
transfusion reactions were fruitless. DIC laboratories were
sent off given her persistent platelet requirement and were
negative for evidence of DIC by haptoglobin, LDH, INR, and
fibrinogen. On two occasions, she did develop rigors and a
rash with infusion of platelets. The most marked at these
reactions was on [**2126-2-21**] upon receiving her stem cells when
she developed significant rigors that were responsive to 25
mg of Demerol as well as 25 mg of Benadryl.
Note regarding her cyclosporin dose, initially the patient
was placed on b.i.d. dosing of cyclosporin. This was changed
to continuous infusion on day minus one. It took her a
prolonged period of time to develop therapeutic levels of
cyclosporin. At the time of dictation, the patient's
cyclosporin level was 637. Thus, the dosing will likely be
adjusted to be dictated at a later time.
3. Infectious disease: She did develop febrile neutropenia,
and was started on Vancomycin as well as cefepime. The most
likely source was her two indwelling catheters namely the
PICC line as well as the Hickman. These were not removed
because of the difficulty of obtaining IV access on the
patient, and the difficulty in placing these lines in the
first place. The Vancomycin was rotated between ports, and
she was afebrile for 48 hours at the time of dictation.
Given the fact that she had been persistently febrile,
however, despite initially being on Vancomycin and cefepime,
AmBisome was added on [**2126-2-28**]. Blood cultures from [**2126-2-21**]
did grow out coag-negative Staph pansensitive to Vancomycin
in [**4-7**] bottles. Surveillance cultures are negative at the
time of dictation. Urine cultures and urinalysis were
negative. She was maintained on acyclovir 400 mg IV t.i.d.
as well as fluconazole 200 mg IV. The fluconazole dose was
decreased from an initial dose of 400 mg, and this may have
accounted for some of the interaction with the cyclosporin.
4. Pain control: Given the patient's diffuse bone and muscle
pain as well as her later development of mucositis pain, she
was started on a PCA on [**2126-2-25**] with good effect.
5. Depression: The patient was started on Celexa 20 mg p.o.
q.d. on [**2126-2-23**].
6. Fluids, electrolytes, and nutrition: TPN was begun on
[**2126-2-28**] given the patient's decreased p.o. intake and likely
NPO status for the foreseeable future.
7. Dermatology: The patient developed a series of rashes
throughout her hospital course felt to be most likely
secondary to atopic dermatitis secondary to tape or to
platelet transfusion reactions. These areas were not
biopsied, but generally resolved within a number of hours
each time.
8. Gastric reflux: Patient was started on Protonix p.o./IV.
9. Glucose control: She was maintained euglycemic on an
insulin-sliding scale and fingerstick glucose checks b.i.d.
This dictation covers the dates from [**2126-2-15**] through
[**2126-3-2**]. An additional discharge addendum will be dictated.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], M.D. [**MD Number(1) 7775**]
Dictated By:[**Last Name (NamePattern1) 1811**]
MEDQUIST36
D: [**2126-3-2**] 15:07
T: [**2126-3-4**] 10:10
JOB#: [**Job Number 51101**]
ICD9 Codes: 5845, 4280, 5789 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8708
} | Medical Text: Admission Date: [**2134-9-23**] Discharge Date: [**2134-10-1**]
Date of Birth: [**2062-11-12**] Sex: M
Service:
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: In brief, the patient is a
71-year-old male with a history of hypertension and
myocardial infarction, status post a catheterization on
[**2134-9-14**] showing three vessel disease insisted on going home
and has now had a two to three day history of complaint of
left sided chest pain and pressure unrelieved with sublingual
nitroglycerin. The catheterization on [**2134-9-14**] revealed an
ejection fraction of approximately 60% with a proximal LAD,
100% occlusion with collaterals to the OM1, mid circumflex
lesion 100% occlusion, RCA proximal 99% stenosis and a mid
100% occlusion and OM1 70% stenosis. The patient does not
complain of any diaphoresis, shortness of breath, paroxysmal
nocturnal dyspnea, orthopnea or any pedal edema. However, he
was readmitted on [**2134-9-23**] with these complaints and was
quickly referred to cardiac surgery and went to Dr. [**Last Name (Prefixes) 411**] for coronary artery revascularization.
PAST MEDICAL HISTORY:
1. Hypertension
2. Hypercholesterolemia
3. No diabetes
HOME MEDICATIONS:
1. Monopril 40 mg po qd
2. Aspirin 325 mg po qd
3. Lipitor 10 mg po qd
4. Toprol XL 25 mg po qd
ALLERGIES: SULFA, HE GETS A RASH.
SOCIAL HISTORY: He is a retired pharmaceutical researcher,
has a positive tobacco history of 2 packs per day x55 years
and drinks about two to four drinks a day.
FAMILY HISTORY: There is a positive history of coronary
artery disease.
PHYSICAL EXAM:
VITAL SIGNS: He was afebrile with stable vital signs.
HEART: Regular rate and rhythm.
LUNGS: Clear to auscultation.
ABDOMEN: Soft, nontender, nondistended.
EXTREMITIES: No cyanosis, clubbing or edema.
PERTINENT LABS: White count 12.3, hematocrit 43.5. INR of
1.0, potassium of 4.1. BUN and creatinine of 21 and 0.8.
HOSPITAL COURSE: The patient underwent coronary artery
bypass graft x3 on [**2134-9-29**] by Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]. He
received a left internal mammary artery graft to the LAD,
saphenous vein graft to the OM and also a saphenous vein
graft to the PDA. The patient tolerated the procedure well
without any complications. He was extubated postoperatively
and was noted to be stable.
On postoperative day #1, he was transferred to the floor.
Physical therapy was consulted and the patient was noted to
be doing well with his ambulation. On the evening of
postoperative day #1, the patient was noted to go into atrial
fibrillation. He was started on an amiodarone drip and was
noted to convert on the morning of postoperative day #2 into
a sinus bradycardia rate of approximately 50 to 55 beats per
minute. The patient's blood pressure remained stable and he
remained asymptomatic with this heart rate. His pacing wires
were noted not to be function. Thus, the patient could not
be paced at a higher rate.
On postoperative day #3, the patient continued to remain
stable. He remained afebrile with heart rate of 51 and a
blood pressure of 120/65. His Lopressor was held and the
patient was continued on po amiodarone. His home dose of
Monopril 40 mg po qd was added. His wires were removed.
On postoperative day #4, the patient was again noted to
return to atrial fibrillation in the morning. He remained
rate controlled with his atrial fibrillation at approximately
90 to 100 beats per minute on the amiodarone. Thus, Coumadin
was started and his Lopressor continued to be held due to his
likelihood of conversion back to sinus bradycardia. Physical
therapy was able to walk the patient upstairs, thus making
him a level 5 and the patient was ready to be discharged on
hospital day #4 in stable condition in rate controlled atrial
fibrillation.
DISCHARGE CONDITION: Stable
DISCHARGE DIAGNOSIS:
1. Coronary artery disease, status post coronary artery
bypass graft x3
SECONDARY DIAGNOSES:
1. Hypertension
2. Hypercholesterolemia
DISCHARGE MEDICATIONS:
1. Monopril 40 mg po qd
2. Lasix 20 mg po qd x3 day
3. KCL 20 milliequivalents po qd x3 days
4. Aspirin 81 mg po qd
5. Lipitor 10 mg po qd
6. Percocet 5/325 1 to 2 po q 4 to 6 hours prn
7. Colace 100 mg po bid
8. Amiodarone 400 mg po qd x7 days, then 200 mg po qd
9. Coumadin 2 mg po qd for a goal INR of 2.0
The patient will be discharged home with VNA for vital checks
and for INR checks. The patient's INR will be followed by
his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 35642**] [**Name (STitle) 35643**].
DI[**Last Name (STitle) 408**]E INSTRUCTIONS: The patient should take his
amiodarone. The patient should not take any Lopressor. The
patient should take Coumadin for a goal INR of 2.0. INR will
be followed by primary care physician. [**Name10 (NameIs) **] patient should
return to see Dr. [**Last Name (Prefixes) **] in approximately three weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 3181**]
MEDQUIST36
D: [**2134-10-1**] 10:06
T: [**2134-10-1**] 11:32
JOB#: [**Job Number 33212**]
ICD9 Codes: 4111, 9971, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8709
} | Medical Text: Admission Date: [**2108-4-10**] Discharge Date: [**2108-4-22**]
Date of Birth: [**2027-2-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / metformin
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
Fever, cough, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 81M with HIV, last CD4 369 in [**Month (only) 404**], prostate CA
s/p chemo/XRT recently stopped for treatment failure (no PSA
response) who presented to his PCP [**Name Initial (PRE) 151**] 3 days of worsening
generalized fatigue and malaise and dyspnea. He also notes that
he and his partner had URTI about 2 weeks ago that improved and
he denied recent fever and cough. On admission, he required 0-2L
to maintain 02 >95%, he had WBC 13.6 (82%N, 0%B), acute on
chronic renal failure BUN/Cr 36/1.8. CXR showed a left lingular
PNA and he was started on Levofloxacin for presumed CAP.
.
The patient specifically denies chest pain, but does note some
dizziness. His dyspnea is not positional. Since his retirement
2 years ago he has traveled extensively to [**Location (un) **], [**Country 26231**],
[**Country 3396**], [**Country 651**], most of Europe. He denies any febrile
illnesses on any trip. He also denies history of TB or known
exposure to TB, and had a PPD several years ago that was
negative.
.
On the inpatient floor, the patient felt well other than
reporting continued generalized weakness/fatigue that is not his
baseline. No cough.
.
ROS: Denies headache, vision changes, rhinorrhea, congestion,
sore throat, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
- HIV, diagnosed ~[**2089**], CD4 369 [**12/2107**]
- Prostate CA, s/p XRT/hormonal chemo (PSA unresponsive)
- HTN
- Hyperlipidemia
Social History:
Born in [**Country 26232**]. Has traveled extensively over past 2 years
to [**Location (un) **], [**Country 26231**], [**Country 3396**], [**Country 651**], most of Europe. Lives with
male partner who is a psychiatrist. Prior tobacco, quit 16y ago,
unclear pack-years. Denies ETOH. Former illicts, denies ever
IVDU, quit 18y ago.
Family History:
Mother deceased at [**Age over 90 **]yo; brother and sister alive at 82 and 83
with no medical problems.
Physical Exam:
ON ADMISSION:
VS - Temp 100.4F, BP 140/60, HR 78, R 26, O2-sat 98% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate,
speaking full sentences
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no wheezing or rhonchi, min crackles at
bilateral bases, good air movement, resp unlabored, no accessory
muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), no crepitus
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-12**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, gait not tested
.
ON ADMISSION TO ICU:
GENERAL - well-appearing man using abdominal muscles, but
stating he feels comfortable speaking full sentences but
somewhat short of breath at the end of his sentences
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS -
HEART - RRR, distant heart sounds, no rub appreciated
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-12**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, gait deferred
.
ON DISCHARGE:
VS: Tm 99.0 BP 95-141/74-90 HR 92-94 RR 18 94% on 3L
GENERAL: No acute distress, speaking full sentences without
accessory muscle use
HEENT: Sclerae anicteric and without injection, MMM, oropharynx
clear
NECK: Supple
LUNGS: Mild rhonchi in both bases, no wheeze
HEART: S1, S2, no murmurs auscultated
ABDOMEN: Soft, non-tender, no rebound/guarding, BS +
EXTREMITIES: WWP, no edema, 2+ radial/pedal pulses
NEURO: Awake, A&Ox3, CNs III-XII grossly intact, motor strength
grossly intact
Pertinent Results:
ADMISSION LABS:
[**2108-4-10**] 01:10PM BLOOD WBC-13.6* RBC-3.72* Hgb-12.2* Hct-34.6*
MCV-93 MCH-32.8* MCHC-35.3* RDW-12.5 Plt Ct-190
[**2108-4-10**] 01:10PM BLOOD Neuts-81.7* Lymphs-12.8* Monos-4.1
Eos-0.9 Baso-0.3
[**2108-4-10**] 01:10PM BLOOD Plt Ct-190
[**2108-4-12**] 06:45AM BLOOD WBC-12.6* Lymph-12* Abs [**Last Name (un) **]-1512 CD3%-79
Abs CD3-1193 CD4%-7 Abs CD4-112* CD8%-72 Abs CD8-1092*
CD4/CD8-0.1*
[**2108-4-10**] 01:10PM BLOOD Glucose-116* UreaN-36* Creat-1.8* Na-136
K-4.1 Cl-99 HCO3-26 AnGap-15
[**2108-4-11**] 07:10AM BLOOD ALT-32 AST-54* AlkPhos-72 TotBili-1.5
[**2108-4-11**] 07:10AM BLOOD Calcium-8.5 Phos-2.0* Mg-1.7
[**2108-4-15**] 03:51AM BLOOD Vanco-7.9*
[**2108-4-13**] 05:45PM BLOOD Type-ART FiO2-96 O2 Flow-2 pO2-53*
pCO2-31* pH-7.49* calTCO2-24 Base XS-1 AADO2-615 REQ O2-98
[**2108-4-13**] 05:45PM BLOOD Lactate-1.8
[**2108-4-14**] 05:26AM BLOOD freeCa-1.07*
.
DISCHARGE LABS:
[**2108-4-21**] 05:21AM BLOOD WBC-12.0* RBC-2.91* Hgb-9.8* Hct-28.2*
MCV-97 MCH-33.5* MCHC-34.6 RDW-13.1 Plt Ct-402
[**2108-4-21**] 05:21AM BLOOD Glucose-111* UreaN-40* Creat-1.5* Na-140
K-3.7 Cl-101 HCO3-28 AnGap-15
.
MICRO:
Blood Culture, Routine (Final [**2108-4-16**]): NO GROWTH.
Blood Culture, Routine (Final [**2108-4-16**]): NO GROWTH.
URINE CULTURE (Final [**2108-4-12**]): <10,000 organisms/ml.
URINE CULTURE (Final [**2108-4-13**]): NO GROWTH.
URINE CULTURE (Final [**2108-4-16**]): NO GROWTH.
MRSA SCREEN (Final [**2108-4-16**]): No MRSA isolated.
.
Legionella Urinary Antigen (Final [**2108-4-13**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
.
HIV-1 Viral Load/Ultrasensitive (Final [**2108-4-13**]):
HIV-1 RNA is not detected.
.
[**2108-4-12**] 8:30 pm SPUTUM Source: Induced.
GRAM STAIN (Final [**2108-4-12**]):
<10 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2108-4-14**]):
MODERATE GROWTH Commensal Respiratory Flora.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2108-4-14**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
ACID FAST SMEAR (Final [**2108-4-13**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
[**2108-4-14**] 2:51 am SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2108-4-14**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2108-4-16**]):
MODERATE GROWTH Commensal Respiratory Flora.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final [**2108-4-14**]):
SPECIMEN QNS FOR THIS TEST.
ACID FAST SMEAR (Final [**2108-4-16**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
This is only a PRELIMINARY result. If ruling out
tuberculosis, you
must wait for confirmation by concentrated smear.
DUE TO QUANTITY NOT SUFFICIENT concentrated smear not
available.
ACID FAST CULTURE (Final [**2108-4-14**]):
SPECIMEN QNS FOR THIS TEST.
.
[**2108-4-15**] 6:47 pm SPUTUM Source: Induced.
GRAM STAIN (Final [**2108-4-15**]):
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
ACID FAST SMEAR (Final [**2108-4-16**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
RESPIRATORY CULTURE (Final [**2108-4-17**]):
SPARSE GROWTH Commensal Respiratory Flora.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final [**2108-4-16**]): NEGATIVE for Pneumocystis jirovecii
(carinii).
.
NEGATIVE
- PCP x 2
- AFBs
- ASPERGILLUS GALACTOMANNAN ANTIGEN
- B-GLUCAN
- MYCOPLASMA PNEUMONIAE ANTIBODIES
.
IMAGING:
[**2108-4-10**] CXR
PA and lateral views of the chest were obtained. Low lung
volumes result in bronchovascular crowding. Focal consolidation
in the left hilar region is a pneumonia. The cardiac and
mediastinal silhouettes are normal. No pneumothorax.
IMPRESSION: Lingular pneumonia. Recommend repeat radiograph in
four to six weeks to document resolution.
.
[**2108-4-12**] CXR
As compared to the previous radiograph, the lung volumes have
slightly decreased. On the left, in both the lung periphery and
the perihilar areas, the pre-described massive pneumonia is
visible in unchanged manner.
No newly appeared focal parenchymal opacities. No pulmonary
edema. No pleural effusions. No pneumothorax. Unchanged size of
the cardiac silhouette.
.
[**2108-4-13**] CXR
Comparison is made to the CT scan performed on the same day as
well as prior chest radiograph from [**2108-4-12**].
There are again noted areas of consolidation within the left
lung. These have increased particularly in the left upper lobe.
Cardiac silhouette is upper limits of normal. Small area of
consolidation at the right base medially is also present. There
are no pneumothoraces or large pleural effusions.
.
[**2108-4-13**] CT CHEST
IMPRESSION:
1. Multifocal pulmonary consolidation involving both lungs,
worse in the left upper and lower lobes, concerning for
multifocal pneumonia. There is no evidence of airway
obstruction. Recommended follow up imaging after treatment to
assess resolution.
2. Mild ectasia of the ascending thoracic aorta measuring 4 cm.
3. Indeterminate adrenal nodules.
.
[**2108-4-15**] CXR
IMPRESSION: Widespread alveolar opacities, some of which have a
nodular configuration. In a patient with HIV infection, this is
most consistent with multifocal pneumonia. Bacterial and fungal
organisms should be considered. Infection complicated by
organizing pneumonia is also possible.
.
[**2108-4-16**] CXR
As compared to the previous radiograph, there is unchanged
evidence of diffuse left parenchymal opacity strongly suggestive
of pneumonia. The opacities show a slightly peripheral
predominance. No evidence of pleural effusions. No other
pathologies, the right lung is unremarkable, except for a spot
of increased lung density in the region of the right apex that
could be caused by a projection phenomenon.
Normal size of the cardiac silhouette.
.
Brief Hospital Course:
81M with HIV, prostate CA s/p chemo/XRT now presenting with 3
days of SOB, non-productive cough, fevers and CXR concerning for
pneumonia. He was initially admitted to the inpatient general
medicine service and empirically treated with levofloxacin for
empiric CAP treatment.
.
On the day after admission, the patient spiked fever up to 101.4
so Vancomycin was empirically started. A CD4 at that time was
112 and VL undetectable. CXR was repeated and was unchanged.
This morning, the patient was requiring 2L 02 and had another
fever so antibiotics were switched to
Vanco/Aztreonam/Azithromycin (Aztreonam because wanted to avoid
levofloxacin due to concern for TB and because he reports upper
airway swelling with PCN). Induced sputum was sent which was
AFB smear negative, had 2+GPCs and 1+GNRs with growth of only
commensal respiratory flora.
.
Late in the afternoon the patient was noted to be tachypneic to
the 30s and he was satting the the low 90s. ABG at this time
showed 7.49/31/53/24 and his 02 was increased to 6L. His sats
improved but he was still visibly dyspneic so was transferred to
the MICU for closer monitoring. The remainder of his hospital
course is outlined below by problem.
.
# Hypoxic respiratory distress/Multifocal pneumonia, bacterial:
Pt had a clinical decompensation requiring MICU, admission and
despite extensive infectious work up, there was no bacterial
source identified. Repeat imaging revealed diffuse multifocal
PNA. PCP stains were negative x 2. Induced sputum for TB was
negative x 3 for AFB and sputum Cx were positive for oral flora
only. Ultimately, pt developed a steady clinical response to
the combination of vancomycin, cefepime, and levofloxacin.
Pulmonary was consulted and felt that COP was a possible
underlying diagnosis but did not recommend treatment with
steroids or further work up at this time as pt seemed to having
consistent clinical response to the above antibiotic regimen.
Pt remained afebrile for >72hrs before discharge. The patient
should continue antibiotic coverage with vancomycin, cefepime &
Levaquin for 14 days for HCAP (final day [**2108-4-29**]). He may
continue albuterol and ipratriopium nebs with IS as needed. Pt
was given referral to see [**Location (un) 2274**] pulmonary after discharge to
ensure resolution of PNA.
.
#. HIV: Most recent CD4 was 350 in [**Month (only) 404**] though he was noted
to have a low CD4 now in the setting of acute illness. Unclear
why, but patient listed as taking an NNRTI (etravirine) +
boosted PI (lopinavir/ritonavir) which would not be a typical
outpatient MD, "he has had stable virologic suppression on this
two drug regimen. Initially he was on raltegravir in addition
but did not tolerate it - felt general malaise - and better off
of it. While a 2 drug HIV regimen is not standard of care for
initial therapy - there are a lot of studies confirming what he
has - which is prolonged stable virologic suppression and CD4
improvements on just 2 antivirals after suppression has been
achieved." Continued on home regimen.
.
# Leukocytosis: Etiology unknown. Pt denied any new localizing
symptoms but has loose stools at baseline and wanted to use
immodium. Cdiff toxin was negative x2 and UA was not
suggestive of infection. White count was resolving by the time
of discharge
.
# Acute-on-chronic renal failure: Recent baseline 1.3-1.6,
increased to 1.8 here with FENA consistent with prerenal
azotemia. He received IV support and creatinine improved to
1.5. The patient's creatinine remained stable once po intake
improved.
.
# Hypertension: Enalapril and HCTZ restarted once patient's
creatinine had stabilized.
.
# Hyperlipidemia: Continued home statin/ASA.
Medications on Admission:
- Aspirin 81 mg PO Daily
- One Daily Multivitamin PO daily
- Calcium PO daily
- Pravastatin 40 mg QHS
- Lopinavir-ritonavir 200 mg-50 mg 3 tablets [**Hospital1 **]
- Enalapril-hydrochlorothiazide 10 mg-25 mg PO Daily
- Acyclovir 400 mg PO Twice Daily
- Fish oil-fat acid comb8-herb comb137 1,200 mg (400
mg-400mg-400mg) PO daily
- Etravirine 100 mg 2 tablets PO daily
- Lorazepam 1 mg PO QHS
- desonide 0.05 % Topical Cream Topical [**Hospital1 **] to rash in ears
[- Bicalutamide 50 mg PO daily] stopped recently; PSA
nonresponsive
[- finasteride 5 mg PO daily] stopped recently; PSA
nonresponsive
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. lopinavir-ritonavir 200-50 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
4. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. desonide 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day) as needed for to rash in ears.
6. enalapril maleate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
8. acyclovir 400 mg Tablet Sig: One (1) Tablet PO twice a day.
9. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
10. omega-3 fatty acids Capsule Sig: One (1) Capsule PO
DAILY (Daily).
11. etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
12. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Two (2) Tablet, Chewable PO DAILY (Daily).
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q2H (every 2
hours) as needed for SOB.
14. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
15. cefepime 2 gram Recon Soln Sig: Two (2) gram Injection Q12H
(every 12 hours) for 6 days: Continue through [**2108-4-29**].
16. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 6 days: Continue through
[**2108-4-29**].
17. levofloxacin in D5W 750 mg/150 mL Piggyback Sig: Seven
[**Age over 90 1230**]y (750) mg Intravenous Q48H (every 48 hours) for 6
days: Continue through [**2108-4-29**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Nursing & Therapy Center [**Location 1268**]
Discharge Diagnosis:
Primary diagnosis: Pneumonia, bacterial
Secondary diagnoses:
HIV
Hypertension
Chronic kidney injury
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 26233**],
It was a pleasure participating in your care at [**Hospital1 771**].
You were admitted because you had a pneumonia. After a brief
stay in the Intensive Care Unit, you remained stable with a
combination of antibiotics. You will go to a rehabilitation
facility that will continue these antibiotics for a total course
of 14 days.
During your stay, your home medications did not change. At the
rehabilitation facility, you will continue the antibiotics:
vancomycin, cefepime, levofloxacin. You will also have available
albuterol and ipratropium nebulizers if you feel short of
breath.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] J.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
**Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge. Also
please contact your provider to schedule an appointment within
2-4 weeks with Pulmonary**
ICD9 Codes: 5849, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8710
} | Medical Text: Admission Date: [**2152-3-5**] Discharge Date: [**2152-3-9**]
Date of Birth: [**2102-3-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
49-year-old man with morbid obesity, HTN, DM2 presented with a
week of worsening shortness of breath, productive coughs. For
the past week he has experienced productive coughs and shortness
of breath both on exertion and at rest. Reports some myalgias
and generalized fatigue. Denies having been vaccinated for flu.
Denies sick contacts. [**Name (NI) **] chest pain, nausea, vomiting. The night
prior to admission, he had a hard time breathing and experienced
some chills. and the morning of admission he was intermittently
confused at home. His wife called EMS and he was initially
brought to [**Hospital3 4107**] where he was found to be hypoxic with
O2 sat in the 60s. He was put on BiPAP. CXR there reportedly
suggested multilobular pna, and patient received ceftriaxone and
azithromycin. Cr 1.5, trop-I 0.76, and ECG with ST changes. Was
transferred to [**Hospital1 18**].
.
In the [**Hospital1 18**] ED, initial VS: afebrile, HR 97, BP 153/93, RR 22,
70%RA when off BiPAP. NRB was placed. Exam revealed scattered
wheezing on expiration with poor aeration throughout. WBC 7.2,
Cr 1.7, lactate 0.9, trop 0.13, CK 495, MB 8. ECG had 0.5-1mm
STE in V2, V3, <0.5mm-STD in V5-6, II, TWI in V3-V6. Cards saw
patient in ED and proposed working diagnosis of demand ischemia
from a pulmonary process. Chest CTA showed bibasilar patchy
opacities, no central PE. He received albuterol and ipratropium
nebs, methylprednisolone, and was started on heparin gtt. Prior
to transfer to the MICU, his HR was 93, BP 152/86, 96% on NRB.
ABG was 7.29/74/92/37.
ROS: Denies night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
morbid obesity
HTN
DM2
Social History:
works as a computer network manager. Lives with wife. Smokes 0.5
pack/day; used to smoke up to 1.5 pk/day for decades. No drug
use. No alcohol abuse.
Family History:
n/c
Physical Exam:
GENERAL: morbidly obese man on nasal cannulae, looking
HEENT: EOMI, PERRL, OP with sputum
CARDIAC: normal rate, regular rhythm, normal S1/S2, no m/r/g
LUNG: expiratory wheezes throughout, poor aeration bilaterally,
no crackles
ABDOMEN: obese, soft, nontender, nondistended
EXT: very minimal ankle edema bilaterally
NEURO: oriented x 3
Pertinent Results:
[**2152-3-5**] 06:56PM WBC-7.2 RBC-4.27* HGB-13.3* HCT-41.0 MCV-96
MCH-31.2 MCHC-32.5 RDW-15.0
[**2152-3-5**] 06:56PM NEUTS-67 BANDS-0 LYMPHS-14* MONOS-19* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2152-3-5**] 06:56PM PLT SMR-LOW PLT COUNT-116*
[**2152-3-5**] 06:56PM PT-13.5* PTT-26.5 INR(PT)-1.2*
[**2152-3-5**] 06:56PM CALCIUM-7.8* PHOSPHATE-4.0 MAGNESIUM-2.1
[**2152-3-5**] 06:56PM LACTATE-0.9
[**2152-3-5**] 06:56PM CK(CPK)-495*
[**2152-3-5**] 06:56PM cTropnT-0.13*
[**2152-3-5**] 06:56PM CK-MB-8
[**2152-3-5**] 06:56PM GLUCOSE-182* UREA N-29* CREAT-1.7* SODIUM-142
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-35* ANION GAP-9
Brief Hospital Course:
49-year-old man with history of morbid obesity, HTN, DM2
presented with respiratory difficulty and hypoxia, found to have
wheezing on exam and elevated troponin.
.
# Respiratory failure: Chest CTA showed no pneumonia or PE. Lung
exam revealed poor aeration bilaterally and diffuse wheezes. No
clinical evidence of heart failure. The impression was a COPD
exacerbation in the setting of a possible pulmonary infection.
He was treated with standing nebulizers and prn nebulizers,
steroids with methylprednisolone then prednisone, empiric
antibiotics with ceftriaxone and levofloxacin then just
levofloxacin upon clinical improvement. He was also started on
oseltamivir; however, when the flu swab and rapid viral panel
from nasapharyngeal aspirate came back negative, the oseltamivir
was discontinued. By the time of transfer to the floor, his
oxygen saturation was in the high 80s to mid 90s on 5-6L of NC,
asymptomatic, feeling much better. He was discared on home o2,
nebulizors and a prednisone taper.
.
# Elevated troponin on admission: on admission his troponin was
0.15 with normal CKMB fraction. ECG showed some minimal ST
elevations in V2-V3 and ST depressions in V3-6 and II.
Cardiology saw the patient in the ED and proposed demand
ischemia in the setting a pulmonary process. Patient never had
chest pain. He was initially on aspirin, statin, metoprolol, and
heparin gtt, which was discontinued after the cardiac enzymes
trended down. An echocardiogram revealed ild biventricular
cavity enlargement with low normal global systolic function.
.
# Acute kidney injury: Cr. 1.7 on admission with unclear
baseline. Most likely prerenal azotemia in setting of pulmonary
infection. Cr down to 1.1 after IVF. His quinapril was held.
# HTN: SBP in 130s-140s. Quinapril was held, and metoprolol was
started. After his acute renal injury resolved his quinapril was
re-started.
.
# DM2: Glyburide was held. He was hyperglycemic in the 400s
after the initiation of steroids, requiring insulin gtt for a
few hours before getting back on SC insulin. Patient was
discharged on metformin, glyburide and insulin glargine while on
prednisone.
# CODE: full
Medications on Admission:
quinapril 10 mg qday
glyburide 5 mg qday
Discharge Medications:
1. Oxygen
Home O2 4L NC conserving device or portable.
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
Disp:*QS QS* Refills:*0*
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*QS QS* Refills:*0*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 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:*0*
6. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*2 Tablet(s)* Refills:*0*
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*QS Disk with Device(s)* Refills:*2*
8. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
11. Calcium 500 500 mg (1,250 mg) Tablet Sig: Three (3) Tablet
PO once a day.
Disp:*90 Tablet(s)* Refills:*0*
12. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
13. Nebulizor Machine
Please dispence 1 Nebulizor Machine
14. One Touch UltraMini Kit Sig: One (1) Unit Miscellaneous
once a day.
Disp:*1 Unit* Refills:*0*
15. One Touch UltraSoft Lancets Misc Sig: One (1)
Miscellaneous once a day.
Disp:*90 Strips* Refills:*2*
16. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) Units
Subcutaneous once a day for 1 months: Take at night while on
prednisone.
Disp:*QS QS* Refills:*0*
17. Insulin Syringe Ultrafine [**1-15**] mL 29 x [**1-15**] Syringe Sig: One
(1) Miscellaneous once a day.
Disp:*QS QS* Refills:*0*
18. Quinapril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
19. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
20. Prednisone 10 mg Tablet Sig: per taper Tablet PO once a day
for 1 months: Per taper.
Disp:*50 Tablet(s)* Refills:*0*
21. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
5 days: Per taper (after all 10mg are done).
Disp:*5 Tablet(s)* Refills:*0*
22. One Touch Ultra Test Strip Sig: One (1) In [**Last Name (un) 5153**] twice
a day.
Disp:*90 Strips* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
COPD
Pneumonia
NSTEMI
Acute renal failure
Diabetes type II, uncontrolled
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
On supplemental O2
Discharge Instructions:
You were admitted to the hospital because of shortness of
breath. Given your symptoms and history of smoking you were
treated for COPD. You required BiPAP for breathing but did not
need to be intubated. You improved with steroids and nebulizor
treatments. You will need a long course of steroids for the
COPD. It is important that you follow up with a lung doctor
after the hospital.
Because you are on the steroids, your blood sugars became
elevated. In the hospital you were treated with insulin. We
started you on your home glyburide and added metformin at
discharge.
Medication changes:
START Metformin 500mg twice a day.
START ipratroprium nebs as needed.
START Aspirin 325mg daily
START Metoprolol 25mg twice a day
START Fluticasone-Salmeterol inhailor twice a day
START Albuterol nebs as needed
START Insulin glargine 10 units at night while on prednisone.
START Levofloxacin (antibiotic) for two more days.
START Prednisone taper as directed:
40mg for 5 days
30mg for 5 days
20mg for 5 days
10mg for 5 days
5mg for 5 days
While on prednisone please take protonix 40mg daily and calcium
and vitamin D supplements.
Continue Glyburide 5mg daily
Continue quinapril 10mg daily
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) 251**] T. [**Telephone/Fax (1) 4475**]
Please call Pulmonary office at [**Telephone/Fax (1) 612**] to schedule an
appointment in [**1-15**] weeks (before prednisone is out)
Please also call the same number to schedule an appointment with
a sleep doctor.
ICD9 Codes: 5849, 486, 2762, 3051, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8711
} | Medical Text: Admission Date: [**2169-1-13**] Discharge Date: [**2169-1-16**]
Date of Birth: [**2095-1-16**] Sex: M
Service: CCU
This is a patient who was initially transfered from [**Hospital 1474**]
Hospital for elective AICD who en route developed respiratory
distress and was initially admitted to the [**Hospital1 346**] MICU status post intubation. He was
then transferred from the MICU to the CCU after AICD and
catheterization.
HISTORY OF PRESENT ILLNESS: This is a 74-year-old male with
a history of dilated cardiomyopathy with an ejection fraction
of 20%, chronic obstructive pulmonary disease, NSVT, atrial
fibrillation who is status post a V fib arrest at [**Hospital 1474**]
Hospital and transferred here for AICD placement.
The patient had a syncopal episode on [**2169-1-8**] and
was found to be in V tach by EMS, but stable. He developed
increased shortness of breath upon arrival to [**Hospital 1474**]
Hospital and was found to have wide complex tachycardia at
195 beats per minute at that time. He was cardioverted and
went into V fib arrest and was defibrillated. He was
intubated at this time for airway protection, loaded with
Amiodarone. Status post his defibrillation, he also spiked a
fever to 101.5 F and was started on antibiotics for a
question of aspiration pneumonia which were later
discontinued when he failed to spike again and failed to have
an increased white blood cell count. He is transferred to
[**Hospital1 69**] for an AICD placement at
this time.
On the ambulance ride over to [**Hospital1 188**], the patient had increasing shortness of breath, chest
tightness and respiratory distress. His pulse went from 78
to 140. In the emergency room at [**Hospital1 190**], he was found to be in atrial fibrillation
with wide complex with his history of old left bundle branch
block. He was thought to be in congestive heart failure and
given Lasix. He continued to develop increasing respiratory
distress and was intubated once again. He was placed on AC
ventilation 12 / 700 / 5 / 100% fio2 and was noted to have
poor air movement on auscultation and an ABG of 7.31 / 53 /
370. At this time, he was thought to have a chronic
obstructive pulmonary disease exacerbation and was given
Solu-Medrol. A chest x-ray done during this period of
respiratory distress showed a right patchy opacity and the
patient was thought to have a question of infection and was
also started on Levaquin.
During the intubation, the patient had a decreased blood
pressure to 60 systolic after being started on Propofol. He
was initially admitted to the MICU Team. The patient had a
cardiac catheterization and AICD placement and then was
transferred to the CCU Team.
PAST MEDICAL HISTORY:
1. Dilated cardiomyopathy times 12 years status post
inferior MI [**2168-11-27**] with an ejection fraction of 20%
with moderate pulmonary hypertension, biventricular
enlargement.
2. Nonsustained ventricular tachycardia previously on
Amiodarone which was discontinued four weeks ago.
3. Chronic obstructive pulmonary disease with a history of
multiple intubations, FEV1 of 1.37.
4. Home oxygen.
5. Question of pulmonary fibrosis.
6. Atrial fibrillation.
7. Hypothyroidism.
8. Patient has a pacemaker.
MEDICATIONS AT HOME:
1. Nitroglycerin.
2. [**Doctor First Name **] 60 b.i.d.
3. Levoxyl 25 mcg q.d.
4. Coumadin three q.o.d. and four q.o.d.
5. Allopurinol.
6. Advair Diskus.
7. Atrovent.
8. Lipitor 40 q.d.
9. Patient recently completed a steroid taper.
MEDICATIONS ON TRANSFER TO [**Hospital1 18**] FROM OUTSIDE HOSPITAL:
1. Flovent b.i.d.
2. Advair Diskus.
3. Lipitor 80 q.d.
4. Synthroid 75 mcg.
5. Allopurinol.
6. Amiodarone.
7. Flagyl 500 t.i.d.
8. Ambien.
9. Coumadin.
MEDICATIONS ON TRANSFER FROM THE MICU TO THE CCU:
1. Vancomycin 500 mg b.i.d. times three days status post
AICD placement.
2. Amiodarone 400 b.i.d.
3. Metoprolol 12.5 b.i.d.
4. Aspirin 325 q.d.
5. Levaquin 500 q.d.
6. Flagyl 500 t.i.d.
7. Albuterol / Ipritroprium inhaler.
8. Protonix 40 q.d.
9. Levothyroxine 75 q.d.
10. Atorvastatin.
11. Heparin drip.
12. Fentanyl.
13. Colace.
14. Senna.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] is 150
pack year smoker who quit 15 years ago. Patient quit alcohol
two years ago. Formerly had six beers per day times 50
years.
VITAL SIGNS AFTER TRANSFER: Afebrile, blood pressure 118/60,
MAP 78, pulse 72, saturation 98% on AC vent 12 / 650 / fio2
40%.
PHYSICAL EXAMINATION: In general patient is intubated, awake
and responds to commands. Head, eyes, ears, nose and throat:
Pupils equal and reactive. Anicteric sclerae. ETT in place.
Neck: The patient is lying flat. Chest: He is vented and
clear anterolaterally. Cardiac: Faint heart sounds, no
murmurs. Abdomen: Normoactive bowel sounds, nontender,
nondistended with no organomegaly. Extremities: No bruit at
right groin. Clean, dry and intact cath site. No hematoma.
No cyanosis, clubbing or edema. Dorsalis pedis pulses are 2+
bilaterally. Neuro: The patient moves all four extremities
and follows command. He is pulling at his endotracheal tube.
LABORATORY DATA: White blood count 7.6, hematocrit 34.4,
platelets 298,000. INR 1.7. Sodium 140, potassium 4.9,
chloride 105, bicarbonate 24, BUN 32, creatinine 1.4, glucose
160, calcium 8.1, phosphorus 3.3, magnesium 2.5.
Urinalysis with large blood, positive nitrates, total
protein, no leukocyte esterase, no white blood cells, no
yeasts, 21 to 50 red blood cells. Urine BUN 889, urine
creatinine 125, urine sodium is 66, fractional secretion of
BUN is 31%.
CKs are 319 to 221, MB 9 and 7, troponin less than 0.3 times
two.
Sputum with oropharyngeal flora, greater than 25 polyps,
lactate 1.0.
ABG: 7.45 / 373 / 36 on 100% fio2.
Chest x-ray: Endotracheal tube 7.9 cm above the carina,
hyperinflated lungs, improved interstitial opacities
consistent with congestive heart failure is asymmetric.
Echo: Ejection fraction of less than 15% global, LV
hypokinesis, dilated left atrium, normal valves.
Cardiac catheterization: Hemodynamics show a right atrium of
9, right ventricular of 36/10, PA pressure 36/24, pulmonary
capillary wedge pressure of 17. Cardiac output of 4.8,
cardiac index of 2.2. SVR 1233, PVR 117. SVC saturation
69%. RCA shows 20% stenosis, distal LAD 50% stenosis.
HOSPITAL COURSE: This is a 74-year-old male with severe
nonischemic cardiomyopathy with an ejection fraction of less
than 15%, history of IMI, atrial fibrillation, NSVT formally
on Amiodarone which was discontinued recently for a question
of pulmonary fibrosis, chronic obstructive pulmonary disease
who is transferred from an outside hospital after syncope and
V fib arrest. The patient is also status post intubation
upon arrival to [**Hospital1 69**] for
question of congestive heart failure / chronic obstructive
pulmonary disease exacerbation and respiratory distress.
1. CARDIAC: A. PUMP: Patient has nonischemic
cardiomyopathy as his cardiac catheterization did not show
significant coronary artery disease. For his cardiomyopathy,
he was started on Captopril 6.25 mg p.o. t.i.d. which was
later changed to Lisinopril 2.5 q.d. and this can be
increased as his blood pressure tolerates. He will also be
continued on Toprol XL 25 q.d. Mr. [**Known lastname 24397**] will follow up
with Dr. [**Last Name (STitle) **] in the Heart Failure Clinic.
B. EP: Patient has a history of nonsustained V tach and
recent V tach and V fib arrest now status post AICD
placement. He also has a history of atrial fibrillation and
continued in well rate controlled atrial fibrillation during
this admission. He was continued on a beta blocker. His
Amiodarone was discontinued for his history of question of
pulmonary fibrosis. He was restarted on Coumadin for his
history of atrial fibrillation and cardiomyopathy. His
Coumadin level will be followed by his primary care doctor
and the visiting nurses will draw his INR level. He will
follow up with the Device Clinic in seven days.
C. CORONARY ARTERY DISEASE: The patient had no evidence of
flow limiting lesions on his cardiac catheterization. He
will continue on aspirin 81 mg p.o. q.d. He will also
continue his Atorvastatin 40 p.o. q.d. and his beta blocker.
2. PULMONARY: Patient with history of severe chronic
obstructive pulmonary disease and multiple intubations. He
was extubated on the morning after his admission to the
Coronary Care Unit. He had no other episodes of respiratory
distress after his extubation. His antibiotics were stopped
as there was no evidence of pneumonia on his chest x-ray,
rather it was likely consistent with asymmetric congestive
heart failure. This improved after some mild diuresis. He
will continue on his Advair Diskus and his Combivent inhalers
at home.
3. GENITOURINARY: The patient had evidence of urinary
obstruction after his Foley catheter was discontinued. This
was relieved after he was started on Finasteride 5 mg p.o.
q.d. and continued on this.
4. ENDOCRINE: He was continued on his Levothyroxine for his
history of hypothyroidism.
5. OPHTHALMOLOGIC: He was continued on Gentamycin
ophthalmic drops for his conjunctivitis.
6. RENAL: His creatinine was 1.4 and remained stable status
post cardiac catheterization with no evidence of contrast
nephropathy.
7. HEMATOLOGY: His hematocrit remained stable in the low
30s without any signs of bleeding. He was restarted on his
Coumadin for discharge and will follow up with his primary
care doctor for level monitoring.
DISPOSITION: The patient was discharged home with VNA
Services, home O2 and INR monitoring. Goal INR was 2 to 3.
He will take Coumadin 7.5 once on the day of discharge and
then have it dose as per his levels. He will follow up at
the Device Clinic at [**Hospital1 69**] in
seven days and his PCP within two weeks. He will follow up
with his outpatient cardiologist within two weeks which is
Dr. [**Last Name (STitle) **]. He will also call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 3512**] to
follow up with her in Heart Failure Clinic.
DISCHARGE DIAGNOSIS:
1. Tachycardic ventricular fibrillation status post AICD.
2. Atrial fibrillation.
3. Chronic obstructive pulmonary disease.
4. Congestive heart failure.
5. Cardiomyopathy.
6. Hypothyroidism.
CONDITION ON DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE:
1. Warfarin dose as per INR.
2. Aspirin 81 p.o. q.d.
3. Finasteride 5 mg p.o. q.d.
4. Gentamycin Sulfate ophthalmic drops, two drops OU q. 12
hours for two weeks.
5. Advair Diskus inhaler.
6. Combivent inhaler.
7. Pantoprazole 40 mg p.o. q.d.
8. Levothyroxine 75 mcg p.o. q.d.
9. Atorvastatin 40 mg p.o. q.d.
10. Toprol XL 25 mg p.o. q.d.
11. Lisinopril 2.5 mg p.o. q.d.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Last Name (NamePattern1) 7783**]
MEDQUIST36
D: [**2169-1-18**] 14:01
T: [**2169-1-18**] 16:01
JOB#: [**Job Number 46447**]
ICD9 Codes: 4271, 4254, 4280, 2449, 2720, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8712
} | Medical Text: Admission Date: [**2109-7-12**] Discharge Date: [**2109-7-18**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Endoscopy [**2109-7-15**]
History of Present Illness:
Admission information and pertinent hospital course:
84 year old male c DM, HTN, OA, afib not on coumadin, CKD stage
IV, Chronic CHF recently discharged [**Date range (1) 12474**] for R ankle pain
(resolved on own, no etiology) and mild heart failure
exacerbation, is readmitted on [**7-12**] for Chest pain. While in ED,
had episodes of hematemesis, thus was admitted to MICU.
As for chest pain: Pt reports experiencing a sharp, stabbing,
left sided CP started [**7-12**] am, on/off since that day.
Reproducible on exam. EKG unremarkable. Trops negative. Pain is
better today. Thought to be musculoskeletal with possible GI
component.
As for episode of hematemesis. Has chronic anemia, but recent
admission his hgb was lower than baseline ([**7-20**]) to 6.5,
hemeoccult neg, no obvious bleeding, got 2U. had no GI
complaints, was told to follow up. This admission, initially no
GI complaints other than chest pain. No melena, no further
hematemesis. NGL was performed in ER, and per report showed old
blood that cleared after 700 cc's. He was started on IV PPI and
transfered to MICU, where per notes, another NGL done, still old
blood, but easily cleared. NGT removed [**1-12**] nausea/discomfort.
Seen by GI. hgb and vitals have been stable, thus EGD defered to
[**7-15**] am. Over past couple days, has c/o intermitted
periumbilical/epigastric pain, but that has also resolved by
time of transfer to floor. He is tolerating clears. Of note, pt
with hematemesis approx 1 year ago. EGD at that time showed some
gastritis in the antrum. He was prescribed high dose PPI.
Also, while in ER, initially CXR with possible RLL PNA, started
on levaquin, no fevers/white count/cough.
Past Medical History:
PMH:
CHF, nonischemi, systolic EF per echo [**11-17**] 45%, diastolic
dysfunction. Etiology, ?HTN (Echo '[**03**] only 30%prox LCx, otw
normal)
HTN c mod LVH
dyslipidemia
Afib-not on coumadin
CKD IV, baseline 2.6-2.9, sees Dr. [**Last Name (STitle) 4883**]
Anemia, normocytic, AoCKD likely
Ex Tobacco user
DM, on insulin, hgb A1c 8.4
OA
CaP s/p prostatectomy
Urinary incontinence
Gastritis, EGD [**2107**] (p/w hematemesis) on PPI
Social History:
Lives with daughter and [**Name2 (NI) 802**]. Wife just passed away end of
[**6-18**]. Quit smoking 4 years ago but smoked [**12-12**] PPD for 40 years.
Drank 1 shot of whiskey everyday in the past. No drugs.
Family History:
no CAD, no cancers
Physical Exam:
PHYSICAL EXAM on ICU admission/transfer:
Vitals: BP 112/63, HR 80
Gen: NAD, A & O x3
HEENT: No oropharyngeal erythema or exudate.
CV: RRR. No m/r/g.
LUNGS: CTAB
ABD: +BS. Minimal tenderness slightly below umbilicus, ND
Recta: Brown, guaiac negative stool in rectal vault.
EXT: No c/c/e.
Discharge Exam:
==============
Vitals: 98.6 96-104/56-68 95%RA
Pain: 0/10
Access: PIV
Gen: pleasant, nad, walking around
HEENT: o/p clear, mmm
Neck: JVD 7cm at 45deg
CV: irreg irreg, [**1-16**] SM LSB
Resp: CTAB with bibasilar crackles, stable, no wheezing
Abd; soft, nontender, +BS
Ext; no edema
Neuro: A&OX3, nonfocal
Skin: no changes
psych: pleasant
Pertinent Results:
See below for 24hour Labs:
interpretation:
creat up from 2.9-->3.3-->3.1-->2.9 today BUN stable 45-55
Hgb around 10.
Other labs:
Trops X2 unremarkable (0.08, 0.07), proBNP of 2312, and
urinalysis unremarkalbe. Blood cultures were also sent, ntd.
.
.
Imaging/results:
.
Echo: There is moderate symmetric left ventricular hypertrophy
with normal cavity size and moderate global hypokinesis (LVEF
=30-35%). The estimated cardiac index is borderline low
(2.2L/min/m2). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). The right
ventricular free wall is hypertrophied. The right ventricular
cavity is mildly dilated with moderate global free wall
hypokinesis. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2108-12-7**],
biventricular systolic function is more depressed. The estimated
pulmonary artery systolic pressure is higher.
These findings are suggestive of an infiltrative process (e.g.,
amyloid).
.
.
EGD: normal esophagus, antral erythema and friability,
antral/fundus erosions, angioectasia, first part of duodenum
ECG [**7-12**]: Afib, good vent rate, frequent PVCs vs aberrantly
conducted beats.
.
.
Chest x-ray [**7-12**]:new RLL possible infiltrate
XRAY repeated [**7-13**] and [**7-14**] NO infiltrate
*has nonspecific RUL nodule, need f/u CT in few months (last
[**4-18**])
.
.
Echo: [**11-17**]: EF 45%, mod cLVH, no WMA
Cath '[**03**]: normal except 30% prox LCx.
.
Brief Hospital Course:
ASSESSEMENT AND PLAN:
84year old male with a history of NICM and chronic HF, CKD stage
IV, DM on insulin, afib off coumadin, gastritis, admitted to
MICU [**7-12**] with chest pain and hematemesis, transfered to Gen Med
[**7-14**]. Underwent EGD, revealing gastritis, no further bleeding.
Protonix increased to [**Hospital1 **] for 4weeks, then back to qd. Aspirin
changed to EC 162mg qd. While on Med service, Low BP (80-90SBP)
and rising creatine limiting diuresis and NS holding
coreg/valsartan. Echo repeated, EF 35%, PE c/w volume overload
still, pt asymptomatic for low BP, thus meds reintroduced. Now
is stable once again on home cardiac regimen. Doing well, ready
for discharge home today.
UGIB/hematemesis X1: h/o gastritis. hematemesis in ED and NGL
with old blood, but hgb here has been stable. No further
bleeding.
-EGD with gastritis c friable mucosa/erosions, no ulcers. Bx for
H.pylori sent (note, neg serologies in past)
-will place on on protonix [**Hospital1 **] X4weeks, then back to qd
-appreciate GI recs, also started on carafate
-should be on EC [**Hospital1 **], no NSAIDs
.
.
Chronic heart failure: NICM, systolic HF EF 45% 12/07, also has
diastolic dysfunction. Currently appears euvolemic to slightly
hypervolemi (though has slight crackles, elevated jvd, elevated
BNP). Unfortunately, fluid removal is limited by CKD. Echo
repeated [**7-16**] showing global drop in EF 35% (was 45% 12/07, 35%
6/07).
-did well on lasix 120mg [**Hospital1 **] yesterday, creat stable today. Will
continue at this dose and coreg 3.125mg [**Hospital1 **] and valsartan 40mg
qd (tolerated all three yesterday). He will have f/u Dr. [**First Name (STitle) 437**],
cards, on [**7-23**], at which time her creat should be rechecked.
-Also of note, echo suggestive of infiltrative process such as
amyloidosis, which can be seen in CKD patients. However, not
sure if further w/u would be of any significancea at this age.
.
.
CKD stage IV: creat baseline 2.6-2.9. Again, tricky situation
in setting of fluid overload, will need to find regimen that
keeps him more or less euvolemic with stable creatinine.
Electrolytes otw stable.
-he seems to be doing well with lasix 120mg [**Hospital1 **], cont this dose
with outpt follow up
-cont Calcitriol for hyperpara
-cont Fe supp for AoCKD, consider epo as outpt, defer to Dr.
[**Last Name (STitle) 7473**]
[**Name (STitle) 12475**] dose meds, avoid nephrotoxins, monitor uop
.
.
Periumbilical pain/epigastric pain: LFTs with elevated alk phos
and lipase. However symptoms resolved, tolerated clears
-RUQ US unremarkable, symptoms resolved.
.
Chest pain, atypical. Reproducible and ?GI related vs volume
related. ruled out with trops, unremarkable EKG, no sig CAD
(cath essentially normal [**2103**], except 30% prox LAD), so less
concern for ischemia.
-follow for now, has essentially resolved. tylenol prn
.
.
Diabetes- Levemir=>Glargine here
-cont 45U qdinner
-cont SSI
.
.
Atrial fibrillation - Rate well-controlled off coreg currenlty.
- unclear whether coumadin has been addressed but not issue
currently in setting of erosive gastritis. Can be readdressed
after 6weeks of high dose PPI [**Hospital1 **]. EC [**Hospital1 **] on discharge until
f/u PCP or cards
.
.
Right-upper lobe opacity - Persistent from [**2109-4-21**]. Will
need repeat Chest CT in [**2-14**] months.
-Need to notify PCP to [**Name9 (PRE) 702**] after discharge.
.
.
Urinary incontinence - Continue imipramine, though has not
helped, will discuss with PCP.
.
.
Dyslipidemia: atorva 10, [**Name9 (PRE) **] EC 81 to be resumed in next couple
days
.
.
Geriatric Care: recent death of wife, pt is grieving. Also has
MMP and 4hosp in past 6months.
-appreciate social work help, he is set up VNA services for
medications, home PT, nutrition consult. Fortunately, pt lives
with daughter, who is involved in his care
-med reconciliation to d/c unneccesary meds
.
.
FEN/proph: HLIV, monitor lytes, cardiac/diabetic diet as
tolerated, no AC, encourage ambulation TEDs/SCDs, PPI PO BID as
above, bowel regimen, PT/OT following
.
.
Dispo/code: Full code. discharge home today in good condition.
f/u is set with renal, PCP, [**Name10 (NameIs) 2086**] NP.
POA is daughter,[**Name (NI) 12469**] [**Telephone/Fax (1) 12470**], is updated by myself,
social worker, and nursing staff. She will pick patient up at
6pm.
Medications on Admission:
MEDS:
1. Aspirin 162mg
2. Atorvastatin 10 mg
3. Valsartan 40mg daily
4. Carvedilol 3.125 [**Hospital1 **]
5. KlorCon 20mEq daily
6. Furosemide 120 mg [**Hospital1 **]
7. Flonase [**Hospital1 **]
8. Levemir insulin 45 units at supper
9. Pantoprazole 40 mg
10. Imipramine HCl 10 mg HS
11. Calcitriol 0.25 mcg daily
12. Iron 325 mg daily
13. Colace 100 mg [**Hospital1 **]
14. Senna
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day: x four weeks
then daily.
[**Hospital1 **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
[**Hospital1 **]:*120 Tablet(s)* Refills:*0*
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO twice a day.
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
[**Hospital1 **]:*qs Capsule(s)* Refills:*2*
5. Imipramine HCl 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
[**Hospital1 **]:*qs Tablet(s)* Refills:*2*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*qs Tablet(s)* Refills:*2*
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
[**Hospital1 **]:*qs Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
9. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Hospital1 **]:*qs Tablet(s)* Refills:*2*
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): for constipation. Hold for diarrhea.
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime): for constipation.
[**Hospital1 **]:*qs Capsule(s)* Refills:*2*
12. Furosemide 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
[**Hospital1 **]:*120 Tablet(s)* Refills:*2*
13. Klor-Con 10 10 mEq Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO at bedtime.
[**Hospital1 **]:*qs Tablet Sustained Release(s)* Refills:*2*
14. Flonase 50 mcg/Actuation Spray, Suspension Sig: [**12-12**] Nasal
twice a day.
[**Month/Day (2) **]:*qs bottle* Refills:*2*
15. Levemir 100 unit/mL Solution Sig: 45U Subcutaneous once a
day.
[**Month/Day (2) **]:*qs qs* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hematemesis, GAstritis, anemia
chronic heart failure
Discharge Condition:
Good
Discharge Instructions:
Call your doctor if you have fevers, worsening shortness of
breath, chest pain, weight gain.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet, no canned foods.
Fluid Restriction: 1.5L per day
Your medications are the same, except, you aspirin should be
enteric coated. Your protonix is increased to twice a day. your
iron should be twice a day.
Followup Instructions:
Geriatric Consult: Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2109-7-22**] 3:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2109-10-21**] 11:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2109-7-23**] 11:00
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**]
Date/Time:[**2109-7-23**] 2:00--Cardiology, Dr.[**Name (NI) 3536**] nurse
practioner
ICD9 Codes: 4254, 2724, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8713
} | Medical Text: Admission Date: [**2130-2-17**] Discharge Date: [**2130-2-25**]
Date of Birth: [**2053-8-29**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Pneumonia
Major Surgical or Invasive Procedure:
Intubation/mechanical ventilation
Arterial line placement
Central venous line placement
History of Present Illness:
76 yo M w/ St. [**Male First Name (un) 1525**] AVR, Afib, CHB pacer dependent, prostate
CA on lupron/ketaconazole/hydrocortisone presents from home
after acutely developed chills and vomiting this morning. After
the vomiting episode, his family reported worsening mental
status and he was taken to an OSH ED. There he was found to be
hypotensive, febrile 102, WBC 12, got trace fluids 250cc. A CT
head and CT ab/pelvis were unremarkable, UA negative, CXR was
concerning for bilaterally pulmonary infiltrates. There they
administered avelox 400mg IV, CTX 1gm IV, and vanco 1gm x1 and
he was transferred to [**Hospital1 18**] ED. On arrival, he was hypotensive
initially improved with IVF 2L, and was started on dopamine. A
CVL was placed in the right IJ and he was intubated for
respiratory failure on lying flat. Labs in the ED were notable
for WBC 14. INR 4.4. Cr 1.7 and Lactate 2.7. Blood and urine
cultures were sent. Prior to transfer, VS HR 73 BP 97/46 RR 16
100% AC 550/16/5/100%, and he was on fentanyl, versed bolus for
sedation.
On the floor, he was intubated and sedated. Family was at
bedside to confirm details as above. There have been no sick
contacts and patient has not been out of the house for the past
5 days.
Review of systems:
(+) Per HPI
(-) Family denies fever, 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 bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
- Prostate cancer: On Lupron last [**2130-1-26**], ketoconazole and
hydrocortisone(off since [**10-31**] [**1-24**] elevated LFTs).
- Renal tumor, found incidentally on CT scan, most recently
imaged in [**2128-9-22**].
- Right lower lobe lung nodule, followed regularly by a CT
scan.
- AVR - [**First Name8 (NamePattern2) **] [**Male First Name (un) 1525**] at [**Hospital1 **] in [**2107**]
- Complete heart block status post pacemakerx2, last in [**Month (only) **]
[**2127**].
- Lower extremity edema from venous stasis.
- History of Reiter's syndrome in his 20s.
- Atrial fibrillation
- Hypertension
PAST SURGICAL HISTORY:
Status post TURP in [**2125**]
Status post right hip replacement in [**2124**]
Social History:
The patient is retired, formerly worked at [**Company 2676**] as a
contractor and IRS. He reports rare ethanol. He is a former
smoker, stopped 10 years ago and has a roughly 75-pack-year
history. He currently lives with his wife in [**Name (NI) 4310**] and does all
his ADLs but minimally active at baseline.
Family History:
The patient has two children and three grandchildren. Father
died at 64 years old of an MI, also had diabetes. Mother died of
old age and also had [**Name (NI) 2481**] disease. Only other diabetic is
a paternal grandmother. [**Name (NI) **] history of CAD, other oncologic
disorders.
Physical Exam:
VS: 101.4 78 127/55 23 97%RA
General: intubated and sedated
HEENT: Sclera anicteric, MMM, oropharynx clear, OG tube with
billous aspirate
Neck: supple, JVP elevated to 10cm, no LAD
Lungs: Diffuse rales, no wheezing or ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley with yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, hyperpigmentation of b/l shins
Pertinent Results:
[**2130-2-17**] 02:50PM BLOOD WBC-14.1*# RBC-4.37* Hgb-13.0* Hct-38.3*
MCV-88 MCH-29.7 MCHC-33.9 RDW-13.8 Plt Ct-128*
[**2130-2-17**] 02:50PM BLOOD Neuts-90.3* Lymphs-5.0* Monos-3.8 Eos-0.7
Baso-0.2
[**2130-2-17**] 02:50PM BLOOD PT-41.3* PTT-40.4* INR(PT)-4.4*
[**2130-2-17**] 09:07PM BLOOD Fibrino-337
[**2130-2-17**] 09:07PM BLOOD FDP-0-10
[**2130-2-17**] 02:50PM BLOOD Glucose-123* UreaN-25* Creat-1.7* Na-141
K-3.8 Cl-109* HCO3-26 AnGap-10
[**2130-2-17**] 02:50PM BLOOD ALT-30 AST-57* LD(LDH)-405* CK(CPK)-43*
AlkPhos-137* TotBili-0.6
[**2130-2-17**] 02:50PM BLOOD Lipase-40
[**2130-2-17**] 02:50PM BLOOD CK-MB-2 cTropnT-<0.01
[**2130-2-17**] 09:07PM BLOOD CK-MB-3 cTropnT-0.02*
[**2130-2-18**] 04:04AM BLOOD CK-MB-3 cTropnT-<0.01
[**2130-2-17**] 09:07PM BLOOD CK-MB-3 cTropnT-0.02*
[**2130-2-18**] 04:04AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.7
CXR AP [**2130-2-17**]:
1. Appropriate positions of endotracheal tube and right IJ line
with no
pneumothorax.
2. New retrocardiac airspace opacity which may represent focal
pulmonary
edema or atelectasis, though aspiration cannot be excluded.
3. Stable cardiomegaly and mild pulmonary vascular congestion.
ECHO [**2130-2-20**]:
The left atrium is dilated. Left ventricular wall thicknesses
and cavity size are normal. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded.
Diastolic function could not be assessed. Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is moderately dilated. An aortic valve prosthesis is
present. The transaortic gradient is higher than expected for
this type of prosthesis. No masses or vegetations are seen on
the aortic valve, but cannot be fully excluded due to suboptimal
image quality. The mitral valve leaflets are moderately
thickened. There is no mitral valve prolapse. No masses or
vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. There is mild valvular
mitral stenosis (area 1.5-2.0cm2). Trivial mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: poor technical quality due to patient's body
habitus. Left ventricular function is probably normal, a focal
wall motion abnormality cannot be fully excluded. The right
ventricle is not well seen. There is an aortic prosthesis -
which appears most likely a bioprosthesis. The gradient is
higher than expected for this kind of prosthesis.
[**2130-2-21**] 7:33 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2130-2-23**]**
FECAL CULTURE (Final [**2130-2-23**]):
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final [**2130-2-23**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2130-2-21**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2130-2-17**] 9:58 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT [**2130-2-20**]**
Respiratory Viral Culture (Final [**2130-2-20**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2130-2-18**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
[**2130-2-17**] 3:15 pm URINE HEME S# 1220C URS/LEG ADDED
[**2130-2-17**].
**FINAL REPORT [**2130-2-18**]**
Legionella Urinary Antigen (Final [**2130-2-18**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
CXR: HISTORY: A 76-year-old man with CHF, increasing shortness
of breath. Assess for interval change.
IMPRESSION: AP chest compared to [**2-20**].
Mild pulmonary edema has improved in the left lung, worsened at
the right
base. Moderate-to-severe cardiomegaly unchanged, pleural
effusion, minimal if any. Transvenous right atrial and right
ventricular pacer leads are in
standard placements, unchanged. No pneumothorax. Of note,
pulmonary edema
was not present on [**2-19**].
[**2130-2-24**] 06:40AM BLOOD WBC-5.9 RBC-4.39* Hgb-12.8* Hct-38.5*
MCV-88 MCH-29.2 MCHC-33.4 RDW-13.9 Plt Ct-206
[**2130-2-25**] 09:15AM BLOOD WBC-3.9* RBC-4.14* Hgb-12.9* Hct-37.7*
MCV-91 MCH-31.0 MCHC-34.1 RDW-14.0 Plt Ct-183
[**2130-2-23**] 05:25AM BLOOD PT-62.1* PTT-42.7* INR(PT)-7.1*
[**2130-2-23**] 05:00PM BLOOD PT-40.4* PTT-38.3* INR(PT)-4.2*
[**2130-2-25**] 09:15AM BLOOD PT-14.1* PTT-81.5* INR(PT)-1.2*
[**2130-2-24**] 06:40AM BLOOD Glucose-116* UreaN-39* Creat-1.4* Na-147*
K-3.7 Cl-112* HCO3-27 AnGap-12
[**2130-2-25**] 09:15AM BLOOD Glucose-123* UreaN-27* Creat-1.5* Na-143
K-3.4 Cl-106 HCO3-29 AnGap-11
[**2130-2-23**] 05:25AM BLOOD ALT-25 AST-25
[**2130-2-18**] 04:04AM BLOOD CK-MB-3 cTropnT-<0.01
[**2130-2-20**] 04:30AM BLOOD CK-MB-7 cTropnT-0.02*
[**2130-2-25**] 09:15AM BLOOD Calcium-8.6 Phos-2.1* Mg-2.0
[**2130-2-21**] 03:46AM BLOOD PSA-95.2*
[**2130-2-25**] 04:22AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016
[**2130-2-25**] 04:22AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2130-2-25**] 04:22AM URINE RBC-100* WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
Brief Hospital Course:
Mr. [**Known lastname 31**] is a 76 yo M w/ AVR on coumadin, CHB pacer
dependent, Afib, prostate CA on hydrocortisone po presents from
home with acute onset chills and vomiting followed by septic
shock and respiratory failure.
# Septic Shock - Felt to be most likely [**1-24**] urosepsis given +
urine cultures (40,000 e. coli and +group B strep) and h/o
urosepsis with only 10,000 pseudomonas growing in urine 3 yrs
ago after urologic procedure. CXR concerning for concurrent
pneumonia in the left intrahilar region. CXR also concerning for
pulmonary edema or ARDS vs. infiltrate. Ddx includes
gastroenteritis (viral and bacterial), aspiration pneumonia,
biliary source. Abdominal exam benign and CT ab/pelvis w/out
contrast unremarkable at OSH. Also AI a concern given home
steroid use. No clear obstructive or cardiogenic component based
on clinical exam on admission. Pt initially covered broadly for
abdominal source and pneumonia with IV cefepime, flagyl, azithro
all started on [**2130-2-17**]. Azithro was discontinued on [**2130-2-19**].
Given home hydrocortisone, started stress dose steroids. His
septic shock quickly improved with abx, steroids, and IVF.
Patient required a period of mechanical ventilation and pressors
(levophed) but responded well to treatment. Ultimately, his
antibiotics coverage was narrowed to Cefpodoxime for a full 14
day course for pneumonia and UTI. [**2-25**] is day 8.
# Hypoxic Respiratory Failure - Patient required intubation in
setting of lying flat with line placement. CXR consistent with
volume overload, patient has history of dCHF. Cardiac enzymes
negative, ECHO on [**2130-2-20**] showed dilated LA, mod dilated
ascending aorta, no masses or vegetations, mild MS, trivial MR,
mild PAH. Pt was extubated on [**2130-2-18**] without complications.
Started diuresis on evening of [**2130-2-19**] given increasing rales,
CVP of 15. Diuresed well with IV Lasix with improvement in his
respiratory status. Upon transfer to the Medicine floors, Lasix
was briefly held given his acute renal insufficiency, with
improvement in his Creatinine. It was restarted the day prior to
discharge. His pulmonary status remained stable.
# Emesis - Possibly secondary to urosepsis vs viral/bacterial
gastroenteritis vs pneumonia vs. intubation/sedation. No
evidence of obstruction. LFTs underwhelming, exam benign. OSH
non-contrast CT ab/pelvis unremarkable. Resolved with zofran
prn. OGT pulled. Stool cx unremarkable and c diff negative.
# Acute Renal Failure - Likely prerenal in setting of
hypotension and later poor PO intake, with FeNa of 0.2% and
resolved with IVF. Baseline 1.3 ([**2130-1-26**]), up to 1.7 on
admission. Discussed with wife that recently
hydrocortisone/ketaconazole were resumed and she was concerned
that these caused renal impairment in past. Per oncology, plan
is to restart ketoconazole at time of discharge from hospital.
Patient's lasix and lisinopril were briefly held upon transfer
to the regular Medicine floor, and he was encouraged to
liberalize his PO fluid intake, with good gradual improvement of
his Creatinine back to baseline. His lasix and lisinopril are
scheduled to be restarted on [**2130-2-25**].
# AVR/CHB pacer dependent - [**First Name8 (NamePattern2) **] [**Male First Name (un) 1525**] on coumadin.
Supratherapeutic likely [**1-24**] ketoconazole interaction and then
antibiotics interaction (patient received levaquin at OSH).
Coumadin continues to be held in setting of elevated INR. When
his INR was 7+, given risk for falls, patient received Vitamin K
2mg PO X1 which dropped his INR to 1.3. His goal is 2.5-3.5.
Given concerns for thrombolic events with his prosthetic valve,
patient was started on heparin gtt. He was also resumed on
Warfarin 5mg daily. he was offerred a PICC but refused. He may
be amenable to PICC placement in the future. Heparin gtt should
be continued for 48 hours after INR is therapeutic 2.5-3.5. INR
should be checked daily while titrating INR.
# Delirium: Patient was hyperactively delirious in the ICU,
likely due to the multiple factors of ICU admission, recent
intubation, sedative/hypnotic medications, stress dose steroids,
pneumonia/UTI etc. He was treated with Zydis given concern for
laryngospasms with Haldol, to good effect. On the Medicine
floors, he continued to wax and wane and showed signs of
emotional lability (tearful). Delirium precautions were
maintained and brief hypernatremia was aggressively managed with
D5 1/2NS. His sodium was 143 the day of discharge. He was
emotionaly labile the day of discharge, with frequent crying.
- Continue delirium precautions: OOB --> chair, physical
therapy, family at bedside when possible, maintain sleep/wake
cycle, avoid sedative/hypnotic medications, minimize
drains/lines
- Patient was found to be coughing with pills. Continue
aspiration precautions and crush meds, moist ground solids, thin
liquids, 1:1 supervision with meals
- Zydis as needed
# Prostate CA: Oncology recommended repeat PSA which is elevated
to 95, approximately doubled from one month ago. Held
ketoconazole in setting of acute illness and supratherapeutic
INR. po hydrocortisone initially switched to IV given shock but
patient has been on home po hydrocortisone regimen since [**2130-2-20**].
The patient will need to follow-up with his outpatient
oncologist after discharge. His ketoconazole will be restarted
the day of discharge. In addiiton, he will need to have a psa
re-checked the week of [**3-11**] and results faxed to his
oncologist's office. The patient will also need outpatient
follow-up for sclerotic iliac lesions noted on CT pelvis from
[**Hospital **] [**Hospital 1459**] hospital. An ekg should be checked daily
while restarting the ketoconazole. Ketoconazole can prolong the
QTc interval, if the QTc prolongs then ketoconazole should be
discontinued.
Medications on Admission:
Econazole [Spectazole] 1 % Cream [**Hospital1 **] to feet
Hydrocortisone 20mg QAM, 10mg QPM
Ketoconazole 400mg [**Hospital1 **]
Furosemide 40 mg Tablet once a day
Lisinopril 40 mg Tablet daily
Lupron 1 mg/0.2 mL Kit every 3 months
Metoprolol Succinate 25 mg Tablet Sustained Release daily
Potassium Chloride 10 mEq Tablet Sustained Release daily
Warfarin
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer vial Inhalation Q4H (every 4
hours) as needed for shortness of breath, wheezing.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb vial
Inhalation Q6H (every 6 hours) as needed for shortness of
breath, wheezing.
7. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for Dyspepsia.
8. Olanzapine 5 mg Tablet Sig: 0.5-1 Tablet PO QID (4 times a
day) as needed for Agitation.
9. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 6 days: Last day is [**2130-3-3**].
10. Hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
11. Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO QPM (once
a day (in the evening)).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for
nausea/vomiting.
14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
15. Sodium Chloride 0.9 % 0.9 % Piggyback Sig: Three (3) ML
Intravenous Q8H (every 8 hours) as needed for line flush.
16. Heparin (Porcine) in D5W 20,000 unit/500 mL Parenteral
Solution Sig: 1350 (1350) units Intravenous infusion: Weight
based dosing protocol.
Once INR at goal 2.5-3.5, continue heparin gtt for 48-72 hours
more before discontinuing.
17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
18. Ketoconazole 200 mg Tablet Sig: Two (2) Tablet PO twice a
day.
19. insulin sliding scale
20. Outpatient Lab Work
Please check a PSA in 2 weeks, which will be the week of
[**2130-3-11**].
Please fax the reuslts to Dr.[**Name (NI) 31162**] office.
21. Econazole 1 % Cream Sig: One (1) application Topical twice a
day: apply to feet.
22. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary Diagnoses:
Pneumonia
Urinary tract infection
Sepsis
Respiratory distress
Delirium
Secondary Diagnoses:
Prostate cancer
Aortic valve replacement (St. [**Male First Name (un) 1525**])
Complete heart block s/p pacermaker X2
Venous stasis changes
Atrial fibrillation
Hypertension
Discharge Condition:
Mental Status: Confused - sometimes, emotionally labile
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
-You were admitted with chills and vomiting. You were found to
have a urinary tract infection and pneumonia that progressed to
septic shock. You developed respiratory distress, likely given
extra fluid build-up in your lungs. Your kidneys were also found
to be functioning less well, likely due to the septic shock. You
were briefly intubated and on medications to keep your blood
pressure normalized. You were treated with antibiotics and
responded well. Your kidney function improved and the fluid
build-up in your lungs resolved.
You also developed some confusion due to the many insults to
your body (ICU stay, strong medications - steroids, sedatives,
pneumonia/UTI, intubation/extubation etc). This will take some
time to resolve, and you continued to improve during your
hospital stay. You can continue to work on this by working with
physical therapy at Rehab, getting out of bed to the chair
often, having family around.
-It is important that you continue to take your medications as
directed. We made some changes to your medications during this
admission.
Your ketoconazole was restarted.
Your metoprolol was increased from once daily to twice daily.
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools.
Followup Instructions:
APPOINTMENT #1:
Department: CARDIAC SERVICES
When: MONDAY [**2130-5-15**] at 1:30 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2130-5-15**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Please make an appointment to see your primary care doctor, Dr.
[**First Name8 (NamePattern2) 449**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within 2-3 weeks. You can reach his office
at: [**Telephone/Fax (1) 250**].
Please also make an appointment to see your genitourinary
oncologist who manages your prostate cancer, Dr. [**Last Name (STitle) **]. You will
need to have your PSA level checked two weeks after discharge.
Dr.[**Name (NI) 31162**] phone number is ([**Telephone/Fax (1) 31163**].
Please contact your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 250**] to
schedule an appointment upon discharge from [**Hospital1 **].
ICD9 Codes: 486, 5990, 2930, 2760, 4280, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8714
} | Medical Text: Admission Date: [**2153-4-13**] Discharge Date: [**2153-9-9**]
Date of Birth: [**2153-4-13**] Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname 32348**] [**Known lastname 72746**] is a 25 [**1-31**] week gestational
age infant [**Month/Day (4) **] to a 40-year-old G2, para 0-0-1-0 mother who was
admitted to [**Hospital1 69**] on [**2153-3-31**],
after transfer from [**Hospital6 204**] due to sudden onset
of vaginal bleeding and was subsequently diagnosed with abruptio
placenta. Mother received antenatal steroids after 24 weeks
gestation and was betamethasone complete at the time of delivery.
Mother remained as inpatient with expectant management, and
delivered about 2 weeks later. Her prenatal labs were as
follows: Blood type AB+, antibody negative, hepatitis B antigen
negative, rubella immune, RPR nonreactive, GBS unknown. Baby was
[**Name2 (NI) **] by spontaneous vaginal delivery. Delivery was complicated
by double-footling breech. Aminotic fluid was dark with rusty
color consistent with old blood. The infant had spontaneous
respiratory effort, heart rate was more than 100, baby was active
and had good tone for her gestational age. Baby was given facial
CPAP with oxygen in the delivery room and recovered to a good
pink color. Apgars were 8 and 8. Infant was intubated with 2.5 ET
tube without complication and transferred to the NICU. On
admission, baby was stable and was put on high frequency
oscillator ventilator. On admission to the NICU, baby's weight
was 706 gm, the length was 32.5 and the head circumference was
21.5.
PHYSICAL EXAMINATION AT DISCHARGE: Baby looks well,
comfortable, sleeping in room air. She is normocephalic, no
dysmorphic features, red reflex bilaterally. Neck supple, no
masses. Thorax symmetric, no retractions. Lungs clear
bilaterally, good air entry. Cardiovascular - regular rate
and rhythm, S1, S2 normal, soft systolic murmur consistent
with peripheral pulmonary stenosis. Femoral peripheral pulse is
present bilaterally. Abdomen soft, nontender with active bowel
sounds, no organomegaly or masses present. She has a large,
easily reducible umbilical hernia. GU - normal female genitalia.
Musculoskeletal - hips stable. Anus patent. Neurologic - good
tone, good sucking and grasp. Skin - several capillary
hemangiomas.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: Initially [**Known lastname 32348**] was on the high frequency
oscillating ventilator with MAP of 9 and amplitude of 15. She
received 2 doses of surfactant. In less than 24 hrs, she was
transitioned to conventional mechanical ventilation, then she was
extubated a day later to CPAP 6cm in 21-28% O2. She was started
on caffeine for apnea of prematurity. She required CPAP for the
first 2 months of life, then was able to wean to nasal canula
oxygen on [**6-10**]. One week later, she was weaned to room air
and has been stable in room air for the remainder of her hospital
stay. Caffeine was discontinued at 36 weeks corrected
gestational age. [**Known lastname 32348**] had prolonged apnea and bradycardia
spells, through 46 weeks CGA. These were initially attributed to
reflux, but when they did not resolve on reflux therapy, she
underwent a pneumogram on [**8-30**]. This showed no prolonged central
apnea, no obstructive apnea, occasional desaturations to 84%-88%
in conjunction with periodic breathing, and frequent bradycardia
to the 50s following short central apnea. No significant acid
reflux was detected (the study was done on Reglan and feeds of
Enfamil AR). Caffeine was restarted at that time. Her
bradycardia events tapered off over the following week, and her
last episode was a self-resolving brady to the 40s on [**9-3**]. She
is discharged on an apnea monitor and caffeine.
2. CARDIOVASCULAR: [**Known lastname 32348**] had hypotension after
admission to NICU and received 1 bolus of normal saline. On
[**4-16**] echocardiography showed a patent foramen ovale but no
patent ductus arteriosus (PDA). A repeat echocardiogram on [**4-24**]
again showed no PDA, but did reveal mild peripheral pulmonic
stenosis as an explanation for her soft cardiac murmur, which is
still present at the time of discharge.
3. FLUIDS, ELECTROLYTES, NUTRITION: [**Known lastname 32348**] was initially kept
NPO on parenteral nutrition by umbilical venous catheter, then
through PICC line. Feeds were started on the fifth
day of life with breast milk and were advanced slowly to full
feeds by day 18 of life. Breast milk caloric consistency was
advanced slowly to a maximum of 30 calories per ounce. This was
later decreased to 24 calories per ounce due to adequate growth.
[**Known lastname 32348**] had some feeding intolerance manifested by spitting and
apneas associated with feeding so on [**8-2**] she was started
on Reglan and Zantac for gastroesophageal reflux. On [**8-14**], she was switched to Enfamil AR 24, on which she will be
discharged. Zantac was discontinued on [**8-20**].
She was started on iron with vitamin E at 21 days of life. The
vitamin E was discontinued on [**7-16**]. She received also
vitamin A in the first 4 weeks of life to decrease her risk of
chronic lung disease.
Her weight at discharge is 4315 gm.
[**Known lastname 32348**] had hyperbilirubinemia. She was under phototherapy for
about 10 days. Her maximal bilirubin was 4.1 with a direct
component of 0.3 on [**4-23**], and her most recent bili was 3.7/0.3
on [**4-25**].
4. HEMATOLOGY: [**Known lastname 32348**] received 3 PRBC transfusiosn during her
stay. The last hematocrit done on [**8-6**] was 33.4 with
a reticulocyte count of 2.6%.
5. INFECTIOUS DISEASE: [**Known lastname 32348**] was on Ampicillin and Gentamicin
for 7 days for clinical evidence of sepsis. Blood culture drawn
at birth was negative. She did not require any other antibiotics
during her stay.
6. NEUROLOGY: [**Known lastname 32348**] had head ultrasounds on days of life 4, 13,
30 which were all normal.
7. SENSORY: Hearing screening was performed with automated
auditory brain stem responses and was passed bilaterally.
8. OPHTHALMOLOGY: [**Known lastname 32348**] had repeated eye examinations which
showed retinal immaturity until the last eye exam done on [**7-24**] showed mature retinas. A follow-up with ophthalmology at 9
months of age was recommended.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: [**Known lastname 32348**] will be discharged home with
mother in car seat. Her primary pediatrician is [**First Name8 (NamePattern2) **] [**Last Name (un) 42720**] in
[**Location (un) 15749**].
CARE RECOMMENDATIONS: [**Known lastname 32348**] will be discharged home on
Enfamil AR 24 calories per ounce. Her medications are Reglan
0.42mg PO q6hrs (0.1mg/kg/dose), caffeine citrate 30mg PO daily
(7mg/kg/dose), and ferrous sulfate 0.4mL of a 25mg/1mL solution
daily (2mg/kg/dose). Car seat test was done and she passed. State
newborn screening was done on all four were negative.
She received immunizations. She received first dose of hepatitis
B on [**5-21**]. She received the 2 month old vaccinations of
Pediarix on [**6-21**] and Hib and pneumococcal vaccine on [**6-22**] and she
received the 4 month vaccines on [**8-23**].
Recommended immunizations:
Synagis RSV vaccine should be considered from [**Month (only) **] through
[**Month (only) 958**] for infants who meet any of the following four criteria:
1. [**Month (only) **] at less than 32 weeks.
2. [**Month (only) **] between 32-35 weeks with two of the following:
Daycare during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities or school
age siblings.
3. Chronic lung disease.
4. Hemodynamically significant congenital heart disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contact and out of home caregivers.
This infant has not yet received rotavirus vaccine. The American
Academy of Pediatrics recommends initial vaccination of preterm
infants at or following discharge from the hospital if they are
clinically stable and at least 6 weeks but not more than 12 weeks
of age.
Follow-up appointments recommended:
1. With Dr. [**Last Name (STitle) 42720**] 1-2 days after discharge
2. With dermatology at 6 months for capillary hemangioma
3. With ophthalmology at 9 months for follow-up of prematurity
DISCHARGE DIAGNOSIS:
1. Prematurity 25 weeks.
2. Respiratory distress syndrome.
3. Clinical sepsis.
4. Apnea of prematurity.
5. Anemia of prematurity.
6. Umbilical hernia.
[**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 72747**]
Dictated By:[**Name8 (MD) 72748**]
MEDQUIST36
D: [**2153-9-7**] 14:59:20
T: [**2153-9-7**] 21:04:14
Job#: [**Job Number 72749**]
ICD9 Codes: 769, 7742, 4589, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8715
} | Medical Text: Admission Date: [**2138-7-22**] Discharge Date: [**2138-7-24**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 82 yo female h/o DKA three month ago, presents with
hyperglycemia. Over the preceeding 2-3 days, her blood sugars
(as done at NH) were in the 300s (her baseline being in the 200s
to occasional 300s). This AM, she received 6 units of lantus (as
part of her usual AM regimen) and 10 units of regular at 7:30 am
with a FS of 372. She was given 12 units of regular at 12 pm, 8
units of regular at 1 pm, and 6 units regular at 2 pm, each time
her BS were read as "critically high". Per the aides, her urine
smelled "fruity."
In the ED, VS on admission were: T: 98.6; HR: 80; BP: 138/70;
RR: 18; O2: 94 RA. Initial labs showed a glucose of 761, gap of
26 with a bicarb of 16. She was given 10 units of subcutaneous
insulin at 5:30 pm. At 6:25 pm BS noted to be in 700s, insulin
gtt was started at 10 units/hr. Next two blood sugars in ED were
"critically high." She also received 4 L of normal saline while
in the ED.
Of note, the patient finished a 7 day [**Last Name (un) 10128**] of Bactrim DS on
[**2138-7-10**] for a UTI. Per her son, she was admitted three months
agofor DKA (admitted to [**Hospital 11694**] Hospital ([**Location (un) 2251**])). She also
was in [**Hospital 6930**] Hospital secondary to UTI.
The patient denies any chest pain, shortness of breath, dysuria,
cough, nausea, vomiting, diarrhea. She is not in pain.
Past Medical History:
1. Diabetes Mellitus- Diagnosed 15 years ago. She has been in
DKA five times and has always been on insulin.
2. HTN - currently off meds
3. Alzheimer Dementia- At baseline: she knows name, not where
is. Short term memory is poor.
4. Anemia
5. Right wrist fracture
6. Dysphagia
Social History:
Worked as a legal secretary. Has five sons. Nursing home
resident. Smoked quit 30 years ago, 1 ppd x 7 years. No EtOH.
Family History:
Son: DM (? type)
Physical Exam:
VS: T: 98.0; HR: 101; BP: 104/71; RR: 20; O2: 97 RA
Gen: Speaking in full sentences
HEENT: MMM; sclera anicteric; OP clear
Neck: No LAD.
CV: TAchycardic S1S2. No M/R/G
Lungs: CTA b/l with decreased BS at bases though poor effort
Abd: Soft, NT, ND. No hepatomegaly. +midline scar
pubis-->umbilicus. Also + scar 3 inch LLQ above inguinal line.
Ext: Trace edema b/l
Neuro: Alert. Oriented to name only. CN II-XII tested and
intact. Reflexes upper extremities intact.
Pertinent Results:
Initial Chemistries ([**2138-7-22**]): GLUCOSE-761* UREA N-31* CREAT-1.1
SODIUM-130* POTASSIUM-6.3* CHLORIDE-89* TOTAL CO2-15* ANION
GAP-32* CALCIUM-10.1 PHOSPHATE-5.5* MAGNESIUM-2.2* freeCa-1.19
Repeat: GLUCOSE-688* LACTATE-3.9* K+-4.9
Cardiac Enzymes ([**2138-7-22**]): CK-MB-NotDone cTropnT-0.01
Blood Gas ([**2138-7-22**]): TYPE-ART TEMP-37.0 PO2-96 PCO2-37 PH-7.29*
TOTAL CO2-19* BASE XS--7 COMMENTS-ROOM AIR
CBC ([**2138-7-22**]): WBC-8.9 RBC-3.25* HGB-10.1* HCT-29.9* MCV-92
MCH-31.1 MCHC-33.7 RDW-16.6*
Coags: ([**2138-7-22**]): PT-11.6 PTT-19.2* INR(PT)-1.0
LFTs ([**2138-7-22**]): ALT(SGPT)-19 AST(SGOT)-25 LD(LDH)-295*
CK(CPK)-46 ALK PHOS-157* TOT BILI-0.8* LIPASE-24
Urine ([**2138-7-22**]) BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-250
KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD* RBC-8*
WBC-23* BACTERIA-MANY YEAST-NONE EPI-0
CBC on Discharge ([**2138-7-24**]): WBC-6.6 RBC-3.59* Hgb-10.7*
Hct-32.9* MCV-92 MCH-29.7 MCHC-32.4 RDW-16.8* Plt Ct-268*
Neuts-80.5* Bands-0 Lymphs-14.7* Monos-3.6 Eos-0.8 Baso-0.3
Chemistries on Discharge ([**2138-7-24**]): Glucose-111* UreaN-9
Creat-0.4 Na-143 K-4.1 Cl-110* HCO3-24 AnGap-13
Radiology:
CXR ([**2138-7-22**]):
1. Right hilar prominence. Comparison to old chest radiographs
is recommended. In the absence of prior studies, CT can be
performed for further evaluation.
2. Biapical pleural thickening.
3. No evidence of pneumonia.
Brief Hospital Course:
82 year old female with history of history of DM, dementia and
recently treated UTI who presented with DKA and another UTI.
1. DKA: This was thought to be secondary to a UTI, especially
given her prior history of DKA from UTI. She was initially
started on an insulin drip along with IVF resuccitation. Her
gap closed (26 to 8) and her BS normalized. The morning after
admission she was started on SC heparin (Lantus in the AM with a
HISS); this overlapped with her insulin drip for a couple hours.
Potassium was repleted PRN; phosphate did not require any
repletion. Once she began taking good PO, her IVF were
discontinued.
2. Acidosis: The patient presented with a gap acidosis in
addition to a respiratory acidosis (pH was 7.29; gap of 26;
bicarb of 16; pCO2 of 37). This was thought to be secondary to
DKA (i.e. ketones); additionally, her lactate at presentation
was 3.9 - this may have contributed to her gap acidosis. The
etiology of her respiratory acidosis was unclear, although some
degree of mental status change with hypoventilation could have
been present. With treatment of her DKA, her gap closed and
chem 7 normalized. A repeat lacate was 1.9.
3. UTI: This was the probable cause of her DKA. At discharge,
the culture had grown 10,000 to 100,000 GNR without
differentiation. She was started on Cipro, 500 PO BID and will
continue this for a seven (7) day course.
4. Agitation: Initially, the patient was quite agitated (e.g.
attempting to get out of bed and pulling at her lines). This
was presumed to be secondary to (a) underlying dementia
underlying a change in environment, and (b) delerium from her
UTI. She was treated with reassurance and haldol PRN. At
discharge she was much improved.
5. Dementia: Stable. Abilify was restarted the morning after
admission.
6. History of HTN: Had been off anti-hypertensives since early
[**Month (only) 205**]. Her blood pressure was controlled of BP meds during her
hospital course.
7. F/E/N:
Nutrition: Initially, the patient was kept NPO. The morning
after admission, a diet was begun consistent with her diet at
the nursing home (pureed solids and nectar thick liquids).
Lytes: Potassium was repleted PRN; she did not require phosphate
repletion.
IVF: Initially treated with NS (4 liters in the ED, continued in
the ICU); once her BS fellow below 250 D5 1/2 NS was begun.
Once her PO intake improved, IVF were discontinued altogether.
8. Access: 2 PIVS. She had no need for central access.
9. Contact: [**Name (NI) **] [**Name (NI) **] [**Name (NI) **] is HCP and guardian:
[**Telephone/Fax (1) 61790**], cell phone: [**Telephone/Fax (1) 61791**]. PCP: [**Name Initial (NameIs) 6993**]
[**Telephone/Fax (1) 608**]
10. Prophylaxis: SC heparin. No indication for PPI. ASA per
outpatient.
11. Code Status: DNR/DNI; Arrived with comfort care form. Also
corroborated with her son, [**Name (NI) **] who is HCP.
Medications on Admission:
Lantus 8 units qam, Novolin SS
Marinal 2.5 mg [**Hospital1 **]
Metoprolol 25 mg [**Hospital1 **]-d/cd [**2138-7-10**]
MVI
Colace 100 mg qday
ASA 81 mg qday
Abilify 10 mg qam
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
6. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. insulin
Lantus, 8 units QAM
9. insulin
Regular insulin sliding scale as attached.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis
Diabetic Ketoacidosis
UTI
Delerium
Secondary Diagnosis
Diabetes Mellitus
Dementia
Discharge Condition:
Patient is doing well. Her is tolerating PO well and her mental
status is at baseline.
Discharge Instructions:
Please call your doctor and/or go to the emergency room if you
have blood sugars that are unable to be controlled, fevers,
chills or for any other concerns.
You must call the microbiology lab [**Telephone/Fax (1) 4645**] to follow up on
your urine cultures.
Followup Instructions:
Please follow-up with your PCP with seven days of discharge.
ICD9 Codes: 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8716
} | Medical Text: Admission Date: [**2145-2-16**] Discharge Date: [**2145-2-20**]
Date of Birth: [**2094-6-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Cerebrovascular accident
Major Surgical or Invasive Procedure:
[**2145-2-16**] - Minimally invasive closure of patent foramen
ovale.
History of Present Illness:
This 50-year-old patient is with a previous history of CVA who
was investigated and found to have a PFO with aneurysm of
septum, and he was electively admitted for closure of the same.
There was no other cardiac abnormalities, and his coronary
angiogram showed normal coronary arteries.
Past Medical History:
PFO
CVA/TIA
Hypercholesterolemia
HEad Injury
Traumatic Splenectomy
Anxiety
Social History:
Works in construction. Lives alone. Divorced with 2 children in
marriage. Denies drug use and uses alcohol only in moderation.
Family History:
No premature coronary artery disease.
Physical Exam:
Vitals: Stable
General: well developed male in no acute distress
HEENT: oropharynx benign, poor dental health
Neck: supple, no JVD, transmitted murmur to carotid noted
Heart: regular rate, normal s1s2
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Brief Hospital Course:
Mr. [**Known lastname 1024**] was admitted to the [**Hospital1 18**] on [**2145-2-16**] for elective
surgical management of his patent foramen ovale. He was taken
directly to the operating room where he underwent a minimally
invasive closure of his patent foramen ovale. Postoperatively he
was taken to the cardiac surgical intensive care unit for
monitoring. Within 24 hours, Mr. [**Known lastname 1024**] [**Last Name (Titles) 5058**] neurologically
intact and was extubated. Aspirn and beta blockade were started.
He was then transferred to the cardiac surgical step down unit
for further recovery. He was gently diuresed towards his
preoperative weight. The physical therapy service worked with
him to help improve his strength and mobility. He steadily
improved his ability to ambulate to include climbing stairs
unassisted. He was discharged home in good condition with
services and follow up with his PCP and will be given a
cardiology referral at that time. He will also follow up with
Dr. [**Last Name (STitle) 1290**] as an outpatient.
Medications on Admission:
Lipitor
Aspirin
Cymbalta
Ativan
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:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. 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*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Two (2)
Capsule, Sust. Release 24HR PO DAILY (Daily).
7. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day) as needed
for depression.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours).
Disp:*56 Capsule, Sustained Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Caregroup VNA
Discharge Diagnosis:
PFO
CVA/TIA
Hypercholesterolemia
HEad Injury
Traumatic Splenectomy
Anxiety
Discharge Condition:
Good
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) Report any weight gain of greater then 2 pounds in 24 hours
or 5 pounds in 1 week.
4) Call with any questions or concerns.
[**Last Name (NamePattern4) 2138**]p Instructions:
Follow-up with Dr. [**Last Name (Prefixes) **] in 4 weeks.
Follow-up with your cardiologist in [**2-8**] weeks.
Follow-up with your primary care physician [**Last Name (NamePattern4) **] 2 weeks.
Call all providers for appointment.
Completed by:[**2145-2-20**]
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8717
} | Medical Text: Admission Date: [**2119-7-18**] Discharge Date: [**2119-7-26**]
Date of Birth: [**2069-6-30**] Sex: M
Service: MEDICINE
Allergies:
vancomycin / Ertapenem
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Fever, rash
Major Surgical or Invasive Procedure:
1. Skin biopsy on the medial part of left fore-arm
2. PICC line placement
History of Present Illness:
Pt. is an otherwise healthy 50 y/o M who sustained a cat bite on
([**5-28**]) s/p 14-day course of amoxicillin-clavilunate, c/b abscess
formation drained on ([**6-16**]), and was found to have osteomyelitis
with cultures growing prevotella. He was treated with a 21 day
treatment with vancomycin/ertapenem after which he developed a
diffuse morbiliform rash and fevers to 102.8.
.
The pruritic rash first started on his right hip, progressed to
his inner thighs bilaterally and then diffusely on his entire
body. Bernadryl and Zytrec did not relieve the rash at home
although fevers responded to tylenol but he presented to the ED
due to increased edema at the base of the rashes. He denies any
pain with the rash, blistering, skin sloughing and the pruritis
was transcient. He also denies any fevers/chills, night sweats,
nausea/vomiting, chest pain/SOB/chest tightness/palpitations,
diarrhea/consitpation, dysuria, weakness, arthralgias, myalgias.
.
In the ED, initial VS: 102.6 72 112/64 16 99% RA. On exam, the
patient did not have hyperemia or edema of his oropharynx or
tongue, conjunctivitis or skin sloughing or blisters. There was
no anal involvement and the patient denied chest tightness,
dysphagia, shortness of breath. Plastics/hand surgery evaluated
the patient and felt his hand was improved. Dermatology saw the
patient and felt this was likely a uncomplicated drug
hypersensivity reaction vs DRESS. The patient's Vanc and
Ertapenem were held in the ED. Derm recommended Triamcinolone
cream for symptoms and requested no steroids until the patient
is evaluated by Infectious Disease. The patient received Mg
repletion and 2L NS IVF, as well as Diphenhydramine IV,
Ibuprofen 600mg, and Acetaminophen 1gm prior to his transfer to
the MICU
.
On arrival to the MICU, the patient reported significant
improvement of his extremity swelling after receiving IV
Diphenhydramine in the ED. He denied pruritis, shortness of
breath, wheezing, swelling of his orpharynx or tongue, pain, or
progression of his rash. He was started on daptomycin, cipro and
flagyl ([**7-18**]) for his osteomyelitis. He was evaluated by
Infectious Disease who thought his symptoms were due to atypical
DRESS and agreed with the antibiotic change and receommended an
echo which came back normal. He was further managed with tylenol
and ice packs for his fevers. He also received IV bernadryl and
IV famotidine. He got about 7L of IVF for insensibile losses.
Dermatology biopsied his rash (pathology report pending) and
recommended Prednisone taper starting from 60mg 1mg/kg.
Past Medical History:
1. Dupuytrens contracture
2. Left shoulder capsulitis
Social History:
Lives in [**Location **]/[**Location (un) 3320**] by himself. Owns a cat as pet. Works
as a computer programmer and has been unable to work over the
past two months due to R hand injury. Social EtOH. Monogamous
with significant other. [**Name (NI) **] hx of STDs or recent travels.
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 99.6 92 106/64 93%RA
GENERAL: Well-appearing, comfortable, diffuse mild-moderate
swelling and erythema but in no acute distress.
HEENT: PERRLA, EOMI, sclerae anicteric, MMM, OP without lesions,
thrush on tongue, no edema of oropharynx or tongue.
NECK: Supple, no JVD.
LUNGS: CTAB, no wheezes/rales/rhonchi, fair air movement b/l,
resp unlabored.
HEART: RRR, nl S1-S2, no murmers/gallops/rubs.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ DP pulses b/l.
SKIN: Diffuse erythematous morbilliform rash of face, b/l UE's
and LE's, and trunk with swelling. No erythema around left PICC
site.
NEURO: Awake, A&Ox3, moving all extremities.
.
DISCHARGE PHYSICAL EXAM:
.
VS: Tmax 99.2 Tc 96.8, BP 118-132/63-74 P 70-95 O2 97-97 on
RA
GENERAL: AOx3, well-appearing in NAD
HEENT: PERRLA, EOMI, sclerae anicteric, MMM, OP without lesions,
no edema of oropharynx or tongue, multiple 1-3cm grouped
vesciles mostly on ventral tongue and buccal mucosal.
NECK: Supple, no JVD.
LUNGS: CTAB, no wheezes/rales/rhonchi, fair air movement b/l,
resp unlabored.
HEART: RRR, nl S1-S2, no murmers/gallops/rubs.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ DP pulses b/l.
SKIN: Desquamation of chest, abdomen and back. Residual
erythematous macules and papules coalescing in the lower
extremities.
NEURO: Awake, A&Ox3, moving all extremities.
Pertinent Results:
[**2119-7-18**] 01:25PM BLOOD WBC-15.1*# RBC-4.44* Hgb-15.2 Hct-42.4
MCV-95 MCH-34.2* MCHC-35.9* RDW-13.8 Plt Ct-294
[**2119-7-18**] 01:25PM BLOOD Neuts-74* Bands-16* Lymphs-1* Monos-3
Eos-4 Baso-0 Atyps-1* Metas-1* Myelos-0
[**2119-7-18**] 01:25PM BLOOD Glucose-105* UreaN-18 Creat-1.1 Na-138
K-4.4 Cl-103 HCO3-25 AnGap-14
[**2119-7-18**] 01:25PM BLOOD ALT-105* AST-48* LD(LDH)-282* CK(CPK)-61
AlkPhos-112 TotBili-0.6
[**2119-7-18**] 01:25PM BLOOD Albumin-3.3* Calcium-8.4 Phos-1.4*
Mg-1.5*
[**2119-7-18**] 01:25PM BLOOD CRP-107.9*
DISCHARGE
[**2119-7-26**] 05:32AM BLOOD WBC-30.0* RBC-3.10* Hgb-10.0* Hct-29.1*
MCV-94 MCH-32.2* MCHC-34.2 RDW-15.4 Plt Ct-375
[**2119-7-26**] 05:32AM BLOOD Neuts-38.6* Lymphs-38.0 Monos-1.8*
Eos-20.5* Baso-1.1
[**2119-7-26**] 05:32AM BLOOD Glucose-86 UreaN-11 Creat-0.7 Na-142
K-3.8 Cl-106 HCO3-30 AnGap-10
[**2119-7-26**] 05:32AM BLOOD ALT-50* AST-17 LD(LDH)-374* AlkPhos-109
TotBili-0.4
MISC
[**2119-7-23**] 01:00PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2119-7-23**] 06:08PM BLOOD STRONGYLOIDES ANTIBODY,IGG-PND
Also pending is final read of immunophenotyping
TTE ([**7-20**]):
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
75%). Right ventricular chamber size and free wall motion are
normal. The aortic root is mildly dilated at the sinus level.
The aortic arch 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 mild bileaflet mitral valve prolapse.
Trivial mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
R Hand Xray ([**7-19**]):
Soft tissue swelling. Slight progression of erosions at the
second metacarpal, at the index metacarpal head, possibly
representing
infection given the history. Mottled appearance of the carpal
bones without direct evidence of infection in the carpal bones.
MRI may be of utility to assess extent of abnormality.
Skin Biopsy ([**7-19**]): Focal intraepidermal pustule, marked
papillary dermal edema, and neutrophilic and eosinophilic
inflammatory infiltrate. The findings are consistent with a
bullous hypersensitivity reaction such as a bullous drug
eruption. The finding of an intraepidermal pustule (in deeper
sections) suggests the possibility of acute generalized
exanthematous pustulosis. The pustule overlies a follicle and
the differential diagnosis includes a component of folliculitis.
Special stains (PAS and gram) are negative for organisms. The
lack of prominent apoptosis and/or necrosis and finding of a
mixed cell infiltrate speak against erythema multiforme and
toxic epidermal necrolysis.
CXR ([**7-18**]):
In comparison with study of [**6-19**], there has been placement of a
left
subclavian PICC line that extends to the lower portion of the
SVC. No
evidence of pneumonia, vascular congestion, or pleural effusion.
Brief Hospital Course:
Mr [**Known lastname 88996**] is an otherwise healthy 50M who sustained [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] bite
on [**5-28**] c/b abscess formation drained on [**6-16**] found to have
osteomyelitis with culture growing prevotella and a 21d course
of vanc/ertapenem after which he developed a diffuse morbiliform
rash and fever, c/w DRESS. Rash significantly improved on
prednisone and has been afebrile. Osteomyelitis resolved on 5
week course of IV antibiotics. Course complicated by severe HSV
eruption in mouth. Discharge to home.
Active Issues:
1. Likely DRESS- Attributed to vanc and/or ertapenem. Brief
MICU stay given presenting high fever (102.8) with potential
evolution to TEN/SJS. CBC with Differential with bands and eos
that improved over hospital course. Flow immunophenotyping
prelim read was negative for malignancy. TTE did not show
myocardial involvement. Rash significantly improved on
prednisone. Biopsy was c/w drug hypersensitivity (DRESS vs
AGEP). Currently on 40mg of prednisone. Will continue at this
dose until end of the week, then taper to 20mg for 5days and
then 10mg for 5days. He will follow-up with dermatology next
Tuesday to assess whether he continues to improve on the taper.
Pruritis controlled with benadryl and triamcinolone. Patient
will be considered allergic to Vanc, Ertapenem heretofore
2. HSV1 ulcers (ventral tongue and bucchal muccosa)- + DFA,
negative for varicella. Pt is s/p 2 doses of 2000mg of Valtrex.
He will go home on 500mg [**Hospital1 **] for 14 days. Denies any
side-effects of current dose.
Inactive Issues:
1. Osteomyelitis: s/p 5 week course of IV antibiotics. Was
briefly on dapto/cipro/flagyl before clinically deciding that
infection resolved. Functionally improving. He will followup
with orthopedics, plastics and ID for assessment of improving
hand function.
Transitional Issues:
1. Resolution of HSV1 infeciton on Valtrex
2. Monitor for continual resolution of skin rash without flare
while on steriod taper, readdress at clinic visits
3. Strongyloides antibody pending
4. Flow immunophenotyping final read was pending at time of
discharge - subsequently returned negative for lymphoma
5. Possible need for MR follow up of right hand after lucency
detected previously
Medications on Admission:
- Vancomycin 1250 mg IV q12h x6 weeks
- Ertapenem 1 gram Injection Q24h x6 weeks
- Acetaminophen 325-650 mg PO Q4H
Discharge Medications:
1. triamcinolone acetonide 0.025 % Cream Sig: One (1)
application Topical once a day as needed for itching.
Disp:*1 tube* Refills:*0*
2. mupirocin 2 % Ointment Sig: One (1) application Topical once
a day: apply to areas of breakdown.
Disp:*1 tube* Refills:*0*
3. valacyclovir 500 mg Tablet Sig: One (1) Tablet PO twice a day
for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
4. prednisone 10 mg Tablet Sig: Take 4 tablets daily for four
days, then take 2 tablets daily for five days, then take 1
tablet daily for five days Tablet PO once a day.
Disp:*31 Tablet(s)* Refills:*0*
5. lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane TID (3 times a day) as needed for sore mouth.
Disp:*500 ML(s)* Refills:*0*
6. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itching, swelling.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Primary Diagnosis
-Osteomyelitis
-Drug hypersensitivity rash likely to vancomycin and ertapenem.
DRESS (Drug reaction with eosinophilia and systemic symptoms )
vs. AGEP 9Acute generalized exanthematous pustulosis)
2. Secondary diagnosis
-Dupuytrens contracture
-Left shoulder capsulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 88996**],
It was a pleasure taking care of you when you were admitted to
the [**Hospital1 18**] for morbiliform rash and fever thought to be from a
drug reaction. You were first admitted to the medical intensive
care unit where your fevers were controlled and you were
evaluated by the dermatologists and infectious disease doctors.
The two medications you were on which could have likely
precipitated your drug reaction: vancomycin and ertapenem were
stopped and they were replaced with different anti-bioitics. You
were also evaluated by the plastic surgeons who felt the wound
on your right hand were healing well and were not concerned for
worsening infections.
Your rash continued to evolve and get better over the course of
your hospital stay on the medicine floor with prednisone.
Followup Instructions:
Provider HAND CLINIC Phone:[**Telephone/Fax (1) 3009**] Date/Time:[**2119-8-1**] 10:00
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8157**], M.D. Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2119-8-8**] 1:45
Name: NP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (works with [**Last Name (LF) **],[**First Name3 (LF) 177**] G. )
Location: PULMONARY & PRIMARY CARE ASSOCIATES
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 40624**]
Phone: [**Telephone/Fax (1) 18696**]
Appt: [**8-2**] at 1:30pm
Department: ORTHOPEDICS
When: TUESDAY [**2119-8-1**] at 10:00 AM
With: HAND CLINIC [**Telephone/Fax (1) 3009**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2119-7-28**]
ICD9 Codes: 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8718
} | Medical Text: Admission Date: [**2163-7-6**] Transfer Date: [**2163-7-10**]
Date of Birth: [**2163-7-6**] Sex: M
Service: NB
The patient was transferred to the [**Year (4 digits) **] Nursery on
[**2163-7-10**].
HISTORY: This is a full term baby boy at 37 weeks to a 27
year old gravida VI, para IV to V mother, with prenatal
screens O positive, antibody negative, RPR nonreactive,
rubella immune, hepatitis B surface antigen negative, GBS
unknown. Pregnancy was uncomplicated. By report, mother
relayed that one of the infant's kidneys is one centimeter
more dilated than the other. He was born by repeat cesarean
section due to mother presenting in labor. Apgar seven at
one minute and eight at five minutes of age. He was noted to
have grunting, flaring and retracting soon after delivery and
was transferred to the Neonatal Intensive Care Unit for
further evaluation. Obstetrician was Dr. [**Last Name (STitle) 57967**] and
pediatrician is Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 29768**] [**Hospital2 16663**] [**Hospital3 37830**].
PHYSICAL EXAMINATION: Upon admission, weight was 3.010
kilograms and 75th percentile, length 46.5 centimeters and 50
percentile, head circumference 35 centimeters at 90th
percentile. Temperature was 97.3, heart rate 160,
respiratory rate 48, oxygen saturation 94 percent in room
air, blood pressure 64/36 with a mean of 39. Dextrostix was
81. Head, eyes, ears, nose and throat normocephalic. Facial
bruising noted on forehead, red reflex deferred. Intact
palate, mucous membranes moist and pink. Neck was supple
without masses. Clavicles intact. Skin was pale with
bruising noted in addition to the face in the right groin and
upper thigh of the right leg. Chest notable for grunting,
intermittent intercostal retractions, nasal flaring,
bilateral and equal breath sounds. Cardiovascular regular
rate and rhythm, no murmur, femoral pulse plus two
bilaterally. Abdomen soft with active bowel sounds, no
masses or distention. Three vessel cord clamped.
Genitourinary - male external genitalia, testicles descended
bilaterally. Anus is patent. Spine is midline with no
sacral dimple. Hips are stable. Neurologic - moves all
extremities equally, normal suck, gag and normal tone.
HOSPITAL COURSE: Respiratory - The baby was placed on
continuous positive airway pressure of seven centimeters for
respiratory distress. Oxygen saturations remained over 95
percent in room air. The patient never developed an oxygen
requirement in the Neonatal Intensive Care Unit stay. He did
have a chest x-ray which was consistent with mild Surfactant
deficiency, however, these symptoms of respiratory distress
resolved with application of continuous positive airway
pressure which was weaned from continuous positive airway
pressure of seven initially on admission to continuous
positive airway pressure of five centimeters continued in
room air, was weaned to a nasal cannula on day of life two
and was weaned off nasal cannula at around noon time on
[**2163-7-8**]. The baby has remained in room air off nasal
cannula without additional respiratory support needed for 48
hours prior to being transferred to the [**Date Range **] Nursery.
Cardiovascular - Initial mean blood pressure was 39 with poor
perfusion. The baby received one normal saline bolus with
improvement of perfusion and mean blood pressures which have
remained with means in the 40s throughout this Neonatal
Intensive Care Unit stay.
Fluids, electrolytes and nutrition - The baby initially was
made NPO due to respiratory distress and transient
hypotension. He was maintained on intravenous fluids of D10W
and had Dextrostix ranging from 70 to 150. He was weaned
from his intravenous fluids and started p.o. feeding on day
of life two as he weaned off continuous positive airway
pressure. He has been breast feeding well ad lib and taking
supplemental formula as needed. He had good urine output and
has passed meconium and then transitional stools. His discharge
weight was 2835 grams.
Gastrointestinal - Maximum bilirubin was noted on day of
transfer to the [**Date Range **] Nursery, day of life four, with
bilirubin of 14.7 over 0.4. He has not had phototherapy at
this point in time.
Hematologic - The baby had an initial complete blood count
and blood culture drawn upon admission to the Neonatal
Intensive Care Unit. His white blood cell count was 19.1
with 36 polys and one band. His hematocrit is 46.0 percent
and platelet count was noted to be 307,000. He did not
receive any blood products during this Neonatal Intensive
Care Unit stay.
Infectious disease - From the infectious disease standpoint,
following blood culture, Ampicillin and Gentamicin were
started and were given for 48 hours pending negative
cultures. Cultures have remained negative and the baby has
remained clinically well off antibiotics.
Audiology - The baby needs a hearing screen prior to
discharge.
Psychosocial - Social worker following this family is [**First Name8 (NamePattern2) 553**]
[**Last Name (NamePattern1) **] and she may be reached at [**Telephone/Fax (1) 36390**].
CONDITION ON DISCHARGE: Good.
DISPOSITION: To the [**Telephone/Fax (1) **] Nursery.
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 29768**] [**Hospital2 16663**] [**Hospital3 37830**].
FEEDS AT DISCHARGE: Breast feeding p.o. ad lib on demand.
MEDICATIONS ON DISCHARGE: None.
Car seat positioning screening was performed prior to
transfer to the [**Hospital3 **] Nursery. The baby passed. [**Name2 (NI) **]
Screening status was sent on day of life three. Results are
pending at this time. The baby needs hepatitis B vaccine
with consent prior to discharge.
FOLLOW UP: Follow-up appointment will be with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 29768**] following discharge from the hospital.
DISCHARGE DIAGNOSES: Term infant with respiratory distress.
Rule out sepsis.
Physiologic jaundice.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) 54678**]
MEDQUIST36
D: [**2163-7-10**] 08:47:37
T: [**2163-7-10**] 11:00:39
Job#: [**Job Number 57968**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8719
} | Medical Text: Admission Date: [**2142-3-10**] Discharge Date: [**2142-3-14**]
Date of Birth: [**2074-7-10**] Sex: F
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: This is a 67 year old female
severe steroid dependence, home oxygen dependent chronic
obstructive pulmonary disease, congestive heart failure, who
had a colonoscopy performed on [**3-7**], at an outside
hospital for the second part of the large 4 to 5 cm polyp
removal by colonoscopy. The patient was not an operative
candidate due to her underlying cardiopulmonary disease and
this was the second operation to remove the large polyp in
question when seen at an earlier date. She was observed over
night at the hospital and discharged on [**3-9**]. She was to
be seen the following day after discharge for bleeding at
home, however, was stable there and discharged again. She
had a second episode again after her second admission at the
outside hospital for a large amount of hematochezia, and
presented herself to [**Hospital6 256**]
Emergency Department where she had another large episode of
bright red blood per rectum. She denied having any abdominal
pain, nausea, vomiting, back pain, fevers, chills, difficulty
breathing or chest pain. Actually her breathing was at her
baseline severe chronic obstructive pulmonary disease status.
Her initial hematocrit in the Emergency Department was 37.8,
however, she was in some mild acute renal failure with a
creatinine of 1.2 which after intravenous fluids and
normalization of her creatinine decreased to 30 to 31 range
later in the hospital course where it remained constant
throughout her hospitalization.
PAST MEDICAL HISTORY: Previous medical history includes - 1.
Severe chronic obstructive pulmonary disease on 3 liters of
cannula oxygen at rest, 4 liters/minute activating on chronic
Prednisone therapy for at least two months. 2. Congestive
heart failure, unknown etiology, no coronary artery disease.
3. Hypertension. 4. Gastroesophageal reflux disease. 5.
Type 2 diabetes mellitus felt to be related to steroid use.
6. Status post cholecystectomy. 7. Status post right knee
surgery.
MEDICATIONS PRIOR TO ADMISSION:
1. Losartan 50 mg b.i.d.
2. Lasix 60 mg b.i.d.
3. Spironolactone 25 mg b.i.d.
4. [**Doctor First Name 233**]-Ciel 30 mg b.i.d.
5. Combivent, Advair, Flovent inhalers
6. Singular 10 q.h.s.
7. Prednisone 20 mg q.o.d. and 10 mg q.o.d., alternating
days.
8. Nortriptyline 25 mg h.s.
9. Paxil 10 mg h.s.
10. Clonazepam 0.25 mg t.i.d.
11. Numerous Vitamins
12. Pantoprazole
13. Insulin sliding scale.
ALLERGIES: She states she is allergic to numerous
medications, however, after chart review with her primary
care nurse practitioner, the only documented allergies we
could find were rashes with Bactrim, Ceftin and Keflex. She
had reported myalgias with fluoroquinolones but there is no
report of any rash or difficulty breathing associated with
that class of medication. She has had reported shortness of
breath with Tetracycline, however, no rash, and has reported
that she has tolerated Macrolides in her chart despite giving
a history of rash.
SOCIAL HISTORY: The patient no longer smokes, however, has
an extensive smoking history and is now home oxygen
dependent. She lives with her husband in [**Name (NI) 5450**],
[**State 350**]. She denies frequent alcohol use or illicit
drugs.
HOSPITAL COURSE: She was admitted to the Medicine Intensive
Care Unit with a baseline hematocrit of 38 prior to
resuscitation of her hypovolemic status where she was
tachycardiac in the Emergency Department, however, never
hypotensive. Upon intravenous fluid replacement, her
creatinine decreased. Her tachycardia resolved and her
hematocrit decreased, ranging between 30 to 33, where it
remained stable throughout her hospital course. She never
required transfusion during her hospital stay. After being
observed in the Medicine Intensive Care Unit and not having
any further bright red bowel movements, she was transferred
to the floor. She had three small dark maroon stools without
associated decreases in her hematocrit or abdominal pain that
was felt to be residual blood from her proximal large bowel
lesion. The Gastroenterology Service followed the patient
closely throughout her course and the plan was made for
colonoscopy.
On hospital day #5, however, the patient had brown, clear,
rectal affluent and had no blood. Given this fact, her
stable hematocrit, and the lack of having fresh bleeding
since admission to the hospital in the Emergency Department,
the decision was made to forego colonoscopy and have the
patient discharged with close follow up. The patient
understands that if she should have any recurrence of bright
red blood per rectum that she should immediately return to
the Emergency Department via ambulance as there is the
potential for rapid rebleeding should the surgical site where
her mass was resected start to bleed again.
This was discussed with her nurse practitioner and she has an
appointment on Monday with her at Dr.[**Name (NI) 49335**] office for
repeat hematocrit check. Throughout her hospital stay she
had no associated problems related to her chronic obstructive
pulmonary disease. She was maintained on her home level of
oxygen as well as continued on her chronic obstructive
pulmonary disease medications including her steroids and she
had no associated dyspnea or orthopnea with it from her
congestive heart failure. She does continue to be limited by
her inability to walk distances greater than 20 feet due to
dyspnea, but this is stable per the patient. She will be
discharged on hospital day #5 with the following diagnosis.
DISCHARGE DIAGNOSIS:
1. Lower gastrointestinal bleed, status post 4 cm mass
excision in the proximal colon via colonoscopy seven days
ago.
2. Anemia due to bleeding, hematocrit stable for several
days now.
3. Chronic obstructive pulmonary disease, stable, continue
on her home oxygen and Prednisone.
4. Acute renal failure, upon admission, resolved with
intravenous rehydration.
5. Congestive heart failure which has been stable throughout
her hospital course.
6. Gastroesophageal reflux disease, has been stable on
Protonix.
She will follow up with her primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 20932**] on Monday, for hematocrit check and she will also
follow up with the [**Hospital 6283**] Clinic in one to two
weeks where she will return to the Emergency Department if
she has any further bleeding or other problems.
DISCHARGE MEDICATIONS:
1. Lasix 80 mg p.o. b.i.d.
2. Albuterol
3. Fluticasone
4. Serevent
5. Singular 10 mg q.d.
6. Levoxyl 1 to 2 mcg q.d.
7. Spironolactone 25 mg b.i.d.
8. Clonazepam .5 mg b.i.d.
9. Protonix 40 mg b.i.d.
10. Raloxifene
11. Prednisone 20 mg q.o.d. and 10 mg q.o.d., alternating
days.
12. Paxil 10 mg q.d.
13. Amitriptyline 25 mg h.s.
14. Insulin per sliding scale.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Last Name (NamePattern1) 4791**]
MEDQUIST36
D: [**2142-3-14**] 15:25
T: [**2142-3-14**] 18:24
JOB#: [**Job Number 49336**]
ICD9 Codes: 496, 4280, 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8720
} | Medical Text: Admission Date: [**2166-5-5**] Discharge Date: [**2166-5-19**]
Date of Birth: [**2083-4-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 1575**] [**Name Initial (NameIs) **].
Address: [**Street Address(2) **] [**Apartment Address(1) 86397**], [**Location 86398**],[**Numeric Identifier 86399**]
Phone: [**Telephone/Fax (1) 54195**]
Fax: [**Telephone/Fax (1) 86400**]
83 yo gentleman with little PMHx was admitted from ERCP suite
with history epigastric pain.
He was initially admitted to [**Hospital6 204**] (LGH) 10
days ago with acute on chronic epigastric pain and diagnosed
with pancreatitis. Additional review of systems is notable for
the following: intermittent epigastric pain and anorexia over
last 3-4 months. He denies fevers or jaundice. At LGH, labs were
notable for leukocytosis with WBC >20,000, increasing serum and
fluid amylase levels with serial fluid amylase readings of
[**2156**]-3600s. Imaging was notable for the following: abdominal CT
with peripancreatic and ascitic fluid; MRI which revealed an
amorphous pancreatic head suggestive of hemorrhagic
pancreatitis. A paracentesis was performed on [**2166-4-28**], and fluid
total protein was elevated, a SAAG was near zero, and fluid cell
count revealed WBC 1700 with neutrophilic predominance. For
treatment, he was started empirically on Unasyn on [**2166-4-26**] and
then changed to Zosyn on [**2166-4-29**]. He also had a drain placed
into one of his abdominal fluid collections. Additional issues
include the following:
- malnutrition - He was started on TPN in the setting of being
NPO and with marked hypoalbuminemia with Alb 1.5.
- anemia - He received 1 unit pRBCs.
- Atrial Fibrillation - He developed rapid afib on [**2166-4-29**]. He
was initially started on diltiazem with minimal improvement, and
he was then transitioned to amiodarone. A pigtail drain was
placed [**2166-5-1**] to drain ascitic fluid.
He was transferred to [**Hospital1 18**] Assessment for ERCP and possible
transpapillary drainage with stenting. Finger stick glucose was
elevated to 225 this afternoon.
ROS:
Constitutional: No weight loss, fatigue, fevers, chills, night
sweats, (+)anorexia for 3-4 months
Neuro: No headaches, confusion, numbness of extremities,
dizziness or light-headedness, vertigo, weakness of extremities,
tremor, parasthesias
Psychiatric: no depression, no suicidal ideation
Eyes: No blurry vision, diplopia, loss of vision, photophobia
ENT: No dry mouth, oral ulcers, bleeding nose or gums, tinnitus,
sinus pain, sore throat
Cardiac: no chest pain, DOE, syncope, PND, orthopnea,
palpitations, (+) chronic bilat LExt peripheral edema
Pulmonary: No shortness of breath, cough, hemoptysis, pleuritic
pain
GI: (+) intermittent epigastric abd pain especially last 10
days, none now. no nausea, vomiting, diarrhea, constipation,
hematemesis, melena, hematochezia,
Heme: no easy bleeding, bruising, lymphadenopathy
GU: no dysuria, hematuria, (+) increased frequency, urgency
chronically, but no incontinence
Endocrine: no changes in hair, skin, heat or cold intolerance,
change in hat or glove size, weight changes, change in energy
Skin: (+) new rash mild today, no pruritis or lacerations,
Musculoskeletal: no myalgias, arthralgias, back pain
Allergy: no seasonal allergies; drug allergies as above
Past Medical History:
1. Cirrhosis
- by recent MRI (no known prior eval / pt not aware)
2. New onset Rapid Afib
- recently at LGH in setting of fluid overload, started on
amiodarone, now resolved
3. Chronic Diastolic Congestive Heart Failure
4. Benign Hypertension
5. BPH
- prior prostate biopsy negative for Cancer per pt, has
urgency/frequency, no incontinence, no recent hydro
Social History:
Home: Lives alone downstairs from brother in law and nieces.
Childless widower. Was in the service.
Occupation: Former shipping department worker for box company.
Tobacco: Never smoked.
EtOH: Occasional ETOH in past
Drugs: Denies
Family History:
No cancers or genetic diseases
Physical Exam:
Elderly gentleman, pleasant, slightly hard of hearing in no
distress
T 96.6, BP 118/50, HR 75 regular, RR 22 SpO2 95%RA
HEENT: anicteric, OP mildly dry, no thrush, no lesions
Neck: JVP not elevated, no [**Doctor First Name **], neck is supple
COR: RRR, nl s1/S2, no MRG, normal PMI
LUNGS: scant crackles at bases, otherwise CTA bilaterallly
ABD: Distended with ascites, non-tender, no guarding, cannot
evaluate for organomegaly given fluid
EXT: chronic venous stasis hemosiderosis, ++ bilat symmetric
LExt edema
NEURO: alert/oriented x 3, mild sensory hearing loss, no focal
abnormalitis
SKIN: mild blanching rash on chest/back arms.
Pertinent Results:
OSH LABS:
[**2166-4-26**]
Na 133 / K 5.1 / Cl 96 / CO2 27 / BUN 46 / Cr .18 / BG 192
Alb 2.6
Ca 8.2 / TB 1.2 / Alk Phos 230
AST 31 / ALT 38 / Amylase 157 / Lipase 1803
WBC 25.6 / hct 34 / Plt 700
N 94 / L 4 / M 2
ESR 75
[**2166-4-28**]
WBC 28.4 / Hct 31 / Plt 589
CA [**75**]-9 - 44
[**2166-4-29**]
WBC 22 / Hct 28.4 / Plt 578
N 87 / Bands 8 / L 0 / M 5
Na 140 / K 4.3 / Cl 107 / CO2 24 / BUN 47 / Cr 1.4 / BG 198
ALT 19 / AST 18 / Alk Phos 120 / Amylase 185 / Lipase 1456
BNP 159
[**2166-4-30**]
WBC 18.2 / Hct 28.2 / Plt 489
N 77 / Bands 4 / L 10 / M 7 / E 2
Na 125 / K 3.8 / Cl 93 / CO2 26 / BUN 38 / Cr 1.9
Alb 1.6
TB .5 / DB .4 / Alk Phos 96 / ALT 14 / AST 15 / Amylase 124 /
Lipase 827
[**2166-5-4**]
Na 136 / K 3.8 / Cl 102 / CO2 30 / BUN 19 / Cr .9
Ca 6.8 / Phos 2.6 / Mg 2.1
Alb 1.5
Alk Phos 128 / TB .8 / AST 28 / ALT 23 / Amylase 149 / Lipase
952
INR 1.2
WBC 16.1 / Hct 27.6 / Plt 386
[**2166-4-28**] Peritoneal fluid
WBC 1774 / RBC 10,000 / Alb 1.9 / Amylase 1640 / Glucose 31
- no malignant cells. Increased PMNs with fibrinopurlent debris
MICROBIOLOGY:
[**2166-4-26**] Blood Cx x 2 pending --> negative
[**2166-4-28**] Ascites Fluid Cx pending --> negative
[**2166-4-28**] AFB Smear - negative
OSH STUDIES:
Peritoneal Fluid - no malignant cells
CT abd [**2166-4-26**]:
1. cirrhosis with moderate ascites
2. high density soft tissue pancreatic head abnormality c/w
hemorrhagic fluid
3. no air within the focus to suggest perforation. Fluid
collection within central mesentary.
4. Probable ileus
5. marked enlarged prostate
6. hiatal hernia
KUB [**2166-4-27**]: moderat ileus, no obstruction
CXR [**2166-4-29**]: low lung volumes with atelectasis and small bilat
effusions.
MRCP [**2166-4-28**]:
1. Pancreatic head mass secondary to acute hemorrhagic
pancreatitis, need to r/o underlying mass.
2. Secondary mild diation of main PD 6mm, unchanged from prior
CT, no intra/extra hepatic biliary dilation.
3. Mild GB distention w/o stones.
4. Cirrhosis and moderate ascites.
U/S [**2166-4-28**]: Abdominal ascites with septations. Heterogeneous
liver, nl spleen, no hydronephrosis, small bilat effusions.
ECHO [**2166-4-29**]: Mild LVH, nl LV size, EF 65%, grade 1 diastolic
dysfunction, nl RV, mod LAE, minimal Aortic stenosis w/ peak
grad 15mmHg, tr TR, no pericardial effusion
[**Hospital1 18**] LABS:
ADMISSION LABS [**2166-5-6**]
WBC 17.7 / Hct 32.1 / Plt 401
Na 138 / K 3.5 / Cl 102 / CO2 30 / BUN 17 / Cr .8 / BG 67
Ca 7.1 / Mg 1.9 / Phos 2.9
ALT 24 / AST 29 / Amylase 212 / Lipase 166 / Alk Phos 151 / LDH
227 / TB 1 / Alb 2.1
IgG 1527
HBsAg negative / HBsAb negative / HBcAb negative
Hepatitis A antibody - negative
[**Doctor First Name **] negative
Hepatitis C Antibody negative
DISCHARGE LABS:
[**Hospital1 18**] MICROBIOLOGY:
[**2166-5-7**] C.diff Toxin - positive
[**2166-5-7**] Urine Cx negative
[**2166-5-7**] Blood Cx [**3-6**] - Prelim GPC in clusters
[**Hospital1 18**] STUDIES:
[**2166-5-5**] ERCP
1. Edematous major papilla
2. The bile duct was not dilated. The distal bile duct filled
poorly, most likely due to extrinsic compression from the
pathology at the pancreatic head. No filling defects were noted.
3. Contrast was injected into the pancreatic duct, which
appeared to terminate abruptly in the pancreatic head, with no
filling beyond that point. This is in keeping with the reported
MRCP findings and is concerning for an obstructing pancreatic
mass.
[**2166-5-6**] Endoscopic Ultrasound
1. A 3.2 cm X 4.1 cm discrete anechoic lesion, consistent with a
cyst was noted in the head of the pancreas.
2. The walls of the cyst were thick measuring 0.22cm.
3. Layering debris was noted in the dependent part of the cyst.
4. A pseudoaneurysm was noted on the lateral wall of the cyst.
5. The cyst appeared to obstruct the main pancreatic duct, which
was dilated distally. The cyst was also noted to compress the
portal vein.
6. A single perigastric lymph node was noted, which measured
1.8 x 0.8cm.
Otherwise normal EGD to third part of the duodenum
[**2166-5-7**] CTA Abd/Pelvis
1. Multiple areas of fluid collection throughout the abdomen
including the
large bilobed pseudocyst above and below the pancreas, in the
right paracolic gutter, transverse mesentery, and within
anterior abdominal wall.
2. 6-mm pseudoaneurysm located within the pseudocyst at the
level of the
pancreas. There is also a 10-mm aneurysm at the origin of the
common hepatic artery.
3. Dilatation of the main pancreatic duct due to compressive
effect of the
pseudocyst.
Brief Hospital Course:
83yo male with history of BPH was transferred from an OSH for
evaluation of pancreatitis. Evaluation was notable for large
pancreatic pseudocyst with multiple intra-abdominal fluid
collections thought related to his pseudocyst. His course was
complicated by unexplained PEA arrest. The patient had an ICU
course s/p resuscitation wherein he did not regain mental
faculties or responsiveness. His family chose comfort measures
and Mr. [**Known lastname 59996**] [**Last Name (Titles) **] on [**2166-5-19**].
# PEA arrest - unclear precipitant. Patient never regained
mental faculties.
1. Pancreatititis, Pancreatic Pseudocysts, Intra-abdominal fluid
Collections
On ERCP, patient was found to have bile duct filling defect,
suggestive of external compression. He underwent follow-up EUS
which revealed a large pancreatic pseudocyst. CTA Pancreas was
also performed, which confirmed the large pseudocysts but also
noted multiple large abdominal fluid collections. He was
evaluated by our general surgery team, who thought his abdominal
process of pancreatic pseudocyst and associated inflammation was
relatively immature, and that surgical intervention or drainage
at this time was not indicated. He developed a bleeding GDA
aneurysm and was taken to IR for embolization before which he
developed PEA arrest. This GDA was ultimately embolized.
2. Clostridium difficile infection
Within 48 hours of admission, patient developed increased
diarrhea and marked leukocytosis from 17 to 26. He was C. diff
positive and started on flagyl on [**2166-5-7**] with improvement in his
diarrhea. He was recommended to continue flagyl for 2 weeks from
4/7-20/10.
3. Hepatic Cirrhosis
Imaging from abdominal CT and MRCP revealed hepatic cirrhosis,
although patient has no history of this in the past.
4. Atrial Fibrillation
Patient was diagnosed with atrial fibrillation at the OSH and
was started on diltiazem before being transitioned to
amiodarone. Upon transfer to [**Hospital1 18**], his PICC line was noted to
be advanced into the right atrium, and it was thought that this
may have been triggering his atrial fibrillation. During his
hospitalization at [**Hospital1 18**], he remained in sinus rhythm and with
excellent rate control. His amiodarone was discontinued.
5. Acute Renal Failure
During his admission at the OSH, his creatinine was as high as
1.9 and then remained stable between .[**8-31**].
6. Malnutrition
Patient was started on TPN at the OSH and was continued on this
during his hospitalization. He was NPO during this
hospitalization and was NPO on discharge. At rehab, we recommend
that he remain NPO for the first week. He could take sips for
comfort after this time.
7. Anemia
Unknown baseline. His hematocrit has remained stable during this
admission from 27-30.
8. Hyperglycemia
He was started on insulin during his hospitalization at [**Hospital3 25354**] and was continued on insulin during his
hospitalization at [**Hospital1 18**].
9. Family Contact
Patient's family contact is the patient's niece [**Name (NI) 86401**]
[**Name (NI) 86402**]. Her home number is ([**Telephone/Fax (1) 86403**]; work number is
([**Telephone/Fax (1) 86404**]; cell number is ([**Telephone/Fax (1) 86405**].
Medications on Admission:
TRANSFER MEDICATIONS:
1. Amiodarone 400mg [**Hospital1 **]
2. Nitroglycerin ointment SS QID (SBP >120 2 in, 110-119 1.5in,
100-109 1 in, <100 wipe off
3. Octreotide 100mcg IV q8hr
4. Pantoprazole 40mg PO q 24
5. Zosyn 3.375 IV q6hr (Day 1 - [**2166-4-28**])
6. Tamsulosin .4mg PO daily
7. Neutra-Phos 2pack PO BID
8. Bacitracin ointment TOP daily prn
9. Demerol 50mg IM q4h prn pain
10. Demerol 75mg IM q 4hr
11. Zoldipem 10mg qhs prn
12. TPN per nutrition
HOME MEDICATIONS:
1. Lasix
2. Tamsulosin
Discharge Medications:
deceased
Discharge Disposition:
[**Month/Day/Year **]
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2166-5-21**]
ICD9 Codes: 0389, 5845, 9971, 4280, 4275, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8721
} | Medical Text: Admission Date: [**2169-5-18**] Discharge Date: [**2169-5-31**]
Date of Birth: [**2085-9-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
lisinopril
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2169-5-18**] Left Ventricular Lead Placement via Left Thoracotomy
History of Present Illness:
This is an 83yo male with chronic systolic congestive heart
failure, chronic slow atrial fibrillation and a left bundle
branch block who recently underwent an upgrade to his St. [**First Name5 (NamePattern1) 923**]
[**Last Name (NamePattern1) **] ICD in [**2169-4-11**]. Unfortunately Dr. [**First Name (STitle) **] was unable to
place the LV lead at that time. He was therefore referred for
surgical placement of epicardial LV leads. Currently his
symptoms include dyspnea on exertion. He denies orthopnea, PND,
LE edema, lightheadedness, chest pain.
Past Medical History:
- Chronic Systolic CHF
- Coronary Artery Disease s/p STEMI in [**2165**]. Underwent Taxus
stent to LAD at [**Hospital6 33**].
- Atrial Fibrillation
- History of NSVT
- Hypertension
- Dyslipidemia
- Chronic Renal Insufficiency, baseline Cr 1.4 to 1.7
- Osteoarthritis
- Spinal Stenosis, Chronic Low Back Pain
- Retinopathy
- BPH
- Complete occlusion of the left mid subclavian vein with
reconstituion medially via collateral vessels.
- History of Colon Cancer
- History of Basal Cell Carcinoma
- Psoriasis
- Iron Deficiency Anemia
- History of H. pylori [**2165**]
- Gout
- History of GI Bleed while on Lovenox [**2165**]
s/p St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) **] ICD [**2169-4-14**]
s/p Single chamber AICD [**2166-9-12**]
s/p Mohs surgery (Multiple) for basal cell
s/p Total Colectomy
s/p TURP
Social History:
Lives with: Alone in [**Location (un) 38**]
Occupation: Retired
Tobacco: quit 15 years ago after 50 pack year history
ETOH: [**3-17**] high balls weekly
Family History:
Son with coronary artery disease
Physical Exam:
PREOP EXAM:
Pulse: 50 AF Resp: 18 O2 sat: 98%
B/P Right: 121/65 Left: 120/65
Height: 67" Weight: 173lb
General: WDWN elderly male in NAD
Skin: Warm, Dry and intact. Multiple nevi and keratosis
HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: Irregular rate and rhythm
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Trace Edema
Varicosities: Mild
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:1 Left:1
PT [**Name (NI) 167**]:1 Left:1
Radial Right:2 Left:2
Carotid Bruit Right: None Left: None
Pertinent Results:
[**2169-5-20**] Transthoracic Echo:
The right atrium is markedly dilated. 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. Overall left ventricular systolic function is severely
depressed (LVEF= 25 %) with global hypokinesis and regional
septal and apical akinesis. No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
[**2169-5-20**] Renal Ultrasound:
1. Normal kidneys, without hydronephrosis, nephrolithiasis, or
mass lesion. 2. Large ascites.
[**2169-5-23**] Abdominal Ultrasound:
1. Contracted gallbladder with gallstone identified within it.
2. Moderate amount of intra-abdominal ascites.
3. Bidirectional flow with reflux noted in the hepatic veins
with associated pulsatile flow in the portal vein - findings are
consistent with sequelae of right heart failure.
[**2169-5-31**] 04:35AM BLOOD WBC-5.5 RBC-2.60* Hgb-9.2* Hct-27.7*
MCV-107* MCH-35.2* MCHC-33.0 RDW-17.7* Plt Ct-145*
[**2169-5-30**] 04:30AM BLOOD WBC-5.6 RBC-2.56* Hgb-9.1* Hct-27.7*
MCV-108* MCH-35.4* MCHC-32.8 RDW-17.8* Plt Ct-128*
[**2169-5-31**] 04:35AM BLOOD PT-17.1* INR(PT)-1.5*
[**2169-5-30**] 04:30AM BLOOD PT-18.0* INR(PT)-1.6*
[**2169-5-31**] 04:35AM BLOOD Glucose-97 UreaN-40* Creat-2.6* Na-138
K-4.1 Cl-99 HCO3-31 AnGap-12
[**2169-5-30**] 04:30AM BLOOD Glucose-106* UreaN-25* Creat-1.9* Na-140
K-4.4 Cl-100 HCO3-29 AnGap-15
[**2169-5-29**] 04:05AM BLOOD Glucose-103* UreaN-41* Creat-2.4* Na-138
K-4.2 Cl-102 HCO3-24 AnGap-16
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent epicardial lead placement
via left mini-thoracotomy by Dr. [**Last Name (STitle) 914**]. For surgical details,
please see operative note. Following the operation, he was
brought to the CVICU in stable condition. Within 24 hours, he
awoke neurologically intact and was extubated without incident.
Device check on postoperative day one showed a normal
functioning biventricular ICD. He otherwise maintained stable
hemodynamics and transferred to the SDU on postoperative day
one. On postoperative day two, he became oliguric and
hypotensive with little response to fluid resuscitation.
Creatinine was rising, and patient became hyperkalemic. Renal
ultrasound showed normal appearing kidneys while echocardiogram
revealed no evidence of tamponade. Renal ultrasound was however
notable for large amount of ascites. He returned to the CVICU
for invasive monitoring. He was started on inotropes and CVVH
was initiated. Given findings of ascites, Warfarin was held for
the possibility of paracentesis. Renal service was consulted and
continued to manage CVVH. It appeared much of his acute on
chronic renal failure was attributed to contrast nephropathy
dating back to [**2169-4-11**] during failed attempt for percutaneous
left ventricular lead placement. Over several days, urine output
improved as did his creatinine. He gradually weaned from
inotropic support. He was transitioned from CVVH to intermittent
hemodialysis via tunnelled right internal jugular catheter. He
did have a 80 mg IV Lasix trial and made minimal urine in
response. His foley was removed and he is to be straight cathed
Q 24 hrs - last hemodialysis run was [**5-31**]. He is on a Mon Wed
Friday schedule for HD. He continued to make good progress and
was cleared for discharge to [**Hospital1 **] at [**Doctor Last Name 1263**] in
[**Location (un) 686**] on POD # 13 in stable condition Target INR 2.0- 2.5
for chronic A Fib. All follow up appointments were advised.
Medications on Admission:
-ALLOPURINOL - 100 mg Tablet - 1.5 Tablet(s) by mouth every
morning
-CALCITRIOL - 0.25 mcg Capsule - 1 Capsule(s) by mouth every
morning
-CHOLESTEROL STUDY DRUG THROUGH [**Hospital1 112**] - 3 pills every evening
-COLCHICINE - 0.6 mg Tablet - 1 Tablet(s) by mouth as needed
-FUROSEMIDE - 40 mg Tablet - 2 Tablet(s) by mouth every
morning, one tablet at 6pm
-METOPROLOL SUCCINATE - 50 mg tablets - 2 Tablet(s) by mouth
every morning
-WARFARIN - 2 mg Tablet - 0.5 (One half) Tablet(s) by mouth
M/W/F, one tablet all other days
-VITAMIN D3 - 1,000 unit Capsule - 1 Capsule(s) by mouth once a
day
-FERROUS SULFATE - 325 mg Tablet - 1 Tablet(s) by mouth three
times a day
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb IH Inhalation Q6H (every 6 hours)
as needed for wheezes.
8. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
10. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Dose
2.5 mg Coumadin dose 4/20 (INR 1.5).
12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Tunneled Access Line (e.g. Hickman), heparin dependent: Flush
with 10 mL Normal saline followed by Heparin as above daily and
PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
Failed Left Ventricular Lead Placement
Chronic Systolic Congestive Heart Failure
Coronary Artery Disease, Prior PCI/Stenting
Chronic Atrial Fibrillation
Acute on Chronic Renal Insufficiency/ HD
Ascites
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol
Incisions:
Thoracotomy - healing well, no erythema or drainage
2+ lower extremity 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 while taking narcotics
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] Tuesday [**6-20**] @ 1:45 pm
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] @ [**Location (un) 38**] office [**6-21**] @ 2:20
pm
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) **] in [**5-16**] weeks
[**Telephone/Fax (1) 3530**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication atrial fibrillation
Goal INR 2.0 to 3.0
First draw day [**6-1**]
*****please arrange for coumadin/INR f/u prior to discharge from
rehab***
Completed by:[**2169-5-31**]
ICD9 Codes: 5845, 4280, 412, 2724, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8722
} | Medical Text: Admission Date: [**2139-8-26**] Discharge Date: [**2139-8-28**]
Date of Birth: [**2112-8-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Head trauma s/p fall, seizure
Major Surgical or Invasive Procedure:
Intensive Care Unit admission
CT head
CT torso
IVF
PRBCs x3 units
History of Present Illness:
Patient is a 27 year old male with past medical history of
elipesy, who presented to the [**Hospital1 18**] after a fall [**Hospital1 14628**].
Patient works at [**Hospital1 778**], and reports that he does not recall any
of the details of his fall. Per report from his friends, he was
standing, and then suddenly fell over. He then recalls waking up
in the [**Hospital1 18**] emergency room.
.
Of note, he reports that he was not feeling like "himself" over
the last several days. On Monday, the fire alarms at [**Hospital1 778**] were
being tested, which bothered him due to the lights and sounds,
and he went home early. He has felt "sick to my stomach" since
the weekend, and reports a very poor appetite with little PO
intake. He has been trying to drink fluids such as water and
gatorade, but has had trouble keeping them down at times. He
reports vomiting and some diarrhea as well. He has felt some
chills, but no fever. No cough, dysuria, rashes, or other
symptoms. He reports he took a "B-1" supplement from CVS (no
other additives), but aside from that no other medications.
.
He states he had not been taking his Dilantin for about 1 month,
and re-started yesterday. He reports his last alcoholic drink
was either Friday or Saturday. He drinks "a few" drinks a week,
usually beers.
.
Review of systems: Notable for 20 lb weight loss over the last
year or so. Possible night sweats. No fevers, rashes, itching.
No abdominal pain. No cough, dyspnea, chest pain. He had a
seizure on the [**6-10**], prior to that in [**Month (only) **]. No
headaches, numbness, weakness. No leg swelling. No bruising or
bleeding.
Past Medical History:
-one seizure in [**6-5**]
-Broken arms and legs as child
Social History:
Patient lives alone, but at times lives with his family when he
feels unwell. He does not smoke, and drinks "a few" drinks per
week, usually beer. He works [**Hospital1 14628**]. Denies any ilicit
drug use.
Family History:
-no history of seizures
-CAD hx in family
Physical Exam:
General: Male appearing stated age, resting in bed with bandage
around head, in NAD, pleasant. Alert, oriented, slightly
fatigued.
HEENT: Large laceration over right parietal area with
significant soft tissue swelling, sutures in place with small
amount of oozing. No scleral icterus or conjunctival pallor.
Mucous membranes slightly dry.
Pertinent Results:
[**2139-8-26**] 01:00AM NEUTS-92.3* LYMPHS-5.7* MONOS-1.8* EOS-0.2
BASOS-0
[**2139-8-26**] 01:00AM PLT COUNT-194
[**2139-8-26**] 01:00AM WBC-16.7*# RBC-2.96*# HGB-10.1*# HCT-27.3*#
MCV-92 MCH-34.2* MCHC-37.1* RDW-13.4
[**2139-8-26**] 01:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2139-8-26**] 01:00AM PHENYTOIN-3.4*
[**2139-8-26**] 01:00AM ALBUMIN-4.0
[**2139-8-26**] 01:00AM ALT(SGPT)-96* AST(SGOT)-211* LD(LDH)-281*
CK(CPK)-853* ALK PHOS-60 TOT BILI-1.3
[**2139-8-26**] 01:00AM GLUCOSE-225* UREA N-16 CREAT-2.6*#
SODIUM-129* POTASSIUM-2.3* CHLORIDE-85* TOTAL CO2-32 ANION
GAP-14
[**2139-8-26**] 05:59AM RET AUT-1.5
[**2139-8-26**] 05:59AM FIBRINOGE-121*
[**2139-8-26**] 05:59AM FDP-10-40
[**2139-8-26**] 05:59AM PT-14.2* PTT-22.9 INR(PT)-1.2*
[**2139-8-26**] 05:59AM HCT-22.3*
[**2139-8-26**] 05:59AM PHENYTOIN-16.6
[**2139-8-26**] 05:59AM CORTISOL-35.8*
[**2139-8-26**] 05:59AM TSH-1.9
[**2139-8-26**] 05:59AM OSMOLAL-279
[**2139-8-26**] 05:59AM calTIBC-166* VIT B12-1086* FOLATE-9.0
HAPTOGLOB-105 FERRITIN-1208* TRF-128*
[**2139-8-26**] 05:59AM ALBUMIN-3.4 CALCIUM-7.3* PHOSPHATE-3.0
MAGNESIUM-1.2* URIC ACID-11.6* IRON-23*
[**2139-8-26**] 05:59AM CK(CPK)-652* AMYLASE-47
[**2139-8-26**] 01:20PM LIPASE-19
[**2139-8-26**] 01:20PM AMYLASE-38
[**2139-8-26**] 05:16PM URINE RBC-[**2-4**]* WBC-[**2-4**] BACTERIA-FEW YEAST-NONE
EPI-0
[**2139-8-26**] 05:16PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-TR KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG
[**2139-8-26**] 05:16PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.021
[**2139-8-26**] 05:16PM URINE OSMOLAL-495
[**2139-8-26**] 05:16PM URINE HOURS-RANDOM UREA N-510 CREAT-447
SODIUM-19
[**2139-8-26**] 05:17PM URINE EOS-NEGATIVE
[**2139-8-26**] 05:17PM URINE AMORPH-MOD
[**2139-8-26**] 05:17PM URINE RBC-[**2-4**]* WBC-[**2-4**] BACTERIA-FEW YEAST-NONE
EPI-0
[**2139-8-26**] 05:17PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-TR KETONE-15 BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG
.
Labs at discharge
[**2139-8-28**]
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
4.3 3.00* 9.8* 27.2* 91 32.5* 35.9* 15.2 115*
4.9 3.11* 10.2* 28.3* 91 32.7* 35.9* 15.3 116*
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
119* 4* 1.0 137 3.5 102 28 11
.
.
Imaging:
[**2139-8-25**] CT C-spine:
IMPRESSION: No fracture or malalignment.
.
[**2139-8-25**] CT head:
IMPRESSION:
1. No acute intracranial pathology including no hemorrhage.
Right subgaleal
hematoma.
2. Age advanced involutional changes, compatible with atrophy.
.
[**2139-8-26**] CXR: Normal heart, lungs, hila, mediastinum and pleural
surfaces.
.
[**2139-8-27**] Abd U/S:
IMPRESSION: 1) Markedly abnormal echogenic renal cortices
suggest underlying parenchymal disease. Further evaluation
warranted. 2) Normal liver, GB and biliary tract.
.
[**2139-8-28**] CT torso: No hematoma or suspicious free fluid
concerning for bleeding.
Brief Hospital Course:
# Epilepsy - Patient had seizure in setting of marked
electrolyte abnormalities and after being off dilantin for a
month's time, only re-initiated yesterday. It is also possible,
although less likely based on his story, that alcohol
consumption or withdrawal played a role. His Dilantin was
restarted at his home dose regimen, which he tolerated well
without further seizures.
.
# Fall - The patients head laceration was sutured by the Surgery
team. It was well-healing over the hospital course, with minimal
drainage. Surgery to take out sutures in [**6-11**] days as
outpatient. The patient was ambulating without difficulty and
did not have a recurrence of falls.
.
# Electrolyte abnormalities - The patient was found to be
hyponatremic and hypokalemic on admission, in addition to an
acute renal failure. He was stabilized in the MICU and given
fluids and supportive care. On the floor, the patient's lab work
had normalized. There is likely a combination of dehydration and
medication effects, but there were found to be kidney
parenchymal abnormailites on U/S that should be worked up in the
future.
.
# Anemia - The patient's HCT dropped just after arrival to the
ED and he was transfused 3 units PRBCs in the MICU. Likely it is
a combination of dilutional effect of fluid infusion and blood
loss from head laceration. However, there may be an element of
occult anemia as the Retic count showed a hypoproliferative
picture. The HCT eventually bumped appropriately, but there was
concern for occult bleeding, yet a CT torso on day of discharge
was negative. Hematology has suggested a bone marrow biopsy in
the future.
Medications on Admission:
Restarted Dilantin x1 day after one month off - 200mg in AM,
100mg in PM
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO once a day: Take 2 capsules in the morning and 1
capsule at night.
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Seizure
Head trauma
Secondary diagnoses:
Acute renal failure
hyponatremia
hypokalemia
anemia
Discharge Condition:
Good, tolerating diet, VSS, ambulating, pain well-controlled,
voiding
Discharge Instructions:
You were seen and treated for a fall with head trauma sustained
when you had a seizure. A head CT and a CT of your torso did not
show any bleeding. Your lab tests were initally abnormal, with
low sodium, low potassium and low blood counts. These labs are
all normalizing. However, it appears as though you might have
anemia with an unknown cause. You will need to follow-up as an
outpatient in order to receive the results of your blood work
that are pending at the time of discharge from the hospital.
You were restarted on your home dose of Dilantin. Please
continue to take this medication, as it is very important to
keep you from having seizures in the future. You should not
drive a car until you are cleared by your PCP or [**Name Initial (PRE) **] Neurologist.
You or someone close to you should call your doctor or return to
the Emergency Department right away if any of the following
problems develop:
* You have an additional seizure.
* You experience new headaches or vomiting.
* You have shaking chills, or a fever.
* You experience difficulty with speech or walking, changes in
your vision, or weakness in one part of your body.
* You do not return to normal quickly after a seizure.
* You notice any serious change in your symptoms, or any new
symptoms that concern you.
Followup Instructions:
Please follow up your appointment with Dr [**Last Name (STitle) 19688**] ([**Telephone/Fax (1) 1247**])
on Tue [**2139-9-1**] at 3 pm on the [**Hospital Ward Name **] [**Hospital1 18**], [**Hospital Ward Name 23**]
building [**Location (un) 448**].
.
Please follow up your appointment with Dr [**Last Name (STitle) **] ([**Telephone/Fax (1) 8693**]) , who will be your primary care provider and Dr [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] on [**2139-9-22**] at 1.30 pm on the [**Hospital Ward Name **] [**Hospital1 18**], [**Hospital Ward Name 23**]
building [**Location (un) 448**]. Please call your insurance and switch your
primary care provider to Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
.
Please call Neurology at [**Telephone/Fax (1) 40554**] to schedule an appointment
with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] within 2 weeks of discharge.
.
Please call Hematology at [**Telephone/Fax (1) 57817**] to schedule an
appointment with Dr [**Last Name (STitle) **].
Completed by:[**2139-8-29**]
ICD9 Codes: 5849, 2761, 2768, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8723
} | Medical Text: Admission Date: [**2107-3-29**] Discharge Date: [**2107-4-3**]
Date of Birth: [**2034-9-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Respiratory failure, blast crisis
Major Surgical or Invasive Procedure:
# Central line insertion
# Arterial line insertion
# Intubation
History of Present Illness:
72M h/o Non-Hodgkin's lymphoma, secondary AML (M4) (transfusion
dependent), transferred to [**Hospital1 18**] ED from [**Hospital1 1474**] after
developing hypotension, fever and respiratory distress after
transfusion.
.
After receiving a blood transfusion on the day of admission, pt
developed dyspnea (88% on 4L NC), chills and diaphoresis, with T
100.1, and creatinine 3.9 from 1.8 earlier in [**Month (only) 958**]. Pt was
transferred to the [**Hospital1 1474**] ED where he was found to be
tachycardic, febrile to T 103, increasingly dyspneic, and
vomiting. Pt underwent elective intubated, after which he was
transferred to the [**Hospital1 18**] ED. En route, patient became
hypotensive despite 1.5 L NS bolus, and phenylephrine was
started.
.
Prior to admission, pt had been recently treated for a sinus
infection with levofloxacin and amoxicillin/clavulanate.
.
[**Hospital1 18**] ED course:
# VS: T 101.8, HR 130, BP 78/40, ventilated, O2 sat 10O%.
# Meds: Vancomycin, ceftazidime, diphenhydramine 50 mg IV x1,
acetaminophen.
# Notable labs: WBC 73.2 (blasts 26%), Cr 3.9, Na 132., LDH
1001, uric acid 15.8.
Past Medical History:
# Non-Hodgkin's lymphoma ([**2097**]), s/p fludarabine x 6 ([**2102**]),
rituximab [**11-8**]
# Acute myelogenous leukemia (M4), diagnosed [**5-/2106**]
--[**10/2106**]: Splenic radiation (2500cGy)
--12/10-18/07: Decitabine x4 c/b persistent cytopenias
Social History:
# Personal: Lives in [**Location 1475**], [**State 350**], with wife
# Professional: Retired elementary school principal
# Tobacco: Past, quit [**2059**]
# Alcohol: Social
Family History:
# Mother, died: GI malignancy
# Father, died 60s: Alcohol-related complications
Physical Exam:
VS: T 100.1, P 121, BP 85/95, SaO2 99% on vent A/C 550/22/5/100%
General: Sedated, intubated, NAD
HEENT: NCAT, small pupils, slow reaction to light bilaterally
Neck: Left IJ. JVP not noted
Chest: B rhonchi anteriorly
Cardiac: RRR, S1S2, holosytolic murmur heard throughout
precordium, best at RUSB
Abdomen: Soft, NT/ND, BS+
Extremities: 1+ BLE edema
Skin: No rashes or lesions noted
Neurologic: Sedated
Pertinent Results:
# CHEST (PORTABLE AP) [**2107-3-29**] 8:20 PM
1. Standard position of the endotracheal and NG tube.
2. Diffuse increased interstitial marking consistent with the
mild interstital edema. The differential includes congestive
heart failure, fluid overload or transfusion-related lung
disease (TRALI).
.
# TTE Echocardiogram [**2107-3-30**] 11:40:43 AM
No evidence of endocarditis or abscess seen. Dilated,
hypokinetic right ventricle with pressure/volume overload. Mild
mitral regurgitation.
.
# CT C-SPINE W/O CONTRAST [**2107-4-1**] 12:20 AM
1. No acute pathology to explain the patient's upper extremity
neurologic findings. Please note, MRI is more sensitive for
evaluation of cord pathology.
2. Right apical ground-glass opacity is nonspecific and may
represent underlying infection or alveolar edema.
.
# CT C-SPINE W/O CONTRAST [**2107-4-1**] 12:20 AM
1. No acute pathology to explain the patient's upper extremity
neurologic findings. Please note, MRI is more sensitive for
evaluation of cord pathology.
2. Right apical ground-glass opacity is nonspecific and may
represent underlying infection or alveolar edema.
.
# CT HEAD W/O CONTRAST [**2107-4-1**] 12:16 AM
1. No acute intracranial pathology identified. Please note MRI
is more sensitive for evaluation of ischemia or lymphomatous
involvement.
2. Chronic appearing sinus changes with suggestive element of
acute sinusitis involving the left maxillary sinusitis. This
should be correlated with clinical exam.
.
# CHEST (PORTABLE AP) [**2107-4-1**] 3:33 AM
Mild interval improvement of bilateral airspace opacities.
Brief Hospital Course:
72M h/o secondary AML, admitted with respiratory failure s/p
transfusion and blast crisis.
.
# Hypoxic respiratory failure: Pt developed acute respiratory
decompensation after receiving blood products, raising the
concern for TRALI, transfusion-associated cardiac overload [**2-5**]
acute diastolic CHF, progressive AML with leukostasis,
overwhelming infection 2/2 blood products received, or PNA, with
the first two etiologies considered most likely. Pt was
maintained on ARDS Net protocol while intubated, with VAP
prevention, and was covered empirically with vancomycin,
ceftazidime, and levofloxacin for PNA. Cultures were pending
for blood products received at OSH; blood and urine cultures
were negative or pending during admission. Pt was extubated
without incident, and maintained on face tent with good oxygen
saturations. His family was very clear that they wished to
proceed with hospice care. He was therefore made CMO. He
subsequently developed increased dyspnea and hypoxemia
(uncertain etiology; perhaps leucostasis) and expired.
.
# Hypotension: Likely underlying etiologies considered were
systemic inflammatory response syndrome, sepsis [**2-5**] PNA or
transfusion-related infection, or cardiogenic shock [**2-5**] NSTEMI
given pt's h/o CAD. Pt was maintained on pressors initially but
was weaned off. Echocardigram demonstrated focal wall motion
abnormality, with rising cardiac enzymes. Given pt's low
platelets, aspirin was not administered; as pt was hypotensive,
beta blockers were also held.
.
# Tumor lysis syndrome: Given pt's high phosphate, worsening
creatinine, and hyperuricemia, initial concern was for tumor
lysis syndrome. Pt was hydrated with bicarbonate added to
alkalinize urine, and was started on rasburicase, with
hematology/oncology following.
.
# Acute on chronic renal failure: Immediate etiology considered
was uric acid nephropathy given pt's high uric acid. No
remarkable casts or crystals were noted on urine sediment.
Hemodialysis was held absent active indication. Creatinine
improved throughout admission with gentle hydration with added
bicarb and rasburicase.
.
# DIC: Initial concern raised for DIC given low platelets and
elevated coags, but no schistocytes were apparent and DIC labs
were negative. Platelets were transfused to maintain
10,000-20,000.
.
# Transaminitis: Elevated LFTs were noted with unclear etiology;
underlying causes considered were tumor infiltrate of liver
given pt's possible hepatomegaly on exam. RUQ ultrasound was
held given pt's non-cholestatic picture, and LFTs were trended.
.
# Blast crisis: Pt was noted to have WBC elevated to 165,
indicating likely acute blast crisis. Given pt's deteriorated
mental status as well as his oncologic prognosis, the decision
was made to not intervene with any acute therapies. Pt was
therefore made CMO.
.
# Mental status: Pt was noted to have altered mental status,
absent response to noxious stimuli, and absent responsiveness
after extubation. CT head and C-spine were negative for acute
pathology. Concern was for significant neurologic involvement
of AML. The decision was made to not intervene with any acute
therapies, and pt was made CMO.
Medications on Admission:
# Epoetin alfa weekly
# HCTZ 25mg daily
# Dutasteride (Avodart) 0.5mg daily
# Tamsulosin (Flomax) 0.4mg daily
# Esomeprazole 40mg daily
# Glipizide 10mg daily
# Insulin
# Vit D/Calcium
# Vitamin C
# Cyclosporine ophthalmic emulsion (Restasis)
# Bupropion (Wellbutrin) 100mg
# Eszopiclone (Lunesta) 2mg daily
# Gabapentin 600mg daily
# Acetaminophen PRN
# Celecoxib (Celebrex) 200mg
# Oxycodone PRN
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary diagnosis
.
# Transfusion-related acute lung injury
# Transfusion-associated cardiac overload [**2-5**] acute diastolic
congestive heart failure
# Blast crisis [**2-5**] secondary acute myeologenous leukemia
# Non-ST elevation myocardial infarction
# Acute on chronic renal failure [**2-5**] uric acid nephropathy
# Respiratory failure [**2-5**] cardiac arrest
.
Secondary diagnosis
.
# Diabetes mellitus type 2
# Benign prostatic hypertrophy
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2107-4-4**]
ICD9 Codes: 5185, 5849, 4280, 3572, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8724
} | Medical Text: Admission Date: [**2161-11-4**] Discharge Date: [**2161-12-18**]
Date of Birth: [**2161-11-4**] Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: [**Known lastname 37189**] is the 1400 gm product
of a 32 [**3-14**] week twin gestation born to a 37 year old gravida
1, para 0 mother. Prenatal laboratory values: Maternal
blood type 0-positive, DAT negative, negative, RPR nonreactive.
The mother's past medical history is significant for: 1.
Tuberculosis, mother was treated in [**2153**] according to chart with
subsequent negative chest x-ray, and 2. Infertility.
The pregnancy was complicated by twin gestation and by
polyhydramnios with apparent duodenal atresia and nuchal
thickening consistent with Trisomy 21 in the B co-twin.
Amniocentesis was not performed. Maternal hypertension was
noted in the doctor's office and Mom was referred to
nonreassuring fetal tracing, necessitating an urgent cesarean
section. Twin #1 cried spontaneously at birth, was bulb
suctioned and received Blow-by oxygen. Apgars were 8 at one
minute and 8 at five minutes. Twin #1 was noted to be in a
breech presentation.
Sepsis risk factors: No fever, no fetal tachycardia, rupture
of membranes at delivery. Group B Streptococcus status
unknown.
PHYSICAL EXAMINATION: Well-appearing female without distress
on admission to the Newborn Intensive Care Unit. The patient
had a weight of 1400 gm, length 41.5 cm and head circumference of
29.25 cm. Anterior fontanelle, soft and flat, palate intact,
nondysmorphic features. Lungs: breath sounds clear and equal
bilaterally, no retractions. Heart: regular rate and rhythm, no
murmur, normal S1 and S2, pulses 2+. Abdomen: soft,
nondistended. Without hepatosplenomegaly, without masses.
Normal female genitalia. Anus patent. Positive suck,
positive grasp. Skin intact. Size appropriate for gestational
age, 32 week female.
SUMMARY OF HOSPITAL COURSE:
1. Respiratory - [**Known lastname 37189**] was initially placed in nasal cannula
oxygen to maintain oxygen saturation greater than 94. On day of
life #1, caffeine was started. [**Known lastname 37189**] weaned to room air on day
of life #6. Caffeine was discontinued on day of life #19.
Breath sounds, clear and equal, without retractions, respiratory
rate 30s to 60s.
2. Cardiovascular - The patient has been cardiovascularly
stable without murmur.
3. Fluids, electrolytes and nutrition - Birthweight was 1400
gm, 25th percentile. The patient was initially started on
D10/W at 80 cc/kg/day. She began enteral feeds on day of
life #2 advancing to mother's breastmilk 30 with ProMod at
150 cc/kg/day. Baby received parenteral nutrition and lipids
for four days. No hypoglycemia issues noted. Baby is
presently tolerating mother's breastmilk with Enfamil powder
to make 24 cal/oz at 130 cc/kg/day. The baby is breastfeeding
well. The plan is for alternating feeds.
4. Gastrointestinal, genitourinary - Peak bilirubin 8.5,
phototherapy times 24 hours. Rebound bilirubin 6.4.
5. Hematology - Most recent hematocrit was 42.8 on [**2161-11-22**]. The baby received no blood products.
6. Infectious disease - No sepsis risk factors. Initial
complete blood count with white blood cell count 14,
hemoglobin 21.6, hematocrit 62.9, 65 neutrophils, no bands,
28 lymphocytes. Blood cultures negative.
7. Neurology - Normal head ultrasound on [**2161-11-19**].
8. Sensory - Audiology, hearing screening was performed with
automated auditory brain stem responses. Baby passed hearing
test on [**2161-12-2**]. Follow up recommended in eight
months. Ophthalmology: eyes were examined most recently on
[**2161-11-25**], revealing mature retinal vessels. A
follow up examination is recommended in six to eight months.
9. Psychosocial - [**Hospital6 **] [**Hospital 36418**]
social work involved with family. The contact social worker
is [**Name (NI) 4457**] [**Name (NI) 36244**] and she can be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) 1790**] [**Last Name (NamePattern1) 1789**], phone
[**Telephone/Fax (1) 1792**], fax [**Telephone/Fax (1) 15418**].
RECOMMENDATIONS:
1. Feeds - Breastfeeding ad lib, supplementing with Enfamil
24 or breastmilk 24 cal/oz made with 1 tsp of Enfamil powder
per 100 cc of breastmilk.
2. Medications - Poly-Vi-[**Male First Name (un) **] 1 cc p.o. q. day; Iron or
Fer-In-[**Male First Name (un) **] 0.2 cc p.o. q. day to give 2 mg/kg/day
3. Car seat screening - Passed.
4. State newborn screening - Last on [**2161-11-18**], all
within normal range.
5. Immunizations received - Hepatitis B vaccine given
[**2161-12-3**].
6. Immunizations recommended -
Synagis respiratory syncytial virus prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the following three criteria - 1. Born at less than
32 weeks; 2. Born between 32 and 35 weeks with plans for
daycare during respiratory syncytial virus season, with a
smoker in the household or with preschool siblings; or 3.
With chronic lung disease.
After some debate, we concluded that [**Known lastname 37190**] was not at
unusually high risk from RSV, but that her sister might be.
[**Known lastname 37190**] probably does not need Synagis at least until her
sibling is discharged from the hospital. It may then be
reasonable to treat both for the balance of the RSV season.
Influenza immunization should be considered annually in the
fall for preterm infants with chronic lung disease once they
reach six months of age, before this age the family and other
caregivers should be considered for immunization against
influenza to protect the infant.
7. Follow up - Follow up appointment with primary
pediatrician within five days of discharge.
DISCHARGE DIAGNOSIS:
1. Prematurity, former 32 4/7 weeks, Twin #1
2. Rule out sepsis
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 33795**], M.D. [**MD Number(1) 35944**]
Dictated By:[**Name8 (MD) 37191**]
MEDQUIST36
D: [**2161-12-17**] 18:20
T: [**2161-12-17**] 18:39
JOB#: [**Job Number 37192**]
ICD9 Codes: 769, 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8725
} | Medical Text: Admission Date: [**2181-6-7**] Discharge Date: [**2181-6-22**]
Date of Birth: [**2101-5-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Cholangiocarcinoma of the distal common bile duct.
Major Surgical or Invasive Procedure:
[**2181-6-7**]:
1. Pylorus preserving Whipple's resection.
2. Open cholecystectomy.
3. J-tube placement.
4. Placement of gold fiducial seeds for CyberKnife therapy.
History of Present Illness:
The patient is an 80-year-old gentleman who presented with
obstructive jaundice. On endoscopic US and CT scan a 3 cm
stricture of the distal bile duct was noted. He underwent stent
placement via ERCP. He is being admitted for a Whipple
resection.
Past Medical History:
1. Gastroesophageal reflux disease.
2. Anemia.
3. Vitamin B12 deficiency.
4. Barrett's esophagus with intramural adenocarcinoma.
5. Prostate cancer with radiation therapy in [**2167**].
6. Osteoarthritis, primariy of the knees
Social History:
Lives with his wife in [**Hospital3 **]. Has two sons and one daughter
who is estranged. He is retired and worked in the press room at
the [**Location (un) 86**] Globe.
Family History:
His father died at age 55 of lung cancer. His mother lived
until age [**Age over 90 **].
Physical Exam:
On Discharge:
Gen:NAD
CVS:RRR, no m/r/g
Resp: CTA b/l
Abd:soft, NT/ND, subcostal surgical incision with steri strips,
JP drain in place, J tube in place.
Ext: well perfused, no e/c/c
Pertinent Results:
[**2181-6-7**] 05:50PM WBC-11.2*# RBC-3.41* HGB-8.7* HCT-27.3*
MCV-80* MCH-25.4* MCHC-31.8 RDW-19.9*
[**2181-6-7**] 05:50PM PT-12.9 PTT-24.9 INR(PT)-1.1
[**2181-6-7**] 05:41PM TYPE-ART PO2-237* PCO2-36 PH-7.42 TOTAL
CO2-24 BASE XS-0 INTUBATED-INTUBATED
[**2181-6-7**] 10:10PM GLUCOSE-214* UREA N-21* CREAT-1.1 SODIUM-138
POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-21* ANION GAP-15
[**2181-6-7**] 05:50PM PHOSPHATE-3.9 MAGNESIUM-1.6
PATHOLOGY: Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 83973**],[**Known firstname 275**] R [**2101-5-18**] 80 Male [**-8/2854**]
[**Numeric Identifier 83974**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **]. WENSON/mtd
SPECIMEN SUBMITTED: FS Bile Duct Margin, Gallbladder, PORTAL
VEIN MARGIN, Jejunum, WHIPPLE SPECIMEN.
Procedure date Tissue received Report Date Diagnosed
by
[**2181-6-7**] [**2181-6-7**] [**2181-6-12**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/aas??????
Previous biopsies: [**Numeric Identifier 83975**] G I BIOPSY (1 JAR).
[**Numeric Identifier 83976**] GI BX ( 1 JAR)
[**-7/4754**] G I BIOPSIES (13 JARS).
DIAGNOSIS:
I. Gallbladder, cholecystectomy (A):
Chronic cholecystitis with cholesterolosis.
II. Bile duct margin (B):
No carcinoma seen.
III. Portal vein margin (C):
Adenocarcinoma present within fibrous tissue.
IV. Jejunum, resection (D-G):
Small intestinal segment, within normal limits.
V. Whipple specimen, pancreaticoduodenectomy (H-AF):
A. Adenocarcinoma, moderately differentiated, see synoptic
report.
B. Adenocarcinoma involving 3 of 12 peripancreatic lymph nodes
([**2-2**]).
C. Duodenal segment with focal periampullary foveolar
metaplasia, acute inflammation and reactive epithelial changes.
RADIOLOGY:
[**2181-6-7**] CHEST PORT:
FINDINGS: In comparison with the study of [**5-24**], there are
substantially lower lung volumes with atelectatic changes at the
left base. Endotracheal tube is now in place with its tip
approximately 7 cm above the carina. Nasogastric tube extends
well into the stomach. Right IJ catheter appears displaced
somewhat to the midline. The tip lies just below the level of
the carina. The resident reports that the line was bringing
back venous blood. However, if the precise position of the
catheter is critical, a lateral view could be obtained.
[**2181-6-13**] ABD CT:
IMPRESSION:
1. Free air likely consistent with recent surgery. Free fluid
within the
abdomen.
2. Peripancreatic fluid collections and stranding adjacent to
the surgical
site may represent post-operative fluid; however, pseudocyst and
leak cannot be completely excluded.
3. Minimal dilation of proximal loops of small bowel measuring
up to 4 cm,
with transition point not clearly identified may represent
post-operative
ileus; however, cannot rule out small bowel obstruction.
4. Small segment of small bowel appears thickened within the
left upper
quadrant and may represent underdistension or may be secondary
to
post-operative changes.
5. Wall thickening at the gastrojejunal anastomosis likely
represents
post-operative edema. Additionally, an area of lobulated
thickened gastric
fold at the GE junction is noted. Recommend attention on follow
up CT. If this persists then endoscopy is recommended.
6. Surgical drain is noted within the right upper quadrant. The
J-tube is not clearly visualized. An NG tube is in place.
[**2181-6-14**] J TUBE EVAL:
IMPRESSION:
1. Multiple dilated loops of small bowel in conjunction with
poor forward
flow of contrast following injection of the J-tube are
consistent with small bowel ileus. There does not appear to be
an obstruction at the entry site of the J-tube.
2. Poor gastric emptying with esophageal reflux.
MICROBIOLOGY:
[**2181-6-8**] 10:25 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2181-6-10**]**
MRSA SCREEN (Final [**2181-6-10**]): No MRSA isolated.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
[**2181-6-7**] for treatment of cholangiocarcinoma. On the same day,
the patient underwent pylorus-preserving pancreaticoduodenectomy
(Whipple) and open cholecystectomy, which went well without
complication (reader referred to the Operative Note for
details).He was transferred to the SICU for postoperative
respiratory insufficiency. The patient was kept on a ventilator,
extubated on [**6-8**]. He was then transferred to [**Hospital Ward Name 121**] 9 and started
on clears on POD4. He had an episode of nausea and vomiting
immediately after lunch, with persistent hiccupping. The patient
also experienced an episode of sinus tachychardia >130bpm, for
which he was triggered. A fluid bolus was given, along with
lopressor for rate control.Tachycardia remitted and HR
stabilized in the 90s. Abdominal distention was also noted and
an NG tube was placed, with significant bilous return
(approximately 2L). A CT scan was performed on [**6-13**] (POD6) to
evaluate for bowel obstruction which showed "minimal dilation of
proximal loops of small bowel with transition point not clearly
identified, questionable small bowel obstruction. Small segment
of small bowel appears thickened, wall thickening at the
gastrojejunal anastomosis likely representing post-operative
edema". An UGI with small bowel follow through performed on [**6-14**]
(POD7) showed multiple dilated loops of small bowel in
conjunction with poor forward flow of contrast following
injection of the J-tube, consistent with small bowel ileus. The
NGT was taken ou the following morning after return of bowel
function.
A KUB was done done on [**6-18**] (POD11) to assess for
obstruction:"persistent dilation of the small bowel, most likely
representing ileus". The JP drain fluid was sent for gram stain
and cultures which showed 4+ GNR, heavy growth, and 1+ GPC,
moderate growth and sparse growth of probable enterococcus. The
patient was started on ciprofloxacin 500mg [**Hospital1 **].
Reglan was discontinued on POD 12 because the patient
experienced neurological side effects (absence-like episodes)
that promptly remitted after the medication was stopped. On
POD12 a CT scan of the abdomen with PO and IV contrast was
ordered for persistent failure to thrive and ileus on KUB with
high JP amylase levels (2400): "thickening of a loop of small
bowel just posterior to the [**Doctor Last Name 406**] drain and adjacent to the
anastomotic site with the pancreas is minimally increased since
[**2181-6-13**] and may represent postoperative changes".
Tubefeeds were re-started on POD12 (Fibersource HN Full
strength;
starting rate: 20 ml/hr, goal rate: 80 ml/hr) and the patient
was started on clears the following day. The patient continued
to do well, ambulating and taking adequate PO.
At the time of discharge on POD15 ([**6-22**]), the patient was doing
well, afebrile with stable vital signs. The patient was
tolerating a clear liquid diet, tube feeds were up to the goal
rate of 80 mL/hr, he was ambulating, voiding without assistance,
and pain was well controlled. Staples were removed, and
steri-strips placed. The patient was discharged to a rehab
facility. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
Lexapro, B12, omeprazole and Zantac
Discharge Medications:
1. Octreotide Acetate 100 mcg/mL Solution Sig: One (1) injection
Injection Q8H (every 8 hours).
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
3. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Erythromycin 250 mg Tablet Sig: One (1) Tablet PO every six
(6) hours for 10 days.
6. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
1. Cholangiocarcinoma of the distal common bile duct.
2. Postoperative respiratory insufficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid.
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-2**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed 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
J tube care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Wash the area gently with warm, soapy water or 1/2 strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
*Flush with 30 cc of water Q8H
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2181-7-2**] 4:00
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**]
Date/Time:[**2181-7-6**] 8:45 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **]
Completed by:[**2181-6-22**]
ICD9 Codes: 5185, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8726
} | Medical Text: Admission Date: [**2140-6-2**] Discharge Date: [**2140-6-14**]
Date of Birth: [**2089-3-11**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This 51-year-old female with
known history of diabetes mellitus and a strong family
history for coronary artery disease awoke on [**2140-5-31**] with
some crushing chest pain radiating to her left arm and back
and felt very lightheaded. She went to an outside hospital
where her Troponin was elevated and she ruled in for a non ST
elevation myocardial infarction. She was transferred into
[**Hospital1 69**] for cardiac
catheterization on [**2140-6-2**].
PAST MEDICAL HISTORY: Insulin dependent diabetes mellitus.
Status post cervical cancer in [**2127**] with hysterectomy.
Status post cerebrovascular accident in [**2139-1-7**] with
slurred speech and left sided weakness but no residual
effect.
Status post pin placement left knee.
Status post appendectomy.
Status post tonsillectomy and adenoidectomy.
ALLERGIES: Levaquin.
Morphine.
Demerol. Both Morphine and Demerol produce nausea and
vomiting.
MEDICATIONS:
1. Aspirin 325 mg p.o. q day.
2. Insulin 70/30 mix 42 units q AM, 30 units q PM.
3. Glucophage 1000 mg p.o. twice a day.
Cardiac catheterization was performed on [**2140-6-2**] on her
admission with the following results. Ejection fraction 45%.
Left ventricular end-diastolic pressure 29. Mild diffuse
left main disease, moderate diffuse mid-LAD disease, severe
diffuse mid to distal left anterior descending coronary
artery, totally occluded left circumflex and severe diffuse
disease of the right coronary artery.
REVIEW OF SYMPTOMS: The patient reported an 80 pound recent
weight loss that was intentional. She also admitted to
frequent urinary tract infections, some wheezing and some
abdominal pain with palpation which he has always had, the
workup is negative. She also said she had no thyroid
problems, bleeding or clotting problems. She worked as a
manager of a convenience store, she had no tobacco or no
alcohol history and no use of marijuana or cocaine and lived
alone.
PHYSICAL EXAMINATION: Her pulse is 106, blood pressure
138/73, respiratory rate 16. She is sating 97% on two
liters. She was awake, and alert and oriented. Her pupils
equal, round and reactive to light and accommodation. EOM's
were intact. Her strength was equal upper extremities and
lower extremities bilaterally. Her heart was regular rate
and rhythm with no murmur, with no rub. Her abdomen was
obese with positive bowel sounds, soft, nontender, with some
tenderness to palpation as previously reported. The patient
said her abdomen is always tender, the workup was negative
prior to this admission. The patient did have some heme
positive emesis in the catheter laboratory with small amount
of not frank blood.
Preop laboratory: White count 10.7, hematocrit 37.0,
platelet count 250,000, sodium 136, K 4.2, chloride 102, CO2
24, BUN 21, creatinine 0.8 with a blood sugar of 360.
Prothrombin time 13.2, INR 1.2, PTT 28.4, ALT 30, AST 109,
alkaline phosphatase 79, total bilirubin 0.6, amylase 39,
lipase was pending. Type and screen was placed on the
computer.
PHYSICAL EXAMINATION: Pulses: The right femoral was in a
sheath but popliteal, dorsalis pedis, posterior tibial,
radial were all 2+. On the left leg, femoral, popliteal,
dorsalis pedis and posterior tibial and radial were all 2+.
The patient had no bruits appreciated in either carotid
artery. Her extremities had no edema or varicosities. Chest
x-ray and urinalysis were ordered. Decision was made to try
and get carotid ultrasounds prior to the operating room.
Aggrastat was to be discontinued at midnight which the
patient had been placed on after her cardiac catheterization.
Later that evening the patient did complain of some heaviness
in her chest with no shortness of breath, nausea, vomiting
but a little bit of a cough. Blood pressure was 157 and then
went down to 119/62, Heparin drip was to be started four
hours after the sheath pull with a plan to start the patient
on a Nitroglycerin drip if the chest pain returned. The
patient was pain free later on, on Heparin drip.
Dr. [**Last Name (STitle) 70**] saw the patient on the 28th and explained
relative high risk of her case. He spoke to Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**]
to have him reassess the patient. The patient did go to the
cardiac catheter laboratory on [**7-4**] for preoperative intra-
aortic balloon in preparation of her surgery.
The patient's height is 5 foot, 1 inches with a weight of 229
pounds. The balloon was placed in the left femoral artery on
[**6-3**] prior to surgery and prior to the operating room she
was on Heparin and Nitroglycerin drips. She also received
Midazolam preoperatively and received 10 units of regular
insulin sliding scale for a blood sugar of 361 at 10 o'clock
that morning. Of note, the patient did not receive her
carotid ultrasound due to the fact of her instability and
intra-aortic balloon placement and moving to the operating
room for her coronary surgery which was performed on [**6-3**] by
Dr. [**Last Name (STitle) 70**] with a catheter coronary artery bypass grafting
times three with a left internal mammary artery to the left
anterior descending coronary artery, to the posterior
descending coronary artery and to the obtuse marginal.
The patient was transferred to the Cardiothoracic Intensive
care unit on a Propofol drip at 30 mcs per kilo per minute
and a Neo-Synephrine drip at 0.5 mcs per kilo per minute in
stable condition. In the evening of [**2140-6-4**] there is no
examination note to be found in the chart from postop day one
on [**6-4**] however, there are a couple of events. The patient
had already been extubated after her operation by the time
she was seen by Anesthesia for the postop check. She was on
Nordinone at that time for decreased cardiac output. She was
otherwise stable. She was seen at 7 o'clock in the evening
on postop day one by the Cardiology Fellow for a diffuse
anterior ST elevation. She was hemodynamically stable
without any symptoms. TTE was performed Stat which showed
that the walls were contracting vigorously and laterally and
at the septum but the anterior inferior walls were less well
seen but appeared to contract well also. There was some
trace MR with an injection fraction of greater than 50% No
effusion was seen on parasternal and apical views, no
subcostal views were performed due to habitus, wires and
chest tube drains. The assessment by Dr. [**Last Name (STitle) 2232**] was that
there was no evidence of acute ischemic territory on limited
views and that he recommended if she became hemodynamically
unstable or had symptoms to consider Transesophageal
echocardiography.
On the evening of [**2140-6-3**] the patient remained on
Propofol and insulin drip. She was also started on Malarone
drip but was extubated by the time Anesthesia saw her on
postop day one. On postop day she remained on a Neo-
Synephrine drip at 0.5 mcs per kilo per minute, on aspirin,
Plavix, Lasix twice a day, and Lopressor twice a day, off her
beta-blockade. She continued with perioperative Vancomycin
for coverage. Her balloon was at 1-to-1. She was in sinus
tach at 114, blood pressure of 92/73 with a cardiac index of
2.1 with the balloon on 1-to-1. She was sating 96% on three
liters.
Laboratory: White count 17.1, hematocrit 32.1, platelet
count 140,000. Sodium 141, K 5.3, chloride 104, CO2 23, BUN
24, creatinine 1.5 with a blood sugar of 129 and a lactate of
1.2. INR of 1.3, Prothrombin time 13.8, PTT 29.1. Her
pacing wires remain in place. She was tachycardiac as noted.
Incisions were clean, dry and intact. She got a new A-line
and the decision was made to at least discuss the Sinatracor.
She received Lasix 60 mg times one to help boost her urine
output.
On postop day two at 11:30 in the morning her intra-aortic
balloon pump was removed the Cardiology Fellow with good
pulses and no hematoma formation
On postop day three she remained on Neo-Synephrine drip at
0.25 mcs per kilo per minute, continuing with aspirin,
Plavix, Lasix and Lopressor. She was also on an insulin drip
at 3 units per hour, still slightly tachycardiac at 108 with
a blood pressure of 127/03, cardiac index of 2.27, sating 96%
on three liters with a blood gas of 7.31/50/87/26/-1. Labs:
White count dropped to 11.8, hematocrit to 28.3, platelet
count dropped again slightly to 113,000, BUN 27, creatinine
1.3, blood sugar of 80. Her lungs were coarse but relatively
clear. Heart was regular in rate and rhythm with
tachycardia. Incisions were clean, dry and intact. Her
sternum is stable. Off Milrinone and the intra-aortic
balloon pump. The chest tubes have been pulled on the
evening prior, [**2140-6-5**]. The patient was seen and evaluated
by Physical Therapy also.
On postop day four the patient had been weaned off Neo-
Synephrine, the Swann was discontinued. She was back on her
insulin drip. Continuing with her oral medications when
insulin drip was still at 3 units per hour, blood pressure
149/81, temperature maximum of 98.9, sinus tachycardia at
110. Lopressor at that time was at 25 mg twice a day. She
was sating 97% on two liters nasal cannula. Her creatinine
dropped to 1.0, blood sugar was at 93 in the morning,
platelet count rose slightly to 150 and white count continued
to drop to 9.1. Her heart was regular rate and rhythm. Her
sternal incision was clean, dry and intact. Her lungs were
clear bilaterally. Abdominal examination and leg incisional
exams were benign. Her Lopressor was increased to 50 mg p.o.
three times a day and the patient was encouraged to be out of
bed and ambulating. She was also evaluated by case
management.
On postop day five she remained in CSRU and was weaned off
her insulin drip, a new line was placed for monitoring. She
remained at Lopressor 37.5 mg p.o. twice a day, she was in
sinus rhythm at 95, with a blood pressure of 107/72, sating
96% now on room air with more normalization of her creatinine
with a BUN of 29 and a creatinine of 0.9. K 4.0. white
count 9.1, hematocrit 28.8 and her platelet count rose
slightly to 165,000. She was quite sleepy but easily
arouseable. Her examination was benign an d a discussion
continued about whether or not to be able to transfer her to
the floor. The patient was out of bed and ambulating in the
CSRU. The patient was seen by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**], Cardiac
Catheterization attending on [**2140-6-8**] who noted her continuing
tachycardia and recommended increasing her Lopressor over the
next 24 hours as her blood pressure would tolerate it.
[**Last Name (un) 3208**]: The patient was screened for nutritional risks by
the Clinical Nutrition team. The patient also had [**Last Name (un) 3208**]
consult on [**2140-6-8**] for management of her diabetes mellitus.
The patient also had a consult. The neurology stroke
attending, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] saw the patient on [**2140-6-8**], was
asked to consult by Dr [**Last Name (STitle) 70**] for a question of acute
stroke verses old stroke that was expressed in this 51-year-
old woman with a new hand paresthesia and an odd sensation.
Please refer to her neurologic examination. She recommended
getting an magnetic resonance imaging with DWI/MRA of brain
to examine her for a new stroke and made other
recommendations in terms of her laboratory work and blood
pressure maintenance. She was noting that the patient may be
re-expressing an old stroke or may have a new event and could
not entirely rule out metabolic encephalopathy. Please refer
to Dr.[**Name (NI) 31849**] examination note.
The patient also was seen by Physical Therapy where she
complained that she could not really feel that arm very well.
The CT of her head on [**2140-6-8**] showed a wedge shaped area of
parenchymal infarct in the posterior aspect of the right
frontal lobe. This was likely recent and clinical
correlation follow-up was recommended. There was no
intracranial hemorrhage or hydrocephalus noted.
The patient also had an MRA of the head done on [**2140-6-11**] which
showed multiple acute infarcts involving the right posterior
superficial water shed and bilateral deep water shed. Her
territories and left cerebellar hemisphere indicative of
acute infarcts and small vessel disease. The MRA of the head
demonstrated normal flow signal within the arteries of
anterior and posterior circulation which was normal MRA of
the head.
A limited carotid ultrasound was done due to the central line
placement on [**2140-6-9**] which showed no evidence of stenosis in
the right or left carotid arteries. The patient continued to
work with physical therapy. On [**2140-6-9**] the patient was alert
and awake and moving all extremities. Left side was stronger
on [**6-9**] and had sensation to left lower extremity and halfway
up distally of left upper extremity, was able to follow
directions. Her mental status seemed to be improved. The
patient from a respiratory point of view was better, was able
to cough up her own sputum, was sating 97% on room air.
On postop day six, [**2140-6-8**] the fluctuating neurologic deficits
of the prior day which ultimately resulted in a diagnosis of
stroke on CT of the head were noted. The patient remained on
Neo-Synephrine drip at 1.8 with a blood pressure of 149/74
and sinus rhythm in the 90's. She is sating well on two
liters nasal cannula. Her neurological status continued to
be monitored. Previous results carotid ultrasound, and
Magnetic resonance imaging of the brain were noted in the
prior paragraph.
On postop day seven, the patient had a stable neurologic
status, had occipital headache overnight which resolved with
Tylenol. She was on Neo-Synephrine drip at 04. Mcs per kilo
per minute. She continued on aspirin, Plavix, Lasix and
Metoprolol at 50 mg twice a day of Metoprolol as well as
Lipitor and Protonix. Blood pressure is 132/83. Sating 97%
on room air in sinus rhythm in the 90's. With laboratory as
follows: White count 11, hematocrit 28, platelet count
312,000. Sodium 140, K 4.1. Chloride 104, CO2 28, BUN 21,
creatinine 0.7, blood sugar 230,000. INR 1.4, Prothrombin
times 14.5, PTT 26.1. Her heart was regular rate and rhythm.
Her sternum was stable,, incision was clean, dry and intact.
Cranial nerves 3 through 12 she was not in any apparent
distress and was alert and oriented. Her Eoms were benign.
Chest was clear bilaterally. She continued to improve and
continue to get out of bed an d ambulate with physical
therapy as tolerated. The patient was also seen again by
[**Hospital 3208**] Clinic for management of her insulin and sugar
control. Was followed daily the stroke consult team and
[**Last Name (un) 3208**] as she remained in the hospital. She continued to
work with physical therapy. On [**2140-6-11**] she was transferred
out to the floor. In the evening on postoperative day 8, she
was on the floor sating well 94% on room air. The blood
pressure 100/58 with a heart rate of 94 and in sinus rhythm.
Her fasting sugar was 114 that morning, she had some mild
crackles left side greater than the right, her examination
was otherwise unremarkable. Her right IJ line remained in
place. Repeat labs were drawn. Her central line was
discontinued later in the day and a follow-up Magnetic
resonance imaging was to be scheduled.
She continued also to see Occupational Therapy and [**Last Name (un) 3208**]
Consult Physician all of whom noted her diagnosis with the
neurologic deficits that have been identified.
On postop day nine, she had some premature ventricular
contractions on telemetry, she was shortness of breath and
desated with some vigorous walking once but was okay and made
a good recovery after that. She had a blood pressure of
102/76. Her examination was unremarkable. The patient
continued to do well and was alert and oriented
neurologically. Stroke consult recommended keeping her
systolic blood pressure above 130. Her insulin at that time
was Lispro 75/25 mixed and she was also on Metformin for
sugar control which was managed by [**Last Name (un) 3208**] Consult
recommendations.
Seh continued to work with physical therapy, she continued to
have some numbness of her hand but continued overall
improvement. On [**2140-6-12**] she did have some diarrhea, C. Diff
was sent. The patient was taking Tylenol for pain at that
point with good relief. Remained afebrile with a blood
pressure of 126/84, sating 97% on room air.
On postop day ten, [**6-13**] she complained of some aching around
her sternum. Telemetry showed a question of some PVCs. Her
heart rate was 96 in sinus rhythm with a blood pressure of
134/83. Sating 94% on room air with a T-max of 99.4. She
had some slight crackles bilaterally. She remained on strict
I&O's.
LAB: White count 8.1, hematocrit 23.3, sodium 142, K 4.7,
BUN 20, creatinine 0.8 with a blood sugar of 91. Magnesium
was given for repletion and a culture repletion and the
culture for C. Diff was waited. The patient continued to
receive p.o. Lasix and was very anxious to get home.
The patient was seen again by Case Management on [**2140-6-13**]. The
patient was also seen by Neurological again on [**2140-6-13**], she
reported in the hallway that bothered her eyes and her vision
blurred a little bit and objects were not well she reported
in the hallway that light bothers her eyes, her vision
blurred a little bit and objects were not well distinguished.
She had no other visual field deficits and was able to see
anything but the lights appeared extremely bright to her.
ASSESSMENT: Follow-up with the Ophthalmologist and this was
discussed with the patient by the Stroke Consult team and
recommended to, continue her on aspirin, Plavix and a statin
for stroke prevention.
On postop day 11, [**2140-6-14**] which was the day of discharge the
examination was as follows. The patient had a T-max of
99.5., was in sinus rhythm at 98 with a blood pressure of
101/68, sating 95% on room air. Her exam was completely
unremarkable. Her chest X-ray showed bilateral pleural
effusions. The C. Diff culture was negative and the patient
continued to do very well with a plan for her to be able to
go home that day.
She had a final evaluation by physical therapy and was able
to be discharged to home on [**2140-6-14**].
DISCHARGE DIAGNOSIS: Status post coronary artery bypass
graft times three.
Coronary artery disease.
Status post cerebrovascular accident postoperatively.
Insulin dependent diabetes mellitus.
Obesity.
Myocardial infarction.
Cervical cancer.
Old cerebrovascular accident.
DISCHARGE MEDICATIONS:
1. Metoprolol 50 mg p.o. twice a day.
2. Potassium Chloride 20 mEq p.o. twice a day times seven
days.
3. Colace 100 mg p.o. twice a day.
4. Aspirin 325 mg p.o. q day, delayed release Entericoated.
5. Protonix 40 mg delayed release Entericoated p.o. q day.
6. Lipitor 20 mg p.o. q day.
7. Metformin 1000 mg p.o. twice a day.
8. Plavix 70 mg p.o. q day.
9. Lasix 20 mg p.o. twice a day times seven days.
10. Insulin 70/30 suspension mix 42 units q AM, 30 units
q PM.
The patient was instructed to follow-up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**] for her postoperative surgical visit in six weeks
in the office. To follow-up with Dr. [**Last Name (STitle) **] of Neurology in
one month. To follow-up with Dr. [**Last Name (STitle) 6984**] the primary care
physician in two to three weeks and to see her Cardiologist
also postoperative in approximately two to three weeks. The
patient was discharged to home on [**2140-6-14**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2140-7-19**] 10:42:15
T: [**2140-7-19**] 12:43:29
Job#: [**Job Number 55491**]
ICD9 Codes: 2762, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8727
} | Medical Text: Admission Date: [**2148-5-3**] Discharge Date: [**2148-5-7**]
Date of Birth: [**2128-5-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
nausea, vomiting, DKA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Name13 (STitle) 12101**] is a 19 yo woman pregnant at 7w2d with h/o DM1
(poorly controlled) on insulin pump, myasthenia [**Last Name (un) 2902**] s/p
thymoma removal [**12-8**], and [**Doctor Last Name 933**] disease (poorly controlled)
who presents with 3d of nausea and vomiting. FS at home have
been 300s-400s for 3 days and she has had large ketones on
dipstick. She presented to her OB today with these symptoms and
was sent to the ER where she was found to be in DKA with anion
gap of 19. She was started on insulin drip and given IVF.
Repeat chem 7 in ER showed anion gap had closed at 10. She was
seen by endocrine who recommended very tight control of her FS
(80-120 for 4-5 hours while still on drip) before transitioning
back to her pump given her history of very poor control.
.
ROS: baseline cough, denies sputum, no dysuria, no other
symptoms. reports feeling much better than at home earlier
today.
Past Medical History:
- pregnant at 7w2d, past TAB x 1
- DM type I x 11 yrs seen by Dr. [**Last Name (STitle) **] at [**Last Name (un) **], on insulin
pump with basal 3u/hr., does not carb count, infrequent FS, does
not give self boluses; A1C 12.5 as of [**2148-4-16**]
- Myasthenia [**Last Name (un) 2902**] s/p thymoma removal at [**Hospital1 2025**]
- [**Doctor Last Name 933**] disease - was on tapazole, changed to PTU on [**2148-4-16**] at
first OB visit. by report has never been well controlled and was
to have surgery vs radioablation. TSH 0.028/FT4 1.4 as of
[**2148-4-16**]
- psych ("mood disorder" - "low grade bipolar") previously on
abilify but now none
Social History:
works as a hairdresser and at the [**Company 3596**]. smokes 1.5 ppd. single.
Family History:
mother with celiac sprue, hypercholesterolemia, htn, DM2. father
s/p suicide.
Physical Exam:
98.6, 97, 128/64, 96% RA
Gen: pleasant, NAD, conversant
HEENT: PERRL, no OP injection, NCAT, no lid lag
Neck: thyroid fulness, + thyroid bruit, no LAD
Cor: s1s2, III/VI fine holosystolic murmur heard best at RUSB,
nonradiating
Pulm: CTAB
Abd:soft, NT, ND, +BS
Ext: no c/c/e, 2+ pt
Neuro: non focal
Pertinent Results:
[**2148-5-3**] 11:45AM BLOOD WBC-7.8 RBC-5.29 Hgb-15.4 Hct-42.0
MCV-79* MCH-29.1 MCHC-36.7*# RDW-14.0 Plt Ct-331
[**2148-5-7**] 06:25AM BLOOD WBC-5.1 RBC-4.45 Hgb-12.8 Hct-35.8*
MCV-81* MCH-28.8 MCHC-35.7* RDW-14.4 Plt Ct-267
[**2148-5-3**] 11:45AM BLOOD Neuts-81.8* Lymphs-12.2* Monos-4.8
Eos-0.3 Baso-1.0
[**2148-5-3**] 11:45AM BLOOD Plt Ct-331
[**2148-5-6**] 04:26AM BLOOD PT-11.4 PTT-20.5* INR(PT)-1.0
[**2148-5-3**] 11:45AM BLOOD Glucose-317* UreaN-13 Creat-0.8 Na-131*
K-4.6 Cl-96 HCO3-16* AnGap-24*
[**2148-5-7**] 06:25AM BLOOD Glucose-60* UreaN-10 Creat-0.4 Na-137
K-3.9 Cl-104 HCO3-22 AnGap-15
[**2148-5-3**] 11:45AM BLOOD ALT-18 AST-14 AlkPhos-161* Amylase-10
TotBili-0.8
[**2148-5-3**] 11:45AM BLOOD Lipase-13
[**2148-5-3**] 11:45AM BLOOD Albumin-4.9* Calcium-10.2 Phos-3.6 Mg-1.8
[**2148-5-7**] 06:25AM BLOOD Calcium-8.9 Phos-4.9* Mg-1.7
[**2148-5-3**] 11:45AM BLOOD Acetone-MODERATE
[**2148-5-3**] 11:45AM BLOOD TSH-0.024*
[**2148-5-3**] 11:45AM BLOOD T3-181 Free T4-2.2*
[**2148-5-4**] 02:06PM BLOOD HBsAg-NEGATIVE
[**2148-5-7**] 06:25AM BLOOD antiTPO-992*
[**2148-5-4**] 02:06PM BLOOD HIV Ab-NEGATIVE
[**2148-5-4**] 02:06PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2148-5-4**] 02:06PM BLOOD CYSTIC FIBROSIS, DNA PROBE ANALYSIS-Test
.
cardiac ECHO [**2148-5-7**]
Impression: normal study
.
Brief Hospital Course:
[**Known firstname **] [**Last Name (NamePattern1) 12101**] is a 19 yo woman who presented in DKA, pregnant
at 7w2d with h/o DM1 and [**Doctor Last Name 933**], both poorly controlled, as well
as myasthenia [**Last Name (un) 2902**] s/p thymomectomy who presents with 3d
nausea/vomiting and was found to be in DKA. Ms. [**Name13 (STitle) 12101**] was
admitted to the Medical ICU for DKA. Her DKA was treated using
our standard ICU protocol with aggressive fluid repletion, FS
measured every hour, and insulin drip. Her anion gap closed
while she was still in the ER and remained closed throughout the
rest of her stay. After her FS dropped below 200 she was
started on D5 1/2 NS for fluids. When her FS dropped below 150
she was allowed to begin eating and her insulin pump was turned
on at her usual basal dose of 3units/hr. She bolused herself
from her insulin pump with a 1:10 carb ratio with meals. She
continued to have high fingersticks, but was no longer in DKA
and anion gap had been closed for three days upon discharge from
the ICU to the floor. The patient was followed by endocrine,
diabetes in pregnancy, and high risk OB during her stay in the
unit.
.
Per OB, we also sent some basic labs including HIV, RPR, Rubella
antibody, Hep B SAg and CF gene (per pt, her ex-boyfriend is
[**Name2 (NI) **]). These will be followed up as an outpatient in OB High
risk clinic. She was kept on a prenatal vitamin during her stay.
Ms. O??????[**Doctor Last Name **] was repeatedly counseled regarding the high
potential for adverse effects on the fetus that her current
health situation presents. Given her elevated A1c ([**12-15**] % on
recent [**Last Name (un) **] readings), macrosomia, and fetal congenital
defects are quite possible. The patient elected to continue the
pregnancy. She has outpatient Ob/Gyn followup, and testing at
appropriate time (16-18 wks) via CVS/amnio/U/S. Her obstetrical
exam was unremarkable at a recent appointment.
.
The patient was kept on PTU for her [**Doctor Last Name 933**] disease during her
stay. Her [**Doctor Last Name 933**] is not well controlled at present, however she
is following with Dr. [**Last Name (STitle) **] as an outpatient and had her
first visit there two weeks ago, when PTU was started. Endocrine
recommended continuing on her usual dose and rechecking thyroid
studies as an outpatient in 2 weeks.
.
The patient is an active cigarette smoker, however she has
decreased from 1.5 packs per day to 5 cigarettes per day. We
discussed the importance of smoking cessation in pregnancy as
well as for her general health.
.
In the medicine [**Hospital1 **], the pt was able to maintain improved
control of blood glucose levels in hospital with insulin pump,
and has demonstrated her ability to correctly program her pump
and make appropriate adjustments. Her current regimen of
baseline humalog was titrated to prevent against transient
hypoglycemia observed in [**Hospital Unit Name 153**]. Patient used ??????carb counting?????? with
1:10 insulin:carbohydration, with correction factor 1:25 for
hyperglycemia. She was closely followed by the endocrine team.
.
On [**2148-5-7**], the pt decided to leave against medical advise. She
was counseled about the potential risks of leaving prematurely,
including potential hypo or hyperglycemia on current insulin
regimen as well as the risk to her fetus including death and
deformity. The pt was urged to follow with her PCP, [**Name10 (NameIs) 65981**]
and Endocrinologist as out-patient.
Medications on Admission:
MEDS from OMR:
Insulin ?????? pump [**First Name8 (NamePattern2) **] [**Last Name (un) **]/Endocrine consult recommendations.
Currently Humalog 3U/hr during day, 2.5U/hr at night.
Ferrous Sulfate 325 mg po qd
Nephrocaps
Colace / Senna
ALL: NKDA
Discharge Medications:
Pt left against medical advise
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1) DKA
2) Pregnancy
Secondary:
1. Hyperthyroidism; patient managed with PTU, recent management
with tapazol. Has been considered for outpatient ablation.
2. [**First Name9 (NamePattern2) **] [**Last Name (un) 2902**]
3. Thymoma s/p surgical resection [**12-8**]
Discharge Condition:
Pt left against medical advise
Discharge Instructions:
Pt left against medical advise
Followup Instructions:
Pt left against medical advise
Completed by:[**2148-6-26**]
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8728
} | Medical Text: Admission Date: [**2192-10-17**] Discharge Date: [**2192-12-7**]
Date of Birth: [**2150-10-24**] Sex: F
Service: SURGERY
Allergies:
Milk / Apple Juice
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Necrotizing pancreatitis
Major Surgical or Invasive Procedure:
[**2192-10-23**]
PROCEDURE:
1. Pancreatic necrosectomy.
2. Left retroperitoneal abscess wide drainage.
3. Right retroperitoneal abscess wide drainage.
[**2192-10-30**]
PROCEDURE: Chest US and Left-sided thoracenteses with pigtail
placement.
[**2192-11-1**]
PROCEDURE: Tracheostomy.
[**2192-10-25**]
OPERATIVE PROCEDURES:
1. Reopen recent laparotomy.
2. Bilateral retroperitoneal abscess washout.
3. Feeding jejunostomy tube placement.
[**2192-11-12**]:
CT-guided drainage of bilateral intra-abdominal abscesses
[**2192-11-28**]: CT guided exchange of the right retroperitoneal
catheter.
History of Present Illness:
Ms. [**Known lastname 88542**] is a 41F with history of alcoholism, HCV, who was
transferred from an outside hospital for management of
complicated pancreatitis. Patient was hospitalized from
[**Date range (3) 88543**] with acute hemorrhagic alcoholic
pancreatitis complicated by ARDS, upper GI bleed, E.coli
bacteremia from ascending cholangitis, and acute renal failure.
After a prolonged ICU course, she was discharged to rehab in
good condition. Patient was recovering well until [**2192-10-11**] when
she developed abdominal pain with distension, fevers (max
101.2), and diarrhea. She denied nausea, vomiting, chest pain,
cough, and
dyspnea. She was admitted again started on IV
Vanco/Levaquin/Meropenem, all blood cultures were negative. She
was transfused 2 units for Hct of 25 which remained stable at 37
for the remainder of her stay. Patient continued to have low
grade fevers, abdominal pain, and significant distension. She
was
transferred to [**Hospital1 18**] for management of her intra-abdominal
collections. Her current complaints include abdominal and back
pain. She denies nausea, vomiting, and malaise. She has not
passed flatus in days but has had multiple daily episodes of
diarrhea.
Past Medical History:
PMH:
- Chronic hep C
- Hepatitis C
- Hypertension
- Depression
- Chronic back pain
- Asthma
PSH: None
Social History:
SH:
Lives at home with two children in [**Location (un) 3610**]. She quit smoking 3
months ago after 20 pack-year history. She has remote history of
IV drug abuse. She has a long history of heavy alcohol abuse
until recent pancreatitis.
Family History:
FH:
- Father died at 75 from liver cirrhosis and Bone cancer
- Mother alive and well at 77
Physical Exam:
On Admission:
Vitals: T-98.8 HR-89 bp-146/89 RR-26 O2 SAT-98% RA
Gen: Well appearing, NAD
HEENT/Neck: Hirsute face, No icteric sclerae, no lymphadenopathy
Resp: breath sounds throughout, muted at left base, no wheezes
CV: RRR, Nl S1 S2
Abd: Markedly distended, tender to percussion of epigastrium,
less tender laterally on abdomen, negative rebound, no guarding
Ext: No edema, no jaundice
Neuro/Psych: Muted affect, A&Ox3, no gross abnormalities
On Discharge:
VS: 98.7, 82, 110/82, 18, 96% RA
GEN: NAD, AAO x 3
HEENT: Tracheostomy with # Portex (cuffless)
CV: RRR, no m/r/g
Lungs: CTAB
Abd: Midline abdominal incision open to air and healing well.
Left pigtail drain to JP bulb suction, site c/d/i. Right old
pigtail site open to drainage, urostomy applied on site, minimal
skin erythema around site. J tube, site coverred with dry
dressing and c/d/i
Extr: warm, no c/c/e
Pertinent Results:
On Admission:
IMAGING:
CXR [**2192-10-12**]: Stable left pleural effusion
AXR [**2192-10-16**]: Ileus
CT ABDOMEN [**2192-10-12**]:
- Large retroperitoneal collections
- Borderline to mild common bile duct
- Small to moderate pelvic ascites, left pleural effusion, left
atelectasis
US PARACENTESIS [**2192-10-13**]:
- Large complex fluid collections, no paracentesis performed
LABS: [**2192-10-16**]
7.0> 12/37 <270 INR 1.3
132 / 95 / 7
---------------
3.8 / 29 / 0.36
AST-15 ALT-8 AP-95 GGT-92 BILI(T)-0.4
MICRO:
[**10-19**] Peritoneal fluid: no growth
[**10-19**] Abcess: no growth
[**10-23**] Peritoneal fluid/tissue: no orgs, pan-sensitive E.coli (1
colony on 1 plate)
[**10-25**], [**11-3**], [**11-6**], [**11-9**]: Cdiff: negative
[**10-30**]: BCx: F- no growth
[**10-30**]: BAL: 10-100,000 2 types yeast, commensal respiratory
flora
[**10-30**]: cath tip: NGTD
[**10-30**]: pleural fluid cx: NGTD
[**11-2**]: Peritoneal fluid: GS- budding yeast and GPC; Cx- heavy
growth coag- staph, [**Female First Name (un) **] (TORULOPSIS) GLABRATA. [**Female First Name (un) **]
ALBICANS.
[**11-2**]: Sputum cx: GS- >25PMNs, no orgs: Cx- commensal resp flora
[**11-3**]: LIJ CVL tip cx: coag- staph (>15 colonies) [**Last Name (un) 36**]. to
rifampin, tetracycline & vancomycin
[**11-3**]: pelvic abscess drainage: GS- no PMNs, no orgs: Cx- NGTD
[**11-3**]: fluid from JP: GS- no PMNs, no orgs: Cx- NGTD
[**11-4**]: BCx x2: pending
[**11-4**]: UCx: YEAST. 10,000-100,000 ORGANISMS/ML
[**11-4**]: VRE screen: NGTD
[**11-5**]: MRSA screen: final negative
[**11-6**]: Sputum: GS [**10-29**] PMNs, 1+ GPCs IN PAIRS AND CLUSTERS.
Cx-SPARSE GROWTH Commensal Respiratory Flora.
[**11-6**]: UCx final no growth
[**11-6**]: BCx x2 P
[**11-6**]: Drain #2 Fluid GS: 2+ GPCs IN CLUSTERS. 2+ GPRs 2+ budding
yesat 2+ GNRs. Cx- mixed bacterial types, abbreviated w/u will
be performed
[**11-9**]: sputum cx: commensal resp flora
[**11-9**]: cdiff: negative
[**11-9**]: BCx: pending
[**11-11**]: BCx: pending
[**11-11**]: sputum cx: SPARSE GROWTH commensal resp flora
[**11-11**]: UCx: NG
[**11-12**]: cx from #2 and #5 drain: NO POLYMORPHONUCLEAR LEUKOCYTES
SEEN.
2+GRAM POSITIVE COCCI.IN CLUSTERS. 1+ YEAST(S).
IMAGING:
[**10-22**] CT Abd/Pelvis: 1. Interval decrease in size to organized
peripancreatic and retroperitoneal collections extending into
the anterior and posterior pararenal spaces with appropriate
positioning to indwelling bilateral pigtail drainage catheters.
2. Interval increase in size to simple left pleural effusion
with adjacent compression atelectasis. Slight interval increase
in amount of nonorganized intra-abdominal ascites. 3. No other
vascular or parenchymal complications of pancreatitis
identified.
[**10-23**] CXR: ET tube is in standard placement, left internal
jugular line ends in the left brachiocephalic vein. Left PIC
catheter tip still in the low SVC. Nasogastric tube should be
advanced 4 cm to move all the side ports into the stomach. Left
lower lobe atelectasis unchanged. Lungs otherwise grossly clear.
Heart size normal. No pneumothorax. Small left pleural effusion
along the left lateral chest wall and apex is new.
[**10-25**] CXR: Interval increase in left pleural effusion and
atelectasis.
[**10-25**] KUB: No retained surgical sponges identified.
[**10-27**] CXR: Unchange from prior: Large left retrocardiac
atelectasis with a small left pleural effusion. basal
atelectasis on Rt
[**10-29**] CT torso: PRELIM - Unchanged left pleural effusion w/
assoc'd left lower lobe collapse. Small right pleural effusion.
2. Interval decrease in size of the peripancreatic,
retroperitoneal and
intraperitoneal fluid collections. Interval increase in the
amount of peritoneal enhancement
[**10-30**]: CXR- S/p L thoracentesis with pigtail catheter in L lung
base, without evidence of ptx. ETT, NGT in unchanged position
since 1 day ago; note side port of NGT is at the GE junction.
Decreased L pleural effusion since 9 hours ago. Bibasilar atx.
Post surgical changes of anterior abdomen redemonstrated
[**10-31**]: CXR: Little change from prior
[**11-1**]: CXR: retrocardiac opacity likely atelectasis improved.
right basal atelectasis unchanged.
[**11-2**]: 1. Right PICC terminates at the cavoatrial junction. 2.
Improvement in right lower lung atelectasis. 3. Persistent
vascular engorgement.
[**11-4**]: 1. Lines and tubes as described. Clinical correlation
regarding the PICC line is requested as it overlies the right
atrium. If clinically indicated, this could be retracted
approximately 3 cm.
2. NG tube probably does not extend below the GE junction, with
side port in mid esophagus. Clinical correlation regarding
potential advancement is requested. 3. Left lower lobe collapse
and/or consolidation, unchanged. 4. CHF, unchanged.
[**11-5**]: CXR RUL consolidation and early pulmonary edema.
[**11-5**]: RUQ U/S Gallbladder packed w/sludge, mild wall edema, no
distention, not typical for acalculous cholecystitis. No
intrahepatic biliary dilatation.
[**11-5**]: TTE: EF >50%, PASP 34, mild LA enlargement, [**Male First Name (un) **] of the
mitral chordae (normal variant). 1+TR RUQ U/S:1. Gallbladder
packed with sludge, with mild wall edema, but not distended, not
typical for acalculous cholecystitis.
2. No intrahepatic biliary dilatation.
[**11-6**]: CXR:As compared to the previous radiograph, the position
of the
tracheostomy tube and the course of the nasogastric tube are
unchanged. Moderate cardiomegaly with increasing bilateral
perihilar opacities and increasing retrocardiac atelectasis.
Minimal newly occurred right-sided pleural effusion.
[**11-7**] CXR: Bilateral perihilar, opacities are unchanged. If any,
there is a small left pleural effusion.
[**11-9**] CXR: Likely stable bilateral hilar opacities with small L
pleural effusion
[**11-10**]: CT abd/pelvis: 1. Mixed response to fluid collections with
essentially stable peripancreatic fluid collection but slight
interval increase in size to the bilateral retroperitoneal
collections. Within the pelvis the presacral and rectouterine
collections are stable to slightly decreased in size with the
supravesicular pigtail-containing collection essentially
resolved. Increased air within the surgically drained collection
is of uncertain significance. Trace pneumoperitoneum noted along
the tract of the anterior placed drain.
2. Slightly prominent loops of small bowel with air-fluid levels
but no clear transition point likely representing a reactive
mild ileus.
3. Remaining pancreatic parenchyma displays homogeneous
enhancement with no further areas of necrosis seen. The splenic
vein is again noted to be severely attenuated. No vascular
pseudoaneurysms identified.
4. Persistent left pleural effusion with near complete left
lower lobe atelectasis. Increased right lower lobe atelectasis.
5. Hyperdense material within the gallbladder likely related to
sludge as suggested on recent ultrasound.
[**11-11**] CXR: increased bilateral perihilar opacities, small L
pleural effusion, bibasilar opacities (L>R), interval worsening
on the R
[**11-12**] CT abd: Technically successful CT-guided drainage of
bilateral
intra-abdominal abscesses with exchange of current to bilateral
16-gauge catheters. Total of 880cc pus aspirated.
[**11-19**] CT abd: IMPRESSION:
1. Interval exchange of right and left-sided catheters draining
retroperitoneal fluid collections, with decrease in overall size
of the
multiple collections. However, there is new hyperdensity in a
left-sided
retroperitoneal collection, suggestive of oral contrast
extravasation and
possible communication with the adjacent colon.
2. Left-sided pleural effusion, minimally decreased, with slight
improvement in left lower lobe atelectasis. Stable right lower
lobe atelectasis.
3. Slight decrease in size of the pelvic fluid collections.
4. Severe narrowing of the portal vein, occlusion of splenic and
superior
mesenteric veins with left upper quadrant variceal formation.
5. Enhancement of the remaining pancreas without evidence of
pancreatic
necrosis. Stable biliary dilation.
[**11-23**] Chest x-ray: Pulmonary edema is no longer present.
Opacification at the left lung base is virtually unchanged since
[**11-6**], probably persistent atelectasis. Pleural effusion,
if any, is minimal. Heart size is normal. Tracheostomy tube is
in standard placement. Right subclavian or PIC line tip projects
over the low SVC. No pneumothorax.
[**11-27**] CT abd: IMPRESSION:
1. Evidence of communication between the left-sided
retroperitoneal
collection and the descending colon with contrast injected into
the left-sided pigtail drain causing opacification of the
descending colon, sigmoid and rectum.
2. Small amount of high-density material seen in the right-sided
retroperitoneal collection likely from communication with the
left sided
collection.
3. Small right-sided pleural effusion with compressive
atelectasis.
4. Stable presacral fluid collections.
5. Persistent narrowing of the portal vein with probable
occlusion of the
splenic vein.
6. Homogenous enhancement of the residual pancreatic tissue.
[**2192-11-26**] 8:57 am BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT [**2192-12-2**]**
Blood Culture, Routine (Final [**2192-12-2**]): NO GROWTH
[**2192-11-28**] 5:50 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2192-11-30**]**
GRAM STAIN (Final [**2192-11-28**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2192-11-30**]):
HEAVY GROWTH Commensal Respiratory Flora
[**2192-11-28**] 2:07 am URINE Source: CVS.
**FINAL REPORT [**2192-12-3**]**
URINE CULTURE (Final [**2192-12-3**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
CIPROFLOXACIN SENSITIVITY REQUESTED BY V. TRAN .
sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- I
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- 2 S
[**2192-11-29**] 12:05 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2192-11-29**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2192-11-29**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2192-11-29**] 7:41 am BLOOD CULTURE
**FINAL REPORT [**2192-12-5**]**
Blood Culture, Routine (Final [**2192-12-5**]): NO GROWTH.
Brief Hospital Course:
Originally admitted [**Month (only) 216**]-[**Month (only) **] for acute hemorrhagic
pancreatitis c/b ARDS, upper GI bleed, E.coli bacteremia from
ascending cholangitis, and acute renal failure. Went to [**Hospital 1319**]
rehab for several days, had repeat episode of abdominal pain and
fevers. She was admitted again started on IV
[**Hospital1 5042**]/Levaquin/Meropenem, all blood cultures were negative. She
was transfused 2 units for HCT of 25 which remained stable at 37
for the remainder of her stay, and she was transferred here for
further management. She continued to complain of abdominal and
back pain. She had a CT which demonstrated large intraabdominal
fluid collections. She had two IR drains placed that did not
grow back any organisms. On [**10-22**] she had a repeat CT scan which
still demonstrated large abdominal fluid collections. On [**10-23**]
she went to the OR for an exploratory laparotomy, pancreatic
necrosectomy, drainage of 1.5 of ascites; 1.5 [**Last Name (LF) **], [**First Name3 (LF) **], urb,
3.5 crystalloid. She was admitted tot he ICU. She returned to
the OR [**10-25**] for ex lap and washout of b/l retroperitoneal
abscesses and placement of Tube.
ICU Course:
EVENTS:
[**10-24**]: Typed and crossed for 4 total units for OR on [**10-24**]. TPN
for nutrition to begin after OR on [**10-25**]. Neo gtt discontinued.
[**10-25**]: returned to OR for debridement, washout, and drain
placement. When returned from OR, had decrease in BP which was
treated w/ crystalloid, colloid, and neo. Plan developed to
resuscitate 05.cc for every cc lost. Had 1800 cc drain output
and 300 from NGT. Was given 1100 cc crystalloid, 25 albumin and
1 RBC. Patient was weaned off neo by morning.
[**10-26**]: d/c' ed IVF, albumin tid, changed sedation from propofol
to Midas. ABX to be mixed with NS, not D5W.
[**10-27**]: bladder pressures noted to be 17. Transfused 2 units
probes for HCT drop to 24-> appropriate HCT rise to 30. Agonal
breathing and placed back on CMV. Diuresed in PM.
[**10-28**]: Diuresed 5ML of fluids w/ Lasix drip. Weaned to PSV 12/5
but then needed to be placed on CMV.
[**10-29**]: Started 25% albumin and Diamox for contraction alkalosis.
continuing on Lasix gtt for goal diuresis of negative 2-5ML.
started on methadone 20'' to aid in weaning fentanyl, later
increased to 40''. CT torso obtained showing unchanged L pleural
effusion w/ LLL collapse and decreased size of intraabdominal
fluid collections. JP amylase 1474.
[**10-30**]: Patient with persistent LLL effusions (atelectasis vs.
pleural collection). Underwent bronchi/BAL and thoracentesis -
dx & therapeutic (600cc removed) with pigtail catheter
placement. Bctx x 2 sent off and PICC removed with tip cultured.
[**10-31**]: TF to full and TPN stopped. Meds converted to PO. Able to
wean to PS for the day.
[**11-1**]: extubated but had to be reintubated after ~2hrs for
tachypnea and increased WOB. s/p perc trach. Lower TVs and
increased airway pressures after trach. Bladder pressure 16, CXR
showed no PTX. fentanyl and roxicet d/c'd. lasix gtt decreased
to 1/hr. methylene blue mixed into TFs for concern of
TF-appearing fluid in JPs.
[**11-2**]: Patient febrile and CVL( wtih tip ctx) and and PICC
placed. Panctx and JP grew out yeast and GPC. ID consulted and
started on vanco/flagyl/fluconazole. Primary team not planning
repeat necrosectomy unless condition worsens.
[**11-3**]: IR drainage of fluid collection, tolerated well. NG
currently. ECHO not done. GPC large growth from peritoneal fluid
[**11-2**]
[**11-4**]: Patient looking more jaundiced, LFTs sent and noted to be
elevated (Tbili 1.7, Dbili 1.0). Meds changed to IV to prevent
clogging of Jtube. Pt persistently febrile throughout the day.
Cipro/flagyl switched to zosyn per ID's suggestion. VRE swab
sent. Foley and Aline changed out. Abdomen appeared to be
increasingly distended. Bladder pressure 22.
[**11-5**]: Abdominal exam slightly worse. Fever 102.9. Lasix gtt d/c.
Tapering ativan.
[**11-6**]: Cultured JP#2. Poor TV on PS d/t abdominal distention.
[**11-7**]: TF restarted. Increasing agitation treated with ativan.
+Diarrhea. Flexiseal in place.
[**11-8**]: Methadone dosing changed to 8AM/8PM. LFTs normalizing. PPI
changed to lansoprazole. Aline d/c'd. Vent weaned to PSV 5/5.
[**11-9**]: Spiked to 103, pan-cultured.
[**11-10**]: weaned to trach collar. Worsening intraabdominal fluid
collections on CT. Drains flushed. Patient had desats and
bigeminy. Had to be put back on vent. Fever to 101.3 CXR and
cultures sent. Possible aspiration from baricat?
[**11-11**]: vent weaned to PSV 5/5. primary team entertaining
possibility of having IR upsize patient's abdominal drains.
[**11-12**]:pat got 1 left and 1 right sided drain placed by IR, 380
and 500ml drained respectively
[**11-13**]: Pelvic drain d/c by surgical team. Patient conversive and
appropriate.
[**11-14**]: started methadone wean. Transferred to the floor
Floor course:
[**11-15**]: Patient was evaluated by Speech/Swallow and her diet was
advanced to clear thin liquids. Patient tolerated well.
[**11-17**]: Patient's diet advanced to fulls.
[**11-18**]: Regular diet. Tube feeding cycled over 18 hrs.
[**11-19**]: After repeated CT scan, two [**Doctor Last Name 406**] drains were
discontinued. Patient failed repeat Speech/Swallow and was made
NPO. TF continued.
[**11-21**]: All antibiotic were discontinued.
[**11-22**]: Foley catheter discontinued, patient voided without any
difficulties. Physiacl Therapy continued to work up with the
patient.
[**11-23**]: Repeated Speech/Swallow recommended thin liquids and
regular solids. Patient's diet was advanced.
[**11-25**]: Respiratory recommended downside trach. Patient started
to ambulate with PT.
[**11-27**]: CT scan - stable bilateral retroperitoneal collections.
[**11-28**]: Spike of fever with 101.4 max. Pancultured. CT guided
drain repositioned output increased after repositioning.
[**11-29**]: Patient's tracheostomy downsised to # 7 Portex with cuff.
Patient started on PO Ciprofloxacin for urinary tract infection.
[**11-30**]: Patient started PMV trails. Patient started to have
diarrhea on TF, c-diff sent and negative.
[**12-1**]: Diarrhea improved with banana flakes
[**12-5**]: Right pigtail discontinued, drainage continue into
urostomy bag.
[**12-6**]: Tracheostomy tube downsised to # 6 Portex cuffless.
Patient tolerated regular diet and TF, ambulating short
distances with minimal assist.
[**12-7**]: Discharged in Rehab in stable condition.
Neuro: Patient's pain well controlled with current regiment.
Goal to wean of Methadone and transfer patient to short acting
pain medications.
CV: Patient stable from cardiac standpoint. Her vital signs were
monitored with telemetry during hospitalization.
Pulmonary: Patient had a history of prolong respiratory failure
and was difficult to extubate. Tracheostomy was performed to
wean patient from ventilator. Currently patient's tracheostomy
tube downsised to # 6, tracheostomy tube should be removed on
[**12-13**].
GI: Patient tolerating regular diet and she is currently
continued on TF. Nutritional status required reevaluation with
goal to wean off TF.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet and her TF, ambulating short distances with minimal assist,
voiding without assistance, and pain was well controlled. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.
Medications on Admission:
- Lopressor 75 mg [**Hospital1 **]
- Diovan 160 mg daily
- Norvasc 5 mg daily
- Lasix 20 mg daily
- Celexa 10 mg daily
- MV
- Folate 1 mg daily
- Vit D 100 mg daily
- Prilosec 20 mg daily
- Albuterol prn
Discharge Medications:
1. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical QID
(4 times a day) as needed for rash under breasts and perianal
area.
2. acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: One (1) PO Q6H
(every 6 hours) as needed for fever.
3. citalopram 10 mg/5 mL Solution [**Hospital1 **]: One (1) PO DAILY
(Daily).
4. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. clonidine 0.2 mg/24 hr Patch Weekly [**Last Name (STitle) **]: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
6. methadone 10 mg/mL Concentrate [**Last Name (STitle) **]: Four (4) PO Q8AM AND
Q8PM ().
7. ipratropium-albuterol 18-103 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two
(2) Puff Inhalation Q4H (every 4 hours) as needed for wheezing.
8. metoprolol tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO BID
(2 times a day).
9. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours).
10. sodium chloride 1 gram Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
11. psyllium 1.7 g Wafer [**Last Name (STitle) **]: One (1) Wafer PO DAILY (Daily).
12. folic acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
13. multivitamin Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
14. Vitamin D-3 400 unit Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**]
Discharge Diagnosis:
1. Nectrotizing pancreatitis
2. Large complex retroperitoneal fluid collections
3. Left pleural effusion
4. Prolonged respiratory failure
5. Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory (short distances) - requires
assistance or aid (walker).
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-14**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed 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.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2835**] Date/Time:[**2192-12-24**]
11:30 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **].
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2192-12-24**] 10:00
Completed by:[**2192-12-7**]
ICD9 Codes: 5119, 5990, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8729
} | Medical Text: Admission Date: [**2155-4-21**] Discharge Date: [**2155-4-24**]
Date of Birth: [**2117-6-19**] Sex: M
Service:
PRINCIPAL DIAGNOSIS: Right renal mass.
PRINCIPAL PROCEDURE: Hand assisted laparoscopic right
nephrectomy.
HISTORY OF PRESENT ILLNESS: This is a 37 year old man with
insulin dependent diabetes mellitus for thirty-six years
presenting with end stage renal disease. Evaluation with
magnetic resonance scan showed an enhancing mass of the right
upper pole of his right kidney. The patient is a candidate
for right nephrectomy prior to renal transplant. He denies
having any fever, chills, nausea or vomiting.
PAST MEDICAL HISTORY:
1. Hepatitis B.
2. Insulin dependent diabetes mellitus.
3. Gastroparesis.
4. Peripheral vascular disease.
PAST SURGICAL HISTORY:
1. Cholecystectomy.
2. Right leg below the knee amputation.
3. Left toe amputation.
MEDICATIONS ON ADMISSION:
1. Lopressor 125 milligrams p.o. b.i.d.
2. Vasotec 20 milligrams p.o. b.i.d.
3. Imdur 60 milligrams p.o. q.h.s.
4. Prilosec 30 milligrams p.o. q.h.s.
5. PhosLo 667 milligrams p.o. t.i.d.
6. Niferex 150 milligrams p.o. b.i.d.
7. Plavix 75 milligrams p.o. q.d.
8. Neurontin 200 milligrams p.o. q.i.d.
9. Reglan 10 milligrams p.o. t.i.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No tobacco and no ethanol.
PHYSICAL EXAMINATION: The patient was afebrile with a blood
pressure of 90/60. He has a port-a-cath in his neck.
Otherwise, the neck is supple. The heart was regular. The
lungs were clear. The abdomen is soft, nontender,
nondistended. Genitourinary examination showed a normal
scrotum, epididymis, testicles and penis. He is circumcised.
Neurologically, the patient was intact.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2155-4-21**], and received a hand assisted laparoscopic right
nephrectomy. He tolerated the procedure well. There were no
apparent complications. Given the patient's underlying
medical condition, he was observed overnight in the Intensive
Care Unit. Postoperatively, he was hypertensive and required
some intravenous Nitroglycerin. He was able to be weaned off
this by the morning of postoperative day number one. His
volume status remained euvolemic and his vital signs were
stable.
On postoperative day number one, he was dialyzed per the
Renal Service. Over the next two days, the patient advanced
his diet as his bowel function returned. His pain was
initially controlled by PCA and then was transferred to p.o.
pain medication. The patient remained afebrile with vital
signs stable. He was mildly hypovolumic after his first
dialysis run but after taking p.o. fluids, his blood pressure
rose from a systolic of 85 to a systolic of 100. He received
a second hemodialysis on postoperative day number two. After
the second dialysis, he was transferred home in stable
condition. Of note, his creatinine ranges between 5.0 and
7.0, and his potassium ranges between 4.0 and 5.0. His
phosphorus was consistently 5.0. His hematocrit was stable
in the 30s postoperatively.
DISCHARGE INSTRUCTIONS:
1. Follow-up - The patient should follow-up with Doctor
[**Doctor Last Name 4229**] in two weeks and call for an appointment. He is
also to be seen by his primary care physician to regulate
medications and to restart Plavix approximately two weeks
after his surgery.
2. Activity as tolerated.
3. Diet is as tolerated.
4. Medications:
a. Vicodin one to two p.o. q4hours p.r.n.
b. Insulin 19 units NPH subcutaneous q.a.m., and 9
units subcutaneous q.p.m.
c. Nephrocaps one p.o. t.i.d.
d. PhosLo two p.o. t.i.d.
e. Lopressor 150 milligrams p.o. b.i.d.
f. Vasotec 20 milligrams p.o. b.i.d.
g. Blood pressure medications are to be held for low
blood pressure.
h. Resume taking his Prilosec.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 8916**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2155-4-24**] 13:28
T: [**2155-4-24**] 18:52
JOB#: [**Job Number **]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8730
} | Medical Text: Admission Date: [**2110-4-3**] Discharge Date: [**2110-4-16**]
Date of Birth: [**2089-10-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
multifocal bacterial pneumonia; probable viral illness
Major Surgical or Invasive Procedure:
bronchoscopy
intubation/extubation
mechanical ventilation
History of Present Illness:
20 yo female [**University/College 86794**] student presents with
multifocal pneumonia. Pt states that she was in USOGH until
Sunday [**3-30**], when she began to develop shaking chills, mild
myalgias, sweats, and headache. The following day, developed a
cough as well, which progressively worsened through the next
several days and became productive of yellow-green sputum. Her
fevers continued to progress, and presented to the ED and was
found to have a fever of 105.4. She was started on Tamiflu, and
Levofloxacin (first dose 3/17 at 2am). Pt was taking tylenol,
aspirin, and ibuprofen, but contin to spike fevers to >104. She
has had a couple of post-tussive emesis, but denies nausea; only
abd discomfort d/t muscular strain from cough.
.
In the ED today, pt had a fever of 104.2, was tachycardic to
134. Her respiratory status remained stable with RR 19-25 and
95% 2L NC. IN [**Name (NI) **], pt given 2 L NS and Levofloxacin 750 mg IV.
Nasal swab for influenza was negative, but pt had been on
Tamiflu >24 hrs. CXR yesterday showed small retrocardiac
pneumonia, but per discussion with Radiology, today's CXR is
much worse with LLL white-out and bronchograms, and RUL and RLL
involvement as well.
.
Pt admitted to Medicine for ongoing management and evaluation.
.
ROS:
+: as per HPI, and fever, chills/rigors, night sweats, anorexia,
sore throat, chest pain with cough, minimal SOB, cough, headache
several days ago (now resolved), mild myalgias - most notable
lower back (pt states not uncommon for her), mild-moderate
dizziness with standing - improved s/p IVF.
.
Denies:
weight changes, photophobia, loss of vision, palpitations, LE
edema, DOE,
hemoptysis, nausea, abdominal swelling, diarrhea, constipation,
hematemesis, hematochezia, melena, LAD, dysuria, rashes,
arthralgias, confusion, vertigo, paresthesias, weakness,
depression.
Past Medical History:
Hx pyloric stenosis as an infant
Social History:
[**Location 86794**] student. She would like her records
forwarded to their Student Health Center.
tobacco: denies
alcohol: occasional. No recent heavy drinking. Does not drink to
stupor or unconsciousness.
drugs: occasional marijuana. Increased use over recent weeks d/t
spring break.
Family History:
mother - denies
father - OCD
brother - OCD
Physical Exam:
VS: 99.5 108/59 98 20 94% 2L NC
GEN: AAOx3. Pleasant. Good historian. Non-toxic.
HEENT: eomi, perrl, MMM.
Neck: No LAD. JVP WNL.
RESP: Able to speak in full sentences without difficulty. Large
area of bronchial breath sounds with +egophony LLL fields. Other
areas with good AE, and minimal insp rales.
CV: RRR. No mrg. Not tachy.
ABD: +BS. Soft, NT/ND.
Ext: No CEE.
Neuro: CN 2-12 grossly intact.
Pertinent Results:
[**2110-4-3**] 12:45AM BLOOD WBC-5.1 RBC-4.60 Hgb-12.5 Hct-37.1
MCV-81* MCH-27.2 MCHC-33.7 RDW-12.9 Plt Ct-177
[**2110-4-3**] 12:45AM BLOOD Neuts-91.4* Lymphs-7.3* Monos-1.2*
Eos-0.1 Baso-0.1
[**2110-4-3**] 12:45AM BLOOD Glucose-133* UreaN-6 Creat-0.9 Na-136
K-3.3 Cl-103 HCO3-25 AnGap-11
[**2110-4-2**] 12:09AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2110-4-2**] 12:09AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2110-4-2**] 12:09AM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2110-4-2**] 12:14AM URINE UCG-NEG
.
CXR [**4-3**] (per conversation with Radiology):
Multifocal pneumonia, with dramatic worsening since yesterday.
Worst in LLL, with near white-out and air bronchograms, as well
as areas in RLL and RUL. No LAD, no pleural effusion. Official
read pending.
CXR [**4-2**]:
CHEST, FRONTAL AND LATERAL VIEWS: Dense retrocardiac
consolidation is
concerning for pneumonia of the superior segment of the left
lower lobe. The right lung is clear. Heart size is normal.
Leftward mediastinal shift may be due to scoliosis.
Increased density of the left hilus may be due to the pneumonia;
however, a follow-up chest radiograph in 6 weeks is recommended
to ensure resolution of these findings.
[**2110-4-3**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN
TEST-Neg; DIRECT INFLUENZA B ANTIGEN TEST-Neg INPATIENT
CT CHEST [**4-3**]:
1. Severe bilateral pneumonia affecting the left lung to a
greater degree
than the right, with an associated moderate left parapneumonic
effusion. There are no CT findings to suggest an empyema, but
correlation with thoracentesis may be helpful if this diagnosis
is being entertained clinically.
2. Enlarged mediastinal and hilar lymph nodes, consistent with
hyperplastic nodes in the setting of a severe pneumonia.
LOWER EXTREMITY NON-INVASIVE [**4-9**]
IMPRESSION: No deep venous thrombosis.
CT CHEST [**4-9**]
1. Interval increase in the degree of patchy and ground-glass
opacities noted throughout the lungs, now extending into
portions of previously spared lung. Also noted are increasing
bilateral pleural effusions. Given these findings, progressive
pneumonia versus other etiologies such as ARDS are not entirely
excluded.
2. Bilateral consolidative opacities at the lung bases, slightly
improved at the left lung base, consistent with the known
multifocal pneumonia.
3. No abnormality identified within the abdomen or pelvis.
CXR [**4-14**]:
Compared to the prior study, there is slight improvement in the
left basal
aeration with still present significant left retrocardiac
consolidation most likely consistent with atelectasis with
potential superimposed infection and small pleural effusion. No
evidence of pneumothorax is present in this supine radiograph,
but repeated examination with upright radiograph is recommended
to exclude the possibility of subtle pneumothorax given the
history of pleural tapping. Right basal opacity is unchanged.
Mild fluid overload is present.
Overall, there is significant improvement when compared to [**4-9**] and [**2110-4-10**].
Brief Hospital Course:
20 yo female college student presents with multifocal pneumonia,
with signif white-out of LLL, and also with involvement of RLL
and RUL, without pleural effusions, despite levofloxacin which
was started approx 36 hours prior to admission. Suspect pt may
have had a viral infection with superimposed bacterial
pneumonia.
# hypoxic respiratory failure. On arrival patient required a
non rebreather to maintain oxygen saturation above 90%. She
became progressively hypoxic, and tachypneic with RR in the 50s,
with significant respiratory distress. On [**2110-4-6**], she became
acutely hypoxic with coughing to an SpO2 of the 60s, with a very
slow recovery to an SpO2 in the high . Patient was electively
intubated for hypoxia, requiring high levels of sedation with
midazolam and fentanyl, and ultimately paralysis with
vecuronium. Initially, she had oxygen saturations of 80% on
mechanical ventilation. A CXR demonstrated diffuse interstitial
markings, presumably from pulmonary edema. She was given 40mg
lasix IV, and put out ~2L and her respiratory status improved.
Her ventilator oxygen concentration was steadily decreased, and
her tidal volumes were decreased and respiratory rate was
increased with the goal of ARDSnet low tidal volume ventilation.
Over the following days, her FiO2 and PEEP were gradually weaned
down. Extubation was delayed for several days secondary to
tongue swelling. Etiology of the tongue swelling was thought to
be positional vs. allergic. Her airway was evaluated on [**4-12**] by
bronchoscopy and found to be patent. Allergy was consulted and
could not find a clear cause for allergy on her med list. Her
tongue swelling resolved with a three day course of IV steroids,
and she was successfully extubated on [**4-13**]. She had initial
difficulty with swallowing but was evaluated by speech & swallow
therapy, who felt it was safe for her to try eating, which she
did so without significant difficulties.
# multifocal pneumonia. Given pattern of pneumonia, clinical
suspicion was high for Streptococcus pneumoniae, although the
initial cause may have been a viral infection with a bacterial
superinfection. She was treated with vancomycin, ceftriaxone
and azithromycin. On day 8, CTX was discontinued as patient had
persistent low grade temps and ID felt that CTX could be causing
drug fever. Sputum cultures grew normal respiratory flora. The
patient completed a ten day course of antibiotics. Antibiotics
were then stopped and the patient remained subsequently afebrile
and stable from a cardiopulmonary standpoint.
# deconditioning - The patient became deconditioned during this
hospital stay and will need outpatient physical therapy. She
was assessed by physical therapy in the hospital and will not
need home oxygen in order to conduct her daily activities.
Medications on Admission:
oral contraceptive pills
Discharge Medications:
1. Fluconazole 150 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
2. Outpatient Physical Therapy
Please perform evaluation & treatment of patient for
deconditioning following hospitalization.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. community-acquired multifocal pneumonia complicated by
respiratory failure and mechanical ventilation
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were seen at [**Hospital1 18**] for pneumonia complicated by difficulty
breathing that required a breathing tube and mechanical
ventilation. Your pneumonia responded appropriately to
intravenous antibiotics and your breathing tube was removed
without difficulty or complications. You do not need to
continue antibiotics for your pneumonia after discharge.
Additionally, you had a fungal infection of your skin treated
with fluconazole. You should take a few more days of this
antifungal medication before stopping treatment.
You will need to continue physical therapy as an outpatient to
regain your strength lost through deconditioning during your
hospital stay.
The following medications were changed during your
hospitalization:
ADDED fluconazole to treat your fungal infection
Followup Instructions:
Appointments have been scheduled for you with both a primary
care physician (Dr. [**Last Name (STitle) **] and the allergist (Dr. [**Last Name (STitle) 2603**].
It is important for you to follow up in order for us to monitor
your chest x-ray findings as well as your symptoms. Please call
[**Telephone/Fax (1) 250**] to update the clinic with your home address and
insurance provider when you get a chance. Please call
[**Telephone/Fax (1) 9316**], Dr.[**Name (NI) 20016**] office, to obtain further information
regarding appointment time and place.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20488**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2110-5-8**] 3:00
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 9316**] Date/Time:[**2110-5-14**]
2:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2110-4-17**]
ICD9 Codes: 5119, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8731
} | Medical Text: Admission Date: [**2178-2-11**] Discharge Date: [**2178-4-1**]
Date of Birth: [**2122-3-4**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7760**]
Chief Complaint:
Coffee-ground emesis
Major Surgical or Invasive Procedure:
Exploratory laparotomy, sigmoid colectomy, placement of
HArtmann's pouch.
History of Present Illness:
55yo F s/p cervical laminectomy on [**2178-2-2**], discharged to rehab
facility. On [**2-9**] pt developed bloody emesis x2, with a high
suspicion for aspiration. Was noted to be dyspneic and hypoxic
in the ED, and was emergently intubated. Was guaiac positive. CT
in ED showed free abdominal air, and pt was taken to OR.
Past Medical History:
Hypothyroidism
[**Doctor Last Name **] Syndrome
Social History:
Lives with husband
Family History:
NOn-contributory.
Physical Exam:
Physical exam on discharge:
VS: 99.1 72 98/59 20 97%RA
Gen: Tired-appearing, in bed
CV: RRR
Pulm: Crackles at both bases, good air movement
Abd: Soft, non-tender. Large, 12cmx5cm open abdominal wound
extending from subxiphoid to supraumbilical. Approx 1.5cm deep,
with good granulation tissue, covered at the margins with small
amounts of fibrinous yellow material (remnants of SIS graft used
in surgery).
Ext: Mild edema throughout
Pertinent Results:
[**2178-2-11**] 01:25AM BLOOD WBC-10.3 RBC-4.38 Hgb-13.5 Hct-42.0
MCV-96 MCH-30.8 MCHC-32.1 RDW-14.0 Plt Ct-721*
[**2178-3-15**] 11:05AM BLOOD WBC-9.1 RBC-3.09* Hgb-9.7* Hct-29.5*
MCV-96 MCH-31.4 MCHC-32.8 RDW-16.9* Plt Ct-284
Brief Hospital Course:
Pt admitted to surgery through ER and taken emergently to
operating room. Please refer to the operative note of Dr [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 6633**] for details of that procedure. Pt was very unstable and
transferred to SICU after procedure. Please note she needed
constant pressors and rate control for atrial fibrillation. Her
initial ICU course was relativley uneventful, and she was taken
back to the operating room on [**2178-2-15**] for tightening of the
abdominal closure, although her abdomen was not fully closed
until the final procedure of [**2178-2-21**]. She was finally extubated
on [**2178-2-24**], and eventually transferred to the floor. She
developed profound difficulty swallowing, although an MRI/MRA
was negative for any acute stroke. Ultimately she required a
Dobhoff tube for supplemental feeds, as a video swallow study
deemed her suitable for purees and nectar-thick liquids,
although thin liquids would be totally unsuitable. Her midline
wound continued to heal well with the use of a VAC closure
device. Although by [**3-5**] the pt was tolerating good oral
intake, she maintained on the tubefeeds to facilitate good wound
healing. Gradually her activity level increased despite her
wound, with the assistance of physical therapy.
At this point the pt was essentially ready for a rehab facility.
However, no facility wished to take her as she was pending
approval for MassHEalth. Hence the pt remained at the [**Hospital1 18**].
Finally her oral intake was sufficient to support her
nutritional needs. This allowed us to d/c her dobhoff tube on
[**3-20**] and switch her entirely to an oral diet. Since that time she
has been taking excellent po, and her wound has continued to
heal nicely. She is dischargd to [**Hospital1 **] House in stable
condition.
Medications on Admission:
Synthroid
Colace
MVI
Xanax
Protonix
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
5. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
10. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
11. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-15**]
Drops Ophthalmic PRN (as needed).
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) 2mL
Inhalation mixture. Inhalation Q4H (every 4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital
Discharge Diagnosis:
Diverticulitis
Atrial Fibrillation
Complex Abdominal Wound
S/p Colostomy placement
Neurogenic dysphagia
Hypothyroidism
[**Doctor Last Name **] Syndrome
Post-operative blood loss anemia
post-operative hypokalemia
Post-operative hypomagnesemia
Discharge Condition:
Stable
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) 6633**] in 3 weeks.
ICD9 Codes: 2851, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8732
} | Medical Text: Admission Date: [**2105-12-11**] Discharge Date: [**2105-12-17**]
Date of Birth: [**2040-4-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional chest discomfort
Major Surgical or Invasive Procedure:
[**2105-12-11**] Coronary artery bypass x2: Left internal mammary artery
graft to left anterior descending, reverse saphenous vein graft
to the ramus intermedius branch
History of Present Illness:
This is a 65 year old male with one month history of exertional
chest discomfort. Stress test in [**2105-10-27**] was consistent
with ischemia. Cardiolite imaging revealed large area of severe
anterior, septal and apical ischemia with LVEF of 47%.
Subsequent cardiac catheterization showed multivessel coronary
artery disease. Based upon the above results, he was referred
for surgical revascularization.
Past Medical History:
- Diabetes Mellitus
- Hypertension
- Dyslipidemia
- Psoriasis
- Prostatism, negative biopsies
Social History:
Race: Phillipine
Lives with: Wife
Occupation: Retired engineer
Tobacco: quit many years ago, 25 PYH
ETOH: Rare
Family History:
No premature CAD
Physical Exam:
Pulse: 79 Resp: 20 O2 sat: 100%
BP Right: 192/98 BP Left: 184/100
Height: 68 inches
Weight: 83.5 kg
General: WDWN male in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur - none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema - none
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: 2 Left: 2
PT [**Name (NI) 167**]: 2 Left: 2
Radial Right: 2 Left: 2
Carotid Bruit - none
Pertinent Results:
[**2105-12-17**] 06:25AM BLOOD WBC-9.0 RBC-3.58* Hgb-10.3* Hct-31.6*
MCV-88 MCH-28.8 MCHC-32.6 RDW-13.4 Plt Ct-225
[**2105-12-17**] 06:25AM BLOOD PT-15.7* INR(PT)-1.4*
[**2105-12-16**] 02:10PM BLOOD PT-13.1 INR(PT)-1.1
[**2105-12-16**] 05:40AM BLOOD Glucose-135* UreaN-15 Creat-0.8 Na-138
K-3.9 Cl-103 HCO3-25 AnGap-14
[**2105-12-17**] 06:25AM BLOOD UreaN-14 Creat-0.8 K-4.0
[**2105-12-17**] 06:25AM BLOOD Mg-2.0
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 83567**] (Complete)
Done [**2105-12-11**] at 11:49:38 AM 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: [**2040-4-26**]
Age (years): 65 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 424.1, 424.0
Test Information
Date/Time: [**2105-12-11**] at 11:49 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW2-: Machine: AW2
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.0 cm <= 5.2 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aorta - Arch: 2.5 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm
Aortic Valve - LVOT diam: 2.0 cm
Findings
LEFT ATRIUM: Moderate LA enlargement. Elongated LA. No
spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
LAA.
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, cavity size,
and global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Normal ascending
aorta diameter. Normal aortic arch diameter. Simple atheroma in
aortic arch. Normal descending aorta diameter. Simple atheroma
in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. No MS. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
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. Frequent atrial premature beats. Results
Conclusions
PRE BYPASS The left atrium is moderately dilated. The left
atrium is elongated. No spontaneous echo contrast or thrombus is
seen in the body of the left atrium or left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **]
was notified in person of the results in the operating room at
the time of the study.
POST BYPASS There is normal biventricular function. Valvular
function remains unchanged. The thoracic aorta appears intact.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent coronary artery bypass
grafting surgery by Dr. [**Last Name (STitle) **]. For surgical details, please
see operative note. Following the operation, he was brought to
the CVICU for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated without inicident. His
CVICU course was otherwise uneventful and he transferred to the
surgical step down floor on postoperative day one. He
experienced bouts of paroxsymal atrial fibrillation which was
treated with an increase in beta blockade. His chest tubes and
epicardial wires were removed. He had a gout flare which
resolved with colchicine and motrin. By post-operative day six
he was ready for discharge to home. Coumadin was initiated for
atrial fibrillation. Dr. [**Last Name (STitle) **] will manage coumadin dosing.
Medications on Admission:
Medications at home:
Aspirin, Metformin 1000mg [**Hospital1 **], Carvedilol 12.5mg [**Hospital1 **], Diazepam
5mg prn, HCTZ 25mg QD, Lisinopril 40mg QD, Simvastatin 40mg QD
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
4. 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*
5. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Outpatient Lab Work
serial PT/INR
dx: atrial fibrillation
goal INR [**12-30**]
Results to Dr. [**Last Name (STitle) **] fax: [**Telephone/Fax (1) 13430**]
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Dose
will change daily for INR goal [**12-30**]. Dr. [**Last Name (STitle) **] to manage. VNA
will draw INR [**12-18**].
Disp:*30 Tablet(s)* Refills:*2*
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
- Coronary Artery Disease, s/p CABG
- Diabetes Mellitus
- Hypertension
- Dyslipidemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] [**1-14**] at 1:00 PM
Primary Care Dr. [**Last Name (STitle) **] in [**11-28**] weeks [**Telephone/Fax (1) 3183**]
Cardiologist Dr. [**Last Name (STitle) **] in [**11-28**] weeks [**Telephone/Fax (1) 83568**]
VNA to draw INR [**2105-12-18**] and fax results to Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 13430**]
confirmed with [**Doctor First Name **]
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2105-12-17**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8733
} | Medical Text: Admission Date: [**2154-10-14**] Discharge Date: [**2154-10-29**]
Service: [**Doctor Last Name 1181**]/MEDICINE
Please see OMR note for history of present illness, physical
examination, pertinent laboratories, x-rays,
electrocardiogram and other tests, concise summary of
hospital course, condition on discharge, discharge status,
discharge diagnoses, discharge medications and follow up
plans.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Last Name (NamePattern1) 9622**]
MEDQUIST36
D: [**2154-12-5**] 06:51
T: [**2154-12-6**] 11:50
JOB#: [**Job Number 27852**]
ICD9 Codes: 5070, 2762, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8734
} | Medical Text: Admission Date: [**2166-12-1**] Discharge Date: [**2166-12-6**]
Service: #58
HISTORY OF PRESENT ILLNESS: This is an 87 year-old gentelman
who presented to Dr. [**Last Name (STitle) **] with a history of gross
hematuria. The patient had been followed for a history of
bladder CA and a history of a tumor in the right renal
pelvis, but was lost to follow up for approximately five
years before this presentation. During the current workup a
right retrograde pyelogram revealed a large right renal
pelvic tumor. This was confirmed on a subsequent CT scan.
The diagnosis was thought to be likely transitional cell
carcinoma, therefore a right nephroureterectomy was
recommended to the patient. The patient was admitted on
[**2166-12-1**] to undergo said procedure.
PAST MEDICAL HISTORY: Diabetes mellitus type 2, gout, status
post TURBP, status post appendectomy, status post
cholecystectomy, history of abdominal aortic aneurysm.
MEDICATIONS ON ADMISSION: Glucotrol, Glucosamine, Proscar,
Ditropan.
HOSPITAL COURSE: The patient was admitted to the hospital
and on [**12-1**] underwent an uncomplicated left
nephroureterectomy with a bladder tumor resection. The
patient was unable to be extubated immediately
postoperatively, because of concern of laryngeal edema
secondary to the large volume of fluid given
intraoperatively. Therefore the patient was recovered
overnight in the SICU and transferred to the floor on
postoperative day one.
With the exception of a transient mild episode of acute renal
failure with a creatinine bump to 1.9 on postoperative day
two the patient's postoperative course was relatively
unremarkable. The transient decrease in urine output was
responsive to fluid boluses and by the day of discharge the
patient's creatinine was continuing to trend down to his
preoperative baseline. The patient was ambulating
independently by postoperative day two. By postoperative day
three he no longer had an oxygen requirement. By
postoperative day four his bowel function had returned and
his diet was advanced without complication. By the day of
discharge on postoperative day five the patient had remained
afebrile, ambulating independently and was having adequate
urine output and tolerating a regular diet. The patient was
discharged home in stable condition.
DISCHARGE DIAGNOSIS:
Transitional cell carcinoma of the right kidney status post
right nephroureterectomy with bladder tumor resection.
DISCHARGE MEDICATIONS: Percocet one to two tabs po q 3 to 4
hours prn pain, Colace 100 mg po b.i.d., all preoperative
medications were continued.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**MD Number(1) 19331**]
Dictated By:[**Last Name (NamePattern1) 3801**]
MEDQUIST36
D: [**2166-12-22**] 11:28
T: [**2166-12-24**] 05:46
JOB#: [**Job Number 92816**]
ICD9 Codes: 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8735
} | Medical Text: Admission Date: [**2162-4-26**] Discharge Date: [**2162-4-28**]
Date of Birth: [**2081-7-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ultram / Prilosec
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
80 year old female s/p AVR on [**4-12**] w/Dr. [**Last Name (STitle) **]. She had an
uneventful post op course and was discharged to rehab on [**4-16**].
She states she has been doing well until a few days ago when
they mixed up her darvocet and neurontin and she
began to have alternating periods of hot and cold, shortness of
breath, chest discomfort mid chest. She was found to be in SVT
pale and diaphoretic w/relative hypotension-SBP 90s. At the
outside hospital, she was given adenosinex3 without success, an
amiodarone bolus and then cardioverted and started on an
amiodarone and heparin drip with improvement in symptoms and
hemodynamics
Past Medical History:
Aortic stenosis s/p AVR
TIAs
Hyperlipidemia
Osteoarthritis
Severe third degree burns during childhood (neck, chest, abd)
Hyperhomocysteinemia
occ. short-term memory loss
Osteopenia
Bursitis bil. hips
H. Pylori 5 yrs ago
Herpes zoster
left facial droop
Colon polyps
s/p Tonsillectomy and adenoidectomy
Multiple reconstructive surgeries with skin grafting
Coccygectomy
Bilateral cataract [**Doctor First Name **].
Cholecystectomy
Total abdominal hysterectomy
left foot [**Doctor First Name **].
Social History:
Lives with: partner
Occupation: retired
Tobacco: none
ETOH: none
Family History:
Mother died of CVA/MI @ 69
Physical Exam:
Pulse:70 Resp:16 O2 sat: 95%
B/P Right:124/60 Left:
Height:5'3" Weight: 188#
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs crackles bilat bases []
Heart: RRR [x] Murmur none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema 2+ None []
Neuro: Grossly intact[x]
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: [**1-2**]+ Left:[**1-2**]+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right: 2+ Left:2+
Carotid Bruit Right:none Left:none
Pertinent Results:
[**2162-4-28**] 05:50AM BLOOD WBC-10.2 RBC-3.10* Hgb-9.2* Hct-28.1*
MCV-91 MCH-29.7 MCHC-32.8 RDW-13.1 Plt Ct-518*
[**2162-4-27**] 12:14AM BLOOD WBC-15.9*# RBC-3.02* Hgb-9.1* Hct-27.9*
MCV-92 MCH-30.0 MCHC-32.5 RDW-13.2 Plt Ct-556*#
[**2162-4-28**] 05:50AM BLOOD Plt Ct-518*
[**2162-4-28**] 05:50AM BLOOD PT-13.2 PTT-21.9* INR(PT)-1.1
[**2162-4-28**] 05:50AM BLOOD Glucose-98 UreaN-18 Creat-0.9 Na-135
K-4.4 Cl-103 HCO3-24 AnGap-12
[**2162-4-27**] 12:14AM BLOOD Glucose-119* UreaN-19 Creat-0.9 Na-137
K-5.0 Cl-105 HCO3-24 AnGap-13
[**2162-4-27**] 12:14AM BLOOD ALT-17 AST-31 AlkPhos-159* Amylase-27
TotBili-0.7
[**2162-4-27**] 12:14AM BLOOD Lipase-36
[**2162-4-27**] 08:44AM BLOOD cTropnT-0.04*
[**2162-4-28**] 05:50AM BLOOD Mg-2.2
[**2162-4-27**] 12:14AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.0
[**2162-4-27**] 12:14AM BLOOD TSH-1.1
Radiology Report CHEST (PORTABLE AP) Study Date of [**2162-4-27**] 7:19
AM
[**Last Name (LF) **],[**First Name3 (LF) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 147**] CSRU [**2162-4-27**] 7:19 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 68431**]
Reason: s/p AVR, readmitted w/SVT/SOB r/o effusion/infiltrate
[**Hospital 93**] MEDICAL CONDITION:
80 year old woman with as above
REASON FOR THIS EXAMINATION:
s/p AVR, readmitted w/SVT/SOB r/o effusion/infiltrate
Final Report
HISTORY: AVR, re-admitted with shortness of breath.
FINDINGS: In comparison with the study of [**4-15**], the left central
catheter has
been removed. Patient has taken a somewhat better inspiration.
The cardiac
silhouette remains mildly enlarged without definite vascular
congestion or
acute pneumonia. Post-operative and atelectatic changes are
again seen at the
left base.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
Approved: TUE [**2162-4-27**] 9:11 AM
Brief Hospital Course:
She was transferred in from outside hospital after
cardioversion, has remained in sinus rhythm since arrival. She
was admitted to the intensive care unit for monitoring and was
transferred the next day to the floor. She continued to improve
and was ready for discharge back to rehab on [**2162-4-28**].
Discharged to [**Hospital 582**] rehab in [**Location (un) 4693**].
Medications on Admission:
Medications at rehab:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever/pain.
lasix 40mg by mouth every other day
paxil 10mg by mouth at bedtime
lorazepam 0.5mg by mouth at bedtime
vicodin 5/500 1tab by mouth every 4 hours as needed for pain
gabapentin 100mg by mouth 3 times/day
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg twice a day for 7 days - decrease to 400 mg once
a day on [**5-4**] - then in 7 days decrease to 200 mg once a day on
[**5-11**].
5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): decreased due to amiodarone - increase back to 20mg
when off amiodarone .
6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 7 days: right forearm phlebitis .
11. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once)
for 1 doses: 2.5 mg on [**4-29**] with INR check [**4-30**] for further
dosing - goal INR 2.0-2.5
received 5mg [**4-27**]
2.5 mg [**4-28**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**]-[**Location (un) 12595**]
Discharge Diagnosis:
Atrial Fibrillation s/p cardioversion at outside hospital
Past medical history:
Aortic stenosis s/p Aortic valve replacement
TIAs
Hyperlipidemia
Osteoarthritis
Severe third degree burns during childhood (neck, chest, abd)
Hyperhomocysteinemia
occ. short-term memory loss
Osteopenia
Bursitis bil. hips
H. Pylori 5 yrs ago
Herpes zoster left facial
Colon polyps
Past Surgical History:
s/p Tonsillectomy and adenoidectomy
Multiple reconstructive surgeries with skin grafting
Coccygectomy
Bilateral cataract [**Doctor First Name **].
Cholecystectomy
Total abdominal hysterectomy
Left foot [**Doctor First Name **]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with walker
Incisional pain managed with tylenol prn
Incisions:
Sternal - healing well, no erythema or drainage
scabbing along wound
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 until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Appointment already scheduled
Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] [**5-13**] at 1:00 PM
Please call to schedule appointments
Primary Care Dr. [**Last Name (STitle) 1492**] in [**1-2**] weeks
Cardiologist Dr. [**Last Name (STitle) 4783**] in [**1-2**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Atrial Fibrillation
Goal INR 2.0-2.5
First draw [**4-30**]
Completed by:[**2162-4-28**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8736
} | Medical Text: Unit No: [**Numeric Identifier 58693**]
Admission Date: [**2191-1-5**]
Discharge Date: [**2191-3-23**]
Date of Birth: [**2191-1-5**]
Sex: M
Service: NB
HISTORY: Of note, at the time of discharge the patient's last
name is going to change to [**Name (NI) 2716**].
[**Known lastname **] is the 1.43 kilogram product of a 33 week gestation
born to a 29-year-old G3, P0 mom. [**Name (NI) **] type O+, antibody
negative, rubella immune, RPR nonreactive, and hepatitis B
surface antigen negative. Prenatal course significant for
noninsulin dependent diabetes mellitus for five years which
became insulin dependent during pregnancy with good glucose
control. Prior history of infant with multiple anomalies
prompting amniocentesis for this pregnancy with normal 46,
XY. Rupture of membranes following amniocentesis with
persistent oligohydramnios since that time. Mother was put on
bedrest and was hospitalized for a long time. No evidence of
chorioamnionitis. The infant's fetal growth was in the 10th
percentile throughout the remainder of the pregnancy.
Presence of preterm labor occurred and she received
betamethasone (complete on [**2190-12-18**]). Due to a
prolonged deceleration on [**2191-1-5**] for greater than 3 minutes,
the decision was made to deliver the infant.
Infant delivered by cesarean section, emerged active with
good respiratory effort, received facial CPAP for central
cyanosis and transferred to the newborn intensive care unit
for further care. Apgar's were 7 and 8.
Other maternal history is notable for depression and
receiving Tylenol 3 for peripheral neuropathy.
PHYSICAL EXAMINATION: On admission birth weight was 1430,
[**9-27**] percentile; length 38 cm, less than 10th
percentile; head circumference 27.75 cm, 10th percentile.
Small-for-gestational age appearing with flat occiput,
anterior fontanel open and flat normal S1 and S2, no murmur,
breath sounds coarse bilaterally. Mild intercostal subcostal
retractions on CPAP. Abdomen soft, nontender, nondistended.
Extremities well perfused, tone appropriate for gestational
age. Patent anus, descended testes bilaterally. Spine intact.
HISTORY:
Respiratory: [**Known lastname **] was admitted to the newborn intensive care
unit initially on CPAP, due to increased respiratory work of
breathing within the first 12 hours he was electively
intubated. He received two doses of Surfactant and was
extubated 48 hours later to CPAP. He remained on respiratory
support for a total of four days at which time he
transitioned to room air. He remained stable in room air for
16 days and then required nasal cannula O2 with feeding and
progressively required nasal cannula O2 at all times. Chest
x-ray obtained at that time demonstrated chronic lung disease
changes and a Lasix trial was initiated. Diuretics were
started on [**2-7**] of Diuril and Lasix every Tuesday and
Friday. He is currently on 50 cc of nasal cannula O2 at 100%
continuously. He is receiving Diuril 40 mg per kg per day and
Lasix 2mg per kg every Tuesday and Friday.
He was treated empirically with methylxanthines for apnea and
bradycardia of prematurity. Caffeine was discontinued on
[**2190-1-15**]. His last documented apnea and bradycardiac
episode was on [**2191-2-23**].
Cardiovascular: He had a murmur present and a echocardiogram
was performed on [**2-28**] which revelaed a PFO versus ASD.
The Cardiology Service at [**Hospital3 1810**] recommended
follow-up in 3 years. Infant continues to have an
intermittent soft murmur; otherwise cardiovascular stable.
Fluid and Electrolytes: Birthweight was 1430 grams. Discharge
weight is 3165 grams. He was initially started on 80 cc per
kilo per day of D10W. Enteral feedings were initiated on day
of life one and he achieved full enteral feedings by day of
life number nine. Maximum caloric intake was 140 mm per kg
per day of NeoSure 30 calorie. He is currently ad lib feeding
with a minimum of 130 milliliter per kg per day of NeoSure 24
calorie demonstrating good weight gain. He is on potassium
supplementation in light of his diuretic therapy. He receives
2 meq twice a day and his most recent set of electrolytes
were done on [**3-22**] revealing a sodium 136, potassium 4.9,
chloride 101, CO2 21.
GI: Peak bilirubin was on day of life 3 was 9.2/03. He
received phototherapy for a total of five days at which time
it was discontinued and he has had no further issues.
Hematology: Hematocrit on admission was 46.8, he is O+,
Coombs' negative. His most recent hematocrit was on [**3-22**]
and it was 36. He has not required any [**Month (only) **] transfusions
during this hospital course.
Infectious Disease: A CBC and [**Month (only) **] culture was obtained on
admission. His admission CBC was noted to be neutropenic on
admission. He received a total of 48 hours of Ampicillin and
Gentamicin. Repeat CBC demonstrated a normal absolute
neutrophil count (ANC).
On day of life 48 the infant had a significant apnea and
bradycardiac episode prompting a sepsis evaluation at which
time the ANC was noted to be 884. He received Vancomycin and
Gentamicin for a total of 7 days. Over the next couple of
days his ANC's ranged from 312 on [**2191-2-24**], 171 on [**2191-2-25**],
558 on [**2191-2-26**], 252 on [**2191-2-27**], 294 on [**3-9**], and 747 on
[**2191-3-23**]. Hematology was consulted and they suggested a
possible diagnosis of neonatal alloimmune neutropenia and
would like to follow-up with the infant in hematology clinic
two weeks after discharge with [**Last Name (un) 1003**]. Telephone number for
hematology clinic is [**Telephone/Fax (1) 51899**] and she should be seeing
Dr. [**Last Name (STitle) 1003**] two weeks after discharge.
The Infectious Disease service did recommend Psuedomonas
coverage if there are concerns for infection and
administering GCSF if a bacterial infection is present.
Neurological: On [**2191-1-7**] a head ultrasound was
performed and there was a question of calcifications on the
right side of the basal ganglia. No intraventricular
hemorrhage was seen. CT confirmed calcifications in the right
hemisphere. Otherwise the infant has been neurological
developmentally appropriate for gestational age.
Audiology: Hearing screen was performed with automated
auditory brainstem responses and referred to the left ear,
appointment will be made by the parents.
Ophthalmology: Was examined on [**2191-1-17**] and eyes are normal
mature, should be seen at 8 months corrected.
Social worker has been involved with this family and can be
reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home.
Name of primary pediatrician is [**First Name8 (NamePattern2) 43395**] [**Last Name (NamePattern1) 57471**], [**Telephone/Fax (1) 56164**].
CARE AND RECOMMENDATIONS: Continue ad lib feeding with a
minimum of 130 cc per kilo per day of NeoSure 24 calorie.
Recommend NeoSure to continue until 6 to 9 months corrected
gestational age.
MEDICATIONS:
1. Aldactone 10 mg p.o. daily
2. Diuril 65 mg p.o. twice a day
3. Lasix 3 mg p.o. every Tuesday and Friday
4. Potassium chloride supplement 3 mEq p.o. twice a day.
5. Ferrous Sulfate 0.3 ml p.o. daily.
State newborn screens have been sent per protocol and have
been within normal limits.
IMMUNIZATIONS: Received Hepatitis B vaccine on [**2-7**] and
HIB [**2191-3-14**], Pediarix (HepB, DTAP, IPV) on [**2191-3-18**] and
pneumococcal vaccine also on [**2191-3-18**]. Synagis was given on
[**2191-2-22**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] with infants
meetings any of the following three criteria.
1. Born at less than 32 weeks.
2. Born between 32 and 35 weeks with two of the following,
day care during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities or school age
siblings or chronic lung disease.
3. Influenza immunization is recommended annually in the Fall
for all infants once they reach six months of age. Before
this age and for the first 24 months of the childs life,
immunization again influenza is recommended for household
contacts and out of home caregivers.
FOLLOW UP APPOINTMENTS:
1. Pulmonology - Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**] on [**2191-4-4**] at 11:30 AM
2. Hematology - two weeks after discharge with Dr. [**Last Name (STitle) 1003**].
3. Ophthalmology at 8 months corrected gestational age.
DISCHARGE DIAGNOSES:
1. Premature infant
2. Respiratory distress with chronic lung disease
3. Rule out sepsis with antibiotics x2
4. Presumed Neonatal Alloimmune Neutropenia
5. Status post anemia of prematurity
6. Status post apnea and bradycardia of prematurity
7. Status post hyperbilirubinemia
DR [**First Name (STitle) 7087**] ,[**First Name3 (LF) **]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2191-3-22**] 21:16:59
T: [**2191-3-22**] 22:19:55
Job#: [**Job Number 58694**]
ICD9 Codes: 769, 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8737
} | Medical Text: Admission Date: [**2147-12-8**] Discharge Date: [**2147-12-13**]
Date of Birth: [**2072-1-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Zestril
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Worsening fatigue
Major Surgical or Invasive Procedure:
[**2147-12-8**] Coronary artery bypass grafts x 3 (LIMA-LAD, SVG-OM,
SVG-PDA)
History of Present Illness:
This 75 year old white male has had known coronary disease and
prior silent myocardial infarction. He underwent bare metal
stenting to his LAD in [**2136**]. Since that time, he has been
relatively asymptomatic. Recently, he denies chest pain but
admits to worsening fatiuge. Following a recent stress test that
was positive for inferior wall ischemia and hypotension, cardiac
catheterization revealed triple vessel disease. He was,
therefore, admitted for coronary surgical revascularization.
Past Medical History:
parotid carcinoma - treated with surgery and radiation
hypertension
s/p bilateral knee and hip replacements
paroxysmal atrial fibrillation
dyslipidemia
hiatal hernia
history of renal calculi
bilateral cataract surgery
prior shoulder surgery
Social History:
He is a psychologist. Denies tobacco. Admits to one bourbon per
day. No history of ETOH abuse. Married, wife is an ER nurse.
Family History:
Mother died of stroke at age 64.
Physical Exam:
discharge exam:
vitals -stable, awake and alert
heart - atrial fibrillation wit ventricular rate 70s
lungs -clear
ext -with out edema
wounds - clean and dry. Sternum stable
Pertinent Results:
[**2147-12-8**] 06:00PM BLOOD PT-16.7* PTT-47.1* INR(PT)-1.5*
[**2147-12-10**] 05:55AM BLOOD PT-14.8* PTT-34.6 INR(PT)-1.3*
[**2147-12-11**] 05:33AM BLOOD PT-14.7* INR(PT)-1.3*
[**2147-12-12**] 05:30AM BLOOD PT-22.4* INR(PT)-2.1*
[**2147-12-11**] 05:33AM BLOOD Mg-1.9
[**2147-12-13**] 05:40AM BLOOD PT-28.5* INR(PT)-2.9*
Brief Hospital Course:
Mr. [**Known lastname 20763**] was admitted and underwent coronary artery bypass
grafting surgery by Dr. [**Last Name (STitle) **]. For surgical details, please
see separate dictated operative note. Following the operation,
he was brought to the CVICU for invasive monitoring. Within 24
hours, he awoke neurologically intact and was extubated without
incident. He was noted to have episodes of atrial fibrillation
but otherwise maintained stable hemodynamics.
On postoperative day one, he transferred to the SDU. Given his
paroxysmal atrial fibrillation, he was started on Warfarin. Low
dose beta blockade was also resumed. INRs were monitored daily
and Warfarin was adjusted for goal INR between 2.0 - 3.0. K+ and
Mg levels were monitored closely and repleted per protocol. Over
several days, he continued to make clinical improvements with
diuresis. He was eventually cleared for discharge to home on
postoperative day 5. His ventricular rate was well controlled.
Prior to discharge, arrangements were made with Dr. [**Last Name (STitle) 20764**] who
will monitor his Warfarin as an outpatient. His first blood draw
is scheduled for [**12-15**]. Discharge medications, instructions and
precautions were discussed with the patient prior to discharge.
Medications on Admission:
ASA 325mg/D
Simvastatin 20mg/D
Atenolol 6.25mg [**Hospital1 **]
MVI
Viagra prn
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Aspirin Low Dose Oral
5. Ibuprofen 200 mg Tablet Sig: Two (2) Tablet PO Q6hours prn as
needed for pain.
6. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every four
(4) hours as needed for pain.
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: decrease to one tablet twice daily beginning
[**12-18**].
Disp:*100 Tablet(s)* Refills:*2*
9. Warfarin 1 mg Tablet Sig: as directed Tablet PO once a day:
take as directed. INR goal 2-2.5.
Disp:*100 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
paroxysmal atrial fibrillation
hypertension
s/p bilateral knee replacements
s/p bilateral hip replacements
h/o parotid cancer
Discharge Condition:
good
Discharge Instructions:
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
shower daily, no baths or swimming
no lotions, creams or powders to incisions
report any weight gain greater than 2 pounds a day or 5 pounds a
week
report any drainage from, or redness of incisions
report any temperature greater than 100.5
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name8 (NamePattern2) 20765**] [**Last Name (NamePattern1) 20764**] or [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 1295**] in [**2-15**] weeks
Dr. [**Last Name (STitle) 17567**] in [**3-19**] weeks
Please call for appointments
Completed by:[**2147-12-13**]
ICD9 Codes: 4019, 2724, 4240, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8738
} | Medical Text: Admission Date: [**2153-6-20**] Discharge Date: [**2153-6-25**]
Date of Birth: [**2104-7-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
CC:[**CC Contact Info 83501**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
48 y/o M with hx of COPD/asthma, Hep C and substance abuse comes
to ED one day after stopping his long prednisone taper with
about half day history of shortness of breath, wheezing and L
sided chest "tingling." Was not a pain in his chest, did not
radiated. He denies hx of fevers, cough, body aches. No nausea,
vomitting, diaphoresis.
In the ED, initial vs were: T 97.6, P 96, BP 148/89, R 30 O2 sat
100 on NRB. He had audible wheezes and was using his accessory
muscles to breath. While on the NRB, he was noted to become
increasingly somnulent and ABG was 7.24/83/262. He was switched
to bipap 8/5 and 30%, and he improved slightly. His next ABG was
7.30/69/67. He was kept on bipap and admitted to the MICU.
Patient was given solumedrol 125 mg IV x1 and Mag. He has 1 20g
PIV.
.
On the floor, patient is somnulent but arousable to voice,
speaks in full sentences but will sometimes fall asleep while
talking. Says he is feeling better. Is complaining of headache
that started last night around the time his breathing worsened.
No vision changes, no dizziness, no fainting. He says his
breathing is much improved than from when he first presented.
Past Medical History:
Asthma/COPD. dx as an adult. Per his report, only has been
on steroids twice in past, Hospitalized 4 times within the last
1.5 years, most recently [**5-15**] to [**5-21**].
Hepatitis C
IBS
"Gastritis and Colitis"
h/o polysubstance abuse
Anxiety and Panic Attacks
Self Reported Bipolar
.
Social History:
Soc Hx:
He recently moved to [**Location (un) 86**] and is living in a dual-dx sober
house [**Location (un) 34564**]. He is a former EtOh & drug abuser
(cocaine & heroin) who says that he is now sober. He is not
working and has a long smoking history but quit about 2 weeks
ago and is using the patch.
.
Family History:
strong FH of asthma/COPD
Physical Exam:
Vitals: afebrile, BP=120s-140s/70s-90s, P=80s-100s, R=22, O2=92%
RA on transfer to the floor
General: Alert and oriented x3, no acute distress, speaking in
full sentences, but somnolent
HEENT: Sclera anicteric, oropharynx clear
Neck: supple, no LAD
Lungs: Poor air movement diffusely, no rhonchi or rales
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:
[**2153-6-23**] 03:45AM BLOOD WBC-15.7* RBC-4.24* Hgb-12.3* Hct-39.6*
MCV-93 MCH-28.9 MCHC-30.9* RDW-14.5 Plt Ct-213
[**2153-6-22**] 05:05AM BLOOD WBC-16.5* RBC-4.05* Hgb-12.3* Hct-36.8*
MCV-91 MCH-30.4 MCHC-33.4 RDW-15.3 Plt Ct-225
[**2153-6-21**] 03:59AM BLOOD WBC-15.1* RBC-4.31* Hgb-12.6* Hct-39.7*
MCV-92 MCH-29.3 MCHC-31.8 RDW-14.1 Plt Ct-182
[**2153-6-20**] 05:20AM BLOOD WBC-15.8* RBC-4.47* Hgb-13.4* Hct-41.7
MCV-93 MCH-30.1 MCHC-32.2 RDW-15.4 Plt Ct-191
[**2153-6-22**] 05:05AM BLOOD Neuts-90.9* Lymphs-6.8* Monos-1.8*
Eos-0.3 Baso-0.2
[**2153-6-21**] 03:59AM BLOOD Neuts-90.6* Lymphs-8.5* Monos-0.8* Eos-0
Baso-0.1
[**2153-6-20**] 05:20AM BLOOD Neuts-69.5 Lymphs-25.0 Monos-3.4 Eos-1.3
Baso-0.8
[**2153-6-23**] 03:45AM BLOOD Plt Ct-213
[**2153-6-22**] 05:05AM BLOOD Plt Ct-225
[**2153-6-21**] 03:59AM BLOOD Plt Ct-182
[**2153-6-21**] 03:59AM BLOOD PT-11.7 PTT-23.9 INR(PT)-1.0
[**2153-6-20**] 05:20AM BLOOD Plt Ct-191
[**2153-6-20**] 05:20AM BLOOD PT-10.8 PTT-22.1 INR(PT)-0.9
[**2153-6-23**] 03:45AM BLOOD Glucose-143* UreaN-31* Creat-0.9 Na-140
K-4.5 Cl-103 HCO3-28 AnGap-14
[**2153-6-22**] 05:05AM BLOOD Glucose-157* UreaN-31* Creat-1.0 Na-140
K-4.9 Cl-101 HCO3-31 AnGap-13
[**2153-6-21**] 03:59AM BLOOD Glucose-144* UreaN-26* Creat-1.0 Na-139
K-4.6 Cl-99 HCO3-30 AnGap-15
[**2153-6-20**] 05:20AM BLOOD Glucose-107* UreaN-23* Creat-1.1 Na-144
K-4.4 Cl-104 HCO3-33* AnGap-11
[**2153-6-22**] 05:05AM BLOOD ALT-30 AST-16 LD(LDH)-184 AlkPhos-65
TotBili-0.2
[**2153-6-20**] 03:26PM BLOOD CK(CPK)-36*
[**2153-6-20**] 05:20AM BLOOD ALT-44* AST-37 CK(CPK)-72 AlkPhos-86
TotBili-0.2
[**2153-6-20**] 03:26PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2153-6-20**] 05:20AM BLOOD cTropnT-<0.01
[**2153-6-20**] 05:20AM BLOOD CK-MB-NotDone
[**2153-6-23**] 03:45AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.0
[**2153-6-22**] 05:05AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.1
[**2153-6-21**] 03:59AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.1
[**2153-6-20**] 05:20AM BLOOD Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2153-6-23**] 03:45AM BLOOD HoldBLu-HOLD
[**2153-6-23**] 06:55AM BLOOD Type-ART pO2-100 pCO2-50* pH-7.41
calTCO2-33* Base XS-5
[**2153-6-23**] 03:55AM BLOOD Type-ART pO2-85 pCO2-58* pH-7.38
calTCO2-36* Base XS-6
[**2153-6-23**] 01:44AM BLOOD Type-ART pO2-82* pCO2-59* pH-7.38
calTCO2-36* Base XS-7
[**2153-6-22**] 11:13PM BLOOD Type-ART Temp-37.6 pO2-113* pCO2-55*
pH-7.39 calTCO2-35* Base XS-7 Intubat-NOT INTUBA
[**2153-6-22**] 01:54PM BLOOD Type-ART pO2-78* pCO2-49* pH-7.45
calTCO2-35* Base XS-8
[**2153-6-22**] 05:13AM BLOOD Type-ART Temp-36.3 Rates-/20 FiO2-31
pO2-81* pCO2-60* pH-7.36 calTCO2-35* Base XS-5 Intubat-NOT
INTUBA
[**2153-6-22**] 12:37AM BLOOD Type-ART Temp-36.3 Rates-/24 FiO2-31
pO2-112* pCO2-55* pH-7.37 calTCO2-33* Base XS-5 Intubat-NOT
INTUBA
[**2153-6-21**] 09:02PM BLOOD Type-ART Temp-36.1 Rates-/24 FiO2-31
pO2-56* pCO2-45 pH-7.46* calTCO2-33* Base XS-6 Intubat-NOT
INTUBA
[**2153-6-21**] 01:49PM BLOOD Type-ART Temp-36.6 pO2-89 pCO2-51*
pH-7.41 calTCO2-33* Base XS-5
[**2153-6-21**] 05:59AM BLOOD Type-ART Temp-35.9 pO2-68* pCO2-53*
pH-7.39 calTCO2-33* Base XS-5 Intubat-NOT INTUBA
[**2153-6-21**] 01:09AM BLOOD Type-ART Temp-36.6 FiO2-30 pO2-61*
pCO2-59* pH-7.36 calTCO2-35* Base XS-5 Intubat-NOT INTUBA
[**2153-6-20**] 09:45AM BLOOD Lactate-1.8
[**2153-6-20**] 06:13AM BLOOD Lactate-0.9
[**2153-6-20**] 05:27AM BLOOD Lactate-1.1
[**2153-6-21**] 05:59AM BLOOD freeCa-1.16
[**2153-6-20**] 10:08PM BLOOD freeCa-1.12
Brief Hospital Course:
This is a 48 year old male with hx of asthma/COPD, hepatitis C,
and poly-substance abuse presenting with worsening shortness of
breath secondary to a COPD flare [**12-1**] day after finishing a long
steroid taper.
.
Brief ICU course: In the MICU, the patient was somnolent but
arousable to voice. He had been speaking in full sentences but
sometimes fell asleep while talking. He originally had a
headache that started around the time his breathing worsened. It
was thought there may have been some element of undiagnosed OSA
and the patient responded well to bipap. On [**2153-6-20**] the patient
was on bipap for most of day with slight improvement in his
respiratory symptoms, although he did have wheezing. Steroids,
azithromycin, and nebs were administered and an a-line was
placed. On [**2153-6-21**], he was on vent mask during the day and did
well. He required bipap overnight with increased PSV over the
course of the night due to increased CO2. He had obvious apneic
periods and a higher CO2 in the morning. On [**2153-6-22**], his pCO2
improved during the day and his bipap at night was set at 16/8.
He was satting well on 2L NC and had been transitioned to PO
steroids before being transferred to the floor.
.
# Hypercarbic Respiratory Failure. This was likely
multifactorial secondary to a COPD flare and likely OSA. His CO2
levels were likely elevated at baseline. He progressively became
less somnolent and responded well to bipap at night.
.
# COPD exacerbation. He was treated with steroids,
azithromycin, and neb treatments PRN during his admission. He
had poor air movement, but was satting 90-95% on room air both
at rest and while walking on the day of discharge. His HR was
in the 80s to 100s while resting at baseline and increased to
the 120s while walking. He was on an insulin sliding scale
while on high dose steroids during the admission. He was
discharged on a long prednisone taper starting at 60mg daily and
decreasing by 10mg weekly.
.
# OSA. Previously undiagnosed, but the patient did very well
using bipap nightly in the hospital. Pulmonary set the patient
up with home bipap using 16/8 settings temporarily before a
sleep study could be performed as an outpatient.
.
# Hepatitis C. Currently stable and LFTs drawn during the
admission were normal.
.
# Psych. His home Abilify, Paxil, Remeron, and clonazepam were
continued. He required several additional PRN doses of
lorazepam for anxiety during his admission. As a result, his
home clonazepam dose was increased from twice daily to three
times daily on discharge.
.
# Hx of substance abuse. He was closely monitored clinically
for signs of withdrawal and continued the nicotine patch for
smoking cessation.
.
# Of note, the patient expressed wishes to transfer his care to
[**Company 191**] and to be followed by [**Hospital1 18**] pulmonologists. A discharge
follow-up appointment was made with an [**Company 191**] provider at the end
of this week. He also has pulmonary follow-up in early
[**Month (only) **] prior to his steroid taper ending.
Medications on Admission:
Aripiprazole 15 mg daily
Combivent 18/103 mcg 2 puffs QID
Paroxetine 20 mg daily
Mirtazapine 30 mg qHS
Advair 250-50 mcg [**Hospital1 **]
Omeprazole 20 mg daily
Clonazepam 1 mg [**Hospital1 **]
Nicotine patch
Advair 250/50 [**Hospital1 **]
Ibuprofen 800mg TID PRN
Milk of magnesia PRN
Mylanta PRN
Benadryl 50 mg HS
Vistaril 50mg Q4h PRN
Albuterol MDI 1 puff q4hr PRN
- Prednisone taper was scheduled to end the day prior to
admission based on previous discharge summary
Discharge Medications:
1. Aripiprazole 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
2. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. BiPAP 16/8 with humidification and 2L O2 titrated to O2
sat>93%
[**Location (un) 83502**]
[**Location 41708**], [**Numeric Identifier 83503**]
Diagnosis: COPD/OSA
O2 sat on RA: 88%
ID Number: [**Telephone/Fax (5) 83504**]
5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for anxiety.
Disp:*90 Tablet(s)* Refills:*0*
6. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
7. Prednisone 10 mg Tablet Sig: Take 6 tablets daily from
[**Date range (1) 82202**], 5 tablets daily from [**Date range (1) 32318**], 4 tablets daily from
[**Date range (1) 83505**], 3 tablets daily from [**Date range (1) 83506**], 2 tablets daily from
[**Date range (1) 83507**], 1 tablet daily from [**Date range (1) 83508**], and [**12-1**] tablet daily
from [**Date range (1) 83509**] Tablets PO taper as directed.
Disp:*172 Tablet(s)* Refills:*0*
8. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
inhalation Inhalation twice a day.
9. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day.
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Ibuprofen 800 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
12. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) cc
PO at bedtime.
13. Benadryl 25 mg Capsule Sig: Two (2) Capsule PO at bedtime as
needed for sleep.
14. Mylanta 200-200-20 mg/5 mL Suspension Sig: Thirty (30) cc PO
every four (4) hours as needed for indigestion.
15. Vistaril 50 mg Capsule Sig: One (1) Capsule PO every four
(4) hours as needed.
Discharge Disposition:
Home With Service
Facility:
NAMC
Discharge Diagnosis:
COPD exacerbation
Secondary diagnoses:
Asthma/COPD
Hepatitis C
IBS
h/o polysubstance abuse
Anxiety and Panic Attacks
Discharge Condition:
Stable, afebrile, ambulatory
Discharge Instructions:
You were admitted to [**Hospital1 **] Hosptial for
shortness of breath and wheezing. You were found to have a COPD
exacerbation. You were first stabilized in the intensive care
unit where bipap ventilation was started at night. This is for
obstructive sleep apnea. You will need a follow up sleep study
to confirm this. This seemed to improve your shortness of
breath dramatically and you will continue to use that nightly as
an outpatient along with a steroid taper to control your COPD.
The following changes have been made to your home medication
regimen:
Prednisone taper
BIPAP
Please follow-up with all of your outpatient medical
appointments listed below.
Please seek medical care if you experience any concerning
symptoms such as increased shortness of breath or chest pain.
Followup Instructions:
Please follow-up with all of your outpatient medical
appointments listed below.
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7449**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2153-6-29**] 1:45
2. Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2153-8-1**] 3:40
3. Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2153-8-1**] 4:00
Sleep HealthCenters
[**Location (un) 83510**].
[**Location (un) 583**], [**Numeric Identifier 994**]
Please call [**Telephone/Fax (1) 16716**] Option 1 to set up an outpatient
sleep study as soon as possible.
Fax: [**Telephone/Fax (1) 83511**]
ICD9 Codes: 4168, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8739
} | Medical Text: Admission Date: [**2163-7-15**] Discharge Date: [**2163-8-1**]
Date of Birth: [**2122-2-5**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
s/p Motorcycle crash
Major Surgical or Invasive Procedure:
[**2163-7-16**] Right Craniotomy
[**2163-7-19**] Open reduction and internal fixation left supracondylar
femur fracture
History of Present Illness:
41 yo male who was med flighted from an area hospital s/p
motorcycle crash. Per med flight report, patient was the
unhelmeted single occupant of a dirt bike, traveling at a high
speed and experienced a head-on collision with a mini [**Doctor Last Name **]. He
was reportedly thrown from bike 50-80 ft, experienced +LOC, then
awoke to call 911 himself. During transport to [**Hospital1 18**] he became
combative and was intubated.
Past Medical History:
HIV+,
+Hep C, and chronic IV drug use.
Social History:
Unknown
Family History:
Noncontributory
Physical Exam:
PHYSICAL EXAMINATION: ON PROPOFOL 60 mcg/kg/min
Vitals: reviewed
General: appears uncomfortable - fighting the vent
HEENT: intubated
Neck: in collar
Cardiac: tachycardic rate, normal S1 and S2.
Pulmonary: Lungs clear to auscultation bilaterally.
Abdomen: Flat. Normoactive bowel sounds. Soft. Non-tender,
non-distended.
Extremities: left distal femur fracture with open wound exposing
sc tissue
Skin: tattoos.
NEUROLOGIC EXAMINATION on PROPOFOL 60 mcg/kg/min:
Mental Status:
* Degree of Alertness: Appears awake, agitated
* Language: does not follow midline or appendicular commands
Cranial Nerves:
* I: Olfaction not evaluated.
* II: PERRL 3 to 2mm.
* III, IV, VI: Gaze conjugate
* VII: No clear facial droop, facial musculature symmetric.
* VIII: Hearing intact to finger-rub bilaterally.
* XII: Tongue protrudes in midline.
Motor:
* Bulk: No evidence of atrophy.
Strength:
* Left Upper Extremity: moves spontaneously at least versus
gravity - very strong movement away from stimulus during
attempts
to reapply foam wrist bracelet
* Right Upper Extremity: moves spontaneously at least versus
gravity
* Left Lower Extremity: moves ankle and toes spontaneously in
setting of fracture
* Right Lower Extremity: moves spontaneously at least versus
gravity
Reflexes:
* Left: 2+ throughout Biceps
* Right: 2+ thoughout Biceps
* Babinski: mute bilaterally
Pertinent Results:
ADMISSION LABS:
[**2163-7-15**] 08:45PM URINE RBC-[**12-31**]* WBC-[**4-15**] BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2163-7-15**] 08:45PM WBC-10.3 RBC-3.71* HGB-11.8* HCT-35.4* MCV-95
MCH-31.8 MCHC-33.3 RDW-13.0
[**2163-7-15**] 10:05PM GLUCOSE-174* LACTATE-2.6* NA+-142 K+-3.2*
CL--109 TCO2-20*
[**2163-7-15**] 08:45PM ASA-NEG ETHANOL-113* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
DISCHARGE LBAS:
IMAGING:
CT HEAD [**7-15**]:
1. 16-mm right occipital epidural hematoma with a central focus
of
hypodensity, which raises the concern for active bleeding or
clot. Since this area is adjacent to the transverse sinus,
further evaluation with the CT venogram or MR venogram is
recommended.
2. Frontal hemorrhagic contusions with adjacent subarachnoid
hemorrhage.
3. 7-mm right frontal subdural hematoma, 3-mm parafalcine
subdural hematoma, and 4-mm bilateral subdural hygroma vs
chronic subdural hematomas.
4. Complex occipital fracture with extension to the left
occipital condyle.
CT HEAD [**7-16**]:
Significant interval increase in IPH now measuring 8.9 x 3.9 cm
(2:16), with moderate edema, and subfalcine herniation. There is
SAH extension and intraventricular extension
CTA Head [**7-16**]:
1. Tiny focus of enhancement in the right frontal lobe, as do
the right of
the midline, can represent a focus of pseudoaneurysm or contrast
extravasation. Please see the detailed report on the subsequent
conventional angiogram.
Otherwise, patent intracranial arteries, with significant
displacement of the A2 segments of the anterior cerebral
arteries on both sides from the
intraparenchymal hematoma and the surrounding edema. Close
followup as
clinically indicated, if no intervention is contemplated.
[**2120-11-19**] MRI cervical spine
IMPRESSION:
1. Non-depressed compression of the superior endplate of the T2
vertebral
body. Alignment of the cervical spine is maintained. No evidence
of anterior or posterior longitudinal ligament injury.
Interspinous ligament edema is seen in the upper cervical as
well as upper thoracic spine regions.
2. Complex occipital bone fracture better appreciated on prior
CT.
3. Non-displaced fracture of the T3 spinous process as seen on
CT
examination.
4. No evidence of spinal cord contusion or hemorrhage.
5. Prevertebral soft tissue thickening and fluid is identified
which may be due to retained fluid in nasoparynx from
intubation.
[**2163-7-26**] Upper extr ultrasound
IMPRESSION: Left PICC line, with a fibrin sheath/thrombus
surrounding the
catheter within the left axillary vein.
Brief Hospital Course:
He was admitted to the Trauma service and transferred to the
Trauma ICU for frequent neuro checks, Keppra for seizure
prophylaxis was initiated. His neurological exam remained intact
for the first several hours of admission; However, early the
next morning, he was noted to have an acute mental status
change, and left-hemiparesis. A stat Head CT was done which
demonstrated a significant increase in the size of the head
bleed. He was taken emergently for an angiogram, which
demonstrated a pseudoaneurysm at the area of the bleed. He was
taken directly to the OR for an emergent right frontal
craniotomy and evacuation of hematoma. Postoperatively he
returned to the Trauma ICU where he remained sedated and vented.
Orthopedics was consulted for the scapula and femur fractures.
He was taken to the operating room on [**7-19**] for open reduction and
internal fixation left supracondylar femur fracture. The
external fixator remains in place and he is non weight bearing
on the left leg. His scapula fracture was managed non
operatively and he is non weight bearing on his right arm.
Infectious disease were consulted for recommendations regarding
resuming his antiretroviral therapies; these were restarted on
[**2163-7-27**]. Once discharged from rehab he will need to follow up
with his PCP for further management of these medications. He was
treated with triple antibiotics for E. coli in his sputum.
He was noted with left arm swelling; of note he had a PICC in
this arm. A ultrasound was done which showed thrombus. The PICC
was removed and a new right PICC was placed. The decision was
made to continue with SQ Heparin tid vs. Coumadin therapy after
discussed with pt's PCP.
Over the course of the next week or so his mental status began
to slowly improve. He was eventually weaned from the ventilator
and was transferred to the regular nursing unit. His mental
status currently is awake and alert and intermittently follows
simple commands.
He was evaluated by Physical and Occupational therapy and is
being recommended for acute rehab.
Medications on Admission:
Unknown
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
2. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. Methadone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day): on for chronic pain syndrome.
9. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Darunavir 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
14. Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML's
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Cape & Islands
Discharge Diagnosis:
s/p Motorcycle crash
Right cerebellar epidural hematoma
Parafalcine subdural hemorrhage
Occipital bone fractureT3-7 spinous process fractures
Right nondisplaced scapular fracture
Left proximal femur fracture
Discharge Condition:
Alert and follows simple commands
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Followup Instructions:
Follow-Up Appointment Instructions:
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in approximately 4 weeks.
?????? You will need a CT scan of the brain without contrast.
?????? You will also need Flexion/ Extension Xrays of your cervical
spine.
Follow up in 2 weeks in [**Hospital 5498**] clinic with [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], NP; call [**Telephone/Fax (1) 1228**] for an appointment.
Follow up with your PCP after discharge from rehab.
Completed by:[**2163-8-24**]
ICD9 Codes: 5185, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8740
} | Medical Text: Admission Date: [**2122-2-13**] Discharge Date: [**2122-3-9**]
Date of Birth: [**2075-4-14**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfamethoxazole/Trimethoprim
Attending:[**First Name3 (LF) 9598**]
Chief Complaint:
Shortness of breath, productive cough
Major Surgical or Invasive Procedure:
ultrasound-guided paracentesis
liver biopsy
History of Present Illness:
-- per admitting [**Hospital Unit Name 153**] resident --
Ms. [**Known lastname 10336**] is a 46 year old lady with a history malignant thymoma
(full onc history below) who presents here due to dyspnea and
cough, which has been progressive over many months. Patient
states that her breathing is getting worse, and that her oxygen
requirement at home has increased from 2.5lpm to 3lpm. She has
also had a worsening cough productive of thick, yellow sputum.
Patient denies fevers, chest pain, headache, abdominal pain,
nausea, vomiting, diarrhea, or BRBPR. She does report darker
colored urine of late and a 30 lb. weight loss ove the past 2
years.
.
One day prior to admission patient called into the Pulmonary
clinic to report worsening eye and leg edema and was instructed
to taper her prednisone over 2 weeks. She says she now comes to
the ED to seek help with shortness of breath, as well as to
receive further treatment for her cancer.
.
In the ED, Initial VS: 97.5 110 112/72 RR 19, SP02 97% @ 3-4LNC.
Patient received Levofloxacin 750mg/Vanc 1gram for questionable
pneumonia due to worsening LUL CXR findings. She also received
20mEq of Potsasium and was continued on oxygen. An 18 gauge IV
was placed. VS prior to transfer: 99 126/80 24 98 % 4.5L NC
.
On arrival to the [**Hospital Unit Name 153**], patient's vitals were R: 99.8, HR: 105,
BP: 119/84, SP02: 97%. Patient complains of shortness of breath
but denies any pain.
Past Medical History:
--Malignant thymoma: Initially presented in [**2115**] with diplopia
and lid droop. She was diagnosed with Myasthenia [**Last Name (un) **].
Subsequently, found to have a thymoma with evidence of
metastases to the pleura.
Treatment History:
1. Neoadjuvant Cytoxan/Adriamycin/Cisplatin--small response
2. Resection of mass and pleural stripping
3. External Beam Radiation
4. 1 cycle of Carboplatin/Paclitaxel with carboplatin infusion
reaction
5. 8 weeks of weekly Taxol completed in [**1-16**]. Developed
pulmonary nodules
6. Tarceva [**Date range (1) 10344**]
7. Prednisone [**Date range (1) 10335**]
8. Plasmapheresis for Myasthenia Flare [**11-18**]
9. Alimta [**Date range (1) 10345**]
10. Xeloda [**Date range (1) 10346**]
11. Doxil [**Date range (1) 10347**], then observation
.
Other Past Medical History:
# Myasthenia [**Last Name (un) 2902**]
- treated with Cellcept since [**6-/2119**]
# Chronic bell's palsy
# Allergies
# Combined restrictive/obstructive lung disease
# Malignant thymoma: Initially presented in [**2115**] with diplopia
and lid droop. She was diagnosed with Myasthenia [**Last Name (un) **].
Subsequently, found to have a thymoma with evidence of
metastases to the pleura.
Treatment History:
1. Neoadjuvant Cytoxan/Adriamycin/Cisplatin--small response
2. Resection of mass and pleural stripping
3. External Beam Radiation
4. 1 cycle of Carboplatin/Paclitaxel with carboplatin infusion
reaction
5. 8 weeks of weekly Taxol completed in [**1-16**]. Developed
pulmonary nodules
6. Tarceva [**Date range (1) 10344**]
7. Prednisone [**Date range (1) 10335**]
8. Plasmapheresis for Myasthenia Flare [**11-18**]
9. Alimta [**Date range (1) 10345**]
10. Xeloda [**Date range (1) 10346**]
11. Doxil [**Date range (1) 10347**], then observation
.
Other Past Medical History:
--Myasthenia [**Last Name (un) 2902**]
--Treated with Cellcept since [**6-/2119**]
--Chronic bell's palsy
--Allergies
--Combined restrictive/obstructive lung disease
--Mild pulmonary hypertension
Social History:
Married and has two young children. Originally from southern
[**Country 651**]. Ms. [**Known lastname 10336**] used to work overnight at a bank, but is
currently unemployed. Her husband works in a restaurant. She
denies use of tobacco, ethanol, or other drugs.
Family History:
No history of cancer, myasthenia [**Last Name (un) 2902**], diabetes, MS, SLE, or
other autoimmune diseases.
Physical Exam:
-- per admitting [**Hospital Unit Name 153**] resident --
T: 99.8, HR: 105, BP: 119/84, SP02: 97% on 4 liters/minute
GENERAL: Jaundiced, thin, short of breath
HEENT: Sclera are jaundiced, EOMI, No LAD
CARDIAC: Holosystolic murmur best heard at left sternal border;
normal S2, sinus tachycardia
LUNGS: Diffuse crackles bilaterally
ABDOMEN: +BS, soft, non-tender, non-distended, no obvious
organomegally
EXTREMITIES: 1+ edema bilaterally; +pedal pulses
SKIN: Circular ecchymotic lesions on back and abdomen, which
patient attributes to "circulation" machine she uses at home.
NEURO: A&Ox3. Appropriate. Some trouble hearing. Belly's
palsy with mild paralysis of right side of face.
Pertinent Results:
[**2122-2-13**] 09:56PM URINE HOURS-RANDOM UREA N-336 CREAT-22
SODIUM-LESS THAN POTASSIUM-24 PHOSPHATE-9.5
[**2122-2-13**] 09:56PM URINE OSMOLAL-236
[**2122-2-13**] 09:56PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2122-2-13**] 09:56PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-NEG PH-7.0 LEUK-TR
[**2122-2-13**] 09:56PM URINE RBC-1 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-1 TRANS EPI-<1
[**2122-2-13**] 12:29PM LACTATE-2.0
[**2122-2-13**] 12:25PM GLUCOSE-235* UREA N-10 CREAT-0.3* SODIUM-130*
POTASSIUM-3.1* CHLORIDE-81* TOTAL CO2-44* ANION GAP-8
[**2122-2-13**] 12:25PM ALT(SGPT)-273* AST(SGOT)-200* ALK PHOS-480*
TOT BILI-20.9* DIR BILI-15.0* INDIR BIL-5.9
[**2122-2-13**] 12:25PM LIPASE-75*
[**2122-2-13**] 12:25PM AMMONIA-111*
[**2122-2-13**] 12:25PM WBC-33.6*# RBC-4.67 HGB-13.0 HCT-41.0 MCV-88
MCH-27.8 MCHC-31.6 RDW-16.6*
[**2122-2-13**] 12:25PM PLT COUNT-255
[**2122-2-13**] 12:25PM PLT COUNT-255
[**2122-2-13**] 12:25PM PT-18.0* PTT-38.9* INR(PT)-1.6*
CXR [**2122-2-13**]
Stable opacification of the left lower and mid lung, attributed
to the
patient's known pleural metastatic disease. Interval patchy
opacities noted at the left lung apex could represent pneumonia
versus progression of metastatic disease. Correlation with
clinical history and possible CT of the chest may be helpful in
further evaluation.
.
RUQ U/S:
1. No intra- or extra-hepatic biliary ductal dilatation.
2. Mildly increased echogenicity of the liver is a nonspecific
finding. This is most likely due to fatty infiltration, although
more advanced liver disease such as cirrhosis or fibrosis cannot
be excluded.
3. New ascites.
.
CT chest/abd/pel [**2-15**]:
1. Multiple lobulated pleural-based masses on the left, which
are unchanged
in size and appearance compared to the prior study.
2. Consolidation and bronchiectasis in the left upper lobe in
addition to
diffuse tree-in-[**Male First Name (un) 239**] opacities, ground-glass opacities, and more
focal nodules within the right lung, all of which are highly
concerning for an infectious process. However, malignancy cannot
entirely be excluded and clinical correlation is recommended, as
well as follow-up imaging surveillance. The appearance includes
a new right basilar consolidation with bronchiectasis, and
apparently superimposed on nearly confluent pleural masses in
the left hemithorax are patchy consolidations, most confluent at
the left apex, with bronchiectasis, probably due to infection,
or potentially radiation if such therapy has been recently
performed.
.
3. No focal liver lesions or intrahepatic biliary dilatation to
explain the patient's LFT abnormalities.
.
3. Marked intra-abdominal ascites.
.
4. Stable-appearing deep pleural metastases noted extending into
the deep
pleural surfaces on the left.
.
TTE [**2-17**]:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
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 aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. No masses or vegetations
are seen on the aortic valve. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2121-12-5**], no major change is evident.
IMPRESSION: no obvious vegetations seen
.
MR liver:
1. Heterogeneous, predominantly subcapsular delayed hepatic
enhancement, most consistent with hepatitis. There are no focal
mass-like areas of enhancement to suggest metastatic disease.
There is no biliary dilatation.
2. Moderate ascites and enhancement along the right peritoneum.
Correlate
with history of paracentesis; if there has been none, findings
could be
infectious or malignant in nature.
3. Numerous enhancing soft tissue masses in the left pleura and
peritoneum, unchanged from recent CT and increased in size from
the remote prior MRI.
.
Peritoneal Fluid Cytology:
Peritoneal fluid:
ATYPICAL.
Atypical cells of undetermined significance, see note.
Note: Recommend submission of additional fluid for cell
block preparation and additional studies
.
Liver, needle core biopsy:
1. Moderate portal and periportal mixed inflammation including
lymphocytes and neutrophils, with predominantly centrivenular
and bridging necrosis and parenchymal collapse involving 20-30%
of the core biopsy, confirmed by reticulin stain.
2. No malignancy identified in this sample.
3. Bile ductular proliferation with associated neutrophils.
4. Moderate canalicular and intracellular cholestasis with
focal bile plug formation.
5. Trichrome stain shows no increase in fibrosis.
6. Iron stain shows no stainable iron.
Note: The findings are consistent with an active hepatitis with
parenchymal collapse, bile ductular proliferation, and
cholestasis. Given the provided clinical information, a
drug/toxin-mediated injury is favored, however,
clinical/serologic correlation is required.
Brief Hospital Course:
# bacteremia - BCx grew out listeria. The patient was known to
consume homemade and potentially unrefrigerated food products
which could have been a potential source. Pt presented with
significant leukocytosis with WBC > 30K. As patient is allergic
to PCN, was started on IV Bactrim [**2-15**]. Pt defervesced early in
hospitalization but remained with significant leukocytosis. TTE
showed no evidence of endocarditis and blood cultures promptly
cleared after initiation of treatment. After discussion with
ID, since patient without neurologic/cardiac involvement, ok to
treat with three weeks of antibiotics. Patient tolerated IV
bactrim poorly several days into her course, developing SOB and
flushing. She was switched to IV meropenem. She developed a
mild arm/leg rash to this antibiotic, but the decision was made
to treat through the possible allergy given that it was felt
that this was the last good option to treat listeria. Patient
finished her antibiotic course in-house and remained stable.
.
# PNA/bronchiectasis - Completed 5 day course of levofloxacin.
Patient back to baseline oxygen requirement with no additional
SOB.
.
# edema - Patient developed asymmetric LUE edema and BLE edema
intermittently throughout hospitalization. Preference of LUE >
RUE edema likely partly due to decreased hydrostatic pressure as
seen on ultrasound (dampened subclavian waveform), possibly from
extrinsic compression from thyroid cyst, coupled with low
oncotic pressure from depressed albumin. Hypoalbuminemia is
likely [**3-17**] liver failure, although nutrition may be playing a
role as well. Was effectively treated with lasix/aldactone to
improve edema but this was limited by the patient developing
hyponatremia. The patient was discharged on a short supply of
lasix/aldactone as she was c/o some edema at time of discharge.
.
# hyperbilirubinemia - The Liver consult service followed this
patient during her time in-house, during which her workup
included a liver MRI, which showed diffuse hepatitis with no
nodules, a tap, which suggested hepatic ascites. Cytology
showed possible atypical cells that could have been worked up
with more fluid (>1L) but there was not enough left to tap. An
IR-guided liver biopsy was performed, which demonstrated zone 3
necrosis consistent with a toxic hepatitis. As the patient had
been taking unspecified herbal medications, it was felt this was
a likely etiology and she was told to stop these medications.
Her LFTs/bili were somewhat improved at discharge but still
significantly elevated.
.
# malignant thymoma - Per Onc team, pt's current sx not directly
attributable to malignancy at this time, no role for
chemotherapeutic intervention. No evidence of tumor progression
on imaging.
Medications on Admission:
MEDICATIONS (PER OMR)
Albuterol Sulfate Q2 PRN
Benzonatate 100 mg PO TID
Calcium Carbonate 500 mg PO Daily
Cholecalciferol 400 Unit PO daily
Cyanocobalamin 100mcg PO Daily
Fexofenadine 60mg PO BID
Fluticasone-Salmeterol 250/50 INH [**Hospital1 **]
Guaifenesin 600mg PO BID
Montelukast 10mg PO Daily
Multivitamin 1 tab PO daily
Mycophenolate Mofetil 500mg PO QD
Nystatin Suspension 5 times daily
Prednisone 5mg PO QOD
Discharge Medications:
1. commode
Please provide patient with bedside commode.
2. wheelchair
Please provide patient with standard wheelchair.
3. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO once a day.
5. Cholecalciferol (Vitamin D3) 400 unit Capsule Sig: One (1)
Capsule PO once a day.
6. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Inhalation twice a day.
9. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO twice a day.
10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Prednisone 5 mg Tablet Sig: 1.5 Tablets PO EVERY OTHER DAY
(Every Other Day).
12. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
Disp:*60 Capsule(s)* Refills:*0*
13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for pruritic rash.
Disp:*2 tubes* Refills:*1*
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every eight (8) hours
as needed for shortness of breath or wheezing.
Disp:*QS for 30 treatments * Refills:*0*
15. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*0*
16. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for cough.
Disp:*30 Lozenge(s)* Refills:*0*
17. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
Disp:*QS for 30 treatments * Refills:*0*
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
19. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
20. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
21. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*14 Tablet(s)* Refills:*0*
22. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a
day: Take with furosemide (lasix).
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary Diagnosis:
1. acute hepatitis; likely drug-induced
2. pneumonia
3. listeriosis
.
Secondary Diagnoses:
1. malignant thymoma
2. myasthenia [**Last Name (un) 2902**]
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 seen at [**Hospital1 18**] for pneumonia, liver failure, and a
bacterial bloodstream infection. Your pneumonia was treated
with antibiotics. Your bloodstream infection was treated with
3.5 weeks of intravenous antibiotics. You completed this
regimen before being discharged.
You were also found to have jaundice and liver dysfunction when
you came to the hospital. After discussion with our liver
specialists, we conducted numerous tests, including an MRI and a
paracentesis (sample of abdominal fluid). These tests suggested
your liver was severely inflamed but did not clearly show what
the cause of the inflammation was. A liver biopsy was
performed. The preliminary report from this biopsy shows no
evidence of cancer. The biopsy results suggests that the liver
injury was from a toxic ingestion; we suspect an herbal
medication you were taking may have caused this. You will be
started on a medication to try to improve your liver function
and will follow up with the liver specialists as an outpatient.
The following medications were changed during your
hospitalization:
ADDED benadryl and sarna lotion, medications that can help
prevent itching from rash
ADDED ursodiol, a medication to try to improve your liver
function
ADDED benzonatate to help with cough
ADDED furosemide (lasix) to help with swelling
ADDED spironolactone to be taken with lasix to help with
swelling
ADDED cepacol lozenges to help with cough
ADDED docusate to help with constipation
ADDED bisacodyl to help with constipation
Followup Instructions:
You have an appointment scheduled with Dr. [**Last Name (STitle) 497**], the liver
specialist, at 8AM on [**3-13**] (this coming Friday) at the
[**Hospital Unit Name **], on the [**Location (un) **]. You can contact his office at
([**Telephone/Fax (1) 1582**].
Provider: [**Name (NI) 2482**] [**Name (NI) 2483**], PT, CCS Phone:[**Telephone/Fax (1) 2484**]
Date/Time:[**2122-3-11**] 9:30
Please call Dr. [**Last Name (STitle) 10351**] at ([**Telephone/Fax (1) 10352**] for a new oncology
provider. [**Name10 (NameIs) **] will also ask Dr. [**Last Name (STitle) 10351**] to get in touch with you.
[**Name6 (MD) **] [**Last Name (NamePattern4) 9601**] MD, [**MD Number(3) 9602**]
Completed by:[**2122-3-12**]
ICD9 Codes: 486, 7907, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8741
} | Medical Text: Admission Date: [**2196-2-8**] Discharge Date: [**2196-2-24**]
Date of Birth: [**2144-10-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
Trachealbronchialmalcia s/p stent evaluation
Major Surgical or Invasive Procedure:
[**2196-2-9**] Flexible Bronchoscopy
[**2196-2-10**] Rigid and Flexible Bronchoscopy, stent Removal
[**2196-2-11**] Triple lumen central line placement
[**2196-2-18**] Rigid bronchoscopy with remainder stent removal
[**2196-2-22**] Right upper extremity ultrasound
[**2196-2-24**] Bilateral lower extremity ultrasound
[**2196-2-24**] Mammogram and bilateral breast ultrasound
History of Present Illness:
Mrs. [**Known lastname **] is a 51 year-old female with
trachaelbronchialmalacis & tracheal stenosis s/p stent placement
6 years ago now with dislodged/fractured stents She has been
referred from [**State 108**] for flexible bronchoscopy to further
evaluate and management of stents and airway.
Past Medical History:
Tracheal stenosis s/p stent removal
Trachealbronchialmalacia
Asthma
Hypertension
Diabetes Mellitus
CVA
Right axillar and right internal jugular thrombus
Mastitis, bilateral
Social History:
She lives with her family in [**State 108**] and has five children. No
ethanol, no tobacco, no recreational drugs.
Family History:
Non-contributory
Physical Exam:
General: 51 year-old spanishing speaking female in no apparent
distress
HEENT: normocephalic, mucus membranes moist
Neck: thick, no lymphadenopathy
Card: regular, rate & rhythm, normal S1,S2, no murmur/gallop or
rub
Resp: decreased
GI: obese, bowel sounds positive, abdomen soft
Non-tender/non-distended
Extr: warm, Right upper extremity with 2+ edema, left non, lower
extremity no edema
Pulses: (B) brachial, radial 2+
Breast: bilateral erythema, warm & tender
Neuro: non-focal
Pertinent Results:
[**2196-2-8**] WBC-16.4*# RBC-3.75* Hgb-9.1* Hct-30.0 Plt Ct-228
[**2196-2-21**] WBC-7.7 RBC-3.17* Hgb-7.4* Hct-25.7 Plt Ct-340
[**2196-2-24**] PT-14.5* PTT-40.3* INR(PT)-1.3*
[**2196-2-8**] Glucose-278* UreaN-13 Creat-0.8 Na-147* K-3.9 Cl-108
HCO3-22
[**2196-2-21**] Glucose-79 UreaN-6 Creat-0.7 Na-138 K-3.4 Cl-102
HCO3-27
Cultures:
[**2196-2-15**] 8:16 am SWAB Source: Rectal swab. R/O VANCOMYCIN
RESISTANT ENTEROCOCCUS (Final [**2196-2-18**]): No VRE isolated.
[**2196-2-15**] 8:16 am MRSA SCREEN Source: Rectal swab.
MRSA SCREEN (Final [**2196-2-17**]): No MRSA isolated.
[**2196-2-12**] 1:46 am SPUTUM Source: Endotracheal. GRAM STAIN
(Final [**2196-2-12**]): >25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2196-2-14**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
[**2196-2-24**] 12:10 pm TISSUE Site: BREAST
LEFT BREAST ABSCESS DRAINAGE. GRAM STAIN (Pending):
TISSUE CULTURE-TISSUE (Pending):
ANAEROBIC CULTURE (Pending):
CT TRACHEA W/O C W/3D REND [**2196-2-9**]
Secretions are demonstrated within the trachea. The diameter of
the trachea is difficult to assess in the presence of the stent,
although at least the diameter of the new stent which is about
13 mm. The right main bronchus, bronchus intermedius and right
lower lobe bronchus are patent during the inspiration. Narrowing
of the orifice of the right middle lobe bronchus is
demonstrated, although it is patent during inspiration. The left
upper and left lower lobe bronchi are patent during inspiration.
The dynamic expiration series demonstrate significant decrease
of the diameter of the right main bronchus, from 7.7 to less
than 3 mm with right middle lobe and right lower lobe origins
almost collapsed on end-inspiration as a collapsed segmental
bronchi in both lower lobes and right middle lobe with
subsequent significant widespread areas of air trapping, most
likely attributed to this dynamic airway collapse.
The evaluation of the lung parenchima demonstrate multiple
rounded opacities, in the right apex, 7:25, in right upper lobe,
7:33, 7:36, extensive areas of centrilobular ground-glass
opacities and more rounded consolidations in right middle lobe
and right lower lobe as well as in the left lung to a lesser
extent, findings which are consistent with widespread
infection/aspiration. There is no pleural or pericardial
effusion. Several mediastinal lymph nodes do not meet the size
criteria for lymphadenopathy ranging up to 8 mm in right lower
paratracheal, 10 mm in subcarinal and 5 mm in the aortopulmonic
window. The heart size is mildly enlarged, stable compared to
the previous studies.
IMPRESSION:
1. Severe bronchomalacia as described, bilateral. The presence
of the endotracheal stent prevents the evaluation of malacia.
The newest internal stent is most likely broken. Narrow lumen
left in left main bronchus.
2. Extensive areas of rounded consolidations, ground-glass
opacities and centrilobular nodules are consistent with
widespread infection/aspiration. Differential diagnosis might
include parenchymal hemorrhage in the appropriate clinical
setup.
CHEST (PORTABLE AP) [**2196-2-20**] 1:23 PM
FINDINGS: Compared to the film from earlier the same day there
continues to be bilateral lower lobe volume loss with question
infiltrate in the right and left lower lobes. The tracheal and
left mainstem stents are unchanged. The left subclavian line is
unchanged.
UNILAT UP EXT VEINS US RIGHT [**2196-2-23**] 12:37 AM
RIGHT UPPER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler
son[**Name (NI) 1417**] of the right internal jugular, subclavian, axillary
veins were performed. The basilic and cephalic veins were not
visualized. There is partially occlusive thrombus within a [**2-21**]
cm segment of the right internal jugular vein. There is an
additional larger partially occlusive thrombus within a 2-3 cm
segment of the right axillary vein.
IMPRESSION: Partially occlusive thrombi within the right
internal jugular and right axillary vein.
BILAT LOWER EXT VEINS [**2196-2-24**] 8:49 AM
IMPRESSION: No evidence of DVT.
Brief Hospital Course:
Mrs. [**Known lastname **] underwent flexible bronchoscopy to evaluate stent
placement and airway. On HD#2 she was taken to the operating
room and underwent flexible and rigid bronchoscopy, foreign body
(stent) removal and bronchoalveolar lavage. She was transferred
to the intensive care unit intubated for airway management. She
was started on intravenous antibiotics for her aspiration
pneumonia. On POD #1 a central line was placed for access and
intravenous antibiotics. She remained stable and on POD#3 was
taken for a flexible bronchoscopy to further evaluate her
airway. She was taken back to the surgical intensive care unit
and was unable to extubate secondary to agitation. On [**2196-2-18**]
she was taken back to the operating room for flexible and rigid
bronchoscopy with silicone stent placement. She tolerated the
procedure well and was extubated on [**2-19**] without difficulty.
She transferred to the floor in stable condition. She was
restarted on her home medications. A clear liquid diet was
started and advanced as tolerated. On [**2-22**] she found to have
right upper arm edema and a right upper extremity ultrasound was
positive for a partially occlusive thrombi within the right
internal jugular and right axillary vein. She was started on
Lovenox and Coumadin. On [**2-23**] she complained of bilateral
breast tenderness and warmth. She was placed on Keflex for
possible mastitis. Given her history of past DVTs a lower
extremity ultrasound was negative for DVT. On [**2-24**] bilateral
breast ultrasound revealed a small left-sided fluid collection
which was drained for 1.5 cc of serous fluid. Cultures were
sent and results are pending.
Medications on Admission:
Prednisone 30 mg once daily
Procardia 60 once daily
Lasix 40 once daily
Percs [**1-20**] prn & morphine 100 mg tid
Albuterol, atrovent;
Xanax 0.5 tid
Zocor 20 qd
Ambien 10 qhs
Asa 325 mg once daily
Nitro prn
insulin 70/30- 25am/15pm
Discharge Medications:
1. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
Sig: Twenty Five (25) Units Subcutaneous once a day.
6. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO every twelve (12) hours:
indefinitely for tracheal stents.
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed.
11. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed: take with food and water.
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
13. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours): until INR > 2.0.
14. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 14 days.
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
16. Coumadin 1 mg Tablet Sig: Take as directed to maintain INR
2.0-3.0 Tablets PO once a day.
17. Regular insulin
per sliding scale finger stick
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **]
Discharge Diagnosis:
Tracheal stenosis s/p stent removal
Trachealbronchialmalacia
Asthma
Hypertension
Diabetes Mellitus
CVA
Right axillar and right internal jugular thrombus
Mastitis, bilateral
Discharge Condition:
Stable
Discharge Instructions:
Call interventional pulmonology [**Telephone/Fax (1) 7769**] as needed
Complete Keflex course for mastitis
Lovenox 80 mg q12h for Right axillar and right internal jugular
thrombus
Coumadin INR Goal 2.0-3.0: Monitor INR and dose coumadin
appropiately
Monitor fingerstick blood surgars before meals and bedtime cover
with sliding scale
Continue albuteral and atrovent nebulizers
Mucinex 1200mg twice daily indefinitely
Monitor CBC, lytes, BUN & Cre
Follow-up on Left breast fluid collection cultures.
Monitor Left breast drain site for signs or symptoms of
infection
Followup Instructions:
Follow-up with your PCP in [**Name9 (PRE) 108**]: for further coumadin
management
Follow-up with interventional pulmonology as needed [**Telephone/Fax (1) 7769**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2196-3-1**]
ICD9 Codes: 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8742
} | Medical Text: Admission Date: [**2102-2-8**] Discharge Date: [**2102-2-27**]
Date of Birth: [**2031-8-15**] Sex: M
Service: [**Last Name (un) 7081**]
HISTORY OF PRESENT ILLNESS: This is a 70 year old male with
Stage 2A esophageal cancer status post chemo and radiation
treatment. Also of note, this patient has myasthenia [**Last Name (un) 2902**]
status post thymectomy and apheresis, transient ischemic
attack in the past, silent myocardial infarction in [**2092**],
hematuria and rosacea. The patient is admitted at this time
for planned laparoscopic and thoracoscopic
esophagogastrectomy to be performed by Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (STitle) 952**]. Mr. [**Known lastname 4427**] has a history of developing regurgitation
that began in [**2101-7-31**] that was associated with
dysphagia without odynophagia and in addition, lost 15 lb.
over the months following [**2101-7-31**]. He had a barium
swallow which showed a 3 cm polypoid mass in the distal
esophagus. Biopsy and esophagoscopy by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 15908**]
confirmed esophageal carcinoma. An infiltrative, fungated and
partially obstructing nonbleeding 5 cm mass was seen at the
lower third of the esophagus. On endoscopic ultrasound, it
extended through the muscularis propriate consistent with a
T3 lesion. No other areas were PET positive.
PHYSICAL EXAMINATION: On admission, weight was 206 lb.,
pulse 81, blood pressure 134/81, temperature 97.5 degrees F.,
O2 saturation 97 percent with a respiratory rate of 14
breaths per minute. Generally, this was a well-appearing male
in no acute distress. Oropharynx was moist and clear with no
mucositis or thrush. Sclerae were anicteric. Extraocular
motions were intact. Neck was supple with no lymphadenopathy
cervically or supraclavicularly and there was no
infraclavicular lymphadenopathy as well. The heart was in
regular rate and rhythm. There were no murmurs, rubs or
gallops. Back showed no spinal or costovertebral angle
tenderness. Chest was clear to auscultation bilaterally.
Abdomen was soft, nontender, protuberant, obese with
normoactive bowel sounds. Extremities revealed no clubbing or
edema. Skin revealed minimal bilateral nasal rosacea, a well-
healed mid sternal scar, minimal erythema on the back from
radiation skin changes and a port site that was clean, dry
and intact with no erythema and was nontender.
HOSPITAL COURSE: Thus, at this time, the patient was
admitted for further treatment and evaluation at the [**Hospital1 1444**] in the form of a
laparoscopic/thorascopic esophagogastrectomy and on [**2-8**], the patient was brought to the operating room after having
been fully preoperatively evaluated where the patient
underwent laparoscopic/thorascopic esophagogastrectomy
performed by Dr. [**Last Name (STitle) 952**] and Dr. [**Last Name (STitle) **]. The patient
received 5.8 liters of crystalloid fluid in the operating
room and there was a blood loss of an estimated 200 ml during
the operation. In the immediate postoperative period, the
patient was brought to the Surgical Intensive Care Unit after
also having received 750 ml of albumin, 500 mcg of fentanyl
and 7 mg of vecuronium. He was extubated shortly after the
operation on the afternoon of [**2102-2-8**] and was
complaining of only peri-incisional pain and tenderness near
the right posterior back incision. He stated that he was not
short of breath at this time and did not feel weak and did
not feel he was having any diplopia. On postoperative day 1,
the patient required a bolus of 500 cc of Lactated Ringers
for mean arterial pressure near 65 and an elevated lactate,
responded well to this and the patient was continued on
maintenance level IV fluids. The patient was briefly out of
bed during this time. The patient was also followed by the
Neuromuscular Service and their plan was to commence Mestinon
and CellCept for his myasthenia [**Last Name (un) 2902**] in that if the patient
began suffering increasing weakness or worsening respiratory
status, to call Neurology at once and not to increase the
Mestinon and to consider possibly plasmapheresis. The patient
was on a planned six doses of Kefzol and Flagyl during this
time. The patient was also seen by the Nutrition Service on
postoperative day 1 and suggested jejunal tube feeds
progressing from half to three-quarter strength. On
postoperative day 1, in the evening, the patient seemed to be
developing fatigability and respiratory issues and was shown
to have some aspect of congestive heart failure on a chest x-
ray. The Neurology Service was consulted at once and
suggested that the vital capacity and negative inspiratory
force be checked every 2 hours and that the patient may need
intubation and diuresis. The patient was having a significant
oxygen requirement at this time and was also complaining of
shortness of breath. He did receive Lasix 10 mg IV times two
overnight and was on a nonrebreather mask with an FIO2 of 100
percent. His urine output was noted to briskly increase after
both doses of Lasix with some improvement in symptoms and
exam. Trophic tube feeds were also started at this time. His
central venous line was also removed during this time. On
[**2102-2-10**], postoperative day 2, the patient received
a bronchoscopy and there was noted to be multiple plugs of
mucus in the lower lobes, right greater than left. These were
removed. The patient required intubation as well on the
second postoperative day due to increased oxygen requirement
and fatigability. On postoperative day 3, the patient was
noted to be febrile and somewhat hypotensive with blood
pressure into the low 100s and high 90s on occasion. The
patient was pancultured at this time, was continued on fluids
and vancomycin and Zosyn were started empirically. A Tensilon
test during this time was noted to be negative. The patient
was bronchoscoped again on [**2102-2-11**] and noted to
again have nonpurulent heme secretions, but that it was noted
to be a much improved exam from [**2-10**], the previous
day. On postoperative day 4, the patient was noted to have
had episodes over the last 24 hours of hypotension, again
requiring fluid boluses with fever to 102 degrees. He was
recultured at this time. The patient at this time also had
bilateral chest tubes with the left putting out copious
drainage and the patient was also transfused with 1 unit of
packed red blood cells at this time. The patient was again
continued to be diuresed at this time with goal 1 [**1-1**] to 2
liters negative. On postoperative day 5, the patient
underwent a Cortrosyn stimulation test that was normal and
then on Monday, [**2102-2-13**], a percutaneous
tracheostomy was performed as the patient was appearing to
require the vent for a significantly longer period of time at
this point. This was done under bronchoscopic guidance. There
were no complications to the procedure and the tracheostomy
was placed carefully and safely. Tube feeds were at goal at
this point and the goal continued to be to wean the
ventilator if possible. The patient was started on physical
therapy at this point and was consistently out of bed to the
chair during this time. On postoperative day 7, his right
jugular venous line was changed for fevers and he was noted
to be tolerating a pressure support wean fairly well and was
down to pressures [**4-4**] and PEEP of 5 at 50 percent for 4
hours. On [**2102-2-15**], the patient had received
bronchoscopy again and the patient tolerated this well. There
were noted to be copious secretions with mucus plugging and a
therapeutic aspiration was performed especially in the right
lower lobe. The patient received another transfusion of 1
unit of packed red blood cells at this time for a hematocrit
of 28.7. His aspirin was restarted at this point and the
patient was out of bed and continued to exercise with
Physical Therapy. On [**2-16**], postoperative day 8, on
chest x-ray, it appeared the patient had a right sided
pneumonia. Vancomycin and Zosyn were continued and the goal
at this point was to establish a trach mask. The patient had
not had a bowel movement and a Fleet enema was instituted.
The patient was ambulating at this point. Also, at this time,
the patient received a CTA that was negative for pulmonary
embolus. On postoperative day 10, a trial of trach mask was
attempted that failed. The patient developed increasing
dyspnea and on the chest x-ray, it was noted that the patient
had a large right pneumothorax. A chest tube was placed on
the right and the hematocrit came back at 26.1 and 1 unit of
packed red blood cells was given. Blood pressure was noted to
improve at this time and a Cortrosyn stimulation test was
performed again that was negative. The patient then received
bronchoscopy again on postoperative day 10, [**2102-2-18**]. There were noted to be some thin secretions and
bronchus intermedius and a bronchoalveolar lavage was sent
for culture. The patient tolerated this procedure well and
seemed to benefit from it. Then, on postoperative day 11,
[**2102-2-19**], the patient was noted to be improving. He
was receiving chest physical therapy also at this time. Of
note, there were still no positive cultures of any kind at
this time from the blood, sputum, urine or pleural fluid. On
postoperative day 12, the patient was noted to be tachypneic
with decreases in pressure support and attempted weans. Also,
of note, the patient's central line was removed for these
fevers. The patient received a bedside swallowing evaluation
on [**2102-2-20**] and was noted to be doing well, but to
be maintained NPO until an upper GI study ruled out free
reflux or regurgitation of material into oropharynx in
regards to maintaining a safety against aspiration. The
patient received a Passy-Muir valve also at this time and
appropriate Passy-Muir precautions were observed. On
postoperative day 13, pressure support was noted to be at 10.
The barium swallow had been normal with normal gastric
emptying the previous day and nystatin was started for an
oral thrush that was observed on physical examination. The
plan at this point was for plasmapheresis for myasthenia
[**Last Name (un) 2902**] issues. On postoperative day 14, the patient had
another chest x-ray done after the removal of the right chest
tube. There was no pneumothorax and the patient was allowed
to advance his diet after the swallow studies. On
postoperative day 14, later in the day, the patient suffered
another right-sided pneumothorax requiring placement of a
chest tube that was placed mid clavicularly in the second
intercostal space. The lung was noted to re-expand well on
chest x-ray that followed the placement of this tube.
Diuresis was continued at this point with Lasix and Diamox.
All antibiotics were stopped at this time. No cultures had
grown back any organisms. On postoperative day 16, the
patient was started on cycled tube feeds, running from 5 p.m.
to 9 a.m. and a rehabilitation screen at this point was in
progress. The patient received another bedside swallowing
evaluation on [**2102-2-24**] that showed him to be a risk
for aspiration of thin liquids and pureed solids. The patient
was recommended to remain NPO until a further study had been
performed. On postoperative day 16, later in the day, the
patient was noted to have decreased breath sounds on the
right by the nurse taking care of the patient and a chest x-
ray was obtained at this time that showed reacquired right
pneumothorax. This chest tube was then again placed back on
suction and the lung was noted to re-expand on chest x-ray
that followed. Tube feeds were resumed at this time. On
[**2-26**], postoperative day 18, the patient was noted to
have tolerated trach mask the previous 24 hours, 9 of those
hours. Tube feeds were advanced to goal. The patient
continued to be gently diuresed with Lasix. On [**2102-2-27**], the patient was deemed fit for discharge and was stable
and had been on trach mask upwards of 10 hours the previous
day.
DISCHARGE INSTRUCTIONS: The patient is to be discharged to
[**Hospital 15909**] Rehabilitation Facility with ventilator to be used
via tracheostomy as needed. The patient is to be placed on
tracheostomy mask during the day when suitable and to receive
is having shortness of breath, chest pain, fevers, chills,
nausea or vomiting or if there are any questions or concerns.
The patient is to receive tube feeds according to enclosed
instructions.
FINAL DIAGNOSIS: Esophageal cancer, myasthenia [**Last Name (un) 2902**],
coronary artery disease, right-sided pneumothorax times
three, status post esophagogastrectomy.
RECOMMENDED FOLLOW-UP: The patient is to follow up with Dr.
[**Last Name (STitle) 952**] in two weeks and appointment to be scheduled at [**Telephone/Fax (1) 15910**]. The patient is to follow up with Dr. [**Last Name (STitle) **] of
Neurology on [**2102-3-20**].
MAJOR SURGICAL AND INVASIVE PROCEDURES:
Laparoscopic/thorascopic esophagogastrectomy, jejunal feeding
tube placement, chest tube placement times three, central
venous line placement, Foley catheter placement.
CONDITION ON DISCHARGE: Good.
DISCHARGE MEDICATIONS: Heparin 5000 units subcutaneously
tid, dorzolamide/timolol 2/0.5 percent drops, one drop
ophthalmic [**Hospital1 **], brimonidine tartrate 0.2 percent drops, one
drop ophthalmic q12h, albuterol sulfate one inhalation q6h as
needed, ipratropium bromide 0.02 percent solution, one
nebulizer q6h, potassium and sodium phosphates [**Telephone/Fax (3) 4228**] mg
packet, pyridostigmine bromide 60 mg per 5 ml, 5 ml to be
given every 8 hours, glutamine 10 g, half a packet po bid to
be given, ferrous sulfate 325 mg po daily in liquid form,
albuterol 90 mcg 2-4 puffs q2-4h, Tylenol 325 mg to 650 mg po
q4-6h as needed and mycophenolate mofetil 200 mg/ml po bid,
Colace 100 mg in liquid form po bid, lorazepam 0.5 mg po q4-
6h as needed for anxiety, Travoprost 0.004 percent drops, one
ophthalmic every other day as needed for glaucoma,
nitroglycerin 0.3 mg tablets sublingual as needed for chest
pain, aspirin 81 mg po daily, lansoprazole 30 mg po daily,
zolpidem tartrate 5 mg po at bedtime, insulin Regular
subcutaneous to be enclosed with discharge materials,
oxycodone/acetaminophen 5/325 ml solution [**5-9**] ml po q4-6h as
needed, potassium chloride 20 mEq packets, two packets po prn
as needed for K less than 3.5, nystatin 5 ml po tid as needed
for oral thrush, bisacodyl 10 mg po bid as needed delayed-
release, acetylcysteine 20 percent in 200 mg/ml solution [**3-4**]
ml q8h as needed, citalopram hydrobromide 20 mg po daily,
calcium gluconate 100 mg/ml and magnesium sulfate as needed.
DISPOSITION: The patient is to be discharged to [**Hospital3 6373**] Facility.
[**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], [**MD Number(1) 15911**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2102-2-26**] 16:50:41
T: [**2102-2-26**] 18:36:47
Job#: [**Job Number 15913**]
ICD9 Codes: 5185, 486, 4280, 4271, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8743
} | Medical Text: Admission Date: [**2128-2-23**] Discharge Date: [**2128-3-7**]
Date of Birth: [**2067-10-25**] Sex: M
Service:
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: The patient is a 60 year old
male, status post ascending aortic dissection and repair with
a hemoshield graft in [**2118**]. He presented to an outside
hospital in [**2127-12-3**], with abdominal pain. Workup
revealed an even larger abdominal aortic aneurysm, previously
3.0 to 4.0 centimeters, to 6.0 centimeters without
dissection. He was also found to have appendicitis and
underwent appendectomy. A follow-up chest CT on [**2128-1-5**],
revealed dissection of ascending aorta from the root to the
arch. The root was dilated at 5.5 centimeters and he was
referred to Dr. [**Last Name (Prefixes) **] for surgical repair. He
underwent outpatient cardiac catheterization in
anticipation of upcoming aortic surgery to rule out coronary
artery disease. This revealed the left ventricular ejection
fraction of 60%, 30% first diagonal, no other
significant lesions.
PAST MEDICAL HISTORY:
1. High cholesterol.
2. Hypertension.
3. Status post aortic surgery [**2118**].
4. Status post appendectomy in [**2127-12-3**].
5. 6.0 centimeter abdominal aortic aneurysm.
6. Gout.
7. Status post tonsillectomy.
HOME MEDICATIONS:
1. Zocor.
2. Atenolol.
3. Dyazide.
4. Digoxin.
5. Aspirin.
6. Cozaar.
7. Probenecid.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Neurologically, the patient is grossly
intact. The patient denies transient ischemic attack
neurological symptoms. Pulmonary - The lungs are clear to
auscultation bilaterally. Cardiovascular - Regular rate and
rhythm, grade II/VI systolic ejection murmur. The abdomen is
benign. Extremities - warm, positive dorsalis pedis and
posterior tibial pulses bilaterally.
LABORATORY DATA: Significant laboratory results included
creatinine 1.5,
HO[**Last Name (STitle) **] COURSE: The patient was admitted to the hospital
and taken to the operating room on [**2128-2-25**]. The patient
underwent redo Bentall procedure with a 23 homograph and 26
gelweave tube graft to include the arch. After the procedure,
the patient was transferred to the Cardiac Surgery Intensive Care
Unit for
close observation. He received Vancomycin antimicrobial
prophylaxis. He was started on Lopressor and Aspirin. He
was also hooked up with physical therapy at that time. After
four days in the Intensive Care Unit, the patient was
transferred to the regular cardiac surgery floor where he
continued to convalesce. Periodically over the course of his
stay, the patient experienced bouts of atrial fibrillation.
The patient was loaded on Amiodarone and started on Heparin
and Coumadin. The patient experienced a prolonged loading
period on the Coumadin which extended his stay. Also, the
patient experienced mild bradycardia and an aberrant
supraventricular impulse. He was therefore seen by
Cardiology who was pleased with his management but cautioned
surgery team to monitor for further bradycardia. Over the
next couple of days, the patient was seen not to have a
problem with progressive bradycardia. Finally on [**2128-3-7**],
the patient had an acceptable INR and was prepared for
discharged. Also, over the course of his hospital stay, the
patient was followed by the Vascular service for his
abdominal aortic aneurysm. It is their wish that the patient
follow-up with them as an outpatient and have recommended a
possible stenting of this abdominal aortic aneurysm. It is
now [**2128-3-7**], the patient is being discharged home. He is in
good condition. He is to follow-up with Dr. [**Last Name (Prefixes) **] in
four weeks. He is to follow-up with his primary care
physician in one to two weeks. He is to follow-up with his
cardiologist in two to three weeks. He is to follow-up with
Dr. [**Last Name (STitle) **] of Vascular Surgery per his request. The patient
is also to receive daily INR checks at a facility of his
choice. INR should be turned in to his primary care
physician or cardiologist for daily monitoring of his
coagulation profile and possible adjustment of his Coumadin
dosing. The patient may observe an ad lib diet. The patient
may observe a nonstrenuous activity level and no driving
while on pain medication.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg p.o. twice a day.
2. Ranitidine 150 mg p.o. twice a day.
3. Aspirin 325 mg p.o. once daily.
4. Percocet one to two tablets p.o. q4hours p.r.n. pain.
5. Lopressor 25 mg p.o. twice a day.
6. Amiodarone 400 mg p.o. once daily.
7. Lasix 20 mg p.o. once daily.
8. Coumadin 10 mg p.o. q.h.s.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 8358**]
MEDQUIST36
D: [**2128-3-7**] 12:11
T: [**2128-3-7**] 12:47
JOB#: [**Job Number 9689**]
ICD9 Codes: 4241, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8744
} | Medical Text: Admission Date: [**2125-4-2**] Discharge Date: [**2125-4-10**]
Date of Birth: [**2047-1-17**] Sex: F
Service: CSU
PREOPERATIVE DIAGNOSES:
1. Iatrogenic injury to the thoracic aorta.
2. Pneumonia.
POSTOPERATIVE DIAGNOSES:
1. Iatrogenic injury to the thoracic aorta.
2. Pneumonia.
PROCEDURE:
1. Repair of descending thoracic aorta from iatrogenic
injury.
2. Left lower lobe bullectomy.
DATE OF OPERATION: [**2125-4-2**].
COMPLICATIONS: Respiratory failure, acute renal failure,
death.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 78 year-old lady
with past medical history significant for hypertension and
hypothyroidism as well as past surgical history significant
for appendectomy and bladder resuspension. She presented to
[**Hospital3 1443**] Hospital on [**3-23**] with shortness of breath
and weakness and was found to have bilateral pneumonia. At
the time, she was treated for the bilateral pneumonia and it
was discovered that she had significantly loculated
pneumothorax on imaging studies. Her respiratory status
worsened and she was intubated on [**2125-3-29**]. She eventually
required pressor support for presumed sepsis. On [**4-2**], at
[**Hospital3 1443**], there was an attempt to drain the large
loculated left pneumothorax by placement of a CT guided
pigtail catheter. Unfortunately, during the procedure , the
descending thoracic aorta was punctured. The patient was
transferred emergently to [**Hospital1 188**] for further evaluation and treatment. Upon arrival,
she was hypotensive to a systolic blood pressure of 70 and
was taken emergently to the operating room.
Intraoperatively, the pigtail catheter was found to be in
through the lung and in the descending thoracic aorta. The
aorta was primarily repaired and the pigtail catheter was
removed without any problems. At the same time, the thoracic
surgery team performed a left lower lobe bullectomy.
Postoperative, the course of the patient was fraught with
complications. She demonstrated extensive bilateral pulmonary
edema and required to be placed on N.O. for elevated
pulmonary pressures and in order to maintain sufficient mixed
venous saturations. Attempts to wean the N.O. initially
failed. The patient's renal function also gradually worsened
and she finally developed acute renal failure, requiring
CVVH. At the same time, she became coagulopathic and
presented with a picture of DIC. Indicative lab values are a
value of fibrinogen of 79, an INR of 4.6, PT which rose as
high as 42 and a PTT which rose as high as 60. Also
indicative was a value of D-Dimer that rose to 7183. Finally,
in the morning of [**2125-4-9**], she came off the N.O. but still
requiring high doses of Neo-Synephrine for pressor support to
maintain her blood pressure. Her condition did not improve
and in the afternoon of [**4-10**], the attending physician had [**Name Initial (PRE) **]
meeting with the family and the patient's critical condition
was discussed. The decision was made by the family for
pressor support to be withdrawn. Comfort measures were
started and the patient expired shortly thereafter. The date
of death was [**4-10**] and the time of death was 16:30 in the
evening. The medical examiner was contact[**Name (NI) **] and the case was
accepted by the medical examiner. The family also requested
an autopsy that will be performed by the pathology department
of [**Hospital1 69**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern1) 78483**]
MEDQUIST36
D: [**2125-4-11**] 07:10:45
T: [**2125-4-11**] 07:29:48
Job#: [**Job Number 78484**]
ICD9 Codes: 5185, 0389, 5849, 2875, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8745
} | Medical Text: Admission Date: [**2139-5-13**] Discharge Date: [**2139-5-17**]
Date of Birth: [**2066-4-30**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
Cardiac Catheterization s/t stent placement to ramus and LIMA
anastamosis
Swan [**Last Name (un) 26645**] Catheter Placement
History of Present Illness:
73YO male with hx CAD s/p CABG with redo [**2120**], CHF with EF 30%,
afib, DM, CRI, PVD who has recent [**Hospital1 18**] stay last month for
decompensated heart failure and ARF that required CCU stay for
tailored therapy and CVVH presents today with worsening DOE. Pt
reports that he has been working with [**Hospital 1902**] clinic to try to
manage his weight gain of 11 lbs since being discharged on
[**2139-4-18**]. His metolazone has been tepered off and his lasix was
increased to 120mg QAM/ 80mg QPM (from 80mg [**Hospital1 **]). He reports
increased DOE today during his work as an [**Doctor Last Name **] at [**Hospital1 778**]. This
worsened to the point that he got SOB walking across a room. He
had some transient chest tightness that was relieved with rest
but no ongoing chest pain. He has chronic non-productive cough,
no fever. He has marked increase in his LE edema in past [**1-26**]
weeks, L>R per baseline. He had a stress test just 4 days ago
that showed defects and is aware that cath is planned for him in
the near future. He has no ongoing SOB currently. He notes easy
fatiguability but - n/v, abd pain. dizziness, LH. -PND,
-orthopnea. He uses 2 pillows at night.
Past Medical History:
CAD (CABG [**2109**] AND [**2120**])
CHF w/ EF 30%, diastolic dysfx
- recent admit with CCU transfer for tailored therapy [**3-30**]. The
patient had a Swan line placed and initially was maintained on
dopamine and vasopressin. His wedge was 33, PAP 63/29, cardiac
output 4.4, cardiac index 2.07. Numbers improved when placed on
Milrinone. He ultimately required CVVH due to severe volume
overload. He was stabilized and transferred back to a floor
where he was maintained on Lasix and metolazone with good urine
output and faily stable renal
function.
AF (dating back to [**2134**])
DM (HBA1c [**2138**] = 7.5)
CRI
GERD
PUD
gout
claudication
s/p CCY
s/p cataract [**Doctor First Name **] [**1-30**]
s/p back surgery
Social History:
Pt is a retired electrial engineer for Ratheon. Currently works
as [**Doctor Last Name **] at [**Hospital1 778**]. lives w/ wife, daughter and
granddaughter in [**Name (NI) 8242**]. Quit tobacco >15 years ago; 50 pk-yr
history.
Social EtOH (2 drinks/week), no illicits. Wife is HCP. Daughter
is cardiac nurse.
Family History:
Noncontributory.
Physical Exam:
Gen: pleasant, comfortable, mild SOB
VS: 98.0 67 94/31 17 100%
HEENT: EOMI, anicteric, mild sclerae injection, MMM
Neck: supple, JVP at 11-12, no LAD
lungs: left basilar rales otherwise CTA bilaterally
heart: irregular, HSM across precordium greatest at LSB
abd; soft NT ND -h/s megaly, midline hernia with scar
ext: 3+ edema bilaterally but L>R (pt states chronic)
neuro: CN intact, A&OX3
Pertinent Results:
[**2139-5-13**] 11:00PM CK(CPK)-81
[**2139-5-13**] 11:00PM CK-MB-NotDone cTropnT-0.44*
[**2139-5-13**] 04:19PM CK(CPK)-106
[**2139-5-13**] 04:19PM CK-MB-12* MB INDX-11.3* cTropnT-0.52*
[**2139-5-13**] 04:19PM PT-21.2* PTT-37.4* INR(PT)-2.1*
[**2139-5-13**] 02:00PM PT-42.4* PTT-44.4* INR(PT)-4.8*
[**2139-5-13**] 01:20PM CK(CPK)-117
[**2139-5-13**] 01:20PM CK-MB-15* MB INDX-12.8* cTropnT-0.48*
[**2139-5-13**] 01:20PM PT-40.1* PTT-39.8* INR(PT)-4.5*
[**2139-5-13**] 08:50AM GLUCOSE-137* UREA N-115* CREAT-2.7*
SODIUM-137 POTASSIUM-3.2* CHLORIDE-96 TOTAL CO2-26 ANION GAP-18
[**2139-5-13**] 08:50AM CK(CPK)-120
[**2139-5-13**] 08:50AM CK-MB-16* MB INDX-13.3* cTropnT-0.40*
[**2139-5-13**] 08:50AM PLT COUNT-104*
[**2139-5-13**] 08:50AM PT-45.6* PTT-40.8* INR(PT)-5.3*
[**2139-5-13**] 07:01AM URINE HOURS-RANDOM UREA N-521 CREAT-69
SODIUM-63 albumin-2.9 alb/CREA-42.0*
[**2139-5-13**] 07:01AM URINE OSMOLAL-373
[**2139-5-13**] 07:01AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2139-5-13**] 07:01AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2139-5-12**] 10:15PM GLUCOSE-274* UREA N-119* CREAT-3.0*
SODIUM-134 POTASSIUM-4.3 CHLORIDE-92* TOTAL CO2-28 ANION GAP-18
[**2139-5-12**] 10:15PM ALT(SGPT)-24 AST(SGOT)-22 LD(LDH)-208
CK(CPK)-93 ALK PHOS-144* TOT BILI-0.4
[**2139-5-12**] 10:15PM cTropnT-0.08*
[**2139-5-12**] 10:15PM CK-MB-NotDone proBNP-5593*
[**2139-5-12**] 10:15PM ALBUMIN-3.8
[**2139-5-12**] 10:15PM DIGOXIN-1.5
[**2139-5-12**] 10:15PM WBC-7.5 RBC-3.18* HGB-10.5* HCT-30.9* MCV-97
MCH-32.9* MCHC-33.9 RDW-15.8*
[**2139-5-12**] 10:15PM NEUTS-82.5* LYMPHS-10.5* MONOS-5.6 EOS-0.8
BASOS-0.5
[**2139-5-12**] 10:15PM MACROCYT-1+
[**2139-5-12**] 10:15PM PLT COUNT-114*
[**2139-5-12**] 10:15PM PT-49.7* PTT-41.4* INR(PT)-5.9*
[**2139-5-12**] 01:15PM UREA N-108* CREAT-2.8* SODIUM-137
POTASSIUM-3.8 CHLORIDE-93* TOTAL CO2-29 ANION GAP-19
[**2139-5-12**] 01:15PM MAGNESIUM-2.0
[**2139-5-12**] 01:15PM DIGOXIN-1.7
[**2139-5-12**] 01:15PM WBC-7.5 RBC-3.18* HGB-10.5* HCT-31.0* MCV-97
MCH-33.0* MCHC-33.9 RDW-16.0*
[**2139-5-12**] 01:15PM PLT COUNT-134*
[**2139-5-12**] 01:15PM PT-43.2* INR(PT)-4.9*
.
[**2139-5-12**] CXR:
1. Mild pulmonary edema.
2. Left lower lobe patchy atelectasis versus pneumonia.
.
[**2139-5-12**] EKG
Atrial fibrillation with a controlled ventricular response.
Since the previous
tracing of [**2138-4-6**] the rate has decreased. ST-T wave
abnormalities are more
marked. Clinical correlation is suggested
.
[**2139-5-14**]
BRIEF HISTORY: 73 year old male with ischemic cardiomyopathy
(EF 20%)
referred for cardiac catheterization for non-ST elevation MI. HI
last
catheterization was on [**2131-4-12**] that showed left dominant system
with
patent LMCA and ramus only, otherwise occluded LAD, LCX, and
RCA. The
LIMA-LAD, SVG-OM, and SVG-PDA were all patent.
INDICATIONS FOR CATHETERIZATION:
Coronary artery disease, Canadian Heart Class II, stable.
Prior CABG
[**2109**] & [**2120**].
PROCEDURE:
Right Heart Catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 7 French pulmonary wedge pressure
catheter,
advanced to the PCW position through an 8 French introducing
sheath.
Cardiac output was measured by the Fick method.
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 5 French angled pigtail catheter,
advanced
to the left ventricle through a 5 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 5
French JL4 and a 5 French JR4 catheter, with manual contrast
injections.
Graft Angiography: of 2 saphenous vein bypass grafts was
performed using
a 5 French right [**Last Name (un) 2699**] catheter, with manual contrast
injections.
Arterial Conduit Angiography: of a left internal mammary artery
graft
was performed using a preformed [**Female First Name (un) 899**] catheter, with manual
contrast
injections.
Percutaneous coronary revascularization was performed using
placement of
drug-eluting stent(s).
Percutaneous coronary revascularization of an additional vessel
was
performed using placement of drug-eluting stent(s).
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.02 m2
HEMOGLOBIN: 10.2 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 22/24/21
RIGHT VENTRICLE {s/ed} 67/22
PULMONARY ARTERY {s/d/m} 64/30/40
PULMONARY WEDGE {a/v/m} 33/36/30
AORTA {s/d/m} 119/50/64
**CARDIAC OUTPUT
HEART RATE {beats/min} 53
RHYTHM SINUS
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 55
CARD. OP/IND FICK {l/mn/m2} 4.6/2.3
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 748
PULMONARY VASC. RESISTANCE 174
**% SATURATION DATA (NL)
PA MAIN 58
AO 98
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DISCRETE 70
2) MID RCA DISCRETE 70
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD DISCRETE 100
11) INTERMEDIUS DISCRETE 90
12) PROXIMAL CX DISCRETE 100
**ARTERIOGRAPHY RESULTS TO SEGMENTS MORPHOLOGY % STENOSIS
LOCATION
**BYPASS GRAFT
28) SVBG #1 17 NORMAL
29) SVBG #2 14 DISCRETE 100
32) LIMA 7 NORMAL
COMMENTS:
1. Selective coronary angiogrraphy of this left dominant system
revealed
severe native three vessel coronary artery disease. The LMCA was
patent.
The LAD, LCX, and RCA all had proximal occlusion. The ramus
intermedius
was the only remaining native vessel supplying the left
ventricle with
proximal 80% stenosis.
2. Selective vein graft angiography demonstrated patent SVG-PDA
with 80%
stenosis in jump segment to the posterolateral branch. SVG to OM
was not
visualized and presumed to be occluded.
3. Selective arterial conduit angiography revealed patent
LIMA-LAD with
90% distal anastomosis stenosis.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent LIMA-LAD.
3. Patent SVG-PDA.
.
[**2139-5-14**] CXR
INDICATION: Swan-Ganz catheter placement.
A Swan-Ganz catheter is present, with the tip making an abrupt
rightward turn in the expected location of the junction of the
main pulmonary artery and its bifurcation into the left and
right pulmonary arteries. The acuity of the angle of the turn is
greater than expected and the catheter could potentially be
slightly coiled on itself at the tip. There is no pneumothorax.
Cardiac and mediastinal contours are stable allowing for
positional differences. There has been interval worsening of a
pattern of perihilar haziness and interstitial opacities
suggesting worsening pulmonary edema. A small left pleural
effusion is noted. Right costophrenic angle has been excluded
from the study and cannot be assessed.
.
[**2139-5-16**] CXR
INDICATION: 72-year-old man with CHF.
COMMENTS: Portable erect AP radiograph of the chest is reviewed,
and compared with the previous study of [**2139-5-14**].
The patient has prior CABG and median sternotomy. The Swan-Ganz
catheter has been removed. No pneumothorax is identified.
The previously identified congestive heart failure has been
improving. There is small bilateral pleural effusion and
bibasilar patchy atelectasis.
.
[**2139-5-17**] CXR
COMMENTS: Portable erect AP radiograph of the chest is reviewed,
and compared with the previous study of yesterday.
The previously identified mild congestive heart failure has been
resolving. The heart is normal in size. The patient has prior
CABG and median sternotomy. No pneumothorax is identified.
.
Brief Hospital Course:
73M s/p CABG x 2, CHF EF 20%, AFIB, DM2, abnormal MIBI, p/w
worsening SOB/DOE, noted to have NSTEMI via markers. He was
admitted to the medical service on [**2139-5-13**] for decompensated
heart failure, NSTEMI and abnormal MIBI. He had INR reversed in
preparation for c. cath and renal consulted for possible CVVH.
At cardiac cath a cypher stent was deployed to the Ramus
(3.0x13) and to the LIMA anastomosis (2.5x13). Patient was then
transferred to the CCU for further monitoring and diuretic
therapy. HD notable for elevated wedge to 29. He was diuresed
with lasix 60mm iv, fluid restricted. Beta blocker held d/t HR,
ACE I held d/t renal insufficiency. HCT 25 and recieved 2 units
PRBC's without complications, lasix IV in between units.
Patient was tranferred back to floor where he was stable and
asymptomatic, breathing comfortably. He had no chest pain or
recurrence of SOB, and he was continued on ASA, avorvastatin,
plavix, BB until discharge. No ACE I was prescribed given CRI,
and the decision to start this medication will be decided by Dr.
[**First Name (STitle) 437**] as an outpatient. He resumed lasix, standing, at 80 mg PO
BID and required no prn doses. An ECHO is planned as an
outpatient to see if EF has improved now that he is s/p
intervention.
.
Patient is chronically in Afib and coumadin was held
(supratherapeutic) for cardiac cath. He was restarted on
coumadin after cath, and no heparin bridge was used. Digoxin
was held d/t elevated level of 1.6, and he is due to restart
this medication on the day after discharge, per Dr. [**First Name (STitle) 437**], every
other day.
.
Diabetes was well controlled with FSQID, diabetic diet, RISS.
Held glyburide d/t renal failure, but this was restarted on
discharge as patient was back to baseline.
.
Developed acute on chronic renal failure (2.8 from baseline
~1.8), likely secondary to decompensated heart failure and poor
forward flow. Renal function improved with diuresis. Renal
team followed patient and decided CVVH was not necessary during
this admission. Cr returned to baseline of 2.0 by discharge.
EPO continued.
.
Medications on Admission:
1. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
3. Ferrous Sulfate 325 (65) mg Tab QD
4. Epoetin Alfa 4,000 unit/mL QMOWEFR (Monday
-Wednesday-Friday).
5. Aspirin 81 mg Tablet QD
6. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY
8. Nexium 40 mg Capsule, QD
9. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO BID *
10 Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
11 Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Epoetin Alfa 4,000 unit/mL Solution Sig: 4000 (4000) units/mL
Injection QMOWEFR (Monday -Wednesday-Friday).
3. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*8*
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO once a day.
9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO QOD: Every
other day.
12. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO twice a
day.
13. Coreg 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Congestive Heart Failure
Non ST elevation myocardial infarction
Atrial fibrillation
Acute on Chronic renal insufficiency
Discharge Condition:
Good. Patient ambulating without shortness of breath. No chest
pain. Feels well.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1 liter
Please note the following changes in your medications:
1) Plavix 75 mg PO QD to prevent clots after stent placement
2) Coreg 6.25 mg PO BID to help with blood pressure and cardiac
function
3) Increase ASA to 162 mg PO QD from 81 mg PO QD
4) Digoxin has been changed from 125mcg every day to 125mcg
every other day
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2139-5-25**]
10:00
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] [**Location (un) 2788**] CARDIOLOGY-PRIVATE
Date/Time:[**2139-5-26**] 8:30
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] [**Location (un) 2788**] CARDIOLOGY-PRIVATE
Date/Time:[**2139-8-4**] 11:00
ICD9 Codes: 5849, 4280, 2749, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8746
} | Medical Text: Admission Date: [**2114-3-17**] Discharge Date: [**2114-3-20**]
Date of Birth: [**2059-5-3**] Sex: F
Service: MEDICINE
Allergies:
Amiodarone / Quinidine
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
palpitations
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
54 y/o with hx. MI age 35, EF 20-30%, [**First Name3 (LF) **] ICD, PAF, VT, s/p
trials of amiodorone, dofetilide, quinidine, recently admitted
([**Date range (1) 42566**]) for MVR d/t 4+ MR presents with palpitations found
to be in AFib with HR in the 120s and SBP 70's-80's (when
discharged yesterday was in NSR), admitted to the CCU for
further management.
Past Medical History:
1. Mitral valvuloplasty for MR ([**Last Name (un) 3843**]-[**Doctor Last Name **] Physio
ring)[**2-21**]
2. MI vs viral myocarditis at age 35
3. EF less than 20% s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (un) 19961**] ICD [**2108**]
4. Spleenectomy [**2106**] d/t ITP
5. Paroxysmal atrial fibrillation, intolerant of amiodarone,
dofetilide and quinine therapy
6. Hypertension
7. Hyperlipidemia
8. noninsulin dependent DM
9. Chronic Kidney Disease
Social History:
She is single and lives alone. She works as office manager for
construction company. Does not smoke, social drinker.
Family History:
Father died of MI in his 70s and mother died of CRI in her 70s.
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Blood pressure was 99/58 mm Hg while supine. Pulse was 126
beats/min and irregular, respiratory rate was 14 breaths/min.
Generally the patient was 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 7 cm. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a normal
S1 and the S2 was normal. There were no rubs, murmurs, clicks or
gallops.
.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities had no pallor, cyanosis,
clubbing or edema. There were no abdominal, femoral or carotid
bruits. Inspection and/or palpation of skin and subcutaneous
tissue showed no stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2114-3-16**] 07:50AM PT-20.9* PTT-27.2 INR(PT)-2.0*
[**2114-3-16**] 07:50AM PLT COUNT-913*
[**2114-3-16**] 07:50AM WBC-22.1* RBC-3.28* HGB-8.7* HCT-28.7* MCV-88
MCH-26.6* MCHC-30.4* RDW-16.0*
[**2114-3-16**] 07:50AM GLUCOSE-92 UREA N-18 CREAT-1.0 SODIUM-136
POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-27 ANION GAP-16
[**2114-3-17**] 03:35PM PT-21.4* PTT-26.0 INR(PT)-2.1*
[**2114-3-17**] 03:35PM PLT COUNT-1089*
[**2114-3-17**] 03:35PM cTropnT-0.16*
[**2114-3-17**] 03:35PM CK-MB-NotDone proBNP-[**Numeric Identifier 42567**]*
.
IMAGING/
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2114-3-17**] for further
management of her atrial fibrillation. Esmolol was used with
good rate control and eventual conversion back into normal sinus
rhythm. Amiodarone was also started to maintain her in a normal
sinus rhythm. Coumadin was continued for anticoagulation. The
electrophysiology service followed Ms. [**Known lastname **] given her
pacemaker in situ and new atrial fibrillation. She remained in
normal sinus rhythm and was discharged home on [**2114-3-20**]. She will
follow-up with Dr. [**Last Name (STitle) **] of the electrophysiology service,
Dr. [**Last Name (STitle) **], her cardiologist and her primary care physician as
an outpatient.
Medications on Admission:
ASA 81
Pravastatin 20
Percocet prn
Calcium Carbonate 500 qid
Captopril 6.25 [**Hospital1 **]
Metoprolol tartrate 50 [**Hospital1 **]
Lasix 40 [**Hospital1 **]
Warfarin 1 mg TTSS, 2 mg MWF
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for
osteoporosis.
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Insulin
Please resume your pre-hospitalization insulin regimen.
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO MWF
(Monday-Wednesday-Friday).
9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
10. Outpatient [**Name (NI) **] Work
PT/PTT/INR on Wednesday [**2114-3-21**] and Friday [**2114-3-23**]. Please fax
results to Dr.[**Name (NI) 21128**] office - Fax: [**Telephone/Fax (1) 18684**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary:
1. atrial fibrillation with rapid ventricular response
2. s/p MV annuloplasty
.
Secondary:
1. Mitral valvuloplasty for MR ([**Last Name (un) 3843**]-[**Doctor Last Name **] Physio
ring)[**2-21**]
2. MI vs viral myocarditis at age 35
3. EF less than 20% s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (un) 19961**] ICD [**2108**]
4. Spleenectomy [**2106**] d/t ITP
5. Occasional palpitations with documented non-sustained VT
6. Hypertension
7. Hyperlipidemia
8. noninsulin dependent DM
9. Chronic Kidney Disease
Discharge Condition:
Stable. Afebrile. Tolerating PO. Ambulates without assistance.
Discharge Instructions:
You were admitted to the hospital for atrial fibrillation with a
rapid heart rate. You should return to the ER or call your
doctor if you experience any of the following symptoms: fever >
101.4, palpitations, chest pain, shortness of breath,
weakness/dizziness, nausea, vomiting or any other concerning
symptoms.
.
Please take all medications as prescribed.
.
Please follow up with all appointments as scheduled. VNA will be
visiting your home on Wednesday and Friday to check your blood
work. Your coumadin dosing should be adjusted accordingly by Dr.
[**Last Name (STitle) **].
Followup Instructions:
1. PT/PTT/INR check on Wednesday and Friday (will be done by VNA
services). Results to be sent to Dr. [**Last Name (STitle) **] (Phone:
[**Telephone/Fax (1) 3183**]).
2. An appointment has been made for you with Dr. [**Last Name (STitle) **] (Phone:
[**Telephone/Fax (1) 3183**]) on Thursday, [**3-29**] at 3:15P.
3. Return to [**Hospital Ward Name 121**] 2 on Tuesday, [**3-27**] for your post-op
check and staple removal with Cardiothoracic surgery.
4. Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-21**] weeks.
.
You have the following appointments scheduled:
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2114-4-13**] 2:20
Completed by:[**2114-3-22**]
ICD9 Codes: 4240, 5859, 4271, 412, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8747
} | Medical Text: Admission Date: [**2103-8-16**] Discharge Date: [**2103-10-11**]
Date of Birth: [**2103-8-16**] Sex: M
Service: NEONATOLOG
This interim summary covers the dates of [**2103-8-16**],
through [**2103-9-6**]. No prior summaries.
HISTORY OF PRESENT ILLNESS: The patient is a now 21 day old
ex-30 2/7 weeks infant who was born at 1.240 kg by C-section
on [**2103-8-16**] at 00:04 a.m. Mom is a 20 year old G2 P 1 to 2
mother with prenatal labs of A positive, antibody negative,
hepatitis B surface antigen negative, rubella immune, RPR
nonreactive. However, these labs were not available at the
time of delivery. Pregnancy was complicated by severe PIH
with renal involvement. Mom was treated with mag sulfate,
hydralazine and betamethasone. Mom has a history of
Chlamydia infection in her past pregnancy which was
appropriately treated (by report).
Delivery was by C-section because of worsening PIH. The baby
came out with good respiratory effort, requiring minimal
resuscitation and received Apgars of 8 and 8. Subsequent to
resuscitation the patient developed retractions and
persistent grunting.
PHYSICAL EXAMINATION: Temperature 94.9, respiratory rate 64,
heart rate 128, blood pressure 68/31 with a MAP of 45, weight
1.240 kg (30th to 40th percentile), length 40 cm (50th
percentile), head circumference 27.5 cm (30th to 40th
percentile). In general, alert, AGA, active, preterm, male
infant. HEENT anterior fontanelle soft and flat, large with
sutures mobile. Respiratory initially with retractions and
grunting, improved post intubation with surfactant. Equal
breath sounds with only a few rales. Cardiovascular normal
S1, S2 without murmur. Good perfusion. Abdomen soft,
nondistended, nontender, normoactive bowel sounds. GU normal
male. Testes palpable bilaterally and descended. Neuro
moving all extremities symmetrically. Tone appropriate.
Extremities hips stable. Skin tiny brown nevus on right
knee.
HOSPITAL COURSE:
1. Respiratory. The patient was intubated shortly after
resuscitation and received a dose of surfactant at 30 minutes
of life. He was treated with two doses of surfactant total
and was able to be extubated to CPAP on day of life 1. He
remained on CPAP through his fifth day of life after which he
transitioned to room air. With his prematurity, patient was
loaded with caffeine prior to extubation. This was
discontinued on day of life 10 with absence of any apnea or
bradycardia spells. However, on day of life 17 caffeine was
restarted with multiple ABCs. Patient currently remains on
maintenance caffeine dosing and has had only one to two
spells a day.
2. Cardiovascular. The patient originally had a murmur that
was suspicious for PDA. However, this resolved within the
first 24 hours of life and was not accompanied by other
clinical signs of PDA. Since that time there have been
comments intermittently about a persistent, soft, systolic
murmur suspicious of PPS. At time of interim this murmur was
no longer noted.
3. FEN. The patient originally remained NPO on PN with
suspicion of PDA. He was able to start feeds on day of life
1 with tolerance. He slowly advanced to full feeds and
currently receives PE or breast milk 30 with ProMod at 150 cc
per kg per day. These feeds are given over 45 minutes for
best tolerance. Patient is showing significant weight gain
of over 24 gm per kg per day during the last week. With this
weight gain the decision has been made to decrease him back
down to 28 kcal and follow. Patient is due for nutrition
labs which will be obtained on [**2103-9-11**].
4. GI. The patient had mild hyperbilirubinemia for which he
received phototherapy. Bilirubin peaked on day of life 2 at
9.7. Phototherapy was discontinued on day of life 5 at a
level of 4.8. Rebound bili was slightly elevated and
followed from days of life 6 through 9 with most recent bili
trending down at a level of 5.2. No other issues from a GI
standpoint.
5. ID. The patient had a 48 hour rule out sepsis with
ampicillin and gentamicin. Cultures remained negative. In
addition, at time of delivery Mom's hepatitis B status was
unknown. Patient received hepatitis B as well as HBIG at
that time. Subsequently mother's labs came back with a
negative hepatitis B status.
6. Neuro. The patient had a normal cranial ultrasound
performed on day of life 7 ([**2103-8-23**]).
Current feeds breast milk or PE 28 with ProMod at 150 cc per
kg per day over 45 minutes. Current meds caffeine, vitamin
E, ferrous sulfate. State newborn screening times two sent.
Immunizations none to date.
INTERIM DIAGNOSES:
1. Appropriate for gestational age premature infant at 30
2/7 weeks gestation.
2. Apnea of prematurity, on caffeine.
3. Hyperbilirubinemia, resolved.
4. Respiratory distress syndrome, status post surfactant
times two.
5. Rule out sepsis, resolved.
[**Name6 (MD) **] [**Name8 (MD) 38353**], M.D. [**MD Number(1) 38354**]
Dictated By:[**Last Name (NamePattern1) 51561**]
MEDQUIST36
D: [**2103-9-6**] 14:43
T: [**2103-9-6**] 14:56
JOB#: [**Job Number 51562**]
ICD9 Codes: 769, 7742, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8748
} | Medical Text: Admission Date: [**2164-2-20**] Discharge Date: [**2164-2-26**]
Date of Birth: [**2082-4-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 5552**]
Chief Complaint:
Shortness of breath, abdominal distension
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
Patient is an 81 y/o M with metastatic NSCLC on Alimta, HTN,
CAD, COPD on home O2 and afib who presents with abdominal pain
and SOB. Per the patient's wife, over the last week he has
developed progressive abdominal distention and discomfort. The
pain is diffuse across his abdomen. He denies nausea or
vomiting. He has also had progressive SOB over the same period
of time. He has been using his nebulizer up to every 2 hours
with minimal relief. His wife reports that his appetite was
intially ok, however over the last few days his PO intake has
decreased and he did not eat anything for dinner last night. He
denies fever, chills, or cough. He also denies dysuria. He has
had constipation fo rwhich he took Milk of Magnesia tablets last
evening and today with his last BM this morning.
.
Of note the patient was recently admitted to [**Hospital1 18**] from
[**Date range (1) 14195**] for dyspnea. He was admitted to the MICU for tachypnea
to 50s and oxygen requirement. In the ICU, he required bipap
which was gradually weaned off to his home 2.5L NC with sats in
the 89-91 range. Patient
symptomatically felt better. A chest X-ray showed RUL infiltrate
consistent with pneumonia. He continued solumedrol and Abx were
tapered to levaquin alone. He developed new onset a fib and was
started on diltiazem for rate control. He was discharged home on
prednisone taper and completed 7 day course of levofloxacin.
.
In the emergency department initial VS were BP 114/54 HR 108 RR
36 O2 sat 99% 4L. CT abdomen was performed and showed new
ascites and worsening of his liver and omental mets. Surgery
evaluated him for ? SBO. They did not see signs of obstruction,
felt that he had likely ileus from progressive metastatic
disease and is not a surgical candidate. NGT was placed for
comfort. Labs were notable for K 6.0 without EKG changes. He was
given D50 and insulin. He also received solumedrol 125mg IV,
vanco 1gm, zosyn 4.5gm, combivent nebs x2 and 2L NS.
.
Currently the patient states his breathing feels much better. He
continues to have some abdominal discomfort with exam. He denies
chest pain, fever, cough, nausea or vomiting. He reports that
the NGT is uncomfortable when he swallows.
Past Medical History:
1) CAD s/p MI in [**2140**] by EKG diagnosis, no admission, no
symptoms, ETT/MIBI [**2159**] showing partially reversible defect in
RCA distribution. No interventions performed.
2) HTN
3) Hyperlipidemia
4) COPD
5) DJD
6) Thoracic artery aneursym, stable
7) Nonsmall cell lung cancer (see below)
ONCOLOGIC HISTORY:
Mr. [**Known lastname 14194**] was in his USOH until [**2163-7-25**] when he
presented with hemoptysis and weight loss of 10 pounds over
previous 1-2 months. He had a CT scan of the chest on [**8-21**] and
it showed a 4.1 x 4.0 right hilar mass with subcarinal
lymphadenopathy, 19 mm right axillary lymph node as well as
multiple right lower lobe and left lower lobe nodules concerning
for lung cancer. On [**2163-8-28**], he was admitted to [**Hospital1 771**] with chest pain and ruled out for a
non-ST elevation MI. He was seen by the hematology-oncology
consult service while in the hospital and underwent FNA of the
right axillary lymph node, the pathology of which showed
nonsmall cell cancer, squamous cell type. He was discharged on
the third of [**Month (only) 359**] and then on [**2163-8-30**], he had a
bronchoscopy done for evaluation of his hemoptysis as well as
bronchial biopsy and the cytology confirmed metastatic nonsmall
cell lung cancer. He has subsequently completed 2 cycles of
Navelbine.
Social History:
He lives in [**Location 3146**]. He is married and has a daughter and a son.
[**Name (NI) **] has two grandchildren. He is here today with his wife & son.
[**Name (NI) **] smoked for at least 50 years, stopped smoking 3-4 years ago.
He drinks occasional alcohol. He used to work as a carpenter, it
is unclear if he has had asbestos exposure.
Family History:
Father died at age 43 of unknown causes.
Mother died of breast cancer complications at age 53.
Sister had breast cancer and lung cancer and died at age 80
Physical Exam:
VS: T 97.2, BP 122/70, HR 97, RR 24, O2sat 93% on 4LNC, Wt 140
lbs,
Height 62"
GEN: Wearing NC, breathing with pursed lips on expiration.
HEENT: NC/AT.
NECK: Thin, suppple, no lymphadenopathy
PULM: Diffusely decreased breath sounds and air movement. No
crackles or wheezes.
CARD: RR, nl S1, Sl S2, II/VI systolic murmur RUSB
ABD: BS+, soft, NT, ND
EXT: Clubbing of fingernails on hands bilaterally, no LE edema
SKIN: No rashes
NEURO: Oriented x 3, non-focal exam
PSYCH: Patient upbeat with joking manner
Pertinent Results:
[**2164-2-19**] CT abdomen
Worsened metastatic disease with innumerable hepatic metastases,
enlarging and new implants adjacent to the stomach and spleen in
the omentum
and new ascites and omental deposits.
[**2164-2-20**] CTA chest
1. Progression of abdominal metastatic disease, partly
visualized and better
characterized on a CT from the prior day.
2. Right hilar mass with a similar degree of narrowing of
segmental pulmonary
arteries, but exerting greater mass effect on descending airways
serving the
right lower lobe, some of which are now occluded.
3. Patchy new peribronchovascular consolidation in the right
lower lobe, most
suspicious for post-obstructive pneumonia.
4. Interlobular septal thickening in each lower lobe, more
prominent on the
right than left. The appearance may reflect fluid overload or
lymphatic
congestion, but the possibility of lymphangitic carcinomatosis
on the
right should also be considered.
5. NG tube terminating in the stomach, but with the sidehole
near the GE
junction. If clinically indicated, it could be advanced to gain
better
purchase in the stomach.
[**2164-2-20**]
Successful paracentesis yielding two liters of clear amber
fluid.
Samples were sent to microbiology and cytology.
Brief Hospital Course:
81y/o M with metastatic non-small cell lung cancer on
chemotherapy with Alimta last given on [**1-31**] who presents with
abdominal pain and SOB.
.
#. Shortness of breath: This was likely multifactorial, with
contributions from COPD, extensive lung cancer disease burden,
possible post-obstructive pneumonia, and increased abdominal
girth. CTA chest negative for PE but showed tumor invasion of
bronchi and pulmonary artery. NG tube for decompression was
placed, vancomycin and zosyn were started, and he was given
standing nebulizer treatments and supplemental O2. He underwent
two 2-L paracenteses with some improvement in shortness of
breath. Several days into his hospital course he developed
episodes of chest pain and increased shortness of breath without
EKG changes, responsive to nitroglycerin and morphine. These
were thought to represent unstable angina with a possible
contribution from aspiration events. Goals of care were
discussed with the palliative care team and eventually revised
to include comfort measures only. Antibiotics were stopped.
Morphine was given to help with shortness of breath and
nitroglycerin as needed for comfort.
.
#. Abdominal distention: Found to have new ascites in setting of
worsening metastatic disease to liver and omentum. Also found to
have ileus in setting of this and combination of these is likely
contributing to his worsening discomfort. Surgery evaluated pt.
in ED and were not concerned for SBO. NGT was placed for
comfort. He was found to have c diff, which was treated with PO
vanc and zosyn. He underwent two 2-L paracenteses under
ultrasound guidance. Antibiotics were stopped when goals of
care were revised to CMO.
.
#. Leukocytosis: WBC on admission 88K rose to >100k during this
admission, increased from 68K on [**2-10**]. This had been discussed
with heme/onc in the past and previously attributed to his
cancer. The acute rise may have been related to infections (c
diff, possible pneumonia). After goals of care were revised,
labs were no longer checked.
.
#. Non-small cell lung cancer: Widely metastatic with worsening
disease despite Alimta. Followed by Dr. [**Last Name (STitle) **]. Palliative
care assisted in discussions with the family and the goals of
care were revised to comfort when it became clear that no
further reasonable therapeutic options were available. He
expired several days later.
.
Medications on Admission:
1. Albuterol MDI prn
2. Citalopram 20 daily
3. Fluticasone-Salmeterol 250-50 [**Hospital1 **]
4. Folic Acid 1 mg daily
5. Combivent MDI, every four (4) hours as needed for shortness
of
breath or wheezing.
6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
7. Nitroglycerin SL as needed as needed for chest pain.
8. Prochlorperazine 10 mg every eight hours as needed for
nausea.
9. Ambien 5 mg prn insomnia.
10. Calcium Carbonate 500 mg [**Hospital1 **]
11. Multivitamin Daily
12. Omeprazole 20 mg [**Hospital1 **]
13. Diltia XT 120 mg daily
14. Aspirin 325 mg daily
15. Prednisone taper completed on [**2-17**]
16. Insulin Aspart SS qid
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
Completed by:[**2164-2-26**]
ICD9 Codes: 486, 4111, 2762, 412, 2767, 496, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8749
} | Medical Text: Admission Date: [**2110-10-19**] Discharge Date: [**2110-10-26**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 80 yo lady w/ h/o NHL dx'd [**2103**] tx w/ CHOP and rituximab,
remote breast ca, and recent RUL resection ([**8-5**]) for spiculated
lung mass (path c/w NHL recurrence), presents to ED w/ acute
worsening sob over last 24 hrs and subacute worsening over last
week. This is in the setting of stopping her daily lasix because
"I feel sick when I am on it." There was some confusion on her
part about whether to take her potassium, lasix, or both, as she
was seen in ED last week for hypokalemia and has not been sure
what to take since that visit. At that time, she was given K
repletion and sent home. She has been taking lasix
intermittently since last week, last dose today. Patient denies
fevers/chills/malaise/abd complaints. She sleeps in seated
position secondary to "inner [**Last Name **] problem," but denies orthopnea.
She denies pedal edema or weight gain. Appetite has been good,
per her report. She was discharged with home oxygen in [**Month (only) 205**], but
has not been using it until this past week. Cannot quantify how
far she can walk w/o fatigue. Denies palpitations, chest
discomfort. Of note, patient notes hoarse voice since her
extubation from her RUL resection.
.
On presentation, T 95.9, BP 160/100; HR 100; sat 83% RA. NRB
placed with sats to 100%. Foley inserted, Lasix 20 mg IV given
w/ 2 L UOP and improvement of sats to 100% 3L NC. Also given
ceftriaxone 1 g IV and levoflox 500 mg IV x 1 for concern of
pna. Pulmonary consult obtained and patient admitted to the
[**Hospital Unit Name 153**].
.
Past Medical History:
Non- hodkins lymphoma s/p chemotherapy, Left breast cancer s/p
mastectomy, now with Right upper lobe lung mass.
PMH:
-admit [**Date range (1) 101596**] to CT surgery service for RUL resection
([**8-12**]) for enlarging, spiculated mass. Post-op course c/b afib
w/ RVR with amiodarone load, anticoagulation initiation; course
also c/b mild ileus and E. coli UTI. Also had bilateral
effusions post op, both tapped on [**8-28**] (1300 cc off right, 900
cc off left, both with negative cytology, ?transdutes but no
serum protein/LDH sent; pleural fluid LDH 140, 207; TP 3.3/3.7;
glucose 143, diff wbc 500 rbc 4700 7% bands, 21%lymphs, 14%
mesothelial; 55% macrophages). Lung biopsy consistent w/ CD10
positive B-cell lymphoproliferative disorder
- h/o NHL s/p CHOP and rituximab [**2103**]-[**2106**], followed by Dr [**Last Name (STitle) 2036**]
- remote Left breast Ca [**2079**] s/p mastectomy and no chemo
- GERD
- HTN
- anxiety
- benign thyroid nodule
- h/o BPV
- admit [**8-4**] w/ LE cellulitis
- echo [**8-5**]: (LVEF> 55%); ascending aorta is mildly dilated.
Trace aortic regurgitation; Mild to moderate ([**2-2**]+) mitral
regurgitation Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension.
Social History:
social: lifetime nonsmoker; occasional drinker but not daily;
lives w/ 85 year old brother, who is also ill. They have VNA
2x/week and homemakers daily. Was supposed to get home PT but
patient keeps "getting ill" when she is to have therapy. Has
nephew, [**Name (NI) **], who lives in [**Name (NI) 620**]: [**Telephone/Fax (1) 101597**]. Has her
medications delivered by local Stop and Shop.
Family History:
fam hx: various family members with cancer-- she is not sure of
all of their diagnoses, but thinks her aunt had gastric cancer,
one brother had prostate and bladder cancer, another brother had
throat cancer; father died of sudden MI at age 56; brother died
suddenly at age 67 of ?MI.
Physical Exam:
PE: T 97.4 BP 131/59 P 91 R 20 93-95% 2L NC
GEN: comfortable, hoarse, elderly lady, with make up on, not
able to speak in full sentences
HEENT: hoarse, MM dry, NC in place, OP clear
NECK: JVP at clavicle, supple, No lad
CV: RRR, ?slight tachy; no m/r/g but quiet heart sounds- mostly
audible on right side of chest
CHEST/back: Left mastectomy; well healed scar over RUL
posteriorly, decreased breath sounds w/ dullness to percussion
over left base [**3-6**] way up and right base [**2-2**] way up. No crackles
or egophany. Upper fields clear. No wheeze. No rales
ABD: distented, soft, tympanitic to percussion, minimal HSM
EXTRM: chronic venous stasis changes bilaterally with cracked,
scaling, erythematous skin on dorsal aspect of BLE up to
mid-shin, 1+ DP pulses bilaterally. Strong radial pulses
bilaterally, regular. Skin is warm with slight cooling in lower
extremities; minimal peripheral edema
NODES: 2x2 cm, mobile node in left axilla; no LAD in clavicular,
para-aortic, or inguinal nodes.
NEURO: vague historian but clear, alert and oriented to place/
self/ time; follows all commands well, moves all extrm well; no
visible cranial nerve defects
Pertinent Results:
IMAGING:
[**2110-10-19**]
BILATERAL DECUBITUS VIEWS OF THE CHEST: The pleural effusions
appear to be layering, with the right larger than left.
Underlying infiltrates, particularly in the right are also
possible. Followup is recommended.
.
[**2110-10-20**]
CHEST X-RAY AP PORTABLE VIEW.
COMPARISON: Decubitus film of [**2110-10-19**].
FINDINGS: There is a moderate-to-severe right-sided pleural
effusion and a small left pleural effusion. The heart size is
normal. There is no other interval change.
IMPRESSION: A moderate-to-large right pleural effusion and small
left pleural effusion
.
[**2110-10-21**]
Comparison is made to the prior examination of [**2110-10-20**].
FINDINGS: Heart is partially obscured, but unchanged and likely
of normal size. There are bilateral pleural effusions, large on
the right and moderate on the left, unchanged. No pneumothorax
identified. Bibasilar atelectasis persists.
IMPRESSION: No change from previous exam
.
[**2110-10-22**]
IMPRESSION: PA and lateral chest compared to [**10-21**]:
Bilateral pleural effusions, moderate to large on the right and
moderate on the left, has increased in volume. There is new
atelectasis or conceivably consolidation in the lateral aspect
of the right mid lung, which should be reassessed following
decrease in pleural fluid. Mediastinum remains shifted slightly
to the right. Heart size is obscured by pleural effusion, but
has not changed in the interim. There is no pneumothorax.
.
[**2110-10-24**]
History of right upper lobectomy and shortness of breath.
There is loss of volume on the right with elevation of the right
hemidiaphragm and shift of heart and mediastinum to the right.
There are bilateral pleural effusions. The ill-defined right mid
zone opacity noted on the prior film of [**2110-10-22**], has
partially resolved. There is persistent ill-defined opacity at
the right lung base. In addition, there is ill-defined opacity
in the left lower zone that is either new or was partly hidden
by the left pleural effusion on the prior film. No definite
pneumothorax.
IMPRESSION: Bilateral pleural effusions and bibasilar pulmonary
opacities consistent with atelectases/consolidation. No
pneumothorax. Partial resolution of the right mid zone opacity.
.
[**2110-10-25**]
LEFT LATERAL DECUBITUS CHEST: A small pleural effusion is seen,
loculated, on the right. Right lateral decubitus films show no
evidence of nondependent air, i.e., no findings to suggest
pneumothorax. Otherwise, findings are not significantly changed
since the examination of 12:15 of the same day.
.
EKG: sinus vs sinus arrythmia, tachy, rate 104; nl axis; no LVH,
nl qwaves or ischemic changes
.
LABS:
[**2110-10-19**] 09:05AM BLOOD WBC-14.9* RBC-3.37* Hgb-10.2* Hct-32.2*
MCV-96 MCH-30.3 MCHC-31.7 RDW-15.5 Plt Ct-343
[**2110-10-19**] 09:05AM BLOOD Neuts-88.5* Lymphs-8.7* Monos-2.1 Eos-0.6
Baso-0.1
[**2110-10-19**] 09:05AM BLOOD PT-15.0* PTT-30.3 INR(PT)-1.5
[**2110-10-19**] 09:05AM BLOOD Glucose-107* UreaN-9 Creat-0.7 Na-145
K-3.7 Cl-104 HCO3-28 AnGap-17
[**2110-10-19**] 09:05AM BLOOD CK(CPK)-56
[**2110-10-19**] 09:05AM BLOOD Calcium-9.5 Phos-3.3 Mg-1.4*
.
[**2110-10-20**] 07:18AM BLOOD WBC-14.0* RBC-3.27* Hgb-10.0* Hct-30.4*
MCV-93 MCH-30.5 MCHC-32.9 RDW-15.4 Plt Ct-335
[**2110-10-20**] 07:18AM BLOOD PT-16.8* PTT-35.6* INR(PT)-2.0
[**2110-10-20**] 07:18AM BLOOD Glucose-106* UreaN-7 Creat-0.7 Na-145
K-3.3 Cl-102 HCO3-34* AnGap-12
.
[**2110-10-21**] 06:33AM BLOOD WBC-15.7* RBC-3.67* Hgb-11.2* Hct-34.7*
MCV-95 MCH-30.6 MCHC-32.3 RDW-15.4 Plt Ct-356
[**2110-10-21**] 06:33AM BLOOD Neuts-82.8* Lymphs-11.8* Monos-3.5
Eos-1.6 Baso-0.2
[**2110-10-21**] 06:33AM BLOOD PT-17.7* PTT-47.8* INR(PT)-2.2
[**2110-10-21**] 06:33AM BLOOD Glucose-113* UreaN-7 Creat-0.6 Na-145
K-3.5 Cl-102 HCO3-34* AnGap-13
[**2110-10-21**] 06:33AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.8
.
[**2110-10-22**] 07:20AM BLOOD WBC-13.6* RBC-3.53* Hgb-10.6* Hct-32.4*
MCV-92 MCH-29.9 MCHC-32.6 RDW-14.9 Plt Ct-336
[**2110-10-22**] 07:20AM BLOOD PT-19.7* PTT-37.1* INR(PT)-2.7
[**2110-10-22**] 07:20AM BLOOD Glucose-97 UreaN-7 Creat-0.7 Na-145
K-3.0* Cl-100 HCO3-37* AnGap-11
.
[**2110-10-23**] 07:30AM BLOOD WBC-13.9* RBC-3.37* Hgb-10.2* Hct-31.8*
MCV-95 MCH-30.3 MCHC-32.1 RDW-15.1 Plt Ct-325
[**2110-10-23**] 07:30AM BLOOD PT-22.0* PTT-39.5* INR(PT)-3.5
[**2110-10-23**] 07:30AM BLOOD Glucose-94 UreaN-7 Creat-0.7 Na-143 K-3.3
Cl-103 HCO3-30 AnGap-13
[**2110-10-23**] 07:30AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.2
.
[**2110-10-24**] 06:35AM BLOOD WBC-17.0* RBC-3.38* Hgb-10.1* Hct-31.6*
MCV-93 MCH-29.7 MCHC-31.8 RDW-14.6 Plt Ct-330
[**2110-10-24**] 06:35AM BLOOD PT-12.4 PTT-29.2 INR(PT)-1.0
[**2110-10-24**] 06:35AM BLOOD Glucose-101 UreaN-9 Creat-0.6 Na-141
K-3.5 Cl-106 HCO3-27 AnGap-12
[**2110-10-24**] 06:35AM BLOOD LD(LDH)-213
.
[**2110-10-25**] 06:50AM BLOOD WBC-19.8* RBC-3.36* Hgb-10.1* Hct-32.5*
MCV-97 MCH-30.1 MCHC-31.1 RDW-15.0 Plt Ct-298
[**2110-10-25**] 06:50AM BLOOD PT-13.3 PTT-28.9 INR(PT)-1.2
[**2110-10-25**] 06:50AM BLOOD Glucose-107* UreaN-12 Creat-0.8 Na-140
K-3.5 Cl-104 HCO3-25 AnGap-15
[**2110-10-25**] 06:50AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.7
.
[**2110-10-26**] 07:50AM BLOOD WBC-23.5* RBC-3.47* Hgb-10.5* Hct-32.5*
MCV-94 MCH-30.2 MCHC-32.3 RDW-14.5 Plt Ct-310
.
Brief Hospital Course:
A/P: 80 yo lady w/ remote br ca, NHL w/ lung recurrence and s/p
RUL lobectomy, here w/ shortness of breath; re-accumulation of
pleural effusions.
.
1. dyspnea: likely [**3-5**] growing effusions in setting of erratic
lasix dosing. Likely transudative on last admission's tap, but
full chemistries not sent, so it remains unclear. [**Name2 (NI) **] good EF
but MR [**First Name (Titles) **] [**Last Name (Titles) **], which likely contribute to her fluid overload.
Patient was afebrile during the admission and did not need to be
on antibiotics. Cytology negative on previous tap. Breathing
markedly improved after IV diuresis and continued on PO diuresis
post ICU. The pleural effusions were serially monitored on CXR.
On HOD#6, patient had bilateral thoracenteses of her pleural
effusions (after reducing her INR with 5mg vit K). FLuid
analysis (LDH ration 0.6) was interpreted as borderline
exudative effusions. Patient had a questionable pneumothorax -
very small in RLL. She was monitored overnight and was not in
any respiratory distress. On HOD#7, she was comfortable on room
air and breath. Repeat CXR could not rule out a loculated
pneumothorax - hence a lateral decubitus film was sent which
showed:A small pleural effusion is seen, loculated, on the
right. Right lateral decubitus films show no evidence of
nondependent air, i.e., no findings to suggest pneumothorax.
Otherwise, findings are not significantly changed since the
examination of 12:15 of the same day.
.
2. NHL: known recurrence in right lung. Followed by Dr [**Last Name (STitle) 2036**].
Candidate for more CHOP?. Performance status [**3-6**] so may need
more rehab before this is possible. Last rec'd chop several
years ago (w/ rituximab). Patient's WBC count began to rise in
[**Month (only) 205**] from 7->14. And on D/c, wbc count was also rising from
13.9->17->19->23.
.
3. AF: on coumadin, dilt, amiodarone as outpatient. These meds
were continued. currently back in sinus arrythmia with stable BP
alternates between afib and sinus arrhythmia. INR was reversed
for thoracentesis; restarted on coumadin 2.5mg qhs afterwards.
Also on Dilt 90mg po qid and continued amiodarone 200qd
.
4. Voice hoarseness: due to past ET tube placement during the
surgery in [**2110-8-1**]. Consider ENT appt as outpt to eval
.
4. HTN: continue lisinopril 10 qd. Patient also was being
diuresed. BP well controlled throughout hospitalization.
.
5. BPV: on meclizine at home. Kept her on low dose here.
.
6. FEN: replete K, Mg now. Watch lytes in setting of diuresis.
Heart healthy/ low sodium diet. Careful I/O and daily weights.
Check albumin.
.
7. communication: patient; brother is next of [**Doctor First Name **]: [**Name (NI) 4049**]
[**Name (NI) **]; [**Name (NI) **] is her nephew in [**Name (NI) 620**] [**Telephone/Fax (1) 101598**]
.
8. code: full, discussed with patient. Patient kept insisting
that she could not bear to be hoarse again, but I believe she
still intends to be intubated, if necessary
.
9. access: peripheral IV's
.
10. ppx: heparin sc until INR >2. Protonix; encourage ambulation
as she is able. Will get PT to see patient.
.
dispo: likely to floor soon, tele bed.; consider thoracentesis
as above; may need placement or more home services. Social work
consult to help with this as well, since the patient's ability
to live at home may be limited. She lives with 84 year old
brother who [**Name2 (NI) 101599**] is sick. Patient was c/o'ed to the floor to
the East Wards teams
----------
Important phone no. [**Telephone/Fax (1) 101600**] Home #, also brother's no.
Proxy: [**Name (NI) **] (nephew) [**Telephone/Fax (1) 101601**]
Pharmacy (stop&shop)[**Location (un) 577**], ma: [**Telephone/Fax (1) 101602**].
Medications on Admission:
ON admission?? Obtained from last d/c summary. She is unsure of
her doses; she gave us her pharmacy number at Stop and Shop ([**Telephone/Fax (1) 101603**]) but they are closed today:
lasix 20 mg qd
meclizine 25 mg tid
diltiazem 30 mg qid
protonix 40 mg qd
lisinopril ? dose
amiodarone "I take one a day"
coumadin "I take 1/2 per day"
home oxygen - as needed since last discharge
Discharge Medications:
1. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*35 Tablet(s)* Refills:*2*
4. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*35 Tablet(s)* Refills:*2*
5. DILT-XR 180 mg Capsule,Degradable Cnt Release Sig: Two (2)
Capsule,Degradable Cnt Release PO once a day.
Disp:*60 Capsule,Degradable Cnt Release(s)* Refills:*2*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*35 Tablet(s)* Refills:*2*
8. home oxygen 2 liters nasal cannula at rest, 3-4 liters with
exercise, keep o2 sats>93%
9. Levofloxacin 250 q24 (started [**2110-10-24**])
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Non hodkins lymphoma
atrial fibrillation
right pleural effusion
Discharge Condition:
stable
Discharge Instructions:
Please come to the ED if you have any shortness of breath or
chest pain.
Followup Instructions:
Please go to your scheduled CT scan
Provider: [**Name10 (NameIs) **] SCAN Where: [**Hospital6 29**] RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2110-12-15**] 10:00
Please f/u with Dr. [**Last Name (STitle) 2036**] as listed below
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2038**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2110-12-24**] 10:00
F/u with oncology on [**2110-11-27**]
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] MULTISPECIALTY MULTI-SPECIALTY
THORACIC UNIT-CC9 Where: CLINICAL CTR. - 9TH FL.
HEMATOLOGY/ONCOLOGY Date/Time:[**2110-11-27**] 11:00
Completed by:[**2110-11-6**]
ICD9 Codes: 4280, 5119, 2768, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8750
} | Medical Text: Admission Date: [**2166-8-28**] Discharge Date: [**2166-8-31**]
Date of Birth: [**2141-10-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
24 y/o M w/ T1DM, followed at [**Last Name (un) **], A1C 8.1, tferred from OSH
where he was admitted for DKA and was noted to have
pneumomediastinum. The patient was in his usual state of health
until this past Monday. He had drank heavily over the weekend,
about a pint of Captain [**Doctor Last Name **], not unusual for him, and then
on Monday began to have severe nausea and vomiting. He was
unable to keep anything down for the next few days. His vomit
was nonbilious and nonbloody. He had no chest pain, shortness of
breath, abdominal pain other than some epigastric soreness,
diarrhea, or dysuria. No fevers or chills. His fingersticks
continued to go up as high as 600. He went to the OSH on
Wednesday secondary to dehydration. There, he was found to be in
DKA with FS in the 300s, and an AG of 17. He also had a WBC of
17.9.
At the OSH, he had a routine workup for infection and a CXR
showed ?pneumomediastinum. A followup chest CT showed again
pneumomediastinum without clear esoph rupture or contrast
extravasation. A barium swallow was negative for extravasation.
He was started on Zosyn.
Patient was transferred to [**Hospital1 18**] for further management of his
DKA and pneumomediastinum.
On arrival, patient reports no nausea or vomiting. He has some
slight right sided burning chest pain intermittently when he
swallows. No SOB, no abd pain.
.
Past Medical History:
PMH:
1. DM1 diagnosed age 1 followed at the [**Last Name (un) **], last A1C 8.1.
-no known retinopathy, neuropathy, nephropathy
Social History:
SHx: Lives with roommate. Works in the jury department at the
Federal Courthouse in [**Location (un) 86**]. Smokes 1ppd. Drinks heavily on
weekends only, about a pint of EtOH is normal. Denies ever
withdrawing. Denies any other recreational drug use.
Family History:
FHX: Grandfather had T2DM.
Physical Exam:
T 98 74 118/53 15 97%RA
GEN: young male NAD, aaox3
HEENT: PERRL, EOMI, anicteric, mmm
NECK: supple, no crepitus
CV: RRR S1S2 no mrg
LUNG: CTA b/l
BaCK: no CVA tenderness
ABD: soft, nt, bs+
EXT: no edema, dps+
Pertinent Results:
[**2166-8-28**] 10:47PM GLUCOSE-125* UREA N-14 CREAT-0.9 SODIUM-141
POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-22 ANION GAP-18
[**2166-8-28**] 10:47PM CALCIUM-8.3* PHOSPHATE-2.7 MAGNESIUM-1.6
[**2166-8-28**] 10:47PM WBC-7.7 RBC-3.96* HGB-12.9*# HCT-35.0* MCV-89
MCH-32.7* MCHC-37.0* RDW-12.4
[**2166-8-28**] 10:47PM PLT COUNT-126*
[**2166-8-28**] 10:47PM PT-12.4 PTT-23.5 INR(PT)-1.0
See below for admit labs.
OSH labs:
WBC: 17.4 --> 11.8 --> 9.3
Hct: 59.2 --> 40.3 --> 39.8
Plt 141
Chem: Na 132 K 4.1 Cl 100 CO 15 BUN 15 Cr 1.2 AG 17
CT chest (OSH): Dissecting air in the sq tissues of the neck and
mediastinum, seen to the level of the GE junction, no definite
laceration of the esophagus is seen, no paraesophageal abcess,
no extravasation of gastrograin in the soft tissues, lungs
clear, no air space disease, no ptx
Barium swallow: Hiatal hernia, no extravasation, normal mucosa.
Brief Hospital Course:
A/P:
24M w/ T1DM, admitted to OSH w/ acute n/v following binge
drinking episode, noted to have pneumomediastinum on CT chest,
transferred for further management.
.
1. DKA: He was admitted with a metabolic acidosis with anion gap
of 17 and glucose in the 300s. He was taken into the MICU, where
an insulin drip was D5 1/2NS was started with potassium
repletion. His gap normalized and his sugars quickly became
controlled. There were no clear infection though low grade
temperature and initial wbc count on admission to osh. He was
pan cultured here with no indications of infection by
microbiology or chest xray. After stabilization and
discontinuation of the insulin drip, he was started on 38U of
glargine with good control of his sugars. His morning sugars
were 85 and 57 and his glargine was decreased to 35U prior to
discharge with close follow up at [**Last Name (un) **]. His prandial sugars
were controlled on a carbohydrate counting regiment.
2. Pneumomediastinum: He experienced severed nausea and
vomitting secondary to alcohol abuse prior to admission. On
chest xray he was noted to have a possible pneumomediastinum.
Thoracic surgery was called, and on follow up CT showed
pneumomediastinum with no clear esophageal perforation, this was
consistent with the negative barium swallow conducted at the
outside hospital, no antibiotics were started. His throat pain
improved and his diet was advanced. He tolerated POs without
difficulty. Thoracics was consulted prior to discharge and did
not have recommendations for further outpatient studies to
evaluate the pneumomediastinum but rather just follow
clinically. He was advised to terminate his alcohol consumption
as this was clearly associated with his pneumomediastinum. He
was clearly instructed that continued alcohol use could result
in esophageal rupture, recurrent DKA, and or death. He
acknowledged his understanding of this information and agreed to
stop drinking alcohol.
3. Etoh/Smoking: He agreed that he would stop smoking and
drinking, he was prescribed zyban and a nicotine patch to assist
in his positive goal
4. Lung Nodule: Small <5mm lung non calcified lung nodules were
noted on his chest CT, he was advised to follow up with his PCP
and reevaluate these lesions after one year.
5. ARF: His elevated creatinine resolved with hydration.
.
6. FEN: [**Doctor First Name **] diet.NPO, IVF + Kcl for repletion.
lytes, diabetic diet
.
7. PPX: SQ heparin, PPI IV
.
8. Full Code, presumed
.
9. Dispo: Follow up with his [**Last Name (un) **] Diabetes Physician, [**Name10 (NameIs) **] PCP
Medications on Admission:
1. NPH 32 AM, 20 PM
2. Humalog ISS
Discharge Medications:
1. Insulin Glargine 100 unit/mL Solution Sig: Thirty Five (35)
Units Subcutaneous at bedtime.
Disp:*1 1* Refills:*2*
2. Insulin Syringe Needless(Disp) 1 mL Syringe Sig: One (1)
Miscell. four times a day.
Disp:*1 1* Refills:*2*
3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Nicotine 21-14-7 mg/24 hr Patch Daily, Sequential Sig: One
(1) Transdermal once a day.
Disp:*1 1* Refills:*2*
5. Zyban 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day: Take 1 tablet once a day
(150mg) for three days. Then take 1 tablet (150mg) twice a day
for 12 weeks.
Disp:*175 Tablet Sustained Release(s)* Refills:*2*
6. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day: Please use according to
carbohydrate counting regiment.
Disp:*1 qs* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
Pneumomediastinum
Alcohol Toxicity
Discharge Condition:
Good, stable
Discharge Instructions:
You were admitted for diabetic ketoacidosis which was likely
caused by your alcohol consumption.
You must avoid alcohol consupmtion, as you have type 1 diabetes
and are at high risk of developing complications, which can
result in death. You developed a pneumomediastinum because of
your alcohol consumption and nausea and vomitting.
You should also avoid Non-steroidal anti-inflammatory
medications.
You should follow up with your PCP within one week. He should
consider another follow chest xray to further monitor your
pneumomediastinum.
A small lung nodule was noted on your Chest CT, you should also
have your PCP follow up with another Chest CT in one year to
monitor these nodules.
You have expressed interest in quitting smoking and alcohol.
You have been prescirbed a nicotine patch and wellbutrin to help
you with this positive goal.
You have been prescribed a protonix to prevent gastric reflux
disease.
Reflux esophagitis (e-sof-uh-[**Last Name (un) **]-tis) happens when stomach acid
flows back into the tube that connects the mouth to the stomach.
This tube is called the esophagus (e-sof-uh-[**Male First Name (un) **]). Acid irritates
the esophagus and may cause you to have heartburn. Heartburn may
get better with treatment, but it may return.
Causes: Heartburn is caused by stomach acid backing up into the
esophagus. This happens because the muscles at the top of the
stomach have gotten weak. Heartburn has nothing to do with the
heart. You may have heartburn if you weigh too much, are
pregnant, smoke, or drink too much alcohol. Eating too much may
cause heartburn. Some medicines or coughing too hard may also
cause heartburn.
Signs and Symptoms: You may feel burning in your chest, usually
at night. Heartburn is most common when you are lying down.
Other signs may be burping. You may have a sour or acid taste in
your mouth. Or you may have a sore throat. The stomach acid may
bother your esophagus or cause other problems, such as ulcers.
Sometimes reflux can cause asthma.
Care: You may need medicine for your heartburn. It may help to
raise the head of your bed 6 to 8 inches on blocks. Check with
your caregiver before taking any medicine if you are pregnant.
Do's and Don'ts: Do eat small meals slowly. Do not bend over or
lie down after eating. Lose weight if you are overweight. You
should drink more fluids, such as water or juices. But you
should not drink alcohol or drinks that have caffeine (coffee,
tea, cocoa, cola drinks). Do not wear tight clothes around your
chest and stomach.
CARE AGREEMENT:
You have the right to help plan your care. To help with this
plan, you must learn about your health condition and how it may
be treated. You can then discuss treatment options with your
caregivers. [**Name (NI) **] with them to decide what care may be used to
treat you. You always have the right to refuse treatment.
Followup Instructions:
Follow up with your PCP within one week. He should take a follow
up chest xray, and arrange for a follow Chest CT in one year for
evaluation of lung nodules.
Follow up with your endocrinologist, Dr [**Last Name (STitle) 9978**] within one week
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
ICD9 Codes: 5849, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8751
} | Medical Text: Unit No: [**Numeric Identifier 66949**]
Admission Date: [**2106-3-7**]
Discharge Date: [**2106-3-15**]
Date of Birth: [**2106-3-7**]
Sex: M
Service: NB
DISCHARGE DIAGNOSES:
1. Premature male infant, 35 weeks gestation.
2. Status post immature feeding.
3. Status post hyperbilirubinemia.
4. Status post rule out sepsis.
HISTORY: [**Known lastname 16518**] is a former 2.465 kilogram male infant
born at 35 weeks gestation via stat cesarean section under
general anesthesia. Mother is a 32 year-old gravida III, para
0, now I, B positive, hepatitis B surface antigen negative,
RPR nonreactive, Rubella immune and group B strep negative
woman. She had a history of preterm labor which was treated
with terbutaline for 4 weeks and she is status post
betamethasone treatment. Terbutaline was discontinued on
[**2106-3-6**]. The mother was admitted to [**Hospital1 346**] with vaginal spotting, preterm
labor. Membranes ruptured less than 1 hour prior to delivery.
Fetal heart tracing revealed late decelerations with slow
recovery followed by fetal tachycardia with decreased beat to
beat variability. The fetal heart rate in the delivery room
had bradycardia 60 to 90 beats per minute for 2 minutes.
There was question of a maternal seizure. Mother underwent
general anesthesia with a stat cesarean section.
Mother was not followed though [**Hospital1 **] for her
obstetrical care.
At delivery infant was mottled, pale, with poor perfusion. No
spontaneous respirations and flaccid tone. Heart rate was 80.
He was suctioned and given bag and mask ventilation when the
heart rate increased immediately to greater than 100 beats
per minute. By 1 minute the infant had spontaneous
respirations with improving color. He had a spontaneous cry
with some mild hypotonia. Apgars were 3 at one minute and 8
at five minutes.
The infant was transferred to newborn Intensive Care Unit at
[**Hospital1 69**]. Of note, he voided x2
in the delivery.
The infant on admission to the newborn Intensive Care Unit
was noted to have some facial nasal compression from his
intrauterine position of being wedged at the base of the
uterus. The remainder of the examination was within normal
limits.
PROBLEMS BY SYSTEM DURING HOSPITAL STAY:
1. RESPIRATORY: The infant remained in room air throughout
his hospital course with no evidence of apnea or
bradycardia.
2. CARDIOVASCULAR: He was cardiovascularly stable with
normal blood pressures and no murmur appreciated.He had a
low resting heart rate 90-120, EKG reported as normal by
cardiac consult.
3. FEEDING AND NUTRITION: The infant was initially placed on
IV with minimal feeds. He advanced to full enteral
feeding within 12 hours of life and the volumes were
advanced over the next 2 days. He is currently put to
breast when mother is available with initially receiving
all gavage feedings following breast-feeding. On [**3-11**]
he was placed to breast and offered bottle as supplement.
He will be supplemented with 2 p.o. feedings per day at
home. His weight today at discharge was 2305 kgs.
4. INFECTIOUS DISEASE: He initially had a complete blood
count which had 15.9 white blood cells, 366 platelets,
46.9 hematocrit with 19 neutrophils, 0 bands and 71
lymphocytes. Ampicillin and Gentamicin were initiated and
at 48 hours with negative blood cultures the antibiotics
were discontinued.
5. HEMATOLOGIC: Mother was B positive. Baby had a peak
bilirubin on [**3-11**] of 12.3 with a direct of 0.4. A
Biliblanket was initiated. Follow up bilirubin
on [**3-12**] was 14.1/0.3 at which time he was switched to
overhead lites from the bili blanket. On [**3-13**] phtx was D'Cd
at 10.4 and [**3-14**], rebound bili was 9.2/0.2.
7. CIRCUMCISION: Performed on [**3-11**].
8. HEARING SCREENING: Prassed on [**3-12**]..
9. Inutero wedged position resulting in nasal compression
and non flexed position position of legs , improved
daily.Hips were checked and revealed no discernable
dislocation. Will get hipultrasound at 6 wks.
Patient was discharged home to be followed up within 5 days
at [**Hospital1 **] [**Location (un) **] Center, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Visiting nurse to come to home the day post discharge.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**]
Dictated By:[**Last Name (NamePattern1) 56049**]
MEDQUIST36
D: [**2106-3-11**] 14:32:06
T: [**2106-3-11**] 15:01:22
Job#: [**Job Number 66950**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8752
} | Medical Text: Admission Date: [**2110-12-25**] Discharge Date: [**2111-1-28**]
Date of Birth: [**2055-3-2**] Sex: F
Service: MEDICINE
Allergies:
Cipro / Doxycycline / Paxil / Quinine / Compazine / Levaquin /
Lithium / Cefepime
Attending:[**First Name3 (LF) 1493**]
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
[**12-25**] Exploratory laparotomy with lysis of adhesions, bowel
decompression and SB enterotomy
EGD
History of Present Illness:
The patient is a 55 yo female w/ hx multiple small bowel
obstructions, likely secondary to previous intraabdominal
surgery who was admitted to [**Hospital1 18**] on [**12-25**] with concerns for
small bowel obstruction, given her symptoms of nausea, vomiting,
and abdominal pain.
(Per surgery admission note)
Past Medical History:
# Hepatic sarcoidosis and regenerative hyperplasia
- s/p TIPS [**12-19**] placed d/t GI bleeding from varices and portal
gastropathy
- TIPS re-do with angioplasty and portal vein embolectomy
- severe portal hypertensive gastropathy
- Grade II varices
- grade 3 esophagitis
# multiple SBOs, most recent [**5-20**]
# Idiopathic cardiomyopathy:
-ECHO demonstrating an EF of 15-20% (no report, ?OSH) and a
p-mibi that confirmed an EF of 23% with no ischemic changes-->
improving [**6-17**] to EF 40-45%, mild-to-moderate global left
ventricular hypokinesis
-Cardiac cath [**2-16**]: no angiographically apparent flow-limiting
lesions, mild mitral regurgitation, and severe systolic
ventricular dysfunction with a left ventricular ejection
fraction of 20%.
-Right heart cath: [**2109-2-18**]: Normal right sided filling
pressures. Mild pulmonary artery hypertension. Preserved cardiac
index.
# COPD, followed by [**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **], PFTs WNL
# Hx of SAH [**2101**] s/p coiling, 2 new aneurysms seen on angio
[**2108-6-21**]
# Colonic AVM and diverticulum
# Evidence of CVA/TIA
# Hypothyroidism
# Anemia
# s/p hysterectomy
# s/p cholecystecomy
# s/p appendectomy
# Reflex Sympathetic Dystrophy s/p fall, on disability, now
resolved
# Raynauds
Social History:
Married, lives in [**Hospital1 **], has 2 sons and 5 grandchildren, 36
pack-year smoking hx quit 2.5 years ago, does not drink EtOH and
denies former abuse, no h/o illicits or IVDU, does not work [**3-15**]
disability for RSD.
Family History:
[**Name (NI) 29555**] MI, [**Name (NI) 29556**]
Physical Exam:
Physical exam on transfer from MICU to [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] wards.
Initial PE not available
VS: Tc 98, Tm98.4, HR 98 (90-100s), 130/64 (100-140/50/80), 19
HEENT: EEG leads in place, sclerae anicteric, PERRL, OP Clear
Neck: Supple, no lymphadenopathy
Cor: rrr, no murmurs appreciated
Pulm: clear anteriorly
Abd: midline laparotomy scar wellhealed, voluntary guarding with
palpation of abdomen diffusely, normoactive bowel sounds, no
rebound
Extrem: no peripheral edema
Neuro: responds to voice, oriented to self & place, states "i'm
worried about him [her husband]. He's always been here for me,"
after being asked if her husband has been in to see her today.
No twitching. Difficulty engaging pt in exam. Moves all ext's
spontaneously
Pertinent Results:
Admission labs
[**2110-12-24**] WBC-6.6# RBC-3.69* Hgb-11.2* Hct-32.9* MCV-89 MCH-30.3
MCHC-34.0 RDW-16.5* Plt Ct-64*
[**2110-12-24**] Neuts-89.5* Lymphs-5.1* Monos-3.4 Eos-1.6 Baso-0.4
[**2110-12-24**] PT-12.9 PTT-30.8 INR(PT)-1.1
[**2110-12-24**] Glucose-95 UreaN-25* Creat-1.1 Na-140 K-4.9 Cl-105
HCO3-24 AnGap-16
[**2110-12-24**] ALT-27 AST-33 AlkPhos-197* TotBili-0.9
[**2110-12-24**] Mg-1.6
[**2110-12-26**] calTIBC-178* Ferritn-418* TRF-137*
[**2110-12-25**] Ammonia-60*
[**2110-12-24**] URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2110-12-24**] URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Miscellaneous Lab Data
[**2111-1-15**] 02:37AM BLOOD WBC-6.3 RBC-3.39* Hgb-9.7* Hct-30.1*
MCV-89 MCH-28.6 MCHC-32.3 RDW-15.2 Plt Ct-74*
[**2111-1-6**] 10:12AM BLOOD WBC-7.0 RBC-3.09* Hgb-9.1* Hct-26.7*
MCV-86 MCH-29.4 MCHC-34.1 RDW-16.8* Plt Ct-106*
[**2110-12-26**] 12:20PM BLOOD WBC-7.2 RBC-3.31* Hgb-10.2* Hct-28.7*
MCV-87 MCH-30.9 MCHC-35.6* RDW-16.5* Plt Ct-60*
[**2110-12-27**] 08:57PM BLOOD Fibrino-598*
[**2111-1-10**] 04:22AM BLOOD Glucose-97 UreaN-41* Creat-1.0 Na-137
K-4.3 Cl-108 HCO3-23 AnGap-10
[**2111-1-13**] 05:30AM BLOOD Glucose-214* UreaN-57* Creat-1.8* Na-148*
K-4.1 Cl-116* HCO3-21* AnGap-15
[**2111-1-14**] 10:45AM BLOOD Glucose-295* UreaN-63* Creat-1.4* Na-150*
K-4.3 Cl-120* HCO3-19* AnGap-15
[**2111-1-19**] 06:58AM BLOOD Glucose-125* UreaN-91* Creat-2.1* Na-136
K-4.6 Cl-109* HCO3-14* AnGap-18
[**2111-1-20**] 06:30AM BLOOD Glucose-119* UreaN-97* Creat-2.6* Na-137
K-4.9 Cl-111* HCO3-11* AnGap-20
[**2111-1-22**] 02:19PM BLOOD Glucose-134* UreaN-93* Creat-3.1* Na-145
K-4.0 Cl-118* HCO3-14* AnGap-17
[**2111-1-26**] 05:00AM BLOOD Glucose-86 UreaN-57* Creat-2.5* Na-138
K-3.9 Cl-108 HCO3-20* AnGap-14
[**2111-1-27**] 05:37AM BLOOD Glucose-82 UreaN-49* Creat-2.2* Na-139
K-3.5 Cl-109* HCO3-20* AnGap-14
[**2111-1-19**] 06:58AM BLOOD ALT-13 AST-17 LD(LDH)-173 CK(CPK)-14*
AlkPhos-177* TotBili-0.4
[**2111-1-1**] 05:20AM BLOOD Triglyc-206* HDL-51 CHOL/HD-2.8
LDLcalc-51
[**2111-1-13**] 04:48PM BLOOD Ammonia-6*
[**2111-1-20**] 11:06AM BLOOD Ammonia-49*
[**2111-1-14**] 01:47AM BLOOD TSH-0.37
[**2111-1-20**] 05:43PM BLOOD Phenyto-18.0
[**2111-1-22**] 02:19PM BLOOD Phenyto-21.2*
[**2111-1-28**] 05:03AM BLOOD Phenyto-12.0
Discharge Labs
[**2111-1-28**] 05:03AM BLOOD WBC-3.7* RBC-3.29* Hgb-9.9* Hct-28.6*
MCV-87 MCH-30.1 MCHC-34.6 RDW-16.0* Plt Ct-90*
[**2111-1-28**] 05:03AM BLOOD Plt Ct-90*
[**2111-1-28**] 05:03AM BLOOD Glucose-92 UreaN-44* Creat-2.0* Na-140
K-3.9 Cl-111* HCO3-20* AnGap-13
[**2111-1-28**] 05:03AM BLOOD ALT-12 AST-18 LD(LDH)-218 AlkPhos-232*
TotBili-0.4
[**2111-1-28**] 05:03AM BLOOD Albumin-3.4 Calcium-8.1* Phos-3.3 Mg-2.2
[**2111-1-28**] 05:03AM BLOOD Phenyto-12.0
.
Imaging: [**12-10**] Abdominal US: No significant abdominal ascites
and no tapable fluid collection. Cirrhotic liver with portal HTN
including splenomegaly. Probable SBO, incompletely visualized on
examination.
[**12-10**] CT A/P: SBO with transition point in RLQ. No bowel wall
thickening or pneumatosis. Also c/w cirrhosis and portal HTN.
TIPS shunt occluded.
[**12-25**] CT A/P: same transition pt in RLQ pelvis with fecalization
of SB proximal to this pt, ? anther transition pt at proximal SB
but contrast passes thru; no pneumatosis
[**12-28**] EGD: 3 nonbleeding grade 2 varices in distal esophagus;
portal hypertension gastritis w small blood clot in stomach; no
active bleeding.
[**1-1**] KUB: persistent small-bowel obstruction or postop ileus
[**1-5**] CT Abd: Persistent dilation of multiple loops of small
bowel with wall thickening and mesenteric edema without a
definitive transition point. Although there is a relative
[**Name (NI) 29563**] point in the terminal ileum, these findings suggest
the possibility of mixed mechanical and functional obstruction;
Cirrhotic liver with TIPS and portal hypertension, such as
splenomegaly; Diverticulosis without evidence of diverticulitis.
[**1-13**] Abd U/S and duplex: scant ascites, patent vasculature, no
biliary dilatation
[**1-15**] CT abd:
There is increased ascites compared to prior study. There is no
focal fluid collection to suggest abscess formation. There is
diffuse anasarca and mesenteric edema. Small bowel is mildly
dilated with mild bowel wall
thickening, decreased since prior study. There is no pneumatosis
or free air.
.
Micro:
[**1-5**] Abd JP: Klebsiella oxytoca and [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**]
[**1-6**] Abd JP: Klebsiella oxytoca
[**1-19**]: ascites fluid gram stain with gram negative rods
[**1-21**] bld cx pending
[**2111-1-26**] 06:15AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
[**2111-1-26**] 06:15AM URINE RBC-5* WBC-12* Bacteri-FEW Yeast-NONE
Epi-1 TransE-<1
[**2111-1-19**] 10:40AM URINE Eos-NEGATIVE
[**2111-1-20**] 03:32PM URINE Hours-RANDOM Na-88 K-30 Cl-93
[**2111-1-19**] 10:40AM URINE Hours-RANDOM Creat-39 Na-48
[**2111-1-18**] 03:45PM CEREBROSPINAL FLUID (CSF)
WBC-0 RBC-93* Polys-20 Lymphs-60 Monos- WBC-0 RBC-[**Numeric Identifier 29564**]*
Polys-33 Bands-7 Lymphs-33 Monos-27
TotProt-32 Glucose-53 LD(LDH)-34
ANGIOTENSIN 1 CONVERTING ENZYME-Test
HERPES SIMPLEX VIRUS PCR-Test Name
Ascites Studies
[**2111-1-5**] 07:44PM ASCITES WBC-7400* RBC-250* Polys-88* Lymphs-4*
Monos-0 Mesothe-3* Macroph-5*
[**2111-1-6**] 06:17PM ASCITES WBC-5250* RBC-200* Polys-93* Lymphs-4*
Monos-3*
[**2111-1-19**] 03:03PM ASCITES WBC-1025* RBC-[**Numeric Identifier 7438**]* Polys-66*
Lymphs-13* Monos-0 Eos-1* Macroph-20*
[**2111-1-27**] 10:00AM ASCITES WBC-125* RBC-5175* Polys-38* Lymphs-46*
Monos-0 Eos-1* Mesothe-2* Macroph-13*
[**2111-1-6**] 06:17PM ASCITES TotPro-0.8 Glucose-157 Amylase-36
TotBili-0.2 Albumin-<1.0
[**2111-1-19**] 03:03PM ASCITES TotPro-1.8 Glucose-118 LD(LDH)-78
Amylase-25 Albumin-1.1
Brief Hospital Course:
HOSPITAL COURSE AS SUMMARIZED BY SURGICAL AND MEDICAL SERVICES
Mrs. [**Known lastname **] is a 55 yo female with with history of ELSD from
hepatic sarcoid who initially presented on [**2110-12-25**] w/ small
bowel obstruction and had hospital course complicated by ARF,
status epilepticus, secondary bacterial peritonitis, and hepatic
encephalopathy.
BRIEF HOSPITAL COURSE BY PROBLEM
Small Bowel Obstruction
The patient was admitted to [**Hospital1 18**] with nausea, abdominal pain,
and diarrhea. Given her history of hepatic sarcoidsis, the
patient underwent CT of abd/pelvis revealing a transition point
in RLQ pelvis with fecalization of SB proximal to this pt. Of
note, prior CT on [**12-10**] had revealed cirrhosis and portal HTN
with TIPS shunt occluded. The patient was thus taken to the OR
on [**12-25**] where she underwent exploratory laparotomy with
enterotomy and lysis of adhesions. Intraoperatively she was
found to have some adhesions with dilated loops of bowel but no
transition point; the small bowel was dilated to the extent that
an enterotomy was required in order to decompress the bowel and
close the abdomen. She also had a CVL placed in the OR.
She was kept intubated overnight and brought to the ICU. She
was weaned to extubated in the am. She received perioperative
antibiotics and stress dose steroids postoperatively.
Esophageal Varices/Anemia/Portal Gastropathy
She also had an EGD on [**12-28**] that revealed 3 nonbleeding grade 2
varices in distal esophagus and portal hypertension gastritis w
small blood clot in stomach; no active bleeding. She had a
relatively stable anemia that trended down around [**1-20**] that was
thought to be morst likely secondary to slow ooze from portal
gastropathy. She was transfused 2 units PRBC [**1-20**], 1 unit [**1-21**]
with subsequent stabilization of HCT. Varices were banded on day
of discharge and she was started on sucralfate for 10 days.
Postoperative Ileus
On [**12-28**] she was transferred to the floor, her NGT was
discontinued, and she was started on sips, which she tolerated
well. On [**1-1**] she was noticed to be increasingly tender
without bowel movements; KUB revealed persistent dilated
small-bowel loops with multiple air-fluid levels concerning for
persistent small-bowel obstruction or post-operative ileus. Her
NGT was replaced. She was started empirically on unasyn.
Acute Renal Failure
While on surgical service, the patient was also noted to have
an increase in her creatinine from 1.3 to 2.2; this was thought
secondary to large fluid losses from her JP drain in her
abdomen; she was started on replacements 1/2 cc/cc with
improvement in her creatinine to 1.2 on [**1-1**]. She had a PICC
placed on [**1-2**] and was started on TPN.
She again developed a rise in her creatinine on [**1-18**]. She was
given albumin 62.5g on [**1-19**] and bicarb and blood on [**1-20**] for
volume rescusitation. Urine microscopy showed granular and
hyaline cast. Urine lytes were not consistent with pre-renal but
renal felt this was a pre-renal/evolving ATN picture. She has a
mixed non-gap and gap acidosis. The gap is likely from the renal
failure and the non-gap from her diarrhea. The bicarb has
improved her acid-base status and lactulose was stopped to slow
down the diarrhea. Creatinine trended down prior to discharge.
Diuretics were held.
Hepatic Encephalopathy
On the floor the patient was noticed to be increasingly less
talkative with a dull affect, thought to be consistent with past
episodes of hepatic encephalopathy. She was given high dose
lactulose PR with initial improvement in her mental status.
Secondary Bacterial Peritonitis
The patient had been improving, and so her NGT was
discontinued. Unfortunately, she then developed increasing
abdominal pain; on [**1-5**] she underwent repeat CT scan of
abd/pelvis that revealed persistent dilation of multiple loops
of small bowel with wall thickening and mesenteric edema without
a definitive transition point concerning for a mixed mechanical
and functional obstruction, a cirrhotic liver with TIPS and
portal hypertension, such as splenomegaly, and diverticulosis
without evidence of diverticulitis.
The JP drain fluid was sent for analysis; Klebsiella oxytoca
and [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**] grew out from the fluid both on [**1-5**] and
[**1-6**]. Infectious disease was consulted; the patient was
started on zosyn for the Klebsiella and [**Month/Year (2) 29565**] for the
[**Female First Name (un) 564**]. The zosyn was eventually changed to cefepime on [**1-9**]
given the sensitivities. Cefepime was later changed to
Meropenem due to concern for precipitating seizure. Her home
gabapentin and amitriptyline were held given their potential
muscarinic effects on peristalsis. The patient had been having
low-grade fevers in the setting of steroids but no mental status
changes at the time. She was thought to have infected
peritoneal fluid possibly secondary to the enterotomy, though
the etiology is not completely clear. Serial paracenteses were
performed until pt no longer had evidence of bacterial
peritonitis with <250 polys in ascitic fluid. She was continued
on antibiotics for two week course after JP pulled to complete
[**2111-2-1**].
The patient's abdominal exam gradually improved, her NGT was
discontinued on [**1-8**], and she was started on a regular diet
given that she was passing gas and having bowel movements. That
said, the patient continued to have low-grade fevers throughout
even though she was still on steroids (tapered to her home dose
from admission) and multiple antibiotics.
Because of her improved exam, decreased output from her JP
and the thought that her fluid status could be better managed
with the drain out, her JP drain was removed. She did have some
tenederness on abdominal exam on [**1-15**], and so she underwent
another CT scan that revealed increased ascites compared to
prior study but no focal fluid collection to suggest abscess
formation. The patient did have diffuse anasarca and mesenteric
edema; the small bowel was mildly dilated with mild bowel wall
thickening, decreased since prior study, and there was no
pneumatosis or free air.
Hypernatremia
The patient also became hypernatremic to a high of 154 on
[**1-14**](she was started on free water replacements), likely
intravascularly depleted given her high BUN, and hyperchloremic
with a low bicarbonate; the later two likely secondary to
previous normal saline/TPN loads.
Given her stable vital signs, she was transferred to the floor
on [**1-15**], though she still remains with altered mental status
further discuused below.
Altered mental status
On [**1-13**] the patient was noted to be increasingly abulic, though
paranoid appearing. She was transferred to the SICU. She
underwent an abd U/S on [**1-13**] that revealed scant ascites, patent
vasculature, and biliary dilatation. Given the results the
patient did not undergo paracentesis even though this was one
possible etiology for her AMS. Both psychiatry (who had
previously been following the patient for depression) and
neurology were consulted. Her mental status waxed and waned
with occasional episodes of increased awareness and pronouncing
her name.
Her altered mental status was initially thought to be due to
toxic metabolic encephalopathy [**3-15**] liver disease, infection, and
underlying brain disease. Her EEG on [**1-15**] was consistent with
this and negative for seizure per neurology although there was a
questionable focus in the frontal lobe. LP and MRI/A were
performed and were both negative on [**1-18**]. NG tube was pulled out
on [**1-17**] and put back in [**1-18**] and patient was treated with
lactulose with stool outputs of a liter per day. Patient had
paracentesis [**1-19**] with reduction in white cells but persistent
bacterial peritonitis and gram negative rods on gram stain. On
[**1-20**], per ID, metronidazole was added to cover anerobes. Patient
had been on cefepime for klebsiella and [**Month/Day (4) 29565**] for [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 563**] since her initial tap. She completed 2 week course
(after JP pulled) with change of antibiotics to Meropenem (then
ertapenem at discharge for once daily dosing) and Caspo.
Status Epilepticus
On the morning of [**1-20**] she was noted to be "twitching". Her
glucose and electrolytes were wnl. Neurology was contact[**Name (NI) **] and
initially did not think this was seizure activity but EEG was
ordered to r/o myoclonic seizure. EEG demonstrated status
epilepticus. She was given 2 mg IV ativan and this resolved. She
was loaded with fosphenytoin and continued on fosphenytoin with
daily monitoring of levels. It was unclear what precipitaed
seizures but may have been form underlying brain disease (h/o
CVA), hepatic encephalopathy, or med effect. Flagyl was
discontinued and Cefeoime changed to [**Last Name (un) **]. She was transferred
to MICU fo closer monitoring. EKG and cxr were wnl during this
episode. When her mental status remained altered after being on
therapeutic dilantin, she was started on Keppra in addition to
Dilantin. Mental status subsequently continued to improve and
she became awake, oriented and conversant. She was started on a
regular diet and started working with physical therapy and was
discharged to home with services.
Hypothyroidism
Continued on levothroxine. TSH WNL.
Code
Full
Medications on Admission:
Albuterol 90 mcg 1 puff INH q4-6h prn, amitriptyline 50 qhs,
cyanocobalamin 1000 mcg/mL qmonth, folic acid 1', Lasix 20',
gabapentin 300'', hydroxyzine 25''', lactulose 10g/15mL soln 2
teaspoons daily, levothyroxine 88', omeprazole 80'', prednisone
10', aldactone 50', sucralfatre 1 QID, ursodiol 600 qAM 300 qPM,
ambien 10 qhs, ferrous sulfate 325'', vit B1 100'
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. [**Last Name (un) **] 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ursodiol 300 mg Capsule Sig: as directed Capsule PO twice a
day: Take 2 tabs in am and 1 tab at night.
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
6. [**Last Name (un) **] 70 mg Recon Soln Sig: 35 mg Recon Solns
Intravenous Q24H (every 24 hours) for 4 doses.
Disp:*2 Recon Soln(s)* Refills:*0*
7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Titrate to 4 BMs per day.
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
9. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) injection
Injection once a month.
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
11. Ertapenem 1 gram Recon Soln Sig: 0.5 grams Intravenous once
a day for 4 days.
Disp:*2 grams* Refills:*0*
12. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for 2 weeks.
Disp:*1 bottle* Refills:*0*
14. Dilantin Extended 100 mg Capsule Sig: One (1) Capsule PO
three times a day.
Disp:*90 Capsule(s)* Refills:*2*
15. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
16. Sucralfate 100 mg/mL Suspension Sig: One (1) gram PO twice a
day for 10 days: Do not take within 2 hours of taking dilantin
(phenytoin).
Disp:*200 grams* Refills:*0*
17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a
day.
18. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO once a
day.
19. Outpatient Lab Work
Please check cbc, chem-10, LFTs on Friday [**1-30**]. Please
have results faxed to Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 4409**]
20. Saline Flush 0.9 % Syringe Sig: One (1) flush Injection four
times a day: 10 cc sash and prn.
Disp:*16 flushes* Refills:*0*
21. Heparin Flush 10 unit/mL Kit Sig: One (1) flush Intravenous
once a day: 3 cc sash and prn.
Disp:*10 flushes* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] vna
Discharge Diagnosis:
Primary Diagnosis
Small Bowel Obstruction s/p Lysis of Adhesions
Acute Renal Failure
Status epilepticus
Secondary bacterial peritonitis
Secondary Diagnosis
Hepatic sarcoidosis listed for transplant
Esophageal varices grade II
Severe portal hypertensive gastropathy
Esophagitis
Multiple admissions for hepatic encephalopathy
Multiple prior SBO's (treated non-operatively)
COPD
h/o CVA/TIA's
hypothyroidism
Raynaud's syndrome
cerebral aneurysms s/p coiling after SAH
Discharge Condition:
Hemodynamically stable, afebrile
Discharge Instructions:
You were admitted to the hospital with abdominal pain. You were
found to have a small bowel obstruction which required surgery
to lyse adhesions in your abdomen. You later developed an
infection in your abdomen and were started on antibiotics. A
repeat paracentesis on [**2111-1-27**] showed that this infection had
resolved but you should continue to tkae antibiotics through
[**2-1**]. During your hospital course, you also developed kidney
failure which may have been from one of the medications you were
taking. You also were confused so you were treated with
lactulose and [**Month/Year (2) 8005**] for hepatic encephalopathy. On [**2111-1-20**],
you had some twitching so an EEG was obtained which showed that
you were having seizures. You were treated with Dilantin and
Keppra and your seizures stopped.
We have made the following changes to your medications
1. We held your diuretics (Lasix and Aldactone) since you had
impaired kidney function. These may be restarted as an
outpatient depending on your kidney function and electrolytes.
2. We added Ertapenem and [**Last Name (LF) **], [**First Name3 (LF) **] antibiotic and
antifungal medication which you will take through [**2-1**]
3. We added Phenytoin and Keppra for seizures
4. We added sucralfate for varices for 10 days, please make sure
not to take this medication within 2 hours of dilantin. They
need to be spaced at least 2 hours.
5. We decreased your gabapentin to 300 mg once daily because of
your renal function.
Please return to the ER or call your primary care doctor if you
develop confusion, abdominal pain, fever, chills, chest pain,
shortness of breath or any other concerning symptoms.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] [**Last Name (NamePattern4) 2424**], MD
Phone:[**Telephone/Fax (1) 463**]. You have an appointment with him at 8:30 am
on [**2-3**].
You also have an appointment for endoscopy on [**2111-2-20**] at 8:30
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 9394**] (ST-3) GI ROOMS.
Please follow up with Neurology regarding your seizures. You
have an appointment with Dr. [**Last Name (STitle) **] and [**Doctor Last Name **] on [**4-7**] at 2:30 pm. Their office is on the [**Location (un) **] of the [**Hospital Ward Name 23**]
Building.
Please follow up with Surgery in the next 1-2 weeks. You have an
appointment with Dr. [**Last Name (STitle) 816**] on [**2-2**] at 8 am. His office
is at [**Last Name (NamePattern1) **]. on the [**Location (un) 436**]. At this time, he will
take out the stitches on your abdomen.
Please follow up with your pcp in the next few weeks as well.
Call Dr.[**Name (NI) 29566**] office when you are able.
ICD9 Codes: 5845, 2760, 2762, 5715, 496, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8753
} | Medical Text: Admission Date: [**2197-9-29**] Discharge Date: [**2197-10-3**]
Date of Birth: [**2148-4-6**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old
female with known coronary artery disease, status post
myocardial infarction, status post coronary artery bypass
graft times three in [**2193**], angioplasty in [**2197-1-31**],
peripheral vascular disease, status post aortofemoral bypass,
and axillobifemoral bypass, hypercholesterolemia, recent
subdural hematoma in [**2197-3-31**] who presented to [**Hospital3 33594**] Center on the morning of admission with anginal chest
pain refractory to medications, lateral ST segment
depressions, and negative cardiac enzymes.
The patient was transferred to the [**Hospital1 190**] for cardiac catheterization. Upon admission,
the patient reports waking up from her sleep at 5 a.m. on the
morning of admission with 7/10 substernal chest pain with
radiation of the pain to the jaw and both arms, accompanied
by diaphoresis. The patient reports similar symptoms in the
past with relief from nitroglycerin; however, this morning
the pain was unrelieved with nitroglycerin tablets times
three.
At the time, the patient went to [**Hospital3 25150**] where she
was put on a nitroglycerin drip, received 5 mg p.o. of
Lopressor times two, and morphine sulfate without relief.
Her cardiac enzymes were negative times one, and an
electrocardiogram relieved lateral ST segment depressions.
Given the patient's history of coronary artery disease,
vasculopathy, and multiple cardiac catheterizations in the
past, the patient was transferred to [**Hospital1 190**] for cardiac catheterization.
At the [**Hospital1 69**], the patient's
cardiac catheterization revealed occlusion of her saphenous
vein graft to first diagonal artery with 100% acute
thrombotic occlusion, 70% occlusion of the lower pole of her
first obtuse marginal, percutaneous transluminal coronary
angioplasty that was opened; 100% right coronary artery
proximal occlusion with collateral filling. Given the small
caliber of the diagonal graft and small amount of myocardium
provided, and the patient's extremely high risk for
reocclusion, percutaneous transluminal coronary angioplasty
was deferred at this time and conservative medical management
was initiated.
The patient was continued on medications and transferred to
the floor. Upon arrival, the patient continued to complain
of substernal chest pain described to be [**6-9**] and was
somewhat relieved with morphine. At the time of arrival to
the Coronary Care Unit, the patient denied shortness of
breath, palpitations, orthopnea, paroxysmal nocturnal
dyspnea, and edema. The patient denies any recent fevers,
chills, diarrhea, melena, and headaches. The patient does
report numbness in the left lower arm since intervention on
the day of admission.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post myocardial
infarction in [**2195**] (as per patient), multiple
catheterizations (the last in [**2197-1-31**] when she
received a stent of her saphenous vein graft to first
diagonal and underwent a percutaneous transluminal coronary
angioplasty of her first obtuse marginal). She is status
post coronary artery bypass graft times three with saphenous
vein graft to both her right coronary artery and first
diagonal.
2. Peripheral vascular disease; status post aortofemoral
bypass in [**2194**]. Also status post axillofemoral bypass.
3. Hypercholesterolemia.
4. Hypothyroidism.
5. Seizure disorder.
6. Heparin-induced thrombocytopenia.
7. Subdural hematoma in [**2197-3-31**].
8. Of note, the patient has anti-K alloantibodies.
PAST SURGICAL HISTORY:
1. Coronary artery bypass graft.
2. Aortofemoral bypass with right subclavian to femoral
bypass.
3. Craniotomy; status post subdural hematoma.
4. Spinal surgery.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. q.d.
2. Zocor 80 mg p.o. q.d.
3. Lopressor 100 mg p.o. t.i.d.
4. Accupril 5 mg p.o. q.d.
5. TriCor 108 mg p.o. q.d.
6. Pepcid 20 mg p.o. q.d.
7. Synthroid 125 mcg p.o. q.d.
8. Depakote 500 mg p.o.
9. Folic acid 1 mg p.o. q.d.
10. Isosorbide 10 mg p.o. t.i.d.
ALLERGIES: HEPARIN, CODEINE, SULFA, CECLOR.
SOCIAL HISTORY: The patient is a reformed smoker after
smoking one and a half packs times 20 years. The patient
denies any current alcohol use. The patient lives in [**Location (un) 7498**] with her husband.
FAMILY HISTORY: Family history is remarkable for peripheral
vascular disease and coronary artery disease.
PHYSICAL EXAMINATION ON PRESENTATION: On admission, the
patient's vital signs were as follows; the patient was
afebrile, heart rate was 98, blood pressure was 132/61,
respiratory rate was 17, with an oxygen saturation of 100% on
2.5 liters of nasal cannula. In general, she was alert and
awake, in no acute distress. Head, eyes, ears, nose, and
throat revealed pupils were equally round and reactive to
light. Her oropharynx was clear. No lymphadenopathy. No
jugular venous distention. Remarkable for bilateral carotid
bruits. Chest examination was clear to auscultation
bilaterally. Cardiovascular examination revealed second
heart sound and second heart sound, tachycardic, a [**4-5**]
decrescendo murmur at her left sternal border. There were no
rubs or gallops appreciated on examination. The abdomen was
obese, soft, nontender, and nondistended. Decreased bowel
sounds in all four quadrants. Extremities revealed there was
no clubbing, no cyanosis, and no edema. Pulses were 3+ by
Doppler in her dorsalis pedis, posterior tibialis, and her
left radial arteries; however, the patient had no right
radial pulse. On neurologic examination, cranial nerves II
through XII were intact. Normal speech. Moved all
extremities. 5/5 strength in extremities, decreased pinprick
sensation at a median distribution of the left hand notable
for flexion contracture of left forearm, and her right palate
drop.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission showed sodium was 138, potassium was 3.8, chloride
was 99, bicarbonate was 25, blood urea nitrogen was 9,
creatinine was 0.5, blood glucose was 135. White blood cell
count was 8.7, hematocrit was 31.8, platelets were 274. On
admission to [**Hospital1 69**], her
creatine kinase was 335, and she had a troponin of 11.2.
RADIOLOGY/IMAGING: Electrocardiogram revealed a normal
sinus rhythm at 80 beats per minute, normal axis, and normal
intervals. No chamber abnormalities. There were 1-mm ST
depressions in leads I, II, aVL, and V3 through V6. T wave
flattening in I, aVL, and aVF which were consistent compared
to baseline electrocardiogram in [**2197-3-31**].
Cardiac catheterization on the day of admission revealed a
proximal left anterior descending artery lesion of 50% with
the first diagonal occluded, the left main coronary artery
with a 30% lesion, left circumflex was patent with the prior
first obtuse marginal, status post percutaneous transluminal
coronary angioplasty, lower first obtuse marginal with a 70%
lesion, right coronary artery with known occlusion with
collateral filling. The saphenous vein graft of first
diagonal had a freshly occluded proximal thrombus. Her left
internal mammary artery was patent, and the left subclavian
stent patent with 20% to 30% in-stent restenosis and normal
central aortic pressures.
HOSPITAL COURSE: The patient was admitted to the Coronary
Care Unit for conservative management of her acute bilateral
myocardial infarction.
1. CARDIOVASCULAR: The patient was continued on aspirin,
beta blocker, ACE inhibitor, statin, and received a
nitroglycerin drip, and was given morphine as needed for
pain. Anticoagulants were held secondary to her recent
history of subdural hematoma and known heparin-induced
thrombocytopenia.
Creatine kinase levels were followed throughout the course of
her hospital stay and peaked at a level of 910. The patient
remained on a medical regimen throughout her hospital course,
and remained on telemetry throughout the remainder of her
hospital stay. The patient was examined by Cardiothoracic
Surgery for any possibility of revascularization. The
patient was told to follow up with Cardiothoracic Surgery as
an outpatient upon discharge.
The patient was weaned off her nitroglycerin drip on hospital
day three and remained off the nitroglycerin drip for the
remainder of her hospital stay, and the patient remained
hemodynamically stable throughout her hospital admission.
(b) Myocardial function: The patient underwent an
echocardiogram on the day of discharge which revealed the
following; the left atrium was mildly dilated, left
ventricular wall thickness was normal, left ventricular
cavity size was normal, overall left ventricular systolic
function was normal with a left ventricular ejection fraction
of 50%; the mid ventricular apical segments of inferior free
wall and anterior free wall were hypokinetic. Right
ventricular chamber size and free wall motion were normal.
The aortic valve leaflets were structurally normal with good
excursion and no aortic regurgitation. The mitral valve
leaflets were structurally normal. There was no mitral valve
prolapse. Moderate 2+ mitral regurgitation was seen. The
mitral regurgitation was extrinsic. There were no
pericardial effusions. Compared with a previous study in [**2196-5-31**], focal left ventricular hypokinesis was now present.
(c) Rhythm: There were no events on telemetry throughout
the time while the patient had a acute myocardial infarction.
(d) Hyperlipidemia: Of note, the patient has a history of
hypercholesterolemia and was referred to the [**Hospital **] Clinic as
an outpatient for evaluation and management of her
hypercholesterolemia as it was believed that this may be a
contributing factor to her severe vascular disease.
2. HEMATOLOGY: The patient has a known history of
heparin-induced thrombocytopenia. Heparin and other
anticoagulants were held throughout this hospital stay.
3. NEUROLOGY: The patient has a history of seizure disorder
and subdural hematoma in [**2197-3-31**]. The patient was
continued on her usual outpatient regimen of Depakote
throughout this stay. The patient had remained
neurologically stable throughout her hospital stay with no
seizure activity noted.
4. ENDOCRINE: The patient has a history of hypothyroidism
and was continued on her Synthroid medication throughout her
hospital stay.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharged to home with physical therapy
as needed.
DISCHARGE DIAGNOSES: Acute myocardial infarction.
MEDICATIONS ON DISCHARGE: (Medication regimen at discharge
is the same as outpatient medications on admission with the
exception of a change in her dose of Lopressor from 100 mg
p.o. t.i.d. to 50 mg p.o. b.i.d. as the patient's blood
pressure remained systolically around 95 throughout the
remainder of her hospital stay).
1. Aspirin 325 mg p.o. q.d.
2. Zocor 80 mg p.o. q.d.
3. Lopressor 50 mg p.o. b.i.d.
4. Accupril 5 mg p.o. q.d.
5. TriCor 108 mg p.o. q.d.
6. Pepcid 20 mg p.o. q.d.
7. Synthroid 125 mcg p.o. q.d.
8. Depakote 500 mg p.o.
9. Folic acid 1 mg p.o. q.d.
10. Isosorbide 10 mg p.o. t.i.d.
DISCHARGE INSTRUCTIONS:
1. The patient was told to follow up with her primary care
physician within the next two weeks.
2. The patient was to follow up with Dr. [**Last Name (STitle) **] of Cardiology
within the next few weeks.
3. The patient was given the number to follow up with
Cardiothoracic Surgery with regard to revascularization.
DR [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 12.749
Dictated By:[**Last Name (NamePattern4) 33595**]
MEDQUIST36
D: [**2197-10-4**] 16:15
T: [**2197-10-11**] 06:46
JOB#: [**Job Number **]
ICD9 Codes: 2720, 2449, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8754
} | Medical Text: Admission Date: [**2190-11-23**] Discharge Date: [**2190-12-11**]
Date of Birth: [**2128-8-24**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
female with a past medical history significant for chronic
obstructive pulmonary disease and asthma who is on two liters
of home oxygen, not on chronic steroids, spontaneous right
pneumothorax, status post suction with video-assisted
thoracic surgery, and talc pleurodesis who now presents with
a history of two to three days of increasing shortness of
breath, chest tightness, and a cough productive of yellow
sputum.
The patient denied any chest pain, fever, or cough; but the
patient did report upper respiratory tract symptoms beginning
two days prior to admission. Her baseline exercise tolerance
is half to one block. She has a chronic with white sputum
with oxygen saturations of 96% on room air with 90% on
ambulation.
In the Emergency Department, the patient's blood pressure was
evaluated at 180/70. Her heart rate was elevated at 130.
Respiratory rate was 20. Her oxygen saturation was 94% on
room air. Initially, she was given albuterol nebulizers but
became increasing dyspneic with a respiratory rate to 30.
Arterial blood gas was 7.03, PCO2 was 105, PO2 was 198, and
the patient was intubated for airway protection. A chest
x-ray revealed hyperinflated lungs, bilateral apical bola, no
infiltrate. She was given Levaquin 500 mg intravenously,
Solu-Medrol 125 mg intravenously, with one and a half liters
of IVF in the Emergency Department and transferred to the
Medical Intensive Care Unit for further workup.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease with a FEV1 of 32%
of predicted; on two liters of oxygen at home. Baseline PCO2
of 50s to 60s.
2. Asthma.
3. Status post spontaneous pneumothorax in [**2190-1-29**]
with resection and right pleurodesis via video-assisted
thoracic surgery.
4. Hypertension.
5. Osteoarthritis.
6. Bilateral total hip replacement.
7. Herpes zoster virus in [**2189-3-1**].
8. Multiple chronic obstructive pulmonary disease
admissions; no prior intubations.
MEDICATIONS ON ADMISSION:
1. Flovent 110 mcg 3 puffs inhaled b.i.d.
2. Atrovent 2 puffs inhaled q.i.d.
3. Serevent 2 puffs inhaled b.i.d.
4. Vitamin D 400 units p.o. q.d.
5. Tums.
6. Albuterol as needed.
7. Levoxyl.
8. Hydrochlorothiazide.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed temperature was 98.7, blood pressure was 101/66, and
heart rate was 84. Respiratory revealed pressure control
ventilation was 26/10, respiratory rate was 12, 40% FIO2,
tidal volumes in the high 600s, oxygen saturation was 98% to
97%. Most recent arterial blood gas on that setting was
7.17/61/67. In general, the patient was awake, responded to
commands. In no acute distress. Head, eyes, ears, nose, and
throat examination revealed mucous membranes were moist.
Neck examination revealed no jugular venous distention.
Lungs revealed diffuse inspiratory and expiratory wheezes
with decreased breath sounds at the bases. Cardiovascular
examination revealed distant first heart sound and second
heart sound. No murmurs, rubs, or gallops. The abdomen was
soft, nontender, and nondistended. Decreased bowel sounds.
No masses. Extremity examination revealed no clubbing,
cyanosis, or edema. No rashes.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed complete blood count with a white blood cell count
of 3.5, hematocrit was 30.9, and platelets were 130. INR was
1. Chemistry-7 revealed sodium was 136, potassium was 4.4,
chloride was 107, bicarbonate was 19, blood urea nitrogen was
23, creatinine was 1.1, and blood glucose was 207. Calcium
was 7.4, magnesium was 2.2, and phosphorous was 2.1.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray revealed
hyperinflated lungs with flattened diaphragm. Bilateral
pleural thickening versus pleural effusion, congestive heart
failure, a sixth rib fracture. No pneumonia. No congestive
heart failure.
Electrocardiogram revealed sinus tachycardia at 140, normal
axis and normal intervals. T wave flattening in lead I and
aVL. 1-mm ST depressions in leads V5 and V6. Left atrial
hypertrophy.
HOSPITAL COURSE: Her hospital course was notable for the
development of metabolic acidosis which the Renal Service
attributed to ethanol-induced nontubular acidosis. She was
given bicarbonate times one day and then self-corrected. She
was given intravenous steroids and nebulizers, and she was
extubated on [**2190-12-3**] but had to be reintubated 20
minutes later because of fatigue. She was felt to have
ventilator associated pneumonia and was started on
ceftazidime for a question of left lower lobe infiltrate on
[**2190-12-3**]; although, all chest x-rays had been
negative.
On [**2190-12-6**], she was extubated and did well. She was
weaned off systemic steroids. Evaluation revealed evidence
of granulation tissue; probably secondary to gastroesophageal
reflux disease prompting continuation of Protonix. A bedside
evaluation revealed evidence of aspiration. She also
received Valium for ethanol withdrawal and tachycardia. She
had no complaints, and review of systems was only positive
for a sore throat and weakness.
She called out to the floor on [**2190-12-7**]. She was
restarted on intravenous steroids, calcium, and vitamin D. A
video swallow was performed which revealed aspiration of both
thin and nectar-thick liquid. She was seen again by
Otorhinolaryngology who did a flexible bronchoscopy which
revealed slight edema of the vocal cords, normal mobility,
less than 3-mm granuloma of the right vocal process,
completely normal post intubation. It was felt to continue
to watch, continue proton pump inhibitor, and repeat the
video in one to two weeks.
Her systemic steroids continued to be weaned. She was
continued on nebulizers and meter-dosed inhalers.
Cefpodoxime was continued for a 10-day course. A pureed diet
was continued.
DISCHARGE DISPOSITION: The patient was encouraged to quit
smoking. The patient was discharged to home with services on
[**2190-12-11**]. The patient was to follow up with
Ear/Nose/Throat in two weeks.
MEDICATIONS ON DISCHARGE:
1. Folate 1 mg p.o. q.d.
2. Thiamine 100 mg p.o. q.d.
3. Atrovent meter-dosed inhaler 2 puffs inhaled q.i.d.
4. Tums p.o. t.i.d.
5. Prednisone 60-mg taper.
6. Protonix 40 mg p.o. q.d.
7. Iron 325 p.o. q.d.
8. Vitamin D 400 units p.o. q.d.
9. Salmeterol 2 puffs inhaled b.i.d.
10. Fluticasone 100 mcg 8 puffs inhaled b.i.d.
11. Cefpodoxime 200 mg p.o. b.i.d. (times three additional
days).
12. Albuterol meter-dosed inhaler.
DISCHARGE DIAGNOSES:
1. Chronic obstructive pulmonary disease and asthma
exacerbation; status post intubation.
2. Aspiration pneumonia.
3. Laryngeal muscle damage; status post intubation.
4. Alcohol withdrawal.
5. Tobacco dependence.
DISCHARGE STATUS: Discharge status was to home with
services.
CONDITION AT DISCHARGE:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 2918**]
MEDQUIST36
D: [**2191-1-28**] 11:46
T: [**2191-1-29**] 04:19
JOB#: [**Job Number 99227**]
ICD9 Codes: 5070, 2762, 2765, 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8755
} | Medical Text: Admission Date: [**2188-5-31**] Discharge Date: [**2188-6-1**]
Date of Birth: [**2134-8-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
Central venous line
Diagnostic Paracentesis
Endotracheal Intubation and ventilation
History of Present Illness:
53M Hep C cirrhosis, smoldering myeloma, here with hypoglycemia.
Recently discharged one week prior with the following issues: 1)
liver failure secondary to Hep C Cirrhosis, 2) new diagnosis of
smoldering myeloma ([**1-17**] anemia), 3) esophageal candidiasis, 4)
suicidal ideation.
Now presents initially with hypoglycemia (fs 20), mental status
changes. Found to have profound metabolic acidosis with bicarb
of 9, AG of 20 (corrected to 27, albumin 1.1), Lactate of 15.4.
Treated empirically with vanco/levo/flagyl. Subsequently, SBP
fell to 90s, then to 50s, and required 7L IVF, started on
levophed. However, MAPs apparently persistently in 50s despite
levophed. Diagnostic paracentesis notable for 2300 WBC,
28%neuts, 21%lymphs, 1% bands, but 6125 RBCs. Began to
experience respiratory distress secondary to volume overload and
was intubated.
On arrival, pt noted to be moving all four extremities, with
livedo, intubated.
Past Medical History:
1. Hepatitic C cirrhosis- Genotype 1. Pt was previously treated
with intron A and Rebetron. He is currently on the transplant
list with a MELD score of 14 as of [**2-20**]-- in speaking with the
liver fellow, it is now increased to around 20. Pt with Grade 1
varices on EGD from 05/[**2187**]. Etiology of hepatitis C felt to be
intranasal cocaine versus tatoos.
2. Early encephalopathy
3. Recurrent abdominal ascites
4. Thrombocytopenia
5. Splenomegaly
6. Cholelithiasis
7. Duodenal ulcer- EGD [**2188-4-24**]. Pt was treated with triple
therapy fo H pylori. Pt reports that he was supposed to start on
protonix following completion of this medication but has not yet
done so.
8. Anemia
9. Obesity
Social History:
Pt is married and lives with his wife. Denies tobacco use. Prior
ETOH use but quit 5-6 years ago. Smoked marijuana 30-40 years
ago--- no current illicit drug use. Worked as a schoolteacher
(teaches shop).
Family History:
NC
Physical Exam:
VS 81 85/33 31 78%
GENERAL: Intubated, sedated
HEENT: PERRL, EOMI, intubated
NECK: Supple, L IJ
CARDIOVASCULAR: S1, S2, reg, tachy
LUNGS: L base rhonchorous, o/w clear
ABDOMEN: Distended, nontender, hypoactive bowel sounds.
EXTREMITIES: Cool, livedo present
NEURO: Intubated and sedated.
Pertinent Results:
[**2188-5-31**] 10:40PM LACTATE-13.3*
[**2188-5-31**] 10:40PM O2 SAT-95
[**2188-5-31**] 10:11PM PLEURAL WBC-2300* RBC-6125* POLYS-28* BANDS-1*
LYMPHS-21* MONOS-24* EOS-26*
[**2188-5-31**] 09:22PM LACTATE-12.2*
[**2188-5-31**] 08:18PM URINE HOURS-RANDOM
[**2188-5-31**] 08:18PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2188-5-31**] 08:18PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-NEG
[**2188-5-31**] 07:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-8.8
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2188-5-31**] 07:00PM PT-35.8* PTT-64.3* INR(PT)-3.9*
[**2188-5-31**] 06:55PM AMMONIA-132*
[**2188-5-31**] 06:55PM LACTATE-15.4* K+-4.6
[**2188-5-31**] 06:50PM GLUCOSE-58* UREA N-27* CREAT-3.1*#
SODIUM-125* POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-9* ANION GAP-24*
[**2188-5-31**] 06:50PM ALT(SGPT)-98* AST(SGOT)-130* CK(CPK)-285* ALK
PHOS-72 AMYLASE-43
[**2188-5-31**] 06:50PM LIPASE-12
[**2188-5-31**] 06:50PM ALBUMIN-1.1* CALCIUM-8.2* PHOSPHATE-8.3*#
MAGNESIUM-2.2
[**2188-5-31**] 06:50PM CORTISOL-38.2*
[**2188-5-31**] 06:50PM CRP-49.2*
[**2188-5-31**] 06:50PM WBC-2.0* RBC-2.72* HGB-10.4* HCT-33.3*
MCV-123*# MCH-38.3* MCHC-31.2 RDW-19.4*
[**2188-5-31**] 06:50PM NEUTS-5* BANDS-18* LYMPHS-1* MONOS-0 EOS-4
BASOS-0 ATYPS-1* METAS-3* MYELOS-2* NUC RBCS-7* OTHER-66*
[**2188-5-31**] 06:50PM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-3+ MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
[**2188-5-31**] 06:50PM PLT SMR-VERY LOW PLT COUNT-69*
[**2188-5-31**] 06:50PM GRAN CT-340*
Head CT:
No evidence of acute intracranial hemorrhage or change from
prior study. MRI with diffusion-weighted images more sensitive
in the evaluation for acute ischemia/infarct.
CXR:
Lungs are much lower in volume, accounting for some interval
increase in heart size. The azygos vein is distended and there
is a suggestion of mild edema in the right lung, but the
combination of hypotension and large heart raises concern for
pericardial effusion and cardiac tamponade. There is no
appreciable pleural effusion. Lateral aspect of the left chest
is excluded from the examination. Other pleural surfaces give no
indication of pneumothorax.
Brief Hospital Course:
53M hep C cirrhosis, smoldering myeloma, here with catastrophic
metabolic acidosis, likely secondary to renal failure and
sepsis.
* Goals of care: On arrival to MICU, discussed with wife. Pt
would wish to have death with dignity, therefore, it was decided
that labs would be drawn to determine if pt had further
decompensated despite full aggressive care. If so, would
proceed to comfort measures only. In the intervening time, pt
was made DNR.
* Shock: Most likely secondary to sepsis, secondary to bacterial
peritonitis. Volume resuscitated with crystalloid to CVP>12.
Maxed out on levophed immediately on arrival to MICU and started
on neosynephrine with only modest effect. MAPs could not be
maintained above 60. Initially planned to start vasopressing
and then dobutamine to maximize cardiac output, however, given
above goals of care and discussion with family, no further
escalation of care was undertaken.
* Acidosis: Most likely secondary to combination of liver, renal
failure, and sepsis. Given shock, given two amps of bicarb
stat, then started bicarb infusion to maximize effect of
pressors.
* Sepsis: Vanco/levo/flagyl given empirically. Subsequent to
death of patient, gram stain of peritoneal fluid was found to
contain heavy GNR along with PMNs, suggesting that most likely
source of overwhelming sepsis was bacterial peritonitis,
although primary reason for this was unclear.
On reevaluation of laboratory values, pt was found to have
continued profound acidosis, profound coagulopathy, continued
failure of gluconeogenesis, other liver dysfunction, as well as
rising potassium. Therefore, given continued dismal prognosis
and patient's wishes, care was withdrawn. Death was declared at
0350.
Medications on Admission:
1. Furosemide 20 mg
2. Spironolactone 50mg [**Hospital1 **]
3. Lactulose (30) ML PO TID
4. Pantoprazole 40 mg Q12H
5. Magnesium Oxide
6. Nystatin 100,000 unit/mL Suspension
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Overwhelming Sepsis
Acute Liver Failure
Bacterial peritonitis
Metabolic Acidosis
Livedo
Acute Renal Failure
Hyperkalemia
Hypoxic respiratory failure
Septic shock
Discharge Condition:
Deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
ICD9 Codes: 0389, 5849, 2762, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8756
} | Medical Text: Admission Date: [**2144-1-15**] Discharge Date: [**2144-1-20**]
Date of Birth: [**2082-2-12**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Keflex / darvon / darvocet / percocet / Percodan
/ strawberry
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Abdominal pain and fever
Major Surgical or Invasive Procedure:
ERCP with stone extraction and stent placement
History of Present Illness:
The patient is a 61yo F depression presenting with
choledocholithiasis with PMH notable for choledocolithiasis 10
years ago s/p CCY.
.
Per patient report and record patient with h/o with
choledocolithiasis s/p gallbladder removal in [**2134**] which was
complicated by cystic stump leak s/p ERCP with sphincterotomy
and stent placment with further complication of duodenal
perforation. Patient has been without instrumentation since that
time.
.
Patient had been in USOH when presented to [**Hospital3 **] with
5 days of abdominal pan [**10-12**], nausea, vomiting and poor po
intake with associated weight loss. She has also noticed
"yellow" stools during this time period as well. She has also
been having subjective fevers and chills. The patient underwent
CT scan that showed a 5x7mm in the CBD with intrahepatic ductal
dilation with air concerning for gas-forming organism. Her
baseline SBP are usually in the 90's per report. She had
documented pressures as low as the 60's at the OSH. She was
given 5L IVF and started on peripheral neo at 50mcg/min. She was
covered with levofloxacin/flagyl/zosyn/vanco po. She was
transferred to [**Hospital1 18**] ED for further evaluation.
.
In the ED, 97.1 93 88/59 18 100% 3L. The patient's labs were
significant leukocytosis of 11.7, Hct 29.7. LFT were remarkable
for TBili 7.3, AP 243, ALT: 95 and AST 40. The patient was
weaned off pressors in the ED. The patient was seen by surgery
who will continue to follow along. The patient was also
evaluated by ERCP with plans to perform the procedure in the AM.
.
On the floor the patient reports feeling better and painis
improved to [**1-13**].
.
ROS: The patient denies any nausea, vomiting, abdominal pain,
diarrhea, constipation, melena, hematochezia, chest pain,
shortness of breath, orthopnea, PND, lower extremity edema,
cough, urinary frequency, urgency, dysuria, lightheadedness,
gait unsteadiness, focal weakness, vision changes, headache,
rash or skin changes.
Past Medical History:
Depression
Fibromyalgia
s/p parathyroidectomy [**2140**] for adenoma,
s/p Cholecystectomy [**2134**]
-- biliary sphincterotomy and placement of biliary stent with
subsequent removal. ERCP complicated by duodenal perforation
Social History:
Patient quit smoking 20years ago with a 40 pack year history.
Occasional ETOH. Denies IVDU
Family History:
Mother died of breast cancer at 54
Physical Exam:
VS: Temp: BP: / HR: RR: O2sat
GEN: pleasant, comfortable, NAD, jaundice, tired appearing
HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no JVD
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: + tenderness over the umbilicus. tenderness to deep
palpation over the epigastric and RUQ, +b/s, soft
EXT: no c/c/e
SKIN: no rashes/ jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
Pertinent Results:
labs on admission:
[**2144-1-14**] 10:40PM BLOOD WBC-11.7*# RBC-3.50* Hgb-10.6* Hct-29.7*
MCV-85 MCH-30.2 MCHC-35.6* RDW-12.9 Plt Ct-220
[**2144-1-14**] 10:40PM BLOOD Neuts-92.5* Lymphs-4.8* Monos-2.5 Eos-0
Baso-0.2
[**2144-1-14**] 10:40PM BLOOD PT-15.6* PTT-25.6 INR(PT)-1.4*
[**2144-1-14**] 10:40PM BLOOD Fibrino-712*
[**2144-1-14**] 10:40PM BLOOD Glucose-125* UreaN-14 Creat-0.8 Na-140
K-3.4 Cl-110* HCO3-23 AnGap-10
[**2144-1-14**] 10:40PM BLOOD ALT-95* AST-40 AlkPhos-243* Amylase-9
TotBili-7.3*
[**2144-1-14**] 10:40PM BLOOD Lipase-13 GGT-262*
[**2144-1-14**] 10:40PM BLOOD Albumin-3.2* Calcium-8.3* Phos-2.2*
Mg-1.9 Cholest-122
[**2144-1-14**] 10:40PM BLOOD Triglyc-136 HDL-7 CHOL/HD-17.4 LDLcalc-88
[**2144-1-15**] 01:30AM URINE RBC-0-2 WBC-[**6-12**]* Bacteri-MOD Yeast-NONE
Epi-0-2
[**2144-1-15**] 01:30AM URINE Blood-SM Nitrite-NEG Protein-75
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-NEG pH-5.0 Leuks-TR
[**2144-1-15**] 01:30AM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.018
CXR: PA & Lateral: Widened mediastinal contour is unchanged and
may be secondary to underlying vascular abnormality/tortuosity
or possibly an underlying mass. An 11-mm nodular opacity
overlies the right first anterior rib. There is no pneumothorax.
There is slight blunting of the costophrenic angles. IMPRESSION:
Prominent mediastinal contour and nodular right apical opacity,
for which dedicated contrast-enhanced Chest CT is recommended
for further evaluation.
ERCP:
Impression: Successful biliary cannulation
Stones at the main duct
Successful stone extraction with spiral basket.
Pus exiting the ampulla
There was a suggestion of narrowing at the biliary hilum
Successful placement of 10cm x 10F biliary stent.
Otherwise normal ercp to third part of the duodenum
Recommendations: Please call Dr.[**Name (NI) 2798**] office at
[**Telephone/Fax (1) 2799**] with any further questions or concerns.
Please call the on call ERCP fellow at [**Telephone/Fax (1) 2756**] with any
immediate concerns such as fever, abdominal pain, bleeding,
following your procedure.
Watch for bleeding, perforation, and pancreatitis.
Repeat ERCP in 3 weeks with Dr. [**Last Name (STitle) **] for stent removal and
reassement of duct for residual stone or stricture.
Continue antibiotic therapy for 14 days.
CT CHEST:
IMPRESSION:
A roughly 11-mm wide right upper lobe nodule corresponding to
lesion seen on
recent chest radiograph should be considered malignant until
proved otherwise.
Any prior chest radiograph should be obtained to see if the
lesion is
longstanding. Otherwise PET CT scanning or short-term followup
in three
months would constitute imaging management. The lesion should be
accessible
to transthoracic CT-guided needle aspiration.
Brief Hospital Course:
61F with history of prior chole c/b stump leak in past now
admitted with findings c/w acute cholangitis / 5x7mm CBD stone.
Febrile o/n but HD stable.
.
# Cholangitis: Patient presented to OSH with symptoms os fevers,
RUQ tenderness and jaundice. CT scan from OSH demonstrated
pneumobilia and a stone in the CBD with intrahepatic ductal
dilation. Initially hypotensive at outside hospital requiring
pressors, however on arrival patient fluid responsive
(Resuscitated with ~6L IVF) and pressors weaned. Patient
continued on Vancomycin and Zosyn for antibiotic coverage. ERCP
was consulted and patient underwent uncomplicated ERCP on
[**2144-1-16**]. ERCP demonstrated successful biliary cannulation,
stones at the main duct, successful stone extraction with spiral
basket, pus exiting the ampulla, and successful placement of
10cm x 10F biliary stent. Her diet was advanced the following
morning to clears, which resulted in increased nausea and
abdominal pain. She then had intermittent abd pain for the next
few days. We suspected mild post ERCP pancreatitis. After more
IVF her pain improved. Repeat LFTs showed improved T. bili,
with mild transaminitis. She was transitioned to Cipro/Flagyl
for which she will need a 14 day total course
- she will need repeat ERCP in 3 weeks
- we recommend repeating LFTs on PCP follow up.
.
# Chest CT Abnormalities: Hilar and right apical abnormalities
noted on initial CXR and on repeat PA/Lateral. CT scan showed
prelim read was 11 x 9mm pulmonary nodule in the right apex,
also with right apical and basilar lung acarring/atelectasis.
PET/CT can be considered for evaluation of metabolic activity).
Given patient's 50 pack-year history and recent 30 pound
unintentional weight loss, this will require close follow-up to
rule-out malignancy.
Final read:
A roughly 11-mm wide right upper lobe nodule corresponding to
lesion seen on
recent chest radiograph should be considered malignant until
proved otherwise.
Any prior chest radiograph should be obtained to see if the
lesion is
longstanding. Otherwise PET CT scanning or short-term followup
in three
months would constitute imaging management. The lesion should be
accessible
to transthoracic CT-guided needle aspiration.
--these findings were discussed with the patient and she
understands the possibility of maligancy.
.
# Coagulopathy: Patient's INR elevated at 1.4 on admission. No
evidence of DIC, fibrinogen was 712. Likely Vit K def in the
setting of poor nutrition. Stable at time of discharge.
.
# Diarrhea: C.difficile sent and was negative.
Medications on Admission:
Codeine
Xanax 2-3mg qhs
Discharge Medications:
1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 9 days.
Disp:*18 Tablet(s)* Refills:*0*
2. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 9 days.
Disp:*27 Tablet(s)* Refills:*0*
3. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
5. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
Disp:*15 Tablet(s)* Refills:*0*
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation: over the counter.
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation: over the counter.
8. alprazolam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)).
9. Outpatient Lab Work
CBC, AST, ALT, Alk phos, T. bili at next follow up.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Cholangitis
Pulmonary nodule
Fibromyalgia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred to the [**Hospital1 18**] for further evaluation and
treatment of your cholangitis. You underwent ERCP with stone
removal and stent placement and were treated with IV
antibiotics. These were transitioned to oral antibiotics, which
you will need to continue taking for a total of 14 days.
As we discussed, you were found to have a lung nodule of
uncertain significance, though it might be a cancer. Please
follow-up with your primary care physician regarding the
pulmonary nodule found on your chest CT as soon as possible.
Medications started:
Ciprofloxacin 500mg twice daily
Flagyl 500mg three times daily (Avoid with alcohol)
Dilaudid as needed for pain. Do NOT use with alcohol or
driving, take with stool softeners
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 10543**] on Thursday, [**1-23**] at
1:30. You will also need to follow-up with the ERCP for a repeat
ERCP in three weeks for stent removal. Their office will be in
contact with you to schedule that procedure.
PCP: [**Last Name (NamePattern4) **].[**Last Name (STitle) 10543**]
Location: [**Hospital3 **] INTERNAL MEDICINE
Address: [**Street Address(2) 4472**]., [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
ICD9 Codes: 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8757
} | Medical Text: Admission Date: [**2111-10-29**] Discharge Date: [**2111-11-5**]
Date of Birth: [**2043-12-14**] Sex: F
Service: SURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Collapsed at home, bright red blood per rectum after recent
hospitalization for upper GI bleed.
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy x 2 - [**10-29**], visible vessels clipped
on [**10-30**]
Colonoscopy [**11-2**]
History of Present Illness:
The patient is a 67 year-old female who was admitted to Dr. [**Name (NI) 74681**] service for a GI Bleed [**Date range (1) 74682**]/07 during which she
recieved 12 units of PRBCs and was found to have a bleeding
ulcers in the antrum & duodenum. She was also started on H
Pylori treatment after her assay was reportedly positive
elsewhere. She was doing well until the day of readmission when
she again started to pass bright red blood per rectum. She had
one episode on the morning of admission and felt her knees give
out afterward. She was brought by EMS to [**Hospital 1562**] Hospital
where her hematocrit was 20. She was transfered from [**Hospital 1562**]
Hospital while recieving her first unit of PRBCs. An NG tube
was placed prior to transfer and lavage reportedly did not
return any blood. The patient denied abdominal pain,
nausea/vomiting, chest pain, shortness of breath.
Past Medical History:
Past Medical History:
- Diabetes mellitus
- End stage renal disease on hemodiaylsis
- hypertension
- coronary [**Last Name (un) **] disease
- peptic ulcer disease
- congestive heart failure
- diverticulitis
Past surgical history:
- appendectomy
- cholecystectomy
- c-section
Social History:
No alcohol, tobacco, drugs. Lives with husband in [**Name (NI) 1562**], MA.
Family History:
not ascertained
Physical Exam:
(per Dr. [**Last Name (STitle) **] on day of admission)
EXAM: HD normal (see nursing note)
Alert, NAD, anicteric
Op-clear, no evidence epistaxis, NGT clear, non-bloody,
non-bilious.
CTAB
RRR
Abdomen-obese, soft, non-tender, non-distended, no mass or
hernia.
Ext-LUE dialysis graft with pulse/thrill
-feet warm, 1+ PT bilaterally
-R.groin CVL
Pertinent Results:
Hematocrit - 21.8 - 30.2 (stable at 31.1 on discharge)
Gastrin (drawn on last admission) - 854
[**10-29**] Esophagogastroduodenoscopy - Normal esophagus. Stomach:
Multiple superficial non-bleeding ulcers were found in the
stomach body, fundus and antrum at various stages of healing.
Prior bicapped ulcer was seen in proximal body- no evidence of
active or recent bleeding. Visible vessel still noted in ulcer.
Additional visible vessel noted in fundus. Nonbleeding.
Duodenum: Normal duodenum.
[**10-30**] Esophagogastroduodenoscopy - Normal mucosa in the
esophagus. Normal mucosa in the duodenum. Blood in the fundus.
Ulcer in the fundus. Visible vessel was seen in the fundus
without clear surrounding ulcer. A clot was adherent to the
vessel and there was stigmata of recent bleeding. Five clips
were placed with good hemostasis. No other sources of bleeding
were seen.
[**2111-11-2**] Colonoscopy - Ulceration, friability and erythema in the
terminal ileum (biopsy), Ulceration, friability and erythema in
the splenic flexure, at approximately 70 cm compatible with
colitis, possibly ischemic (biopsy), Otherwise normal
colonoscopy to cecum
Pathology: Terminal ileum: Active ileitis with ulceration and
granulation tissue; Cecum: Within normal limits; Transverse:
Ulceration with granulation tissue; No granulomas, viral
inclusions, or dysplasia seen.
Urinalysis [**10-29**] - small blood, 100 protein, moderate leukocytes;
0-2 red blood cells, >50 white blood cells, moderate bacteria,
[**4-13**] epithelial cells
Urine Culture [**10-29**] - >100,000 Klebsiella, sensitive to all
antibiotics tested
Brief Hospital Course:
*) GI bleeding - The patient was admitted to the intensive care
unit and underwent an esophagogastroduodenoscopy on hospital day
#1 that demonstrated multiple old ulcers, two visible vessels in
the stomach but no active bleeding. No interventions were
performed. After an episode of hematemesis on hospital day #2,
a second esophagogastroduodenoscopy was performed that showed a
vessel in a fundal ulcer with stigmata of recent bleeding. This
vessel was clipped x 5. While in the emergency department and
ICU, the patient received a total of 8 units of packed red blood
cells (last on [**10-31**] - hospital day #3), subsequently, her
hematocrit was stable. She was transfered out of the intensive
care unit to the floor on hospital day #3. She underwent a
colonoscopy on hospital day #5 that demonstrated an area of
colitis supicious for ischemic colitis; pathology showed
nonspecific findings that, according to GI, were most consistent
with ischemia. A vascular surgery consult recommended no
intervention at this time. Throughout her admission, she was
maintained on Protonix 40mg 2x/day and sucralfate.
*) Urinary tract infection - the patient was given a 7 day
course of Ciprofloxacin for the positive urinalysis on
admission, urine culture grew Klebsiella sensitive to all
antibiotics tested, including Cipro. Completed 5 days in the
hospital, will receive 2 final days as outpatient.
*) Hemodialysis - the patient received ultrafiltrate
hemodialysis while in the hospital. Given her heparin-induced
thrombocytopenia, no heparin was used during dialysis. Used
citrate for clotting.
*) H. Pylori - Given reported positive H. pylori assay from
outside hospital and incomplete course of clarithromycin and
amoxicillin from last admission (planned course 2 weeks, actual
course 8 or 9 days), the patient was again started on a planned
one week course of the same antibiotics. She had one day in the
hosptial and is to receive the final 6 days as an outpatient.
Medications on Admission:
Amoxicillin 250 mg PO daily
B Complex-Vitamin C-Folic Acid 1 mg PO daily
Calcium Acetate [PhosLo] 667 mg PO daily
Clarithromycin 250 mg 2x/day
Vytorin 10-40 1 tablet daily
Felodipine sustained release 5 mg Tues,[**Last Name (un) **],Sat
Lantus 60U qhs
Humalog sliding scale
Metoprolol 100mg daily
Miconazole Nitrate 2 % Powder topically 4x/day
Pantoprazole 40mg delayed release every 12 hours
Valsartan 160mg daily
Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a
day.
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: Two (2)
Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Insulin Glargine 100 unit/mL Solution Sig: Sixty (60) units
Subcutaneous once a day.
9. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous
qAMACHS.
10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
11. Felodipine 5 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO Tu,Th,[**Last Name (LF) **],[**First Name3 (LF) **].
12. Clarithromycin 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 7 days.
Disp:*13 Tablet(s)* Refills:*0*
13. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q24H
(every 24 hours) for 6 days.
Disp:*12 Capsule(s)* Refills:*0*
14. Cipro 500 mg Tablet Sig: One (1) Tablet PO once a day for 2
days.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Male First Name (un) **] nursing center
Discharge Diagnosis:
multiple gastric and duodental ulcers, upper GI bleeding,
mesenteric ischemia
Discharge Condition:
stable
Discharge Instructions:
Please return to emergency room or notify your physician for any
of the following: Bleeding from mouth or rectum, dark/black
stools, abdominal pain, shortness of breath, dizziness,
increasing weakness, [**Male First Name (un) **] over 101.4, nausea and/or vomiting,
or any other symptoms that are concerning to you. Continue a
soft diet.
Followup Instructions:
Please follow up with your regular gastroenterologist,
cardiologist, nephrologist.
ICD9 Codes: 2851, 5856, 4280, 5990, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8758
} | Medical Text: Admission Date: [**2134-3-30**] Discharge Date: [**2134-4-4**]
Date of Birth: [**2087-6-8**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lipitor / Metoprolol
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
coronary artery bypass graft x1 (LIMA-LAD)
Past Medical History:
PAST MEDICAL HISTORY:
-Diabetes type I
-ORIF of right wrist [**2115**]
-s/p fasciotomy of left leg for compartment syndrome
-s/p fractured calcaneus c/b prolonged healing period
-diabetic retinopathy s/p laser surgery OU
-basal cell cancer from left lower extremity
-hypertension
-hypercholesterolemia
-retinal hemorrhage x2 [**5-28**] after laser surgery
Social History:
Caucasian
[**Hospital1 18**] [**Name8 (MD) 110027**] RN on [**Wardname **].
Lives in [**Location 1411**] with partner.
Non-[**Name2 (NI) 1818**]. Rare ETOH
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; father died of lung cancer in 50's, uncle
had CAD in 60's.
Pertinent Results:
Intra-op ECHO
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
[**Name2 (NI) **]: Normal ascending [**Name2 (NI) 5236**] diameter. Simple atheroma in
descending [**Name2 (NI) 5236**].
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-procedure:
No spontaneous echo contrast is seen in the left atrial
appendage.
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 [**Name2 (NI) 5236**].
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 pericardial effusion.
Post-Procedure:
The patient is in SR on no infusions.
Preserved biventricular systolic fxn.
No AI, no MR. [**First Name (Titles) **] [**Last Name (Titles) 5235**].
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2134-3-30**] 14:51
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2134-3-30**] where the patient underwent CABGx1
(LIMA-LAD). Overall the patient tolerated the procedure well
and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Cefazolin was
used for surgical antibiotic prophylaxis. POD 1 the patient was
extubated, alert and oriented and breathing comfortably. The
patient was neurologically [**Date Range 5235**] and hemodynamically stable on
no inotropic or vasopressor support. Pateint reports depression
and profound hypoglycemia with beatblockers so, diltiazem was
started. Ms. [**Name13 (STitle) 1025**] was gently diuresed toward the preoperative
weight. The patient was transferred to the telemetry floor for
further recovery. Chest tubes and pacing wires were
discontinued without complication. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility and was cleared for discharge to home. Ms. [**Name13 (STitle) 1025**]
developed hematuria on POD#3. She notified the surgical team on
POD#4. She had mild right sided low back pain that she thought
was musculoskletal which was relieved with percocet. She denied
dysuria. Renal ultrasound was negative. Her urinalysis was
postive and she was started on cipro course. Her hematuria
improved but did not completely resolve on POD#5. She remained
afebrile with a WBC 4.9. She was cleared for discharge to home
by Dr. [**Last Name (STitle) **] on POD#5 in good condition, ambulating freely with
appropriate follow up instructions. Her sternal wound was
healing well without drainage or redness. Her Niaspan was not
resumed due to her risk of hypoglycemia per her endocrinologist.
Medications on Admission:
ASA 325', Diltiazem 120', Lantus 12u qAM, Novolog SS, Lisinopril
20', Lorazepam 0.5mg q6/PRN, MVI, Niaspan 1500', Plavix 75',
Pravastatin 40'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. 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*
6. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
8. Lantus 100 unit/mL Cartridge Sig: Sixteen (16) units
Subcutaneous once a day.
Disp:*1 cartiridge* Refills:*2*
9. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*5 Tablet(s)* Refills:*0*
10. Ciprofloxacin 500 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:
[**Hospital3 **] Home Care
Discharge Diagnosis:
Hypertension, Hyperlipidemia,s/p stents RCA [**5-28**], LCx [**8-28**],
Insulin dependent diabetic with insulin pump, Diabetic
retinopathy- s/p laser surgery OU complicated by retinal
hemorrhage x2 [**5-28**], Anemia of chronic disease, s/p ORIF R wrist
'[**15**], s/p fasciotomy RLE compartment syndrome, s/p fractured
calcaneus c/b prolonged healing, s/p excision of basal cell
Carcinoma of left lower extremity
Discharge Condition:
alert and oriented
ambulation independently
sternal incision clean and dry.
No Leg incision- 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 until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**2134-5-6**] at 1pm.
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3649**] in [**11-21**] weeks
Cardiologist Dr. [**Last Name (STitle) **] in [**11-21**] weeks
You have a wound check in 2 weeks on [**Wardname 5010**].
Completed by:[**2134-4-4**]
ICD9 Codes: 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8759
} | Medical Text: Admission Date: [**2153-6-15**] Discharge Date: [**2153-6-20**]
Date of Birth: [**2074-12-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9415**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 22305**] is a 78 yo M with CAD, CHF, afib not
anticoagulation, h/o CVA with aphasia, as well as UTI/urosepsis
in the past who presents from [**Hospital1 **] [**Location (un) 620**] with urosepsis and
delirium. Of note, the patient was admitted to [**Hospital1 **] [**Location (un) **] from
[**Date range (1) 56565**] with delirium related to Proteus mirabilis UTI, treated
with Cipro x7 days.
.
Patient was found to have altered mental status at [**Hospital 1036**]
nursing home today. He was found to be less responsive taking
decreased POs. Per report, had not been seen by NP in 1 week.
According to the staff, he has been declining functionally for
the last few weeks, being less energetic, and eating less. At
baseline his is not oriented, is pleasantly demented, and can
interact in simple terms. His gaze deviates to the right. His
son verifies this description, and the family has been moving
towards comfort care. The nursing home staff denies any focal
symptoms otherwise.
.
At [**Hospital1 **] [**Location (un) 620**], initial VS T 101.9, HR 130s, SBP 80s, RR 20s,
99% FM. EKG with afib with RVR at 150bpm. CXR with ? bilat
patchy infiltrates. The patient was given Tylenol 650mg, ASA
300mg PR, Vanco 1g x1, CTX 2g x1 and transferred to [**Hospital1 18**].
.
On arrival, he is awake and answers simple questions, though
appears agitated.
.
ROS: Cannot obtain given patient's mental status
Past Medical History:
Afib -> not anticoagulation due to GIB
CAD
CVA with aphasia
CHF
h/o urinary tract infection
Hypertension
h/o urosepsis
Esophageal ulcer [**2152**]
? history of seizure
Dementia
h/o behavioral disorder
Social History:
He lives at the nursing home. He is dependent in his ADLs,
IADLs.
Family History:
NC
Physical Exam:
VS: T 97.6, HR 114, BP 136/120, RR 21, 2L nc
Gen: awake, responds to name with brief answers, contracted,
deviates to the right, cachectic
HEENT: anicteric sclera, MM dry, parched
Neck: thin, supple
Heart: Tachy, irregular, no m/r/g
Lung: Poor inspiratory effort, no obvious crackles
Abd: thin soft, ND, NT + BS no rebound or guarding
Ext: thin, no pitting edema, warm
Skin: no rashes appreciated
Neuro: awake, answers to name, not oriented, moderately
agitated, deviates to the right, moving all extremities. Does
not cooperate with rest of exam.
Pertinent Results:
[**2153-6-15**] 11:19PM BLOOD WBC-15.5* RBC-4.28* Hgb-12.8* Hct-40.7
MCV-95 MCH-29.9 MCHC-31.4 RDW-14.6 Plt Ct-167
[**2153-6-16**] 05:10AM BLOOD WBC-15.7* RBC-4.00* Hgb-11.8* Hct-37.8*
MCV-95 MCH-29.4 MCHC-31.1 RDW-14.7 Plt Ct-145*
[**2153-6-17**] 04:03AM BLOOD WBC-10.3 RBC-3.32* Hgb-9.9* Hct-30.5*
MCV-92 MCH-29.8 MCHC-32.5 RDW-14.8 Plt Ct-122*
[**2153-6-15**] 11:19PM BLOOD Neuts-82.7* Lymphs-13.7* Monos-3.0
Eos-0.4 Baso-0.2
[**2153-6-15**] 11:19PM BLOOD Glucose-94 UreaN-74* Creat-2.7* Na-169*
K-3.8 Cl-139* HCO3-18* AnGap-16
[**2153-6-16**] 05:10AM BLOOD Glucose-148* UreaN-66* Creat-2.3* Na-165*
K-3.4 Cl-137* HCO3-19* AnGap-12
[**2153-6-16**] 10:23AM BLOOD Na-163*
[**2153-6-16**] 05:15PM BLOOD Glucose-270* UreaN-38* Creat-1.5* Na-148*
K-3.3 Cl-122* HCO3-14* AnGap-15
[**2153-6-16**] 10:22PM BLOOD Glucose-99 UreaN-32* Creat-1.3* Na-156*
K-3.1* Cl-126* HCO3-20* AnGap-13
[**2153-6-17**] 04:03AM BLOOD Glucose-122* UreaN-27* Creat-1.2 Na-152*
K-3.3 Cl-124* HCO3-20* AnGap-11
[**2153-6-17**] 11:46AM BLOOD Na-146*
[**2153-6-15**] 11:19PM BLOOD CK(CPK)-1341*
[**2153-6-16**] 05:10AM BLOOD CK(CPK)-1361*
[**2153-6-17**] 04:03AM BLOOD CK(CPK)-768*
[**2153-6-15**] 11:19PM BLOOD CK-MB-20* MB Indx-1.5 cTropnT-0.09*
[**2153-6-16**] 05:10AM BLOOD CK-MB-16* MB Indx-1.2 cTropnT-0.10*
[**2153-6-17**] 04:03AM BLOOD CK-MB-7 cTropnT-0.08*
[**2153-6-15**] 11:19PM BLOOD Calcium-7.4* Phos-3.7 Mg-2.6
[**2153-6-16**] 05:10AM BLOOD Albumin-2.6* Calcium-7.3* Phos-2.3*
Mg-2.5
[**2153-6-16**] 10:22PM BLOOD Calcium-7.2* Phos-1.9* Mg-1.9
[**2153-6-17**] 04:03AM BLOOD Calcium-6.9* Phos-1.9* Mg-2.5
[**2153-6-16**] 05:10AM BLOOD Valproa-4*
.
[**6-16**] Port CXR
Portable AP chest radiograph was reviewed with no prior studies
available for
comparison.
The patient's heart obscures the lung apices. Cardiomediastinal
silhouette is
normal in size, position and contours. Left retrocardiac opacity
and right
bibasilar opacities are present that might represent areas of
atelectasis,
aspiration or developing infection. The rest of the lungs are
unremarkable.
There is no evidence of failure. There is no appreciable pleural
effusion or
pneumothorax.
Brief Hospital Course:
In short, Mr. [**Known lastname 22305**] is a 78M nursing home resident w CAD,
CHF, A-fib (not on AC), h/o CVA with aphasia, prior UTIs, who
originally presented to [**Hospital1 18**] [**Location (un) 620**] w fever/delirium, was
found to have Proteus urosepsis, hypernatremia, and AF/RVR, and
was subsequently transferred to the [**Hospital1 18**] MICU, where pt was
treated w CTX (d1=[**6-15**]), free water (Na improved from 163 to
146), and supportive measures. Pt required intermittent NS
boluses for hypotension, but was not on pressors. AF/RVR
converted to sinus rhythm without intervetion. Pt was also found
to have ARF and elevated CK, which resolved. Given pt's very
poor baseline functioning and multipe admissions to the hospital
without reasonable hope for improvement, family discussion was
held regarding goals of care in the presence of palliative
specialists. Family agreed that patient would have preferred the
avoidance of further hospitalizations/invasive measures at this
point and pursue comfort measures only.
.
# DNR/DNI
# Comfort measures only:
- zydis SL for agitation
- morphine concentrate for pain PRN
- may use conc haldol
- no IVs, no labs, no vitals, no abx
# Do not hospitalize
# HCP: [**Name (NI) **] [**Name (NI) 122**] ([**Telephone/Fax (1) 82319**], Dtr [**Name (NI) **] ([**Telephone/Fax (1) 82320**]
Medications on Admission:
Medications (transfer):
Ferrous sulfate 325mg daily
Prilosec 20mg daily
MVI daily
Thiamine 100mg daily
Metoprolol 12.5mg [**Hospital1 **]
Depakote ER 250mg ER q24
Tylenol prn
Mg Hydroxide unknown
Biscodyl 10mg PR prn
Lipitor 80mg qHS
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO bid:prn as needed for
constipation.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO daily:prn as needed for
constipation.
4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO tid:prn as needed for agitation.
5. Morphine Concentrate 5 mg/0.25 mL Solution Sig: [**1-26**] PO prn
as needed for pain/SOB.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Proteus urosepsis
Hypernatremia
Altered mental status
Acute renal failure
Atrial fibrillation w rapid ventricular response
.
Coronary artery disease
Chronic congestive heart failure
History of seizures
s/p Stroke
Discharge Condition:
at baseline
Discharge Instructions:
Mr [**Known lastname 22305**] was admitted to the hospital for urinary tract
infection. Given his poor baseline function (AOx0, s/p stroke,
multiple comorbidities), family discussion was held with the
decision to provide comfort measures only.
Followup Instructions:
As needed for comfort measures
Completed by:[**2153-6-20**]
ICD9 Codes: 5849, 5990, 2760, 2930, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8760
} | Medical Text: Admission Date: [**2158-3-22**] Discharge Date: [**2158-5-2**]
Date of Birth: [**2100-1-12**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 58 year old
female who presented to [**Hospital3 **] in [**Location (un) 2498**],
[**State 350**] on [**2158-2-21**], with the chief complaint of
diarrhea and an episode of unresponsiveness from
hypoglycemia. She stated that for the three days prior to
admission she had watery diarrhea and large volume three to
four times per day and problems with hypoglycemia. Her blood
sugar on admission then were in the 20 to 30s. She had a
long complex course at the outside hospital and is
transferred here for management of her multiple active
medical issues.
1. Ascites with SBP - At the outside hospital, she had a CT
scan shortly after admission revealing massive ascites. She
has a history of this and has had multiple large volume
paracenteses in the past. She underwent abdominal
paracentesis on [**2158-2-24**], [**2158-3-3**], and [**2158-3-13**]. Each time,
cultures grew pseudomonas. Initially, she was treated with
Gentamicin and Imipenem, but the Gentamicin was discontinued
on [**2158-3-15**], secondary to an elevated blood urea
nitrogen/creatinine. She has remained on Imipenem.
The etiology of the ascites remains unclear. In the past,
she has had a liver biopsy which showed marked congestive
findings of sinusoidal dilatation, moderate steatosis, mild
to moderately active portal chronic inflammation with
bridging fibrosis. Apparently up until her hospitalization,
her ascites was largely managed only with paracentesis but
when she began to grow pseudomonas during her
hospitalization, much thought began to go into the exact
etiology.
A gastroenterology consultation did not think she had
cirrhosis and, in fact, thought she had an element of
congestive hepatopathy.
An echocardiogram was obtained which showed an ejection
fraction of 65%, 3+ tricuspid regurgitation, mild left
ventricular hypertrophy, biatrial enlargement, evidence of
pulmonary hypertension. A cardiology consultation was
obtained which wrote in the patient's chart that she had an
extensive workup in the past, no details provided and that
she had severe pulmonary hypertension with cor pulmonale and
right sided dysfunction. They also stated that they believed
her heart was the number one of her recurrent ascites.
The possibility of amyloidosis or chronic pulmonary embolus
was entertained. A venous duplex of her legs did reveal
a chronic clot but the patient refused a VQ scan and was not
a candidate for a spiral chest CT secondary to abnormal renal
function.
2. Acute renal failure - Her blood urea nitrogen and
creatinine had been rising to an unclear cause. On transfer
to [**Hospital1 69**], her laboratories
revealed a blood urea nitrogen of 73 and creatinine of 3.7.
A 24 hour urine collection was performed which revealed a
creatinine clearance of 2.0 cc/minute. A renal consultation
was obtained. The team thought her acute renal failure was
multifactorial but primarily due to Gentamicin which has
since been discontinued. They also thought she had an
element of intravascular depletion.
3. Confusion - She has also suffered from increased
confusion possibly from encephalopathy. She was started on
Lactulose empirically on [**2158-3-19**], with an ammonia level of
9.0.
4. Nutrition - Additionally, her p.o. intake has been poor
and she has had a low albumin. TPN has been discussed but
has not yet been started.
PAST MEDICAL HISTORY:
1. Cryptogenic cirrhosis with ascites.
2. Diabetes mellitus times two years.
3. Large volume paracenteses.
4. Hypertension.
5. History of abdominal wall cellulitis and umbilical hernia
repair on [**2158-1-23**].
6. Atrial fibrillation.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Norvasc.
2. Digoxin.
3. Hydrocortisone.
4. Imipenem.
5. Sliding scale insulin.
6. Lopressor.
7. Multivitamin.
8. Oxycodone.
9. Zantac.
10. Heparin.
SOCIAL HISTORY: She denies any drugs or alcohol use. She
does have a history of tobacco use.
FAMILY HISTORY: There is a family history of diabetes
mellitus but no history of kidney disease or cirrhosis.
PHYSICAL EXAMINATION: On physical examination, vital signs
revealed temperature 96, blood pressure 110/60, pulse 62,
respiratory rate 18, oxygen saturation 94% on four liters.
Generally, she is a middle age, awake, alert, well appearing,
obese female in no acute distress. Head, eyes, ears, nose
and throat examination - The head is normocephalic and
atraumatic. The pupils are equal, round, and reactive to
light and accommodation. Extraocular movements are intact.
The sclerae are anicteric. Mucous membranes are moist. The
neck is supple. There is no lymphadenopathy. No jugular
venous distention appreciated. The lungs have decreased
breath sounds throughout with bibasilar rales, no wheezes.
Cardiovascular examination is regular rate and rhythm, normal
S1 and S2, no murmurs, rubs or gallops. The abdomen is soft,
obese, protuberant with shifting dullness, normoactive bowel
sounds. The lower extremities have 2+ edema to the calf
bilaterally. Pulses are 2+ bilaterally.
LABORATORY DATA: On admission, [**2158-3-22**], white blood cell
count 6.4, hematocrit 29.8, platelets 236,000. Chem7
revealed a sodium of 143, potassium 4.6, chloride 109,
bicarbonate 20, blood urea nitrogen 79, creatinine 5.2,
glucose 89. ALT 1, AST 6, LDH 378, alkaline phosphatase 431,
total bilirubin 1.3, GGT 87, albumin 2.2, calcium 7.1,
phosphate 8.0, magnesium 2.3. Iron 30, TIBC 213, Vitamin B12
602, folate 6.4, ferritin 139, transferrin 164.
Triglycerides 160, HDL 47, cholesterol/HDL ratio 3.3, LDL 75.
Ammonia 22. TSH 11.0, free T4 0.7 which is the low normal
range. Hepatitis serologies for hepatitis C, hepatitis B,
hepatitis A and hepatitis D were all noted to be negative.
Antimitochondrial antibody is negative. Anti-smooth antibody
is positive at 1:20 titer. CA125 is 66, AFP is 2.2. Serum
protein immunoelectrophoresis IgG 2697, IgM 227.
Microbiology data - On [**2158-4-6**], blood cultures three out of
four were positive for coagulase negative staphylococcus that
was sensitive to Vancomycin. Blood cultures, [**2158-4-5**], one
out of four with positive for enterococcus resistant to
Vancomycin, sensitive to Linezolid. On [**2158-4-7**], left lower
extremity wound drain culture revealed 3+ polys, no
organisms, wound culture grew out pseudomonas resistant to
Ciprofloxacin but sensitive to Imipenem. On [**2158-4-9**], PICC
line tip culture negative. On [**2158-4-10**], peritoneal fluid
showed 3+ PMNs, micro with rare growth of bacillus species.
On [**2158-4-10**], blood and fungal cultures negative. On
[**2158-4-12**], to [**2158-4-14**], Clostridium difficile toxin negative.
On [**2158-4-20**], right hip wound decubitus culture grew out
pseudomonas resistant to Imipenem but sensitive to
Ceftazidime, Pip/Taz and Tobramycin, also grew out VRE. On
[**2158-4-21**], peritoneal fluid gram stain is negative, fluid
culture is negative. On [**2158-4-28**], peritoneal fluid culture
no growth to date, final culture is pending.
RADIOLOGIC DATA: Chest CTA with contrast done on [**2158-4-20**],
showed no evidence of pulmonary embolism. The soft tissue
windows revealed mediastinal adenopathy with largest lymph
node located to the right of the aortic arch measuring 1.2
centimeters in diameter. She had small right hilar nodes
that are also noted. There is a moderate right pleural
effusion and tiny left pleural effusion. There is anterior
intraperitoneal abdominal fluid collection. Sludge within
the gallbladder is noted.
ASSESSMENT: The patient is a 58 year old female with a
history of diabetes mellitus, hypertension, recurrent ascites
of unknown etiology, who has been transferred here from an
outside hospital with DDTs, ascites of unknown etiology, now
infected with pseudomonas.
HOSPITAL COURSE:
1. Gastrointestinal - The patient has a history of ascites
of unclear etiology. She has had a rather extensive workup
in the past and her ascites at that tine was attributed to
her severe pulmonary hypertension with cor pulmonale and
right sided dysfunction. Her workup here included liver
function tests which have been repeatedly normal except for a
mild elevation in her alkaline phosphatase.
An echocardiogram has shown left ventricular function with
mildly elevated right sided pressures but otherwise normal.
A right upper quadrant ultrasound with Doppler on [**2158-3-30**],
showed no evidence of portal or hepatic or proximal inferior
vena cava thrombosis. Her hepatitis serologies were negative
and antimitochondrial antibody was negative. AFP was noted
to be within normal range.
2. Infectious disease - The patient was admitted from an
outside hospital on Imipenem since the culture of the
abdominal fluid there revealed pseudomonas sensitive only to
Imipenem. The infective source is an abdominal hernia wound
that she has had from an operation in late [**Month (only) 1096**]. Our
cultures here have shown pseudomonas with more broad
sensitivities, but the decision was made not to change
antibiotic classes since she may have multiple flora in her
abdomen. She was, however, switched from Imipenem to
Meropenem since she developed seizures with Imipenem. With
the change, she has had no further seizures.
An abdominal drain was placed in her abdomen under ultrasound
guidance and was removed after approximately two and one half
weeks as the drainage tapered off. A repeat abdominal CT
after drain removal revealed continued ascites. Surgery was
consulted regarding a possible laparoscopy with biopsy and
peritoneal antibiotics. Given her multiple comorbidities,
the surgery team declined to take her to surgery and
recommended medical management of her infected ascites.
Infectious disease was consulted and they recommended
stopping the antibiotics on [**2158-4-24**], effectively two weeks
from the first negative peritoneal culture on [**2158-4-10**]. She
received a total of approximately six weeks of
Imipenem/Meropenem for her pseudomonas infected ascites. A
repeat paracentesis was done on [**2158-4-21**], and again on
[**2158-4-28**]. Culture from [**2158-4-21**], did not grow any organisms
though the fluid did show persistent white blood cells at
14,760. Culture from [**2158-4-28**], is still pending with white
blood cells noted to be 12,350. The infectious disease team
recommends repeat serial paracenteses in the future. If at
that time, an organism were to regrow while off antibiotics,
the decision to undergo laparoscopy or open laparotomy would
again need to be readdressed.
She also developed a left lower extremity fluid collection
that was drained and grew pseudomonas sensitive to Imipenem.
She has also developed a right hip decubitus ulcer that is
colonized at VRE and Imipenem resistant pseudomonas but
sensitive to Ceftazidime, Pip/Taz and Tobramycin. She has
also developed a line infection that grew one out of four
bottles positive for VRE for which she received a seven day
course of Vancomycin, Linezolid for presumed line infection.
The PICC line was also pulled.
3. Hematology - The patient had documented deep vein
thrombosis at the outside hospital and was on Heparin on
admission. She was switched to Lovenox subsequently. She is
anemic with a baseline hematocrit of about 27.0 to 30.0, and
was transfused periodically for a hematocrit less than 27.0.
4. Renal - Her blood urea nitrogen and creatinine were
initially elevated on admission with a peak of 5.3. The
renal team was consulted and it was felt that her acute renal
failure was probably a combination of Gentamicin toxicity and
intravascular depletion. After her Gentamicin was stopped
and she was intravascularly repleted, her creatinine
subsequently improved to 0.9.
5. Nutrition - Her p.o. intake had been very poor on
admission and given her low albumin, she was subsequently
started on TPN. After her p.o. intake improved, this was
continued. She has been taking adequate p.o. for several
weeks with improvement in her nutritional status.
6. Wound - The patient has an abdominal surgical wound as
well as a right hip decubitus ulcer approximately 4.0 by 5.0
centimeters by 4.0 centimeters deep that appears well
granulated and not superinfected. The abdominal surgical
wound should heal by secondary intention and we have been
treating that wound with t.i.d. wet to dry dressing changes.
Additionally, the right hip decubitus ulcer has been examined
by the plastic surgery team and was debrided twice. They
recommended continued wet to dry dressing changes t.i.d. and
to have the patient not lie on the right hip.
7. Psychiatric - The patient was felt to have some component
of depression given her long term hospitalization. She was
evaluated by the psychiatric team who recommended starting
Haldol 0.5 mg p.o. b.i.d. They also discussed with the
patient starting an antidepressant or Ritalin which might
improve her mood, however, the patient declined.
8. Disposition - The patient was evaluated by the physical
therapy team and continued to receive physical as well as
occupational therapy while she was hospitalized. She will
need continued therapy upon discharge to rehabilitation given
her severe deconditioning.
MEDICATIONS ON DISCHARGE: Her medications on discharge will
be dictated in an addendum.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-983
Dictated By:[**Name8 (MD) 17311**]
MEDQUIST36
D: [**2158-5-1**] 20:55
T: [**2158-5-1**] 21:11
JOB#: [**Job Number 38830**]
ICD9 Codes: 5849, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8761
} | Medical Text: Admission Date: [**2176-1-5**] Discharge Date: [**2176-1-16**]
Date of Birth: [**2128-2-22**] Sex: M
Service: MEDICINE
Allergies:
Vitamin K
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
septic shock
Major Surgical or Invasive Procedure:
paracentesis [**1-14**]
History of Present Illness:
HPI: 47 y.o. man with ESRD on HD, Hep C/ETOH cirrhosis, Asthma,
recently discharged [**2175-12-19**] after being treated for enterobacter
pneumonia with hypoxic resp distress, which was complicated by
allergic rxn to certain HD filters, who was found on the floor
by his wife on the evening of [**1-2**]. He was arousable and
responsive, so she did not move him. On the AM of [**1-3**], the
patient's wife again tried to arouse him from the floor, but
this time, he could not be aroused. She called 911 and he was
admitted to [**Hospital3 2568**] ICU.
.
At [**Hospital3 2568**], He was hypotensive (60/30) and started on
levophed, dopamine, and vasopressin to maintain his BP. He also
was hypoglycemic and received D50. Blood cultures (1/2 bottles
on [**1-3**], then 2/4 bottles on [**1-4**]) grew GPC in pairs and
chains. He also had a paracentesis which was consistent with SBP
based on WBC but did not grow any bacteria. He was started on
Vanco/Zosyn, which was changed to Dapto/zosyn out of concern for
VRE, but then . He has a tunnelled HD line which was a potential
source but it was felt that SBP was the more likely source. His
INR was initially 11, which came down to 5 after FFP. B/c of the
coagulopathy, it was felt unsafe to take out the HD catheter. He
had a left IJ line placed.
Past Medical History:
- Cirrhosis [**2-17**] untreated HCV, alcohol abuse, not on transplant
list
- Esophageal varices s/p [**12-20**] banding
- h/o SBP
- ESRD on HD T/Th/Sat (from ATN, HRS)
- Anemia of chronic disease
- Asthma
- Depression
- Schizotypal personality disorder
- Left LE abscess in [**9-/2175**] at [**Hospital3 2568**], growing enterobacter
Social History:
- Personal: Lives with wife.
- Substance abuse: Denies current tobacco, ETOH, or drug use.
Per [**Hospital3 2568**], he may not be reliable and his wife is not
certain since he is alone much of the day.
- Heavy ETOH use in past, prior IV drug use in [**2148**], but last
reportedly [**4-21**]. Former smoker.
Family History:
- No history of liver disease.
- Maternal aunt with DM
Physical Exam:
VS: T 96.1 BP 75/61, HR 87, R 25, 100% 2L
Gen: no apparent distress
HEENT: icteric sclerae, dry MMM,
Neck: no JVD
Lungs: bibasilar crackles
Heart: RRR nl S1S2, no m/r/g
Abd: +BS, mod distention, soft, mild TTP diffusely. No rebound
or guarding.
Ext: 2+ dependent edema up to thighs and sacrum
Neuro: AAO x 3, conversant. strength 5/5, + asterixis
Pertinent Results:
[**2176-1-5**] 07:33PM BLOOD WBC-19.6*# RBC-2.65* Hgb-9.6* Hct-28.9*
MCV-109* MCH-36.1* MCHC-33.1 RDW-25.7* Plt Ct-31*#
[**2176-1-9**] 03:35AM BLOOD WBC-11.1* RBC-2.64* Hgb-9.7* Hct-29.5*
MCV-112* MCH-36.7* MCHC-32.9 RDW-24.5* Plt Ct-82*
[**2176-1-14**] 05:00AM BLOOD WBC-19.49* Hct-33.0* Plt Ct-125*
[**2176-1-5**] 07:33PM BLOOD Neuts-94* Bands-0 Lymphs-4* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-3*
[**2176-1-14**] 05:00AM BLOOD Neuts-84.2* Bands-0 Lymphs-7.0* Monos-8.4
Eos-0.3 Baso-0.1
[**2176-1-5**] 07:33PM BLOOD PT-46.1* PTT-62.1* INR(PT)-5.2*
[**2176-1-8**] 03:23AM BLOOD PT-24.8* PTT-49.9* INR(PT)-2.4*
[**2176-1-10**] 03:33AM BLOOD PT-30.8* PTT-55.8* INR(PT)-3.2*
[**2176-1-14**] 05:00AM BLOOD PT-36.2* PTT-65.1* INR(PT)-3.8*
[**2176-1-5**] 07:33PM BLOOD FDP-80-160*
[**2176-1-7**] 03:15AM BLOOD Fibrino-89*
[**2176-1-5**] 07:33PM BLOOD Glucose-69* UreaN-45* Creat-5.8*# Na-135
K-4.4 Cl-100 HCO3-22 AnGap-17
[**2176-1-6**] 05:11AM BLOOD Glucose-128* UreaN-49* Creat-5.4* Na-133
K-4.4 Cl-99 HCO3-22 AnGap-16
[**2176-1-11**] 06:15AM BLOOD Glucose-98 UreaN-40* Creat-4.2*# Na-133
K-4.4 Cl-99 HCO3-24 AnGap-14
[**2176-1-14**] 05:00AM BLOOD Glucose-56* UreaN-41* Creat-4.5* Na-136
K-5.0 Cl-98 HCO3-20* AnGap-23*
[**2176-1-5**] 07:33PM BLOOD ALT-303* AST-1155* LD(LDH)-609*
CK(CPK)-59 AlkPhos-132* TotBili-12.4*
[**2176-1-11**] 06:15AM BLOOD ALT-57* AST-67* LD(LDH)-421* AlkPhos-158*
TotBili-21.9*
[**2176-1-14**] 05:00AM BLOOD ALT-38 AST-50* LD(LDH)-398* AlkPhos-145*
TotBili-26.3*
[**2176-1-5**] 07:33PM BLOOD Albumin-2.2* Calcium-7.9* Phos-6.5*
Mg-2.0
[**2176-1-15**] 07:24AM BLOOD Calcium-9.4 Phos-9.2* Mg-2.4
[**2176-1-10**] 03:33AM BLOOD calTIBC-105* Ferritn-511* TRF-81*
.
OSH u/s abdomen: portal vein thrombosis
.
[**1-3**]: 4/4 bottles with GPC in pairs/chains -> VRE
[**1-4**]: 2/4 bottles with CPC in pairs/chains -> VRE
[**1-5**]: [**2-17**] - NGTD
.
Paracentesis at [**Hospital3 2568**]:
RBC 14,000
WBC 500
Poly's 97% (#447 after correction for RBCs)
Albumin < 1
Gram stain: no polys, no organnisms. Culture VRE
1. ENTEROCOCCUS
Target Route Dose RX AB Cost M.I.C. IQ
------ ----- ------------------ ------ -- ------ ---------
------
AMPICILLIN R >8
LEVOFLOXACIN SERUM X R >4
LINEZOLID SERUM X S 1
VANCOMYCIN SERUM X R >16
.
US [**2176-1-6**]:
IMPRESSION:
1. Shrunken and nodular liver consistent with cirrhosis as seen
previously.
Large amount of ascites. Gallbladder wall thickening likely
secondary hepatic disease.
2. Splenomegaly.
3. Patent main portal vein with hepatopetal flow. Patent
hepatic vasculature with appropriate waveforms and directional
flow.
.
Echo [**2176-1-6**]:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The aortic valve
leaflets appear structurally normal with good leaflet excursion.
The mitral valve leaflets are structurally normal. Trivial
mitral regurgitation is seen. There is no pericardial effusion.
Normal estimated pulmonary artery pressures.
IMPRESSION: Suboptimal image quality. Focused views. Preserved
global left ventricular systolic function.
Compared with the prior study (images reviewed) of [**2175-12-4**],
left ventricular systolic function remains preserved.
.
Echo [**1-11**]-The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis. The
mitral valve leaflets are structurally normal. A catheter tip
appears to be present in the right atrium near the caval
junction. No Doppler images were obtained.
No vegetation seen but cannot exclude.
Compared with the prior study (images reviewed) of [**2176-1-6**],
there is no definite change.
.
Brief Hospital Course:
47 y.o. man with Hep C/ETOH cirrhosis, ESRD/HD p/w septic shock,
subsequently foudn to have VRE bacteremia due to presumed SBP.
.
# Septic shock: BP was 60/30 upon admission to OSH. He initially
required 3 pressors to keep his MAP > 65. WBC of 19. Patient was
subsequently weaned off Levophed/Vasopresin/Dopamin. HIs
lactate initially was 5.6 and trended down. The ascites fluid
and the blood cultures confirmed VRE as a source. Patient had
his right subclavian tunelled line removed by transplant surgery
on [**1-7**]. He had a L IJ placed at OSH on [**1-5**]. He had a L
IJ/SCL tunelled line placed by IR on [**1-10**]. His blood cultures
remained negative at [**Hospital1 18**]. ([**2092-1-4**]). He was continued on
Daptomycin - started on [**1-5**] @ OSH - with instructions to
continue for 6 weeks and followed up by ID. Patient was also
continued on 5 days of Ceftriaxone but there was no evidence of
other gram negatives. Patient was c/o to the floor on [**1-10**].
His SBP remained in the 90-110 range, he was not tachycardic and
was afebrile x 3 days at that point. From [**Date range (1) 56230**] the
patient remained normotensive and afebrile while continuing
daptomycin. On [**1-14**] the patient was found to be hypotensive
74/40, with increased O2 requirement, dyspnea, Leukocytosis,
decreased blood glucose, and increased somnolence. CXR showed
decreased lung volumes and increased atelectasis. The patient
expressed his desire to not undergo aggressive measures,
including, transfer to MICU, or use of pressors, and wished to
be made DNR/DNI, without any escalation of care. The patient
requested home hospice, however, given his acuity of illness it
was believed his wife would be unable to care for him. Given his
dyspnea, the patient underwent a therapeutic paracentesis with
removal of 3.5L. He reported increased comfort after the
paracentesis. On [**1-15**] the patient's systolic blood pressure
dropped to high 60's to 70's. He was hypothermic with axillary
temp 93.7, and was increasingly somnolent. The patient passed
away at 4am on [**2176-1-16**]
.
# ESLD - Patient was not a transplant candidate due to
nonadherence to his follow ups and social situation. His
bilirubin was considerably increased during this admission,
reaching a high of . He was followed by liver service. His INR
also continued to rise after transfer from MICU to the floor.
The patient was continued on lactulose and rifaxamin.
.
# ESRD - on HD, Tues, Thurs, Sat. Patient HD dependent. He had
his R SCL tunelled catheter removed on [**1-7**], and it was
replaced by a left subclavian temporary dialysis catheter. Plans
for reinserting a permanent dialysis catheter were postponed by
continued increasing INR, refractory to oral vitamin K
administration.
.
# Portal vein thrombosis: New since last u/s done here in
9/[**2175**]. However, US done at [**Hospital1 18**] did not confirm it.
.
# DIC - patient with elevated INR, with acute on chronic
component, also low platelets at baseline and transiently low
fibrinogen suspicious for DIC. He received 1 unit of
cryoprecipitate in the MICU.
Medications on Admission:
1. Rifaximin 400 mg PO TID
2. Nadolol 20 mg PO Daily
3. Lactulose 60 ML PO qid
4. B Complex-Vitamin C-Folic Acid - 1 cap daily
5. Thiamine 100 mg po daily
6. Folic Acid 1 mg po daily
7. Sevelamer 1600 mg PO TID W/MEALS
8. Protonix 40mg daily
9. Fluticasone-Salmeterol 250-50 1 puff [**Hospital1 **]
10. Albuterol 1 puff Q6H
11. Atrovent 1 puff Q4H
12. Dilaudid 1mg PO q6H prn
13. Sucralfate 1gm po QID
.
Meds on transfer:
1. Zosyn 2.25gm Q8H
2. Lactulose QID
3. Insulin sliding scale
4. Levophed gtt
5. Vasopressin gtt
Discharge Disposition:
Expired
Discharge Diagnosis:
Septic Shock
End Stage Liver Disease
Discharge Condition:
expired
ICD9 Codes: 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8762
} | Medical Text: Admission Date: [**2114-2-21**] Discharge Date: [**2114-3-5**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Falling Hct
Major Surgical or Invasive Procedure:
none
History of Present Illness:
85yF with h/o CAD, CHF, COPD tx from [**Hospital 1474**] Hospital for low
Hct and evidence of peri-hepatic hematoma on CT scan. In brief,
she presented to OSH with abd pain, found to have free air on
CXR. Taken to OR and found to have large perforated gastric
ulcer as well as an ischemia perforation of the distal ileum.
She underwent a hemigastrectomy with Roux en Y as well as a SBR.
She developed multiple episodes of resp distress post-op and
had several extubations followed by emergent re-intubations. A
collection was found peri-hepatic. A CT guided drainage was
performed, which probably resulted in a liver injury. She
continued to have falling Hcts, and was resuscitated with PRBCs.
The collection itself grew out [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**] and GNRs. She
also had gram positive cocci in her blood, likely from a line.
She was on linezolid, zosyn, and caspofungin on transfer. The
patient was transferred to our hospital for falling hematocrits
with evidence of a likely peri-hepatic hematoma.
Past Medical History:
PMH: CAD, MI [**2111**], prev EF 55%, HTN, COPD, descending thoracic
AA 4.2cm
PSH: hemigastrectomy with [**Last Name (un) **] and SBR
Physical Exam:
T93.9 HR50 BP135/50 RR24 Sat93%
Vent: AC 50%/450 x 24/ peep10
Intubated, sedated
Anasarca
Dobhoff and OGT in place
Bradycardiac, 1st degree AV block
Coarse breath sounds, rales
abdomen soft, distended, midline wound with some drainage
weeping of fluid from both arms
Pertinent Results:
Admission labs:
13.3
26.4 109
38.8
147 109 84 148
3.9 28 1.5
Ca 6.9, Mg 1.9, PO4 5.3
INR 1.1
AST 59, ALT 263, AP 274, Tb 2.8, Alb 1.8, [**Doctor First Name **] 101, Lip 13
ABG 7.35/50/88/29/0
Ca (ion) 0.93 lactate 1.2
CXR: pulmonary edema, b/l effusions, dobhoff in esophagus, CVL
in SVC
CT abd [**2114-2-22**]:
1. Large 15 x 10 cm heterogeneous subcapsular liver mass/high
attetuation
fluid collection. Given the relatively high attenuation of this
mass and the clinical history of recent biopsy, its appearance
is consistent with hematoma and would not be amenable to
drainage. A few foci of gas are noted within this collection,
likely due to recent procedure but underlying infection cannot
be excluded.
2. Status post Roux-en-Y procedure without evidence of
obstruction. Extensive peripancreatic inflammatory change likely
post-surgical.
3. Evidence of volume overload including large bilateral
pleural effusions, anasarca, and intra-abdominal fluid.
4. Right-sided aortic arch.
5. NGT in good position
FISTULOGRAM/SINOGRAM [**2-28**]: Enterocutaneous fistula with contrast
collecting within an amorphous extraintestinal space before
entering small bowel
CT GUIDANCE DRAINAGE [**2-28**]: Successful CT-guided pigtail catheter
placement into the patient's intraperitoneal fluid collection
RENAL U.S. [**2-27**]:Mild bilateral renal cortical thinning, without
evidence of hydronephrosis.
ECHO [**2-22**]:
left atrium is mildly dilated. mild symmetric LVH. LV systolic
function is hyperdynamic (EF 70-80%). No aortic valve stenosis.
No aortic regurgitation. MV leaflets are mildly thickened. No
MVP. TV leaflets are mildly thickened. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
Brief Hospital Course:
Neuro: The patient was off of sedation and became arousable
shortly after admission. She was kept off sedation other than
prn doses for comfort. Her neurological status deteriorated
late in her hospital course
Cardio: Echo at admission showed a hyperdynamic heart with an EF
of 70-80%. Initially she required no pressors, but as her
multi-organ failure progressed she required norepinephrine
and/or neosynephrine to maintain her blood pressure. Towards
the end of her hospital course the family decided not to
escalate her pressor requirements. Eventually, her BPs were
unable to be maintained and she expired on [**2114-3-5**].
Pulm: She was unable to wean from controlled ventilation. She
was attempted on pressure support multiple times but became very
tachypneic and demonstrated low tidal volumes during these
trials. Her CXR showed worsening pulmonary edema and pleural
effusions.
FEN: She was maintained on her TPN that she arrived with. Her
nutrition labs were checked weekly. Per renal, her diuresis was
limited due to her ARF. She was initially kept on LR, then
switched to MFs, and then KVO in order to maintain an even fluid
balance. The patient had significant anasarca. Her arms wept
almost a liter of fluid a day which was collected in drainage
bags.
GI: Her dobhoff was removed as it was non-functional in its
position. Tube feeds were resumed but down her OGT. She did
have some issues tolerating these with higher residuals and her
TFs were held appropriately at these times. She was continued
on Protonix for GI prophylaxis. She eventually was found to
have developed an EC fistula through one of her open wounds on
her abdomen. A pigtail was placed in this and allowed to drain.
GU: Her BUN/Cr were elevated at admission and continued to
slowly trend up. Renal was consulted. They recommended that we
try to maintain a even fluid balance, and avoid diuresis. They
recommended albumin for fluid if needed. They believed her ARF
was of multiple etiology including: sepsis, hypotension,
contrast etc. They did not believe dialysis was needed at this
time but continued to follow.
Heme: Her Hct was stable at admission but slowly trended down.
Her platelets and WBC also slowly trended down. It was believed
that this was secondary to her multi-organ failure.
ID: Her antibiotics were switched to Dapto, cipro, flagyl, and
caspofungin. These were continued through her hospital stay.
Her cultures grew out yeast and enterococcus from multiple
sources.
Endo: She was transferred with solumedrol on board. This was
stopped after transfer. Her blood sugars were relatively stable
throughout her hospital course and did not require an insulin
drip.
Eventually the patients family made her DNR. A few days later
they decided to not escalate care and she expired shortly after.
Medications on Admission:
[**Last Name (un) 1724**]: combivent, enalipril, imdur, asa
Admission meds: Linezolid, zosyn, caspofungin, solumedrol,
protonix, combivent
Discharge Disposition:
Expired
Discharge Diagnosis:
Perforated gastric ulcer s/p hemigastrectomy with Roux en Y and
SBR
Subcapsular liver hematoma
ARF
Respiratory failure
Enterocutaneous fistula
Anasarca
Discharge Condition:
Expired
ICD9 Codes: 5849, 0389, 5119, 496, 4019, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8763
} | Medical Text: Admission Date: [**2177-6-18**] Discharge Date: [**2177-6-24**]
Date of Birth: [**2133-8-13**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
RUE weakness and numbness transferred from OSH with known left
thalamic/internal capsule hemorrhage.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a 43 year-old right-handed primarily vietnamese
speaking man. Given the urgency of the matter, the patient's
limited english was relied upon for the history. He was in USOH
until 6pm today when while standing and talking to a colleague
he noted his right arm was not reacting as it should to
commands. It "felt like there was no blood getting to the hand".
He attempted treating himself with the alternative therapy known
as coining. A colleague decided to call EMS.
The patient was brought to the [**Hospital6 17032**].
Initial Pressure was 192/108. Head CT revealed a left thalamic
internal capsule hemorrhage measuring 1.8x1.4cm. He was given
labetolol x2 without significant effect. He was then started on
a nipride drip. This was discontinued on arrival here and the
patient was started on here in favor of labetolol gtt.
ROS
The patient denied HA, visual difficulty, hearing changes,
difficulty speaking, language problems, memory difficulty,
difficulty swallowing, dizziness, lightheadedness or vertigo,
unsteady gait, or falls. The patient denied fever, wt loss,
appetite changes, cp, palpitations, DOE, sob, cough, wheeze,
nausea, vomiting, diarrhea, constipation, abd pain, fecal
incont, dysuria, nocturia, urinary incontinence, muscle or joint
pain, hot/cold intolerance, polyuria, polydipsia, easy bruising,
depression, anxiety, stress, or psychotic sx.
Past Medical History:
patient does not have a physician and reports being healthy.
Social History:
Lives with Brother [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 78756**])
works at Plexus making computer chip boards. He is a QA tech.
No Drugs.
Tobacco - 1ppd for 29 years.
ETOH - likely considerable - reported that he cut down 4 years
ago, but that he had 5 beers on sunday.
Family History:
Brother had stroke in [**Country **] at age 50.
Physical Exam:
Vitals: T:96.3 P:90 R:16 BP:159/89 SaO2:100RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, sclera are injected, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: The patient has erythematous streaks on his right arm and
the right neck where he was coining.
Neurologic:
-Mental Status: Alert, oriented to hospital, [**2177-6-17**]. Able to
relate history without difficulty. Attentive, able to name DOW
backward without difficulty. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name a pen and that ink comes
out of the pen. Able to read without difficulty. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. The pt. had good knowledge of current events ([**Last Name (un) 2450**]).
There was no evidence of apraxia or neglect.
-Cranial Nerves: Olfaction not tested. Right 3 to 2. Left 2.5 to
2. Both brisk. VFF to confrontation. There is no ptosis
bilaterally. Funduscopic exam revealed no papilledema, exudates,
or hemorrhages. EOMI without nystagmus. Normal saccades. Facial
sensation diminshed on the right to pinprick. No facial droop,
facial musculature symmetric. Hearing intact to finger-rub
bilaterally. Palate elevates symmetrically. 5/5 strength in
trapezii and SCM bilaterally. Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout.
No adventitious movements noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
C5 C6 C7 C8/T1 L2 L3 L4/S1 L4 L5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 4 5 5- 4 5 4 4 5 5 5 5 5 5 5
-Sensory: Diminished sensation in the right upper and lower
extremity to all modalitie. No extinction to DSS.
-Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF on left or HKS bilaterally. FNF on right
limited
by right sided weakness.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
C5 C7 C6 L4 S1
L 3 3 2 2 2
R 3 3 2 2 2
Plantar response was flexor bilaterally.
-Gait: not test as patient was taken to CT scanner.
Pertinent Results:
Laboratory Data:
137 103 12
---I----I----< 120
3.7 22 0.8
14.7
12.2>---<258
41.4
N:78.7 L:17.4 M:2.6 E:0.8 Bas:0.5
PT: 12.3 PTT: 29.4 INR: 1.0
Radiologic Data:
Head CT at [**Location (un) **] revealed a left thalamic internal capsule
hemorrhage measuring 1.8x1.4cm. Review of the images with the
radiologist here suggested that there was a right pontine stroke
on the scan as well.
NON-CONTRAST HEAD CT: There is a 2.2 x 1.2 cm acute
intraparenchymal hemorrhage centered within the left internal
capsule and thalamus with a small rim of surrounding edema. No
significant mass effect. The remainder of the brain parenchyma
is within normal limits with no additional hemorrhage. The
[**Doctor Last Name 352**]-white matter differentiation is preserved. The ventricles
are normal in size and configuration. There is no
intraventricular extension of hemorrhage. Hypodensity within the
right pons is likely a prior infarct. There is also a linear
hypodensity within the right external capsule which likely
represents an old infarct. The visualized paranasal sinuses and
mastoid air cells are normally pneumatized and aerated. Soft
tissues are normal.
CTA THROUGH THE CIRCLE OF [**Location (un) **]: The left vertebral artery has
a PICA termination. The major branches of the circle of [**Location (un) 431**]
are patent with no flow-limiting stenosis or aneurysm
identified. In the region of the hemorrhage, there is no
evidence of aneurysm or vascular malformation, and no active
extravasation of contrast. There is a developmental venous
anomaly in the right external capsule, abutting the area of
hypodensity, though these are presumably not related to each
other. Multiple periapical lucencies are seen around the
maxillary teeth, which likely represents periodontal disease.
IMPRESSION:
1. Left internal capsule/thalamic hemorrhage, presumably
hypertensive in etiology. No evidence of underlying vascular
malformation or aneurysm.
2. Developmental venous anomaly within the right external
capsule abutting an area of hypodensity which likely is a region
of prior infarct. These two findings are likely unrelated to
each other.
3. Old right pontine infarct.
4. Multiple periapical lucencies concerning for periodontal
disease. Dental evaluation is recommended.
MRI:
1. Acute left internal capsule/thalamic hemorrhage with no
evidence of underlying lesion or vascular malformation.
2. Focus of edema and possible enhancement within the right
external capsule, though the post-contrast images are extremely
limited due to motion. These findings raise the possibility of a
infectious focus. Repeat post-contrast imaging is recommended
when the patient is more clinically stable.
3. Probable old infarct within the right pons
CXR: The lungs remain clear. The heart is normal in size. The
cardiothoracic index is 0.43. The aorta is mildly tortuous.
Mediastinal structures are otherwise unremarkable. The bony
thorax is grossly intact. There is no significant interval
change.
EKG: Sinus rhythm. Modest inferior ST-T wave changes which are
non-specific. No previous tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
71 146 96 [**Telephone/Fax (2) 78757**] -10
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the Neuro ICU for BP management with a
labetalol gtt. This was controlled with goal SBP < 160 and MAP <
130, and he was able to be weaned from the drip by the following
morning. MRI was performed that is limited by motion artifact
but revealed no obvious underlying mass. CTA showed no aneurysm
or vascular malformation. The presumed etiology is hypertensive.
He was started on amlodipine for long-term blood pressure
control; a diuretic was considered but it was felt that, as he
has had poor medical follow-up, he may become too hypovolemic
with a diuretic, with possible neurovascular implications. He
was also started on lisinopril, which was titrated upwards to 10
mg QD. This will need further adjustment.
With his history of alcohol use, he was monitored for withdrawal
with a CIWA scale and given thiamine, folate, and a multivitamin
daily. He did not go through any signficant withdrawal.
His Hb A1c was found to be marginally elevated at 6.5. He will
need to follow-up with primary care physician for further
evaluation for diabetes. He was covered with an insulin sliding
scale while an inpatient. It was D/C'd on the floor.
PT and OT were consulted and recommended acute rehab.
At time of discharge, his exam was mainly notable for a proximal
weakness (R deltoid), and a signficant ataxia resulting in very
poor control over his limbs, and with absence of visual control
he had no spatial awareness on the R side of his body. He was
very motivated for rehab and was exercising in bed already.
Finally, CT showed significant peridontal disease, dental
evaluation is recommended.
Medications on Admission:
Takes tylenol for occasional headaches.
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Thiamine HCl 50 mg Tablet Sig: One (1) Tablet PO once a day.
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
unit Injection TID (3 times a day).
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Left basal ganglia hemorrhage (stroke)
Discharge Condition:
Stable but significant right sensory hemiataxia
Discharge Instructions:
You have been admitted with a deep brain hemorrhage, which is
likely secondary to hypertension (a high bloodpressure). It is
of vital importance that you assume a healthy lifestyle now:
regular exercise, healthy diet, no smoking or excessive alcohol.
You have also been started on Aspirin. Please take all your
medications excactly as directed and please attend all your
follow-up appointments.
Please report to the nearest ER or call 911 or your PCP
immediately when you experience recurrence of weakness,
numbness, tingling, problems with vision, speech, language,
walking, thinking, headache, or difficulties arousing, or any
other signs or symptoms of concern.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2177-8-4**] 1:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2177-6-24**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8764
} | Medical Text: Admission Date: [**2108-12-11**] Discharge Date: [**2108-12-14**]
Date of Birth: [**2059-9-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Transferred after fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
49 year old male transfered from OSH with multiple
injuries, after being found at the bottom of a 20 foot wall.
The
patient was intoxicated, and does not remember how he got there,
though he denies having jumped or attempted to hurt himself.
Imaging studies revealed fractures of C6, T3, T5, and T9. He
also has a sternal fracture, a mediastinal hematoma, and is
being
admitted to the trauma ICU. He was markedly hypothermic at the
scene, and has been rewarming since arrival to the OSH.
The orthopedics spine service is consulted for management of his
multiple spinal fractures.
Past Medical History:
depression, HTN, ETOH dependence
Social History:
Patient lives in [**Location 8117**] NH with his wife. [**Name (NI) **] has masters level
education in music, teaches at prep academy. Two daughters ages
26 and 24. Practicing [**Doctor First Name **].
h/o alcohol dependence, up to one fifth vodka daily, no h/o
seizures or dt's, no h/o detox, has attended a couple aa mtgs
but
not currently
-occasional mj, denies other illicits
Family History:
non contributory
Physical Exam:
Temp92.9 HR 68 BP 116/78 RR 12 Awake, A/O x 3, appears
comfortable. Dried blood covering much
of his head and both hands. C-collar in place.
PERRL, EOMI
Oropharynx dry, but clear
Musculoskeletal Exam
No visible deformities or palpable tenderness to the upper or
lower extremities, aside from superficial abrasions to the
hands.
Full range of motion of upper and lower extremities without
pain.
There is no palpable tenderness or pain with range of motion of
the ankles, feet, or lower legs.
On back exam, there was no focal spinal tenderness, no palpable
deformities.
Rectal tone normal, guaic trace positive.
Reflexes: 2+ in bilateral lower extremities. No clonus.
Vascular: DP, PT, and radial pulses 2+ bilaterally.
Neuro: Strength 5/5 in all muscle groups of upper and lower
extremities. Sensation fully intact throughout upper and lower
extremities. There is no clonus.
Pertinent Results:
[**2108-12-11**] 07:40AM WBC-15.1* RBC-3.74* HGB-12.4* HCT-36.7*
MCV-98 MCH-33.3* MCHC-33.9 RDW-13.5
[**2108-12-11**] 07:40AM NEUTS-90.7* LYMPHS-5.4* MONOS-3.3 EOS-0.3
BASOS-0.3
[**2108-12-11**] 07:40AM PLT COUNT-200
[**2108-12-11**] 07:40AM PT-13.1 PTT-21.7* INR(PT)-1.1
[**2108-12-11**] 07:40AM GLUCOSE-190* UREA N-31* CREAT-1.2 SODIUM-140
POTASSIUM-4.6 CHLORIDE-108 TOTAL CO2-18* ANION GAP-19
[**2108-12-11**] 07:40AM ASA-NEG ETHANOL-203* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2108-12-11**] Chest CT :
1. Fractures of the manubrium, mid sternum, T5 vertebral body,
and T9
vertebral body with stable retrosternal and prevertebral
hematomas.
2. Hazy ground-glass opacities in the right chest, predominantly
in the
anterior segment of the right upper lobe, and in the setting
suggestive of
pulmonary contusions.
3. Streaks of contrast are identified throughout bilateral
kidneys and
suggestive of acute tubular necrosis.
[**2108-12-11**] MRI C, T spine :
1. No evidence of cervical or thoracic cord signal abnormality.
No evidence of epidural hematoma.
2. Edema within the interspinous ligament in the mid cervical
spine without evidence of ligamentous discontinuity.
3. Right C5-6 facet joint effusion with associated C6 superior
facet edema
compatible with known injuries. No evidence of right vertebral
flow void
abnormality.
4. Fractures involving the T3, T5, and T9 vertebral bodies, with
minimal
retropulsion at T5 but no high-grade canal stenosis.
5. Hematoma surrounding the sternum. Please see CT chest for
additional
details.
Brief Hospital Course:
Mr. [**Known lastname 72206**] was evaluated by the Trauma team in the Emergency Room
as well as the Ortho Spine service for evaluation of his
cervical and thoracic spine fractures. Due to his presentation
of the accident being secondary to a suicide attempt the
Psychiatric service and Social service team also were consulted.
From a medical standpoint he required serial hematocrits due to
his retrosternal hematoma and pectoralis hematoma. His
hematocrit on admission was 36 and gradually decreased to the
26-27 range. He exhibited no signs of bleeding with stable
hemodynamics, no dizziness and a stable hematocrit for 48 hours
prior to discharge. He was never transfused. His fractures were
evaluated by Dr [**Last Name (STitle) 1352**] with both CT and MRI's. He will need a
soft collar for comfort only and his restrictions include no
lifting > 2 lbs., no bending and no twisting. Otherwise he can
ambulate as tolerated. Of note, he had no signs or symptoms of
withdrawal.
Mr. [**Known lastname 72206**] was tolerating a regular diet and walking
independently with stable vital signs.
The Psychiatry service evaluated him on admission and a section
12 was obtained. He had a sitter 24 hours a day without any
incidents. The Psychiatry service saw him on a daily basis and
recommended an in patient psychiatric admission after he was
medically stable from his accident.
Medications on Admission:
lexapro 20', propranolol 20', benicar 20'
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
3. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. ipratropium bromide 0.02 % Solution Sig: One (1) inh
Inhalation Q6H (every 6 hours).
6. propranolol 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO at bedtime as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
S/P Fall
1. Right C6 superior facet fracture
2. T3, T7 compression fracture
3. Sternal fracture 6mm
4. Retrosternal hematoma
5. Right pectoral hematoma
6. Left occipital scalp laceration
7. Alcohol dependence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory -
Discharge Instructions:
* You were admitted to the hospital with multiple injuries after
falling.
* You have a cervical fracture that is stable and you can wear a
soft collar for comfort.
* You also have some compresion fractures in the thoracic spine.
You should NOT bend, twist or lift anything > 2 lbs for the next
6 weeks.
* The spine surgeon will re evaluate you in 6 weeks.
* Do NOT drink any alcohol
* If you develop any new symptoms that concern you please call
your doctor or return to the Emergency Room.
Followup Instructions:
Call Dr. [**Last Name (STitle) 1352**] from Orthospine at [**Telephone/Fax (1) 1228**] for a follow up
appointment in 6 weeks.
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**2-15**] weeks.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2108-12-14**]
ICD9 Codes: 5845, 4019, 2859, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8765
} | Medical Text: Admission Date: [**2148-1-5**] Discharge Date: [**2148-2-12**]
Date of Birth: [**2104-4-9**] Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: This is a 43 year old
African-American female with a past medical history
significant for severe chronic obstructive pulmonary disease,
hypertension, and anxiety, who presented to [**Hospital1 346**] on [**1-5**], with one month
history of progressively increasing shortness of breath and
hypoxia. The patient is followed closely by Dr.
[**Last Name (STitle) 217**] on an outpatient basis.
Two weeks prior to admission, her FEV1 was found to be 0.36
and her FVC 1.13. Her obstructive lung disease was so bad
that she was being considered a candidate for a lung
transplant.
In the Emergency Room, the patient was given treatment with
nebulizers, terbutaline, intravenous Solu-Medrol, intravenous
Levaquin and transient Heliox therapy. Unfortunately, none
of these therapies seemed to work and the patient became
increasingly acidemic. She was placed on Bi-PAP but
subsequently became increasingly tachypneic and tachycardic.
Her blood gas revealed a pH of 7.26, carbon dioxide of 65 and
O2 of 95 so as a result she was emergently intubated.
REVIEW OF SYSTEMS: Review of systems before intubation was
remarkable only for a productive cough of yellow sputum.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Asthma / chronic obstructive pulmonary disease.
3. Anxiety.
4. Mitral valve prolapse.
5. Positive PPD status post INH therapy times six months.
MEDICATIONS ON ADMISSION:
1. Atenolol 50 q. day.
2. Hydrochlorothiazide 12.5 q. day.
3. Singulair 10 q. day.
4. Celexa 50 q. day.
5. Clonazepam 0.5 q. day.
6. Flovent twice a day.
7. Serevent 2 twice a day.
8. Albuterol q. four hours p.r.n.
9. Nebulizers p.r.n. at home.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient smoked one to two packs a day
for 15 years and quit in [**2147-1-14**]. She drinks
alcohol socially and denies any intravenous drug use. She
has a 5 year old son. [**Name (NI) 6419**] her parents are in the area.
FAMILY HISTORY: Remarkable for a grandmother with lung
cancer. There is no family history of chronic obstructive
pulmonary disease.
PHYSICAL EXAMINATION: Temperature 98.9 F.; blood pressure
127/81; pulse 110; saturation of 100% on assist control of
600 by 8 with 8 of PEEP and 40% FIO2. In general, before she
was intubated, the patient was visibly uncomfortable. She
was unable to speak full sentences and was gasping for
breath, visibly having a difficult time breathing. Pupils
are equal, round and reactive to light. Extraocular muscles
are intact. Sclerae anicteric. Oropharynx was clear. Neck
was supple without any lymphadenopathy or thyromegaly.
Cardiac examination revealed a normal S1, S2, at a
tachycardic rate, no audible rubs, murmurs or gallops. Lungs
revealed diminished air entry bilaterally with diffuse
expiratory wheezes and a prolonged expiratory time. The
patient's breathing was labored and she was vigorously using
her accessory muscles of breathing. Abdomen was mildly
protuberant, soft, nontender, nondistended, with good bowel
sounds and no masses. Extremities revealed no cyanosis,
clubbing, edema or calf tenderness. Neurologically, the
patient was a little somnolent but otherwise the examination
was non-focal and benign.
LABORATORY: On admission notable for a white blood cell
count of 16.1, hematocrit of 41, platelets 310, BUN 16,
creatinine 0.7, bicarbonate 27.
Chest x-ray demonstrated hyperinflated lungs with flattened
diaphragms but no signs of any focal infiltrate consistent
with pneumonia.
HOSPITAL COURSE: In light of her chronic obstructive
pulmonary disease exacerbation, the patient was placed on
high dose steroids, frequent bronchodilators and adequate
antibiotic coverage with Augmentin initially. She was
intubated and sedated appropriately. Over time, it was
attempted to wean her from the ventilator, but unfortunately
as her pressure support was decreased to minimal levels, the
patient would become desynchronous with the ventilator,
requiring immediate paralysis for ventilation.
Even to this day, it is a mystery as to why these episodes
would occur. The patient eventually received both a
tracheostomy tube and a PEJ tube via surgery. She was given
tube feeds for nutrition and her vent settings were slowly
weaned to pressure support. For her underlying anxiety
disorder, the patient was placed on an around the clock
regimen of Valium with p.r.n. doses of Ativan.
An EMG was performed and confirmed the diagnosis of critical
care polyneuropathy. Because it took a while for the
patient's mental status to return to baseline off of all
sedation, a head CT scan was performed to evaluate for any
signs of an acute hypoxia. Fortunately, the CT scan
confirmed the presence of a pan-sinusitis but no acute
cerebral injury.
For most of her hospital stay, the patient continued to have
frequent intermittent episodes of tachycardia and
hypertension which were most likely related to her underlying
anxiety disorder. Secondary causes of hypertension such as
pheochromocytoma, carcinoid, and hyper-thyroidism were all
ruled out.
The patient's renal function remained excellent throughout
her hospital stay with occasional episodes of oliguria which
responded well to fluid boluses. Iron studies were checked
and were found to be consistent with anemia of chronic
disease. As a result, the patient was started on iron
supplements. A hemolysis work-up was completely negative.
Her electrolytes were checked on a daily basis and were
repleted as needed. She was placed on heparin subcutaneously
and Pepcid for adequate prophylaxis. Towards the end of her
hospital stay, she developed a Methicillin Sensitive
Staphylococcus aureus bacteremia from a line infection. She
was thus treated with adequate doses of Oxacillin for a total
14 day course through her PICC line that was placed by
Interventional Radiology.
The patient developed some diarrhea during her hospital stay
as well and was ruled out adequately for Clostridium
difficile toxin.
Once the patient was stable on pressure support settings,
Physical Therapy was consulted to improve the patient's motor
tone and strength.
DISCHARGE DIAGNOSES:
1. Severe chronic obstructive pulmonary disease with failure
to wean status post tracheostomy.
2. Methicillin sensitive Staphylococcus aureus bacteremia.
3. Severe anxiety.
4. Hypertension.
5. Critical care poly-neuropathy and myopathy.
6. Anemia of chronic disease.
DISCHARGE MEDICATIONS:
1. Prednisone 15 mg q. day until [**2-15**]. Her dose is to
be tapered by 5 mg per week thereafter until she reaches
zero.
2. Oxacillin 2 grams intravenously four times a day until
[**2-21**] (a complete two week course).
3. Valium 5 mg twice a day.
4. Heparin subcutaneously twice a day.
5. Rhinocort two puffs twice a day.
6. Colace 100 mg twice a day p.r.n. constipation.
7. Pepcid, 20 mg twice a day.
8. Albuterol inhaler and nebulizers p.r.n.
9. Serevent 2 puffs twice a day.
10. Flovent 6 puffs twice a day.
11. Celexa 50 mg q. day.
12. Singulair 10 mg q. day.
13. Captopril 50 mg three times a day.
14. Iron sulfate 325 mg twice a day.
15. Ativan 1 mg q. three hours p.r.n.
16. Tylenol p.r.n.
17. Nitroglycerin paste p.r.n.
18. Metoprolol 12.5 mg twice a day.
DISCHARGE STATUS: The patient was discharged in good
condition to a rehabilitation center. There she is to regain
her strength in terms of motor function and respiratory
muscles.
She is to slowly be weaned off of her ventilator.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D. [**MD Number(1) 3091**]
Dictated By:[**Last Name (NamePattern4) 23084**]
MEDQUIST36
D: [**2148-2-11**] 15:39
T: [**2148-2-11**] 17:13
JOB#: [**Job Number 23085**]
ICD9 Codes: 4240, 7907, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8766
} | Medical Text: Admission Date: [**2159-1-30**] Discharge Date: [**2159-2-6**]
Date of Birth: [**2099-10-20**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
man who was referred to [**Hospital1 69**]
for cardiac catheterization, which then resulted in a
subsequent coronary artery bypass graft. He has diabetes
mellitus with exertional angina symptoms for several years.
In [**2157-2-23**], he had a stress test which was positive,
and negative electrocardiogram changes. Myoview showed
inferior wall defect, partially reversible. In [**2158-2-23**], the patient passed out. He has been dizzy a few times
since. He has a history significant for heavy smoking, and
hypercholesterolemia, diabetes.
PAST MEDICAL HISTORY: Significant for deep venous
thrombosis in the [**2126**], insulin-dependent diabetes mellitus
for 12 years.
PAST SURGICAL HISTORY: He has had left leg surgery
secondary to traumatic waterskiing accident, right knee
arthroscopy, and three fingers which were severed partially
and then reattached.
He denies any stroke, cerebrovascular accident or lower
gastrointestinal bleed.
ALLERGIES: No known drug allergies. No allergies to
shellfish.
MEDICATIONS: Lipitor 10 mg once daily, atenolol 50 mg once
daily, aspirin 325 mg once daily, insulin NPH 44 units once
daily and insulin regular 10 units once daily at home.
LABORATORY DATA: On admission, 8.4/46.0/181 for the CBC.
Chemistry 139/4.8/104/29/18/1.1/117, with an INR of .85.
SOCIAL HISTORY: Significant for him being married, and he
is a retired tree landscaper.
HOSPITAL COURSE: Cardiac catheterization showed an ejection
fraction of 30%, left main coronary artery with 50 to 60%
stenosis, mid-left anterior descending of 50%, left anterior
descending of 80%, obtuse marginal I of 70%, obtuse marginal
II of 80%, obtuse marginal III of 100%. The patient had
severe three vessel disease, and was taken for a coronary
artery bypass graft by Dr. [**Last Name (STitle) 1537**] on [**2159-2-1**]. The patient
postoperatively did well, and was extubated and was
transferred to the Cardiothoracic Intensive Care Unit
overnight, where he did extremely well, was weaned off
insulin drip and transferred to the floor the next day.
On the floor, the patient's wires and chest tubes were
discontinued, first his mediastinal tube, and then his Foley
on [**2159-2-3**]. On [**2159-2-4**], the patient had an episode of atrial
fibrillation, where he had a heart rate going to the 110s,
with a blood pressure of 90s to 100/50s. The patient had an
oxygen saturation of 90%, and otherwise vital signs were
stable. The patient was started on amiodarone and increased
on Lopressor. After that, the patient's sinus rhythm
resumed, with no episodes of atrial fibrillation noted.
Chest tubes were discontinued the same day without incident.
On [**2159-2-5**], it was noted that his sugars were as high as 300,
and [**Last Name (un) **] was called for a consult. Their assessment was to
change his NPH to 44 units in the morning and 5 units at
bedtime, and sliding scale adjustment at home. They
suggested follow up with primary care physician and, when
discharged, primary care physician should be aware of a 75/25
mix of insulin might work for him at home.
The patient was discharged on [**2159-2-6**] after tolerating
exercise and progressing well. His physical examination is
significant only for a scar on his sternum, which is healing
very well, as the leg scar is as well. The patient is
afebrile, and his vital signs are stable. The patient is
being discharged to home on [**2159-2-6**], to follow up with Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], his primary care physician, [**Name10 (NameIs) **] his
cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. All surgical issues are
dealt with by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**].
On discharge, the patient is in good condition, and
understands his discharge medications, which include lasix 20
mg by mouth twice a day for a week, potassium chloride 20 mEq
by mouth for one week, Colace 100 mg by mouth twice a day,
Lopressor 25 mg by mouth twice a day, Ranitidine 150 mg by
mouth twice a day, aspirin 325 mg by mouth twice a day,
Lipitor 10 mg by mouth once daily, percocet 5/325 mg tablets
one to two tablets every four to six hours as needed for
pain, amiodarone 400 mg three times a day for four days, then
twice a day for a week, then once daily, insulin NPH and
regular [**First Name8 (NamePattern2) **] [**Last Name (un) **] protocol and his primary care physician.
[**Name10 (NameIs) **] patient understands the discharge plan, and agrees with
it.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 16758**]
MEDQUIST36
D: [**2159-2-5**] 23:45
T: [**2159-2-6**] 01:23
JOB#: [**Job Number 39138**]
ICD9 Codes: 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8767
} | Medical Text: Admission Date: [**2155-12-25**] Discharge Date: [**2155-12-26**]
Date of Birth: [**2089-6-17**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Carotid stenosis
Major Surgical or Invasive Procedure:
Carotid catheterization with stent placement in lt internal
carotid artery.
History of Present Illness:
This 65 year old woman with a history of CAD, s/p two PCIs with
stenting of the RCA and LAD who was found to have a carotid
bruit on routine physical exam. She was referred for a duplex
ultrasound carotid scan which showed 40% rt ICA stenosis and
80-99% lt ICA stenosis. A MRA showed the same degree of ICA
stenosis. She was referred to Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] for carotid
artery stenting. She had her left carotid artery stented today
and is admitted to the CCU for observation overnight.
She reports that she is feeling well and has been free of any
neurological symptoms. No TIA, No CVA, No melena/GIB
Past Medical History:
1. Diabetes Melitis type 2, well controlled on Prandin
2. Hypertension
3. Hypercholesterolemia
4. Breast cancer s/p lumpectomy five years prior, s/p XRT,
previously on Tamoxifen
5. CAD s/p stenting of RCA and LAD in [**4-27**] and [**5-27**] respectively
Social History:
Married with three children, retired.
Family History:
No family history of CAD
Physical Exam:
BP 103/43
Pulse 49
Resp 97% on RA
Gen - Alert, no acute distress
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation 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 [**3-6**] intact,
upper and lower extremity strength 5/5 bilaterally (left leg not
tested secondary to need to remain stationary), sensation
grossly intact
Skin - No rash
Brief Hospital Course:
1. Carotid stent - This 66 year old female s/p IMI with recent
catheterizations s/p RCA and LAD stents presenting with
asymptomatic left ICA stenosis. She had carotid angiography
with stenting of left internal carotid artery. She tolerated
the proceedure well. She was transfered to the CCU for care
after the proceedure where her SBP was maintained >100 and <140
with Neosynephrine drip. She had some symptomatic bradycardia
overnight which was treated with Atropine. All BP meds were
held and neuro checks were performed q1hour X 4, then q2hour X3,
then per routine. She was continued on ASA, Plavix, and
Lipitor. The following morning she was still requiring Neo drip
for hypotension. She was given multiple fluid boluses and the
Neo was weaned off. She was discharged when she was no longer
hyptensive.
2. CAD - She was continued on ASA, Plavix, Lipitor. All BP meds
were held, as mentioned above she had some bradycardia treated
with Atropine but was otherwise asymptomatic.
Medications on Admission:
Mavik 2mg daily
Toprol 100mg daily
ASA 325mg daily
Plavix 75 mg daily
lipitor 40 mg qhs
Prandin 1mg TID
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 300 days.
Disp:*30 Tablet(s)* Refills:*9*
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Prandin 1 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Carotid stenosis s/p stent placement
Secondary diagnosis:
Coronary artery disease
Hypertension
Hypercholesterolemia
Discharge Condition:
Good
Discharge Instructions:
Continue to take all medications as prescribed. Plavix should
be taken daily.
Return to the hospital for any neurological symptoms including
but not limited to: changes in vision, changes in sensation,
changes in movement or strength.
Return to [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **] on Monday [**12-29**] and have
Dr. [**First Name (STitle) **] check your blood pressure.
Return to the hospital for any shortness of breath or chest
pain.
Pt should not take any of blood prssure medication until she
sees Dr. [**First Name (STitle) **].
Followup Instructions:
Follow up with Dr. [**First Name (STitle) **].
Provider: [**Name10 (NameIs) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2156-2-10**] 3:30
Provider: [**Name10 (NameIs) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2156-6-15**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2156-6-15**] 4:00
Return to [**Hospital3 **] [**Hospital3 **] [**Hospital3 **] on [**12-29**] to have Dr. [**First Name (STitle) **]
measure blood pressure
ICD9 Codes: 2765, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8768
} | Medical Text: Admission Date: [**2183-4-13**] Discharge Date: [**2183-5-17**]
Date of Birth: [**2183-4-13**] Sex: M
Service: NB
HISTORY: [**Known lastname **] twin #1 male, is a 31 and [**7-17**] week
gestation, birth weight 1810 grams which is 50 percentile,
length 42 cm 25 percentile with a head circumference of 30 cm
25-50 percentile. Infant was born to a 26 year old gravida 2,
para 1, EDC was [**2183-6-9**]. Maternal prenatal labs: A
positive, antibody negative, RPR nonreactive, rubella immune,
and hepatitis B negative, GBS unknown. Other relevant
maternal pregnancy history: Twin #1, boy has had normal
intrauterine growth, no anomalies noted. Twin B girl was
noted to have finding consistent with Dandy-Walker
malformation at 18 weeks gestation and restriction in growth.
As pregnancy progressed, twin B growth became less than 1
percentile and eventually absent end-diastolic flow.
Completed course of antenatal steroids on [**3-26**].
[**2183-3-27**], due to concerns regarding twin B, C-
section was planned on [**2183-4-14**]. Mother admitted on
[**2183-4-13**] with contractions and C-section was performed
that day. Twin A boy emerged crying, pink, well perfused.
Apgars were 8 at 1 minute and 9 at 5 minutes. Infant began
to have increased work of breathing in delivery room
requiring facial [**Hospital 43216**] transferred to NICU
Upon admission to NICU, infant was intubated with a 3.0 ET
tube with initial vent settings of pressure 22/6, SIO2 of 50%
with a rate of 25%. Infant received first dose of surfactant
without complication and vent support has weaned. Chest x-
ray was consistent with hyaline membrane disease and ET tube
in good position.
PHYSICAL EXAMINATION: NICU admission vital signs: Temp was
98.3, respiratory rate in the 60s, heart rate 150s, blood
pressure 55/23 with a mean of 35. In general, its an AGA
male, 31 and 6/7 weeks gestation, active, well perfused.
Head, ears, eyes, nose and throat: Nondysmorphic. Anterior
fontanelle soft and flat. Ears, nose, mouth and eyes
appeared normal to external exam. Positive red reflex
bilaterally. No neck masses. No lymphadenopathy. Clavicles
normal to palpation.
Lungs: Coarse and equal breath sounds, good entry. CV:
Normal heart rate, no murmur. Blood pressure normal. Pulse
is normal. Infant did have very brief episodes of heart rate
in the high 200s x2 to 3 seconds spontaneously resolved.
Abdomen: No hepatosplenomegaly, positive bowel sounds, 3
vessel umbilical cord, no masses, soft, and nondistended.
UVC placed in good position. GU: Normal preterm male. Anus
patent. Back appears normal. Extremities: Normal. Skin
appears normal. Neuro appears normal for 31 and [**7-17**] week
gestation infant in terms of tone, strength, movement, and
cry, alertness, response to stimuli.
SUMMARY OF HOSPITAL COURSE BY SYSTEM: Respiratory: RDS.
Infant intubated, received surfactant x2, extubated to CPAP
on day of life 3, weaned to room air on day of life 22.
Infant had occasional episodes of apnea and bradycardia,
not required methylxanthine therapy.
He had no episodes for at least 5 days prior to discharge.
Cardiovascular: Intermittant murmur. Echo on day of life 4:
Moderate PDA. PDA closed on own without treatment with
followup echo on day of life 8 revealed no PDA, PFO but right
ventricular systolic pressure increased probably secondary to
increased pulmonary pressures. Oxygen sats were kept > 94 %
and by day of life 22 when pulmonary pressures would have
dropped, his sats were maintained in normal range of 90-94%
This he was able to do in room air. Infant also
had self-resolving SVT with heart rates in the 290s during
his first 3 days of life. EKG performed: Nonspecific ST
changes and prolonged QC intervals. No further episodes of
SVT.
Fluid and electrolyte and nutrition: Infant initially NPO.
IV fluids of D10W began. Enteral feeds of breast milk began
on day of life 3. Full volume enteral feeds reached on day
of life 13. Calorie advancement to BM 24 cals /ounce made
with Neosure powder.
His weight the day prior to discharge was 2640 grams.
GI: The patient had a bilirubin 9.2/0.3 on day of life 3,
treated with phototherapy. Last bilirubin on day of life 15:
9.7/03 f/u level on day of life 18 was 7.7/0.3. Mother A+.
Hematology: Infant had hematocrit of 47.5 with a platelet
count of 303 on admission. Infant has not been transfused.
Current crit on day of life 14: 41.3.
Infectious disease: Infant initially had a 48 hour rule out
on admission to NICU with a negative blood culture. Initial
CBC with a white count of 6.9, 20 polys and 1 band and a
platelet count of 303.
Neurology: On day of life 7, head ultrasound was normal.
Repeat at 31 days of life on [**5-14**] was normal.
Audiology: Hearing screen passed [**5-15**].
Ophthalmology: Immature z 3 ou on [**5-5**], f/u in 3 weeks.
IMMUNIZATIONS: Hepatitis B given [**5-14**].
CIRCUMCISION: Done on [**5-16**].
Psychosocial: [**Hospital1 18**] social work involved with families.
Social worker can be reached at [**Telephone/Fax (1) **].
DISCHARGE MEDICATIONS: Ferrous Sulfate 0.2 PO/Q Day
Vitamins 1 cc PO q Day.
DISCHARGE DISPOSITION: [**Location (un) 2274**]/MFD, Dr.[**Last Name (STitle) **] appt within 5 days
of discharge.
VNA to visit day post discharge
Early Intervention referral
F/U optho exam at [**Location (un) 2274**]/Dr. [**Last Name (STitle) 40944**].
3rd-4th week in [**Month (only) 547**]. Appointment to
be made by Dr. [**Last Name (STitle) **]
DISCHARGE DIAGNOSES:
1. Prematurity, infant born at 31 and 6/7 weeks.
2. Respiratory distress syndrome, resolved.
3. Rule out sepsis, has resolved.
4. Supraventricular tachycardia, resolved.
5. Patent ductus arteriosus, resolved.
6. Apnea/Bradycardia of prematurity.
7. Hyperbilirubinemia.
8. Immature retina z3 ou
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**]
Dictated By:[**Last Name (NamePattern1) 71091**]
MEDQUIST36
D: [**2183-4-28**] 18:43:43
T: [**2183-4-28**] 20:09:52
Job#: [**Job Number 71873**]
ICD9 Codes: 769, 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8769
} | Medical Text: Admission Date: [**2146-10-1**] Discharge Date: [**2146-10-8**]
Date of Birth: [**2070-4-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Left arm pain
Major Surgical or Invasive Procedure:
[**2146-10-4**] Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to
OM, SVG to PDA)
History of Present Illness:
72 yo F h/o HTN, hyperchol, bilat carotid artery stenosis (70%),
bradycardia s/p DDD pacer 3 vessel CAD presented to [**Hospital 1474**]
hospital on [**2146-9-30**] with left arm pain, fatigue on exertion x 3
days. Transferred to [**Hospital1 18**] for CT [**Doctor First Name **] eval for possible CABG.
Past Medical History:
Coronary Artery Disease, Hypertension, Hypercholesterolemia,
Bradycardia s/p DDD pacemaker, Diverticulosis, Peripheral
Vascular Disease/Carotid Stenosis, Endomertrial Cancer s/p
TAH/BSO, Arthritis, s/p Laparoscopic Cholecystectomy, s/p
Appendectomy, s/p Tonsillectomy, s/p benign breast tumors s/p
lumpectomy w/ contrlateral breast reconstruction
Social History:
No tobacco, occasional EtOH, No illicit drugs. Lives with
husband in [**Name (NI) 1474**]
Family History:
strong family Hx of CAD, most members did not live past age 40
Physical Exam:
VS: T 98.9, HR 64, BP 154/69, RR 18, O2sat 95% RA, wt 163 lbs.
Gen: NAD, lying in bed conversing
HEENT: EOMI, PERRLA, MMM, OP benign, sclerae anicteric
Neck: supple, no LAD, no carotid bruits
Chest/Back: chest wall and spine non-tender, no CVAT
Lungs: CTAB
Heart: RRR, no S1, normal S2, no M/G/R
Ab: + BS, S, NT, ND
Ext: WWP, no edema, 1+ PT/DP pulses
Neuro: AOX3, grossly non-focal.
Pertinent Results:
CNIS [**10-3**]: Less than 40% right carotid stenosis. 40-59% left
carotid stenosis.
Echo [**10-4**]: PRE-BYPASS: There is moderate symmetric left
ventricular hypertrophy. Overall left ventricular systolic
function is normal (LVEF>55%). There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. No mitral regurgitation is seen.
Post-Bypass: Preserved biventricular systolic function. Overall
LVEF 55% to 60%. Preserved ascending aortic contours. Trace MR.
CXR [**9-4**]: Left retrocardiac opacity likely representing
atelectasis and small- to moderate-sized left-sided pleural
effusion. No evidence of pneumothorax.
[**2146-10-1**] 12:40PM BLOOD WBC-7.0 RBC-4.31 Hgb-13.9 Hct-38.8 MCV-90
MCH-32.3* MCHC-35.9* RDW-13.3 Plt Ct-239
[**2146-10-7**] 06:30AM BLOOD WBC-10.7 RBC-2.99* Hgb-9.4* Hct-27.4*
MCV-92 MCH-31.4 MCHC-34.4 RDW-13.5 Plt Ct-128*
[**2146-10-1**] 12:40PM BLOOD PT-12.8 PTT-29.1 INR(PT)-1.1
[**2146-10-5**] 03:17AM BLOOD PT-13.5* PTT-29.3 INR(PT)-1.2*
[**2146-10-1**] 12:40PM BLOOD Glucose-89 UreaN-17 Creat-0.9 Na-142
K-4.1 Cl-107 HCO3-24 AnGap-15
[**2146-10-7**] 06:30AM BLOOD Glucose-86 UreaN-14 Creat-0.8 Na-139
K-4.0
[**2146-10-4**] 09:15AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.5
[**2146-10-4**] 06:20AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2146-10-4**] 06:20AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2146-10-4**] 06:20AM URINE RBC-0-2 WBC-21-50* Bacteri-FEW Yeast-NONE
Epi-[**1-2**]
Brief Hospital Course:
As mentioned in the HPI, Ms. [**Known lastname 45417**] was tranferred from an OSH
after undergoing a cardiac catheterization which revealed 3
vessel coronary artery disease. She underwent pre-operative
testing prior to surgery which included echocardiogram, carotid
u/s, lab work and consultations (EP). After all work-up (HD#4)
she was brought to the operating room where she underwent a
coronary artery bypass graft x 3. Please see operative report
for surgical details. Following surgery she was brought to the
CSRU for invasive monitoring in stable condition. She required
PRBC blood transfusion secondary to low HCT. Early on post-op
day one she was weaned from sedation, awoke neurologically
intact and extubated. Also on this day her chest tubes were
removed and Ciprofloxacin was re-started for pre-op UTI. Beta
blockers and diuretics were iniated and she was gently diuresed
towards her pre-op weight. Later on this day she was transferred
to the SDU. Physical therapy followed pt during entire post-op
course for strength and mobility. On post-op day three her
epicardial pacing wires were removed. She continued to improve
with stable labs and physical exam post-operatively and was
discharged home on post-op day # 4.
Medications on Admission:
Vytorin (zetia/simvastatin) 10/40 qd, Atenolol 50 mg [**Hospital1 **], Nitro
paste q4hr, Lovenox 1mg/kg q12 hr, Lisinopril, ASA 325 qd,
Plavix 75 mg qd, Lopid 600 mg [**Hospital1 **]
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*1*
6. Vytorin 10/40 10-40 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO twice a day for 5 days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
Urinary Tract Infection
PMH: Hypertension, Bradycardia s/p DDD pacemaker,
Diverticulosis, Peripheral Vascular Disease/Carotid Stenosis,
Endomertrial Cancer s/p TAH/BSO, Arthritis, s/p Laparoscopic
Cholecystectomy, s/p Appendectomy, s/p Tonsillectomy, s/p benign
breast tumors s/p lumpectomy w/ contrlateral breast
reconstruction
Discharge Condition:
Good
Discharge Instructions:
You may take shower. Wash incisions with gentle soap and water.
Gently pat dry. Do not take bath or swim.
Do not apply lotions, creams, ointments, or powders to
incisions.
Do not lift more than 10 pounds for 2 months.
Do no drive for 1 month.
If you develop a fever or notice drainage from chest incisions,
please contact office immediately.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks
Dr. [**Last Name (STitle) 6700**] in [**3-18**] weeks
Dr. [**Last Name (STitle) 1057**] in [**2-14**] weeks
Completed by:[**2146-10-8**]
ICD9 Codes: 5990, 4111, 5119, 4019, 2859, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8770
} | Medical Text: Admission Date: [**2154-6-2**] Discharge Date: [**2154-6-14**]
Date of Birth: [**2099-4-13**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 55 year-old man
with a history of diabetes/end stage renal disease on
hemodialysis on the renal transplant list who presents with
fever and cough. The patient was in his usual state of
health until the day of admission when he noticed increasing
productive cough, increasing shortness of breath and some
pleuritic chest pain. He denies nausea, vomiting, diarrhea,
substernal chest pain, abdominal pain. He did have some
diarrhea, but no melena or hematochezia. He denies dysuria
or hematuria. Of note the patient also noticed right lower
extremity edema for the two days prior to admission. He
reports increasing fatigue. He denies headache, vision
changes, nuchal rigidity. The patient had a recent admission
on [**4-18**] with pneumonia treated with Ceftriaxone and
Azithromycin and then oral Cefpodoxime on discharge.
PAST MEDICAL HISTORY:
1. Diabetes mellitus type 2.
2. Hypertension.
3. Hypercholesterolemia.
4. End stage renal disease on hemodialysis preparing for
transplant.
5. HCV.
6. Ischemic right foot ulcer status post graft [**5-15**]. [**Doctor Last Name **] to
the posterior tibial.
7. Diverticulosis.
8. C-difficile [**11-16**].
9. Laparoscopic cholecystectomy.
10. AV fistula.
11. Hyperparathyroidism
ALLERGIES: Ciprofloxacin causes mouth swelling, Levo - rigors
MEDICATIONS ON ADMISSION:
1. Metoprolol.
2. Losartan.
3. Atorvastatin.
4. Protonix.
5. Nephrocaps.
6. Tylenol.
7. Lipitor.
8. Aspirin.
9. Ibuprofen.
10. Amlodipine.
11. Sevelamer.
12. Vancomycin.
13. Ceftriaxone.
PHYSICAL EXAMINATION: Temperature 99.7, heart rate 94, blood
pressure 160/88, respiratory rate 24, sating 82% on room air,
90% on a nonrebreather. In general the patient was
somnolent, but arousable. HEENT pupils are equal, round and
reactive to light. Extraocular movements intact. Large
conjunctival hemorrhage. Oropharynx is dry. Cardiovascular
holosystolic murmur. Regular rate and rhythm. Lungs
decreased breath sounds to the left base. Abdomen positive
bowel sounds, soft, nontender, nondistended. Extremities
left fistula thrill, right lower extremity edema. Right toe
necrotic with eschar. No evidence of cellulitis or pus.
LABORATORIES ON ADMISSION: White blood cell count 12.2,
hematocrit 39, platelets 293, 83% neutrophils, no bands, 12
lymphocytes, 8.5 monocytes, 1.9 eosinophils, 4 basophils.
Chest x-ray demonstrated a right lower lobe infiltrate.
Electrocardiogram sinus at 62, normal axis, normal intervals,
peaked Ts in V2, left ventricular hypertrophy, flat T wave
laterally, no ST changes [**2154-5-10**]. No disease on
catheterization per report. No findings in computer. [**4-17**]
echocardiogram EF 60%, trace MR, trace AI. [**5-15**] AK popliteal
to posterior tibial.
HOSPITAL COURSE: 1. Renal: The patient was continued on
dialysis with management of volume status by the renal
consult team.
2. Right toe ischemia: Vascular surgery was consulted,
imaged the right lower extremity. Once the patient's other
issues (see below) are resolved the patient was taken for a
right great toe amputation by Dr. [**Last Name (STitle) **]. He was treated
with perioperative broad spectrum antibiotics and will be
discharged to physical therapy rehab.
3. Pulmonary: The patient was found to have a pneumonia in
the right lower lobe. He was monitored in the Intensive Care
Unit for his hypoxemia. He was intubated on [**6-4**] for hypoxic
respiratory failure. He was treated with Ceptaz, Vancomycin
and Azithromycin, which was switched to Zosyn, Azithromycin
and Vancomycin until [**6-6**] when his regimen was switched to
Vancomycin and Ceftriaxone until [**6-7**] when Flagyl was added.
At that time he required Dopamine for a drop in systolic
blood pressure to the 80s after being given Levofloxacin. He
was intubated approximately two days and then had an episode
of hypertension to 240 and chest pain. He ruled out for
myocardial infarction and was started on antihypertensives.
On [**6-5**] the patient underwent a bronchoscopy with BAL
demonstrating no gross findings and 2+ PMNs with gram
positive cocci in pairs and clusters. On [**6-8**] he underwent
thoracentesis where 600 cc of dark yellow fluid was removed
consistent with transudate. The patient was extubated and
called out. He underwent a noncontrast CT to look for
obstruction cause for pneumonia, but no evidence of
obstruction seen. In addition, video swallow study was done,
which was normal.
The patient was continued on a 14 day
course of antibiotics. He will follow up with his primary
care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] who is also the patient's attending
during the hospital course with repeat CT scan to ensure
complete resolution of the infection. The patient remained
afebrile with adequate O2 sats in the low 90s on room air.
4. Endocrine: The [**Last Name (un) **] Service was following the patient
for management of his diabetes.
5. Code: Full.
DISCHARGE DIAGNOSES:
1. Right great toe necrosis status post amputation on
[**2154-6-12**].
2. End stage renal disease on hemodialysis.
3. Recurrent right lower lobe pneumonia without evidence of
obstruction, aspiration risk or anatomical abnormality. No
specific organisms isolated.
4. Hypertension.
5. Anemia secondary to chronic renal failure.
6. Diabetes mellitus.
7. Levofloxacin allergy.
8. Hypoxemic respiratory failure.
DISCHARGE MEDICATIONS:
1. Atorvastatin 40 mg po q day.
2. Aspirin 325 mg po q day.
3. Metoprolol 100 mg po b.i.d.
4. Losartan 100 mg po q day.
5. Flagyl 500 mg intravenous q 8 hours last dose [**2154-6-16**].
6. Ceftriaxone 1 gram intravenous q 24 hours last dose
[**2154-6-16**].
7. Hydralazine 50 mg po q six hours.
8. Sevelomir 2400 mg po t.i.d.
9. Clonidine patch 0.2 mg transdermal q Monday.
10. Amlodipine 10 mg po q day.
11. Percocet 5/325 one to two tablets po q 4 to 6 hours prn
pain.
12. Insulin NPH 8 units subcutaneous q.a.m.
13. Atrovent/Albuterol nebulizers two puffs inhaled every
four hours prn shortness of breath.
14. Pantoprazole 40 mg po q day.
15. Heparin 5000 units subcutaneous q 8 hours until the
patient is ambulating.
16. Folic acid/vitamin B-complex one capsule po q day.
[**Last Name (LF) **],[**Name8 (MD) **] M.D. [**MD Number(2) 3405**]
Dictated By:[**Last Name (NamePattern1) 3411**]
MEDQUIST36
D: [**2154-6-14**] 07:08
T: [**2154-6-14**] 07:21
JOB#: [**Job Number 3412**]
ICD9 Codes: 486, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8771
} | Medical Text: Admission Date: [**2103-4-8**] Discharge Date: [**2103-4-14**]
Service:
CHIEF COMPLAINT: Lower gastrointestinal bleed.
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
gentleman with no significant past medical history except
disc herniation (on nonsteroidal antiinflammatory drugs and
aspirin for the last 10 years) who was sent from an outside
hospital for a lower gastrointestinal bleed.
The patient initially presented to [**Hospital1 **]-[**Location (un) 620**] on [**2103-4-7**] at noon with back and hip pain (the patient has been
treated for years for a ruptured disc - on nonsteroidal
antiinflammatory drug therapy) and also with a complaint of
bright red blood per rectum for the last six days.
The patient was sent to the [**Hospital1 188**] and was found to have a hematocrit decreased from 36
to 34 and a RED to 27. The patient was transfused one unit
of packed red blood cells. In addition, he had a question of
coffee-grounds emesis in the Emergency Department, but a
negative nasogastric lavage performed by Gastroenterology.
The patient continued to have a moderately brisk lower
gastrointestinal bleed with about 300 cc to 400 cc of bright
red blood per rectum every two to three hours. The patient
then had a tagged red blood cell scan performed by angiogram
which showed no extravasation and was a negative study. The
patient's bleeding slowly trickled down. At the time of
transfer to the Medical Intensive Care Unit, the patient had
only three bowel movements with a mild amount of blood in
each bowel movement.
Of note, the patient had a fall on [**2103-4-2**] with
residual hip and back pain. Starting on [**2103-4-2**] he
had several episodes of pain with dark red stools. He also
complained of some lower abdominal discomfort, but no nausea
or vomiting. He has been taking two tablets of ibuprofen and
one aspirin per day for the last 10 years. The patient is
mildly demented and unable to provide a clear and concise
history.
Review of systems was positive for a 10-pound weight loss
over the last seven to eight ears. He denied any fatigue.
He denied any dizziness or lightheadedness at home. No
orthopnea or paroxysmal nocturnal dyspnea. No chest pain or
shortness of breath.
PAST MEDICAL HISTORY:
1. Benign prostatic hypertrophy.
2. Disc herniation (on nonsteroidal antiinflammatory drugs).
3. Hypercholesterolemia.
4. Possible dementia.
5. Right eye cataract surgery.
6. A colonoscopy 10 years ago (per his daughter which was
within normal limits, although the patient states he has
never had a colonoscopy).
7. Gait instability and frequent falls.
MEDICATIONS ON ADMISSION:
1. Aspirin as needed (for pain).
2. Ibuprofen two tablets once per day as needed (for pain).
3. Iron sulfate.
4. Colace.
ALLERGIES:
SOCIAL HISTORY: The patient lives with his wife who has
suffered a cerebrovascular accident, and the patient
apparently takes care of his wife when he is at home. His
daughter is [**Name (NI) **] [**Name (NI) **]. Her telephone number is
[**Telephone/Fax (1) 54836**]. The patient has a remote history of tobacco
use but quit 30 years ago. He use to smoke 60 to 100 pack
years. He denies any significant alcohol use. He is a
retired firefighter.
FAMILY HISTORY: No family history of colon cancer. His
father died of emphysema and lung cancer. His mother died of
a cerebrovascular accident.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 97.8
degrees Fahrenheit, his blood pressure was 151/95, his pulse
was 86, sinus arrhythmia, and his oxygen saturation was 99%
on 3 liters nasal cannula. The patient weighed 69 kilograms.
In general, he was an elderly male sitting comfortably.
Inattentive and in no apparent distress. Head, eyes, ears,
nose, and throat examination revealed the pupils were equal,
round, and reactive to light. The extraocular movements were
intact. The mucous membranes were moist. The neck was
supple. The sclerae were anicteric. There was no
lymphadenopathy. The chest was clear to auscultation
bilaterally with a decreased inspiratory effort and decreased
breath sounds throughout. Cardiovascular examination
revealed a regular rate. A 2/6 systolic murmur best heard at
the left lower sternal border with radiation to the apex as
well as the left carotid. The abdomen revealed tenderness to
palpation in the bilateral lower quadrants. Otherwise, there
was no hepatosplenomegaly. There was no rebound and no
guarding. The abdomen was soft with good bowel sounds.
Extremities revealed no lower extremity edema. There were no
rashes. Rectal examination (per Gastroenterology) revealed
maroon stool that was guaiac-positive and an enlarged
prostate. Neurologic examination revealed the patient was
alert and oriented times three. The patient stated his name,
he was at a hospital, and it was [**2103-4-8**]. There was
no midline or spinal tenderness to palpation. He had good
bilateral upper and lower extremity strength at 5/5. There
were no cranial nerve deficits.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 7, his hematocrit on transfer was 34 (on
admission on [**4-7**] was 36, then dropped to 33, then stable
at 27, and then up at 34 status post transfusion of one unit
of packed red blood cells - the patient's baseline hematocrit
is 41), his mean cell volume was 90, and his platelets were
262. Chemistry-7 revealed his sodium was 140, potassium was
3.5, chloride was 106, bicarbonate was 27, blood urea
nitrogen was 22, creatinine was 1.1, and his blood glucose
was 93. Calcium was 8.5, his magnesium was 3, and his
phosphate was 2. Alanine-aminotransferase was 18, his
aspartate aminotransferase was 26, his alkaline phosphatase
was 37, his total bilirubin was 0.4, his amylase was .......,
and his lipase was 22. His INR was 1.3. Partial
thromboplastin time was 27. His creatine kinase was 160.
MB was 4. Troponin was less than 0.01.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray was pending.
An electrocardiogram showed a normal sinus rhythm with a rate
of 81. There was right atrial enlargement and left atrial
enlargement. Borderline left ventricular hypertrophy. P-R
prolongation. Poor baseline, but no T wave inversions or ST
changes.
IMPRESSION: This is an 81-year-old gentleman with no
significant past medical history who presented with lower
gastrointestinal bleed.
BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. GASTROINTESTINAL BLEED ISSUES: On admission to the
Medical Intensive Care Unit, the patient's gastrointestinal
bleed appeared clinically to be slowing down. He had a
negative tagged red blood cell scan (as mentioned in the
History of Present Illness) and a negative nasogastric
lavage. The patient's hematocrit stable after his
transfusion of one unit of packed red blood cells in the low
30s. He remained hemodynamically stable throughout his
hospital course.
The patient did have a colonoscopy performed which showed
diverticulosis of the entire colon. No obvious colonic
polyps or large masses were seen; however, the colonoscopy
preparation was poor. Therefore, small polyps could have
easily been missed. Gastroenterology suggested that the
patient continue with a normal diet, and if his hematocrit
remained stable for over 24 hours, from a gastroenterology
standpoint, the patient was safe to be discharged from the
hospital. The patient was to avoid taking aspirin,
ibuprofen, or any other nonsteroidal antiinflammatory drugs
and was to take Tylenol instead for pain. The patient should
follow up with his primary care physician for any further
gastrointestinal issues.
The patient was initially placed on Protonix 40 mg
intravenously twice per day prior to colonoscopy, and with
colonoscopy results indicating the likely source of bleed as
a diverticular bleed the patient was maintained on Protonix
40 mg once per day for gastrointestinal prophylaxis.
At the time of this dictation, at discharge, the patient's
hematocrit had been stable at 32. He has had no further
episodes of gastrointestinal bleeding, and he should continue
to hold nonsteroidal antiinflammatory drugs and aspirin.
2. MENTAL STATUS ISSUES: On admission it was evident that
the patient most likely had a mild dementia since he had some
problems with attention during the history taking. At night,
the patient was more combative and required Ativan and
Zyprexa for sedation. Haldol should be avoided in this
patient since the patient has a prolonged Q-T at baseline.
The patient should also not receive benzodiazepines since
Ativan was administered and the patient was quite sedated
after receiving this medication.
At the time of this dictation, the patient was currently
being worked up for other causes of dementia. A vitamin B12,
folate, and rapid plasma reagin were currently pending. The
patient was also to have a head computed tomography performed
to rule out a bleed or possibly a subdural hematoma given his
history of a fall one week ago. The patient currently has no
neurological deficits, and his mental status was alert and
oriented times three (to person, place, and time) currently;
however, his mental status waxes and wanes and is often worse
at night. The patient has required a one-to-one sitter and
restraints at night to avoid falls since he frequently tries
to get out of bed. It was possible that the patient may have
an adjustment reaction secondary to a change in his
environment; although, it was necessary to rule out other
causes given his age and his fall one week ago.
A Discharge Summary Addendum will be added to update this
Discharge Summary regarding these mental status issues.
Currently, we are trying to wean off the sitter and the
restraints.
3. CHEST PAIN ISSUES: The patient had one episode of chest
pain during the nuclear red blood cell tagged scan which
resolved shortly thereafter. It was possible that this may
have been secondary to demand ischemia from his
gastrointestinal bleed.
An electrocardiogram showed no ischemic changes, but it was a
poor baseline. The patient does have a unknown coronary
artery disease history. The patient's enzymes were cycled
and were negative for a myocardial infarction. He was
monitored on telemetry and did not show any signs of
abnormalities. The patient was restarted on a beta blocker
50 mg twice per day for hypertension after he remained
hemodynamically stable. The patient should not receive
aspirin given his gastrointestinal bleed. He was also
started on Lipitor for a history of hypercholesterolemia and
likely coronary artery disease.
4. HYPERTENSION ISSUES: The patient manifested high blood
pressures in the 170s to 180s. It was unclear whether these
hypertensive episodes may have been secondary to agitation
since the patient was frequently agitated during some of his
hospital course. The patient was started on by mouth
Lopressor as well as on captopril, and his blood pressure at
the time of discharge had been under better control. Prior
to discharge, I would favor either titrating up the Lopressor
or changing the captopril to a one time daily dosing
lisinopril prior to discharge for easier use of medication.
5. DECREASED CREATININE CLEARANCE ISSUES: The patient
initially had a decreased creatinine clearance on admission
which resolved and was likely prerenal secondary to blood
loss. The patient had a normal creatinine upon discharge,
and his urine output remained within normal limits.
6. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was
restated on a regular diet after his colonoscopy. Initially,
he had poor oral intake. However, at the time of this
dictation, he has had improved oral intake.
7. BENIGN PROSTATIC HYPERTROPHY ISSUES: The patient has a
questionable history of benign prostatic hypertrophy which
was not clear on history or on previous records. This issue
will need to be clarified with his primary care physician.
8. LEFT KNEE PAIN ISSUES: On hospital day two, the patient
began to manifest new left knee pain. An arthrocentesis of
the left knee was consistent with pseudogout. Fluid
examination revealed 32,000 white blood cells and [**Pager number **] red
blood cells (with a differential of 72% neutrophils, 3%
lymphocytes, and 25% macrophages). The fluid was rhomboid
trace positive birefringent consistent with calcium
pyrophosphate crystals. However, the Gram stain did not show
any microorganisms, and the fluid cultures have remained no
growth.
Given the patient's left knee pain, Rheumatology was asked
whether intraarticular steroids would be indicated. They
recommended that the patient's pain would most likely resolve
within one week's time, and he did not require further
steroid therapy. If the patient continued to feel pain, a
repeat arthrocentesis of the knee could be performed to
remove further fluid. In the meantime, nonsteroidal
antiinflammatory drugs are contraindicated given his history
of gastrointestinal bleed. The patient will continue with
Tylenol as needed for pain.
9. CODE STATUS ISSUES: Full.
10. PROPHYLAXIS ISSUES: Pneumatic boots and proton pump
inhibitor.
DISCHARGE DISPOSITION: Pending resolution of the patient's
mental status issues, the patient will likely be suitable for
rehabilitation placement. Physical Therapy has evaluated the
patient and felt that he was appropriate for rehabilitation.
DISCHARGE STATUS: To an extended care facility.
CONDITION AT DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE:
1. Zyprexa 5 mg by mouth three times per day as needed (for
agitation).
2. Captopril 12.5 mg by mouth three times per day.
3. Metoprolol 50 mg by mouth twice per day.
4. Atorvastatin 10 mg by mouth once per day.
5. Tylenol 500 mg to 1000 mg by mouth q.4-6h. as needed (for
pain); not to exceed 3 grams per day.
6. Protonix 40 mg by mouth once per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed
to follow up with his primary care physician (Dr. [**Last Name (STitle) **]
within one to two weeks for if any other issues arise.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Name8 (MD) 10397**]
MEDQUIST36
D: [**2103-4-11**] 16:01
T: [**2103-4-11**] 16:14
JOB#: [**Job Number 54837**]
ICD9 Codes: 4019, 2724, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8772
} | Medical Text: Admission Date: [**2164-3-29**] Discharge Date: [**2164-4-2**]
Service: [**Hospital1 212**] MEDICINE
HISTORY OF THE PRESENT ILLNESS: The patient is an
86-year-old female with a past medical history significant
for hypertension and atrial fibrillation on Coumadin with
bilateral lower extremity edema who was originally referred
to the Emergency Room from her PCPs office for increased
lower extremity edema.
In the Emergency Department, she said that she fell three
days prior to admission and hit her forehead on her
refrigerator. There was no loss of consciousness at that
time. She does report increased frequency of falling at home
over the past three weeks. She reports feeling weak and
tired when she fell in the kitchen when she struck her head.
Besides having no loss of consciousness she also reports no
memory deficits. She had a headache, no nausea or vomiting,
neck stiffness in the last two days.
In the Emergency Room, a CT scan was performed which showed a
small right frontal subdural hematoma. In the Emergency
Room, the patient received Lasix 40 mg IV times one, K-Dur 40
mEq times one, vitamin K 10 mg IV times one, and then was
admitted to the MICU under the Neurosurgery Service.
MEDICATIONS AT HOME:
1. Coumadin.
2. Verapamil.
3. Hydrochlorothiazide.
ALLERGIES: The patient has no known drug allergies.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Atrial fibrillation.
3. Bilateral lower extremity edema.
PAST SURGICAL HISTORY: D&C.
SOCIAL HISTORY: She is married. She lives with her husband
at home. Independent lifestyle. No tobacco. No alcohol
use.
FAMILY HISTORY: Mother with CHF.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
96.8, pulse 75, blood pressure 135/74, respirations 14, 100%
on room air. General: Alert and oriented times three,
cooperative. HEENT: Unequal pupils, left greater than
right, both are reactive to light, atraumatic. Neurologic:
Cranial nerves II through XII were grossly intact. Strength:
Normal in all extremities. Sensation intact. No pronator
drift. Neck: Nontender, atraumatic. Cardiovascular:
Irregularly/irregular, II/VI systolic ejection murmur at the
left sternal border. Lungs: A few crackles at the bilateral
bases, good air movement. Abdomen: Soft, nondistended,
nontender, positive bowel sounds. Extremities: There was 4+
pitting edema of the bilateral lower extremities above the
hips.
INITIAL LABORATORY DATA: White count 6.5, hematocrit 27.9,
MCV 77, RDW 16, platelets 230,000. The Chem-7 was remarkable
for a potassium of 3.1. The INR was 2.3.
The initial chest x-ray showed cardiomegaly and mild vascular
redistribution.
The EKG showed atrial fibrillation.
The head CT showed a right subdural hematoma, subacute.
ASSESSMENT: This is an 86-year-old female with a history of
hypertension and A fib on Coumadin with a subdural hematoma
status post fall at home.
HOSPITAL COURSE: 1. SUBDURAL HEMATOMA: The patient was
originally admitted to the MICU under the Neurosurgery
Service to follow the patient for one day. There, in the
MICU, the primary concern was lowering the patient's INR from
the admission INR of 2.3 down to below 1.3 for her subdural
hemorrhage. She was originally given 4 units of FFP with
eventual fall of her INR from 2.3 to 1.6.
Her MICU course was then complicated by flash pulmonary edema
with A fib and rapid ventricular response. For this, she
received additional Lasix as well as a brief course on a
Diltiazem drip which broke the RVR. The patient received
frequent neurologic checks and was deemed stable from a
neurosurgery standpoint. They decided that there was no need
to evacuate the hematoma at this time and that could be
followed.
The patient was given 2 more units of FFP before transfer to
the floor. On the floor, the patient received 5 mg of
vitamin K. By the day of discharge, her INR had fallen to
1.3.
2. CARDIOVASCULAR: The patient was with increasing lower
extremity edema and CHF like symptoms. The patient was given
multiple doses of Lasix throughout her hospital course with
good response in diuresis. The patient also had an episode
of flash pulmonary edema after receiving FFP in the MICU for
which she received additional Lasix. She also was in an A
fib rhythm throughout her hospital course with one episode of
RVR which had to be controlled with a Diltiazem drip. The
patient was then switched from verapamil to Diltiazem p.o.
The patient continued to have A fib throughout her hospital
course; however, only that one episode of rapid ventricular
response. The patient's blood pressure was stable throughout
all times during the hospital course.
The patient received an echocardiogram on the day of
discharge to fully evaluate her heart function which revealed
a left ventricular ejection fraction of 60-65% and a TR
gradient of 25-30 mmHg. The left atrium was normal in size.
Overall left ventricular systolic function was normal. Right
ventricular wall cavity was markedly dilated with depressed
systolic function. There was physiologic mitral
regurgitation and 1+ tricuspid regurgitation. There was
borderline pulmonary artery systolic hypertension. No
pericardial effusion.
Compared with the prior report of [**2160-1-1**], the right
ventricle had become dilated and the function decreased.
Given this information, it was decided that the patient would
be stable for discharge.
3. PT/OT: The patient was evaluated by the PT and OT
Service due to her recent increase in falls for her fall risk
and also for general deconditioning. The patient was deemed
to be a suitable candidate for acute rehabilitation stay.
4. ANEMIA: The patient is with known history of
iron-deficiency anemia. The patient did have a low
hematocrit during her hospital course of 23.6. The patient
received 2 units of packed red blood cells and had an
appropriate increase in her hematocrit to 29.2. Her
hematocrit thereafter was stable and the patient was started
on iron supplementation therapy.
DISCHARGE DIAGNOSIS:
1. Subdural hemorrhage in the right frontal region.
2. General deconditioning with falls.
3. Dilated right ventricle.
4. Iron-deficiency anemia.
DISCHARGE MEDICATIONS:
1. Cardizem CD 120 mg p.o. q.d.
2. Lasix 40 mg p.o. q.d.
3. K-Dur 20 mEq p.o. q.d.
4. Colace 100 mg p.o. b.i.d., hold for loose stools.
5. Iron sulfate 325 mg p.o. q.d.
6. Tylenol 325 to 650 mg p.o./p.r. q. 4-6 hours p.r.n.
7. Hydrochlorothiazide 12.5 mg p.o. q.d.
8. Artificial tears one to two drops O.U. p.r.n.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: To [**Hospital **] [**Hospital **] Hospital for
inpatient rehab stay. The patient should have her
electrolytes including potassium and creatinine checked every
two to three days and have her electrolytes repleted
appropriately. The patient should be weighed every day and
should have her dose of Lasix increased appropriately should
she gain more than [**3-5**] pounds per day.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) 665**], her
PCP, [**Name10 (NameIs) **] the future.
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**MD Number(1) 5046**]
Dictated By:[**Name8 (MD) 8279**]
MEDQUIST36
D: [**2164-4-2**] 03:00
T: [**2164-4-2**] 15:10
JOB#: [**Job Number 96766**]
ICD9 Codes: 4280, 2851, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8773
} | Medical Text: Admission Date: [**2168-10-30**] Discharge Date: [**2168-11-1**]
Date of Birth: [**2087-1-21**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Codeine / Ceftin / Cipro / Penicillin G / Erythromycin
Propionate
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
transfer for ASA desensitization and cardiac catheterization
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
This is an 80 yo female with a history of DM, HTN,
hyperlipidemia, CHF, CAD, stable angina, who presented to [**Hospital 6451**] on [**10-25**] with worsening dyspnea and substernal
pressure-like CP. The patient has basline dyspnea at rest which
worsens with exertion. She also has episodes of angina about
once/wk which may occur at rest and are relieved by rest or NTG.
.
On the day PTA, the patient had been climbing stairs in her home
when she tripped and fell. She noticed feeling more dsypneic
than usual and had a 10 min epi of SS chest pressure rated [**8-11**]
with associated diaphoresis. No radiation,
N/V/LH/palpitations/neck or arm pain. The next morning the
patient was still diaphoretic and short of breath and was told
by her friend that she didn't look good. She went to the ER at
[**Hospital3 417**]. Of note, the patient had noticed that she had
increasing LE edema but denies an increase in salt intake or
medication noncompliance. She complains of 2-pillow orthopnea at
baseline but no PND.
.
While at [**Hospital3 **], the patient was found to be fluid
overloaded with a BNP of 1070 and was diuresed. She had elevated
CE with Trop I 1.46. She underwent a persantine myoview stress
test which showed resversible ischemia in the antero-apical area
of the LV with mild dyskinesis of the L ventricular apex. A TTE
showed an EF 55-60%. The patient has an allergy to ASA (throat
constriction and rash) and was tranferred to [**Hospital1 18**] for ASA
desensitization and ccath.
.
On the floor, the patient denied any CP, SOB, N/V/D. She denied
any diarrhea or constipation, fever, chills, myalgias, HA,
dizzyness, LH, dysuria, hematuria, frequency, urgency,
hematochezia, or palpitations.
Past Medical History:
CHF
CAD
HTN
DM
recurrent DVT and PE x 3
esophageal stricture
GERD
glaucoma
Social History:
Pt lives alone but has one son who lives in [**Name (NI) 1475**]. No
T/E/D.
PT uses a cane and does her own shopping and drives. She can
walk around the grocery store and climb stairs slowly.
Family History:
[**Name (NI) 12329**] mother
Physical Exam:
T 98.8 BP 135/56 P64 Sao2 95% 2L
General: NAD, breathing comfortably on 2L
HEENT: R PERRL, L pupil non-reactive (surgical pupil)~4mm. EOMI,
anicteric sclera, conjunctivae pink
Neck: supple, trachea midline, no thyromegaly or masses, no LAD
Cardiac: RRR s1s2 normal, no JVD appreciated
Pulmonary: L basilar crackles and occ wheezes
Abdomen: obese, +BS, soft, nontender, nondistended, no HSM
Extremities: warm, 2+ DP pulses on R and faint DP on L, trace
edema b/l.
Neuro: A&Ox3, speech clear and logical, no focal deficits
Pertinent Results:
[**2168-10-30**] 09:27PM PT-12.3 PTT-49.0* INR(PT)-1.1
[**2168-10-30**] 09:27PM WBC-8.4 RBC-4.11* HGB-12.1 HCT-35.1* MCV-85
MCH-29.4 MCHC-34.4 RDW-13.3
[**2168-10-30**] 09:27PM CALCIUM-9.2 PHOSPHATE-3.7 MAGNESIUM-2.3
[**2168-10-30**] 09:27PM CK-MB-NotDone cTropnT-0.10*
[**2168-10-30**] 09:27PM CK(CPK)-99
[**2168-10-30**] 09:27PM GLUCOSE-178* UREA N-22* CREAT-1.2* SODIUM-140
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-31 ANION GAP-12
.
CXR: Cardiac silhouette is very large due to cardiomegaly and/or
pericardial effusion. Mediastinal veins are dilated. There is no
pulmonary edema or pleural effusion.
.
CCath: 80% stenosis of D1. No stent placement. [**Hospital **] medical
management. (official report pending in OMR)
Brief Hospital Course:
This is an 80 yo female with a history of DM, HTN,
hyperlipidemia, CHF, CAD, angina, with CHF exacerbation and
demand ischemia/angina with elevated Trops who was found to have
a reversible antero-apical defect with mild dyskinesis of the L
ventricular apex on stress test at an OSH and was transferred to
[**Hospital1 18**] for ASA desensitization and ccath. The following issues
were addressed during this admission:
.
1. Cardiac:
A. CAD: The pt was found to have ischemia with elevated Trops
and a reversible defect on P-MIBI at an OSH. She was started on
a heparin drip at the OSH and was transferred to [**Hospital1 18**] for
cardiac catheterization and ASA desensitization. The patient
likely had demand ischemia with a troponin leak secondary to her
CHF exacerbation as her CP resolved after 10 min. As it was not
thought that she had an acute coronary syndrome, the heparin was
discontinued upon arrival. Her cardiac catheterization showed an
80% stenosis of the D1 was found and not intervened upon.
Optimization of medical management was recommended and the
patient was started on Imdur 30mg QD and Norvasc 5mg QD. The
patient remained asymptomatic and without chest pain during the
duration of her hospitalization. Although she had been placed on
metoprolol at the OSH, this medication was discontinued
secondary to bradycardia. As she had no reaction to the aspirin
desensitization, she was started on aspirin 162mg QD during this
admission. The patient was started on low dose lipitor and
continued on loasartan.
.
B. Rhythm: The patient remained in NSR throughout her
hospitalization.
.
C. Pump: The patient's systolic function was preserved with an
EF of 55-60% (OSH records). She likely has diastolic dysfunction
given her long standing HTN and DM. The patient had been
aggressively diuresed at the OSH and was only slightly volume
overloaded upon transfer to [**Hospital1 18**]. Her lasix was changed to
HCTZ/Triampterene as it will help with BP control in addition to
diuresis. She was kept on a low sodium diet, daily weights and
I/Os were recorded. The patient has an appointment with her PCP
[**Last Name (NamePattern4) **] [**11-2**] and will need close follow up of her electrolytes.
.
2. ASA desensitization: The patient was given increasing dosages
of aspirin per the [**Hospital1 18**] aspirin desensitization protocol
without complication. She was then started on aspirin 162mg QD
s/p cardiac catheterization.
.
3. HTN: The patient has a longstanding history of HTN. Her BP
was controlled on Losartan 50 mg QD, Norvasc 5mg QD, and Imdur
30mg QD. The metoprolol was discontinued secondary to
bradycardia.
.
4. DM: The patient was continued on glargine 20 u Qhs and a HSS.
She received a diabetic diet.
.
5. Glaucoma: The patient was continued on latanoprost,
betaxolol, brimonidine, and carbachol eye drops.
.
6. hypercholesterolemia: The patient was started on low dose
lipitor 10 mg QD and should follow up with her PCP for further
management.
.
7. GERD: The patient was given protonix for her GERD.
Medications on Admission:
lasix 40 mg PO QD
metoprolol XL 50 QD
Nitro SL 0.4 mg prn
Tylenol 325-650mg prn
colace 100mg [**Hospital1 **]
Serax 10mg Qhs
Mylanta prn
MOM prn
Betoptic eye drops
Alphagan eye drops
Lantus 20 u Qhs
Xalatan eye drops
Carbachol eye drops
cozaar 50 mg QD
glyburide 5mg [**Hospital1 **]
RISS
plavix 75mg QD
Azopt eye drops
nitro paste
heparin drip
Discharge Medications:
1. Azopt 1 % Drops, Suspension Sig: One (1) drop Ophthalmic [**Hospital1 **]
(2 times a day).
2. Carbachol 3 % Drops Sig: One (1) drop Ophthalmic twice a
day.
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Lantus 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous once a day.
7. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
8. Betaxolol 0.25 % Drops, Suspension Sig: Two (2) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
9. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 701**] VNA
Discharge Diagnosis:
primary:
CHF exacerbation with demand ischemia
transfer for cardiac catheterization and Aspirin desensitization
.
Secondary:
CHF
CAD
HTN
DM
recurrent DVT and PE x 3
esophageal stricture
GERD
glaucoma
Discharge Condition:
Good
Discharge Instructions:
Please return to the hospital or call your PCP if you experience
shortness of breath, chest pain, or any other symptoms that
concern you.
.
Please take all medications as directed.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 3183**] on Wed [**11-2**] at
3:45. You will need to have your electrolytes and LFTs checked
as you have started on new medications.
Completed by:[**2168-11-2**]
ICD9 Codes: 4280, 2724, 4019, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8774
} | Medical Text: Admission Date: [**2133-5-10**] Discharge Date: [**2133-5-19**]
Service: [**Month/Day/Year 662**]
Allergies:
E-Mycin / Levofloxacin / Aspirin / Metronidazole /
Nitrofurantoin / Tetracycline
Attending:[**First Name3 (LF) 10682**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PCP:
[**Name Initial (NameIs) 7274**]: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital1 **] [**First Name (Titles) 3860**] [**Last Name (Titles) 662**]-[**Location (un) **]/[**Location (un) **]
Address: [**State 21595**],STE LL2, [**Location (un) **],[**Numeric Identifier 9310**]
Phone: [**Telephone/Fax (1) 17753**]
Fax: [**Telephone/Fax (1) 21596**]
Email: [**Hospital1 21597**]
confirmed with patient, last saw PCP [**Last Name (NamePattern4) **]
The patient is a [**Age over 90 **] year old community dwelling female with h/o
CHF and s/p pacer who presents with SOB and cough x 3 days. She
was SOB at rest. She does usualy have DOE but not SOB at rest
so this was new. No CP. She was in her usual state of health
with the exception fo a flare of her neuropathy and arthritis.
No known sick contacts. She has received the flu vaccine. Found
to febrile and to have CAP. She has multiple abx allergies. Of
note the patient stopped taking her potassium for a day or so
because she developed dyspepsia and she thought that the
potassium was contributing to her dyspepsia.
In ER: (Triage Vitals:100.8 70 142/50 22 92% 4L NC )
Meds Given:
Ceftriaxone 1 gm
Tylenol 1 gm
potassium 60 mEQ
Fluids given:500 cc NS
Radiology Studies:
consults called.
Admission 74, 159/61, 22, 96%on 2L.
Upon arrival to the floor she reports that her breathing is much
improved.
PAIN SCALE: 0/10
________________________________________________________________
REVIEW OF SYSTEMS:
CONSTITUTIONAL: [] All Normal
[ +] Fever in the ED but none at home [ ] Chills [ ] Sweats
[ ] Fatigue [ ] Malaise [ ]Anorexia [ ]Night sweats
[- ] weight loss/gain
HEENT: [X] All Normal
[ ] Blurred vision [ ] Blindness [ ] Photophobia
[ ] Decreased acuity [ ] Dry mouth [ ] Bleeding gums
[ ] Oral ulcers [ ] Sore throat [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ]Tinnitus [ ] Other:
RESPIRATORY: [] All Normal
[ +] SOB [+ ] DOE [ ] Can't walk 2 flights [+ ]
Cough- green yellow phlegm
[ ] Wheeze [+ ] Purulent sputum [ ] Hemoptysis [
]Pleuritic pain
[ ] Other:
CARDIAC: [] All Normal
[ ] Angina [ ] Palpitations [ +] Edema- chronic from
amlodipine no worsening [- ] PND
[ ] Orthopnea [ ] Chest Pain [ ] Other:
GI: [X] All Normal
[ ] Blood in stool [ ] Hematemesis [ ] Odynophagia
[ ] Dysphagia: [ ] Solids [ ] Liquids
[ ] Anorexia [] Nausea [] Vomiting [ ] Reflux
[ ] Diarrhea [ ] Constipation [] Abd pain [ ] Other:
GU: [] All Normal
[+] Dysuria- she states that she has this chronically secondary
to her neuropathy [ ] Frequency [ ] Hematuria
[]Discharge []Menorrhagia
SKIN: [X] All Normal
[ ] Rash [ ] Pruritus
MS: [X] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [X] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [x] All Normal
[ ] Skin changes [ ] Hair changes [ ] Temp subjectivity
HEME/LYMPH: [] All Normal
[+ ] Easy bruising <-- secondary to coumadin ---> [+] Easy
bleeding [ ] Adenopathy
PSYCH: [X] All Normal
[ ] Mood change []Suicidal Ideation [ ] Other:
[X]all other systems negative except as noted above
Past Medical History:
1. Hypertension.
2. Hypothyroidism.
3. Polymyalgia rheumatica off prednisone for >2yrs
4. History of upper extremity peripheral neuropathy.
5. Peptic ulcer disease with history of GI bleed secondary
to aspirin 7 years ago.
6. Status post cholecystectomy.
7. Diverticulitis
8. Complete heart block s/p DDD pacer in 5/00
9. COPD
10. CVA in past with no residual deficit on plavix qod for GIB
11. insulin resistance-with prednisone use in past
12. A fib - on coumadin since [**2128-10-25**]
13. ? Polio when she was a child whicmh may have lead to her
neuropathy?
Social History:
She lives in [**Location (un) 538**] in senior housing independent living.
She gets dinner and she makes her other meals. Her daughters buy
her food. She is independent of ADLS and independent of
accounting and meal preparation for breakfast and lunch. She
does her own medications. Her husband passed away 10 years ago.
She uses a rolling walker to ambulate. She has 6 children - 4
sons and 2 daughter who are involved in her care.
She does not smoke or drink alcohol but smoked 1ppd for approx
20 years up to age 62 (20 pack-years). No IVDU.
Her HCP: [**Name (NI) **] [**Last Name (NamePattern1) 21598**] [**Telephone/Fax (1) 21599**]- she lives in [**Hospital1 789**]
RI
Retired billing supervisor at the [**Hospital1 882**]
Aspirin hx of stomach ulcers, "bleeding issues"
Level of Certainty: Moderately Certain History
E-Mycin electrolyte abnormality, "everyone thinks I'm having a
stroke"
Components responsible for reaction(s): Erythromycin Base
Level of Certainty: Moderately Certain History
Levofloxacin - she can't remember what levo caused stroke
like sx?
Metronidazole stroke like symptoms
Level of Certainty: Moderately Certain History
Nitrofurantoin SOB
Tetracycline-she thinks it gave her swelling and difficulty
swallowing.
Family History:
Father: died of MI at 75
Mother: died at 84 of heart attack
brother: died of MI
No other hx of COPD, CA, DMII or CVA.
Physical Exam:
PAIN SCORE= 0/10
Standing weight: 139.5
VS: T = 98.4 P = 68 BP 133/57 RR = 20 O2Sat = 94% 3L
GENERAL: Very pleasant elderly female sitting up in bed. She
appears spritely and is in no acute distress.
Nourishment: good
Grooming: good
Mentation: intact- she is a good historian
Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted
Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Respiratory: decreased breath sounds at the L base and crackles
at the R base.
Cardiovascular: RRR, nl. S1S2, no M/R/G noted
Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no
masses or organomegaly noted.
Genitourinary: deferred
Skin: no rashes or lesions noted.
Extremities: 2+ pitting edema b/l 2+ radial, DP pulses b/l.
Lymphatics/Heme/Immun: No cervical lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
Psychiatric: Appropriate full affect.
Pertinent Results:
Admission labs:
[**2133-5-10**] 10:50PM WBC-18.2*# RBC-4.30 HGB-14.2 HCT-38.8 MCV-90
MCH-32.9* MCHC-36.5* RDW-13.8
[**2133-5-10**] 10:50PM NEUTS-89.6* LYMPHS-6.5* MONOS-3.4 EOS-0.4
BASOS-0.1
[**2133-5-10**] 10:50PM PLT COUNT-266
[**2133-5-10**] 11:01PM GLUCOSE-170* LACTATE-1.5
[**2133-5-10**] 10:50PM GLUCOSE-171* UREA N-26* CREAT-1.0 SODIUM-140
POTASSIUM-2.8* CHLORIDE-100 TOTAL CO2-26 ANION GAP-17
[**2133-5-10**] 10:50PM PT-24.6* PTT-33.4 INR(PT)-2.3*
Discharge labs:
[**2133-5-19**] 05:35AM WBC-17.5 HGB-12.6 HCT-35.5 MCV-90
[**2133-5-19**] 05:35AM PLT COUNT-321
[**2133-5-19**] 05:35AM GLUCOSE-66* UREA N-49* CREAT-1.0 SODIUM-137
POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-35
[**2133-5-19**] 05:35AM INR(PT)-1.1
CHEST (PA & LAT) Study Date of [**2133-5-10**]
IMPRESSION:
1. Increased vascular congestion is consistent with cardiac
failure.
2. Pacemaker device is mobile in patient's chestwall and in a
different
position compared to the prior exam.
4. Complex hiatal hernia.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2133-5-12**]
IMPRESSION:
1. New left apical spiculated lesion, could be a lung carcinoma
or organized pneumonia.
2. Bilateral moderately large pleural effusions and left lower
and lingular lobe atelectasis, new since [**2131-5-26**].
3. Mild interstitial edema.
4. Solitary, right apical subsegmental nonocclusive pulmonary
artery filling defect, probably chronic and unlikely to have any
hemodynamic consequences.
5. Extensive mixed atherosclerotic thoracic aortic plaque and
mild dilatation without progression or aneurysm formation since
[**2131-5-26**].
BILAT LOWER EXT VEINS Study Date of [**2133-5-12**]
IMPRESSION: No DVT in the left or right lower extremity.
CHEST (PA & LAT) Study Date of [**2133-5-15**]
IMPRESSION:
Mild pulmonary edema is slightly improved since prior chest
x-ray. Small bilateral pleural effusions and bibasilar
atelectasis with no
evidence of pneumonia. Nodule at the left lung apex is better
appreciated on the recent chest CT.
ECHO ([**2133-5-11**]):
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
The right ventricular cavity is dilated with depressed free wall
contractility. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] There are three aortic valve leaflets. The
aortic valve leaflets are moderately thickened. There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is no pericardial
effusion.
IMPRESSION: Mild symmetric LVH with normal regional and global
systolic function. Dilated and depressed right ventricle with
moderate to severe tricuspid regurgitation and pulmonary
hypertension. Mild aortic stenosis, moderate mitral
regurgitation.
Compared with the prior study (images reviewed) of [**2128-7-30**],
the degrees of aortic stenosis, mitral regurgitation, aortic
stenosis and pulmonary hypertension have all increased. The
right ventricle appears dilated with depressed systolic
function.
Brief Hospital Course:
The patient is a [**Age over 90 **] year female with a history of atrial
fibrillation s/p pacemaker for complete heart block, along with
chronic diastolic heart failure as well as emphysema who
presented with fevers and increased shortness of breath, likely
multifactorial and due to a combination of a pneumonia, COPD
exacerbation and diastolic CHF exacerbation. She had an acute
decompensation in her respiratory status on [**5-12**] requiring a
24-hour ICU stay and BIPAP. She returend to the medical floor
from the ICU after a 24-hour stay during which she was diuresed
about 1.6 L. She was also started on a steroid taper at the
time of her decompensation and antibiotics were broadened to
Vanco/CFP/Azithro. Her acute worsening was likely due to a
combination of increased bronchoconstriction from COPD as well
as flash pulmonary edema in the setting of hypertension. Of
note, a CTA chest was performed, which was negative for PE but
did show a new pulmonary nodule.
#. Bacterial pneumonia: She failed to improve on Ceftriaxone
alone. She was broadened to CFP/Vanco/Azithro and completed a 7
day course.
#. Acute diastolic CHF: She likely developed flash pulmonary
edema in setting of hypertension. Given her diastolic CHF, she
was started on an ACE-I, which was increased as permitted by her
blood pressure. She was also started on a beta blocker. She was
diuresed during her admission as well and was ultimately
discharged to resume her home diuretic regimen.
#. Acute COPD exacerbation: She was treated with steroids,
antibiotics as above and nebulizer therapy with improvement. She
has completed her steroid.
#. Diabetes mellitus, type 2, uncontrolled, without
complications: Her blood sugars were noted to be elevated on
morning labs. A hemoglobin A1c was checked and was found to be
7.1% consistent with underlying diabetes. Her finger sticks
became even more elevated while on steroid therapy and required
initiation of insulin. Her insulin requirements decreased with
tapering of the steroids.
#. Hypertension: As above, tight blood pressure control will be
very important to prevent further episodes of flash pulmonary
edema. She was continued on amlodopidine and started on an
ACE-I and BB for her heart failure/ high blood pressure.
#. Hypothyroidism: She was continued on her home levothyroxine.
#. Atrial fibrillation: She remained well rate controlled.
Coumadin was held during much of her admission due to a high INR
but was restarted prior to discharge.
#. Leukocytosis: She redeveloped a leukocytosis towards the end
of her stay. She had no localizing signs/symptoms. U/A was
negative; Ucx grew yeast. C. diff toxin was negative. Her
leukocytosis was trending down by discharge.
#. Insomnia: continue serax prn
#. New pulmonary nodule: She will need to have a follow-up CT
scan in 3 months.
*********Transitions of Care**********
- Diabetes management--her insulin may be able to be titrated
off and/or switched to oral antihyperglycemics as the effect of
the steroids were off.
- Pulmonary nodule
Medications on Admission:
amlodipine 10 mg qhs changed 2 weeks ago
lasix 100 mg qam
levothyroxine 75 mcg qd
serax 30 mg qhs
KCL T [**Hospital1 **]
simvastatin 20 mg
Spiriva qam
coumadin 2
vitamin D
Discharge Medications:
1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO once a day.
Disp:*15 Tablet Extended Release 24 hr(s)* Refills:*2*
3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. furosemide 40 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
Tablet(s)
5. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. oxazepam 30 mg Capsule Sig: One (1) Capsule PO once a day as
needed for insomnia.
7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) puff Inhalation once a day.
9. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
13. insulin lispro 100 unit/mL Insulin Pen Sig: 0-14 units
Subcutaneous four times a day: Please see insulin sliding scale.
Disp:*qs x 1 mo * Refills:*2*
14. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
Acute on chronic diastolic congestive heart failure
Acute exacerbation of chronic obstructive pulmonary disease
Bacterial pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you. You were admitted with
shortness of breath, likely due to a pneumonia, worsening of
your heart failure and emphysema exacerbation. You were treated
for all three and improved. You have completed a 7 day course
of antibiotics. You were treated with steroids for your
emphysema exacerbation. While on steroids, your blood sugars
were high and you required insulin. You have finished your
course of steroids and hopefully soon you will no longer need
insulin.
For your heart failure, you were started on lisinopril and
metoprolol. Please weigh yourself every morning and call Dr.
[**Last Name (STitle) **] at [**Telephone/Fax (1) 17753**] if weight goes up more than 3 lbs.
MEDICATION CHANGES:
- START Lisinopril 5 mg daily
- START Toprol XL 12.5 mg daily
- START Humalog insulin.
Followup Instructions:
Please follow-up with your primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
within one week of discharge from rehab. Your [**Hospital 6435**] clinic
number [**Telephone/Fax (1) 17753**].
ICD9 Codes: 4280, 4019, 2449, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8775
} | Medical Text: Admission Date: [**2130-10-16**] Discharge Date: [**2130-10-19**]
Date of Birth: [**2069-10-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Neck and arm pain
Major Surgical or Invasive Procedure:
Cardiac catheterization and stent placement
History of Present Illness:
Mr. [**Known lastname 81858**] is a 61M with DM who presented to an OSH with right
neck and L forearm pain. He describes the pain as a dull ache
that started while walking and did not resolve until he was
treated at the OSH. He denies any history of similar neck and
arm pain. He reports mild shortness of breath with pain but
denies any other associated symptoms such as diaphoresis,
nausea, palpitations, or dizziness. In the OSH his EKG
reportedly showed inferolateral ST depression and initial
troponin I was 0.35. He was given nitroglycerin SL, fentanyl,
and then started on nitroglycerin and heparin drips. He also
received plavix 300mg. Pt was then transferred to [**Hospital1 18**] for
further management and cardiac catheterization.
Pt initially went to the [**Hospital1 1516**] service where his EKG changes
resolved and he was chest pain free and was planned for cath in
AM. Pt does report retroactively that he had some chest pain
overnight that he did not report and AM cardiac enzymes
continued to trend up: CK 1579->1550, Trop 1.4->3.3.
In the cath lab, pt had venous and arterial sheath placed,
received 381ml dye, had SBPs in the 70s requiring 1200ml IVF,
dopamine drip and 1mg atropine. He also received heparin,
integrillin. Pt reported pain with placement of stents (3BMS to
OM2 and 2BMS to midLAD).
On presentation to [**Name (NI) 42137**], pt was off pressors and chest pain
free.
Past Medical History:
DM Type II (diet controlled)
Social History:
Pt is a security guard at [**University/College 4700**]. He lives with his
wife.
[**Name (NI) **] smokes 1 ppd x 40 years.
Drink at social events but denies drinking on daily or weekly
basis. He denies any past or present drug use.
Family History:
Noncontributory
Physical Exam:
Post cath:
VS: T 98.7 BP 100/53 HR 61 SpO2 98% 2L WT 208 lbs
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink,
MMM.
Neck: Supple, JVP to mandible
CV: RRR, no M/R/G
Chest: No resp distress. CTAB, no crackles, wheezes or rhonchi.
Abd: Soft, NTND, No HSM, positive BS
Ext: No c/c/e. Strong distal pulses
Skin: No rashes or lesions
Groin: No bruits, no tenderness, small hematoma (1x2cm)
Pertinent Results:
[**2130-10-19**] 06:05AM BLOOD WBC-9.4 RBC-4.20* Hgb-13.1* Hct-35.9*
MCV-85 MCH-31.3 MCHC-36.7* RDW-13.6 Plt Ct-156
[**2130-10-16**] 09:30PM BLOOD Neuts-61.9 Lymphs-30.7 Monos-6.6 Eos-0.5
Baso-0.3
[**2130-10-17**] 06:05AM BLOOD PT-13.0 PTT-47.0* INR(PT)-1.1
[**2130-10-19**] 06:05AM BLOOD Glucose-104 UreaN-14 Creat-1.0 Na-138
K-3.8 Cl-106 HCO3-24 AnGap-12
[**2130-10-16**] 09:30PM BLOOD ALT-23 AST-97* CK(CPK)-1579*
[**2130-10-17**] 06:05AM BLOOD ALT-33 AST-180* LD(LDH)-560*
CK(CPK)-2550* AlkPhos-71 TotBili-0.5
[**2130-10-17**] 08:05PM BLOOD ALT-42* AST-202* LD(LDH)-755*
CK(CPK)-2209* AlkPhos-67 TotBili-0.7
[**2130-10-16**] 09:30PM BLOOD CK-MB-148* MB Indx-9.4* cTropnT-1.40*
[**2130-10-17**] 06:05AM BLOOD CK-MB-212* MB Indx-8.3* cTropnT-3.33*
[**2130-10-17**] 08:05PM BLOOD CK-MB-103* MB Indx-4.7
[**2130-10-19**] 06:05AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.2
[**2130-10-17**] 06:05AM BLOOD Albumin-4.1 Cholest-246*
[**2130-10-17**] 06:05AM BLOOD %HbA1c-6.9*
[**2130-10-17**] 06:05AM BLOOD Triglyc-303* HDL-40 CHOL/HD-6.2
LDLcalc-145*
[**10-18**] ECHO: Left ventricular wall thicknesses and cavity size
are normal. There is mild regional left ventricular systolic
dysfunction with severe hypokinesis of the basal half of the
inferolateral wall. The remaining segments contract normally
(LVEF = 55 %). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets appear structurally normal with good
leaflet excursion. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with focal
regional dysfunction c/w CAD. Mild pulmonary artery systolic
hypertension. Dilated ascending aorta.
CATH [**10-17**]: No formal results
Brief Hospital Course:
61 year old smoker without recent medical following, presented
to OSH with arm pain and found to have NSTEMI. Pt transferred to
[**Hospital1 18**] and is now s/p cath where he was found to have a total
occlusion requiring 2 BMS to OM2 and 2BMS to mid LAD.
# NSEMI - On transfer to [**Hospital1 18**] pt was pain free with minimal STD
on EKG. His cardiac enzymes continued to [**Last Name (un) **] up and peaked at
CK of 2550 and Trop 3.3 on [**10-17**]. That morning pt underwent
catheterization and found to have total occlusion of the OM2 and
mid LAB with multiple bare metal stents placed in both. Pt was
medically managed with aspirin, plavix, statin, heparin gtt,
integrillin gtt. Beta blocker was initially held for hypotension
and started prior to discharge. Pt will also need addition of
ace inhibitor.
- Continue Toprol XL 25mg daily
- Continue Simvastatin 80mg daily
- Continue ASA daily
# DMt2: Pt not medically managed as outpt. His HbA1c was
measured for risk stratification and found to be 6.9. His blood
sugars were monitored and treated with insulin sliding scale. At
discharge pt was asked to follow up with [**Last Name (un) **] diabetes clinic.
# Tobacco abuse: Pt was given nicotine patch for symptomatic
control and counseled re importance of smoking cessation for
both himself and family.
Medications on Admission:
None
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Non ST elevation MI
Secondary Diagnosis: Type II Diabetes mellitus (diet-controlled)
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital because you had a heart
attack. You had two bare metal stents placed into your heart
vessel to open up the blockage. You were started on new
medications for your heart. It is very important for you to
continue this medication (clopidogrel) as it keeps the stent
open. You should not stop taking this medication unless your
cardiologist tells you to.
.
New medications:
Toprol XL 25 daily
Aspirin 325mg daily
Plavix 75mg daily (keeps stent open)
Atorvastatin 80mg daily
Please stop smoking. Information was given to you on admission
regarding smoking cessation and discussed with you by the
doctors [**Name5 (PTitle) **].
Followup Instructions:
Please call Dr [**Last Name (STitle) 8098**], your new cardiologist, at [**Telephone/Fax (1) **]
to schedule follow up in the next 1-2 weeks.
You should also set up a primary care doctor. You can choose a
PCP or use the [**Hospital 18**] clinic. The [**Hospital 18**] [**Hospital6 **]
phone number is [**Telephone/Fax (1) 250**].
Completed by:[**2130-10-20**]
ICD9 Codes: 3051, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8776
} | Medical Text: Admission Date: [**2118-12-28**] Discharge Date: [**2119-1-13**]
Date of Birth: [**2043-12-6**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Chronic cholecystitis with gallstones and common bile
duct stones
Extensive incisional ventral hernia.
Major Surgical or Invasive Procedure:
Open cholecystectomy
Ventral Hernia Repair with mesh buttress and component
separation.
Omentectomy
Abdominoplasty
History of Present Illness:
This is a 75-year-old gentleman who recently presented with
gallstone pancreatitis over a month ago. He was cared for by my
associate Dr. [**First Name (STitle) **]
[**Name (STitle) **] and at that time he received an endoscopic
sphincterotomy for his common bile duct stone disease. He
recovered well from this but required a cholecystectomy for his
demonstrated gallstone disease. Furthermore, it was a
clear to Dr. [**Last Name (STitle) **] that the patient had a significant ventral
hernia problem from a prior abdominal aortic aneurysm repair
many years ago.
Past Medical History:
PAST MEDICAL HISTORY:
1. Hepatitis B.
2. History of alcohol abuse.
3. Partial portal vein thrombosis.
4. Asthma.
5. Glaucoma.
6. Diverticulitis.
7. Hypertension.
8. Gout.
9. History of urinary tract infections.
10. Multiple SBO
11. gallstone pancreatitis
PAST SURGICAL HISTORY:
1. Left hand surgery.
2. Status post infrarenal aortic aneurysm repair and
appendectomy on [**2111-12-22**].
3. endoscopic sphincterotomy for his common bile duct stone
disease [**2118-11-30**]
Social History:
tobacco x11yrs
h/o EtOH abuse
Family History:
NC
Physical Exam:
At admission
VS: HR 74, BP 119/66
Gen: Well appearing, NAD
Mental Status: no focal deficits, AA+O x 3
HEENT: neck supple, No LAD
CV: RRR, S1, S2
Pulm: WNL
Abd: a "Swiss cheese" abdomen. There are probably 5 or 6
significant hernia sacs that are protruding on each side of the
midline incision; true
pendulous redundant hernia sacs emanating from the abdominal
wall.
tender on palpation.
Pertinent Results:
[**2119-1-3**] 06:05AM BLOOD WBC-7.3 RBC-3.63* Hgb-11.3* Hct-34.9*
MCV-96 MCH-31.1 MCHC-32.4 RDW-13.2 Plt Ct-316
[**2118-12-29**] 09:12AM BLOOD WBC-14.6* RBC-4.03* Hgb-12.9* Hct-37.9*
MCV-94 MCH-31.9 MCHC-34.0 RDW-13.5 Plt Ct-206
[**2119-1-3**] 06:05AM BLOOD Glucose-112* UreaN-15 Creat-0.9 Na-140
K-4.9 Cl-104 HCO3-25 AnGap-16
[**2118-12-29**] 06:25AM BLOOD Glucose-145* UreaN-13 Creat-1.2 K-4.9
[**2119-1-1**] 02:00AM BLOOD CK(CPK)-1532*
[**2118-12-30**] 11:58AM BLOOD ALT-26 AST-98* CK(CPK)-3295* AlkPhos-59
Amylase-26 TotBili-0.5
[**2118-12-31**] 04:05AM BLOOD CK-MB-71* MB Indx-1.6 cTropnT-<0.01
[**2119-1-3**] 06:05AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.1
[**2118-12-30**] 08:56AM BLOOD Calcium-7.8* Phos-3.6 Mg-2.3
[**2118-12-30**] 09:07AM BLOOD Glucose-142* Lactate-2.5*
[**2119-1-2**] 01:06AM BLOOD Glucose-126* Lactate-1.7
CHEST (PORTABLE AP) [**2118-12-30**] 7:09 AM
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with acute asthma attack.
REASON FOR THIS EXAMINATION:
Please evaluate for fluid in airway, aspiration, possible cause
of SOB
Lung volumes are appreciably lower than they were on [**12-23**], a finding that does not correspond to bronchospasm. Mild
cardiomegaly is worse. There is no pulmonary vascular
congestion. The asymmetric vascular distribution, with
deficiency in the right lung is longstanding.
CHEST (PORTABLE AP) [**2118-12-31**] 5:56 AM
Reason: ? RESPIRATORY DISTRESS
FINDINGS: Again noted are diminished lung volumes, which are
stable relative to [**12-30**], but represent acute change
relative to [**12-23**]. These findings are not consistent with
an asthma attack. No focal consolidation is identified. The
cardiomediastinal silhouette is stable. The visualized osseous
structures are unremarkable.
IMPRESSION: Stable examination with low lung volumes and no
superimposed consolidation.
CHEST (PORTABLE AP) [**2119-1-2**] 8:36 AM
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with scattered rales and scattered rhonchi
The heart size is mildly enlarged but stable. The mediastinal
contours, width and position are unremarkable. The bibasilar
atelectasis and small bilateral pleural effusion is unchanged
within the limitation of the apical projection of this film.
On [**1-4**] the patient continue to have respiratory distress.
Whent to xray, and in the wiating room, coded.
Massive PE was discovbered. the patient had 20 of pulseness
electrical activity.
CTA
IMPRESSION:
1. Extensive bilateral pulmonary emboli as described above.
2. Patchy opacities in the left upper lobe, right upper lobe,
right lower
lobe, and left lower lobe.
3. Postoperative changes of the abdominal wall.
4. Mildly dilated loops of small bowel with no obvious
transition point. C/W
ileus.
5. Infrarenal abdominal aortic aneurysm with maximal AP
dimension of
approximately 4.1 cm.
6. Snall amount of fluid within the gallbladder fossa, likely
postoperative
Admitted to icu. No neuro response after. Hypotensive an in PEA
for 20 minutes. Neurology consulted:
CC: seizures
HPI: The patient is a 75yo R-handed man with COPD, s/p AAA
repair, who was admitted [**12-28**] for an open CCY/Ventral
herniorrhaphy. He was brought to the TSICU w/ acute respiratory
distress, ARF, oliguria on POD#1 ([**12-30**]). He improved and was
sent to the floor. On POD#7 ([**1-4**]), he was sent for CXR where
was found down. A code was called after about one minute. He did
not have a pulse and did not breath. CPR was started and he was
intubated at the site. Monitor showed PEA. After atropine and
CPR
for 20 minutes, he developed a pulse.
Workup revealed a saddle embolus and R-popliteal embolus. He is
maintained on a heparin drip.
Since the code he has been remained intubated. His exam off
propofol per team showed intact bs reflexes, but otherwise no
response to noxious. When lowering the propofol in the evening
of
[**1-5**], head and bilateral arm jerking was seen, with eyes rolled
backwards. This activity continued until the propofol was
increased. A CT head was obtained which did not show a
hemorrhage
or acute pathology. He was loaded on an AED at that time.
Sputum cultures grew enterobacter and pseudomonas for which he
is
being treated with cipro.
We are now called to further assist in management and workup of
seizures. No further seizure activity has been noted (but he has
remained on propofol).
ROS:
-unable to obtain
PAST MEDICAL HISTORY per OMR:
1. Hepatitis B.
2. History of alcohol abuse.
3. Partial portal vein thrombosis.
4. Asthma/COPD.
5. Glaucoma.
6. Diverticulitis.
7. Hypertension.
8. Gout.
9. History of urinary tract infections.
10. Multiple SBO
no history of seizures
PAST SURGICAL HISTORY:
1. Left hand surgery.
2. Status post infrarenal aortic aneurysm repair and
appendectomy on [**2111-12-22**].
MEDICATIONS:
-Heparin IV goal PTT 60-80.
-Acetylcysteine 20% 1-10 ml NEB Q6H:PRN thick bronchial
secretions
-Insulin SC (per Insulin Flowsheet)Sliding Scale
-Albuterol-Ipratropium [**2-14**] PUFF IH Q6H:PRN
-Ipratropium Bromide Neb 1 NEB IH Q6H
-Albuterol [**3-19**] PUFF IH Q4H:PRN
-Magnesium Sulfate 2 gm / 100 ml D5W IV PRN Mg < 2.0
-Bisacodyl 10 mg PO/PR DAILY:PRN
-Midazolam HCl 1-2 mg IV Q2H:PRN
-Brimonidine Tartrate 0.15% Ophth. 1 DROP OU Q8H
-Morphine Sulfate 2-4 mg IV Q4H:PRN
-Calcium Gluconate 2 gm / 100 ml D5W IV PRN I Ca < 1.12
-Norepinephrine 0.02-0.28 mcg/kg/min IV DRIP TITRATE TO maintain
map>65
-Ciprofloxacin 400 mg IV Q12H
-Pantoprazole 40 mg IV Q24H
-Dolasetron Mesylate 12.5 mg IV Q8H:PRN
-Phenytoin 1000 mg IV ONCE Duration: 1 Doses
-Dorzolamide 2% Ophth. Soln. 1 DROP OU TID
-Potassium Chloride 40 mEq / 100 ml SW IV PRN K < 3.9
-Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION
-Propofol 20-50 mcg/kg/min IV DRIP TITRATE TO SEDATION
-Fluticasone-Salmeterol (250/50) 1 INH IH [**Hospital1 **]
-Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
ALLERGIES: NKDA
SOCIAL HISTORY:
tobacco x11yrs
h/o EtOH abuse
FAMILY HISTORY: n.c
EXAM (on propofol)
VITALS: T99.6 HR103 BP108/55 RR23 sO2 97% CVP 9-10.
GEN: intubated
HEENT: mmm;
NECK: no LAD; no carotid bruits; neck supple
LUNGS: vented bs
HEART: Regular rate and rhythm, normal S1 and S2, no murmurs,
gallops and rubs.
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: edema; pulses
MENTAL STATUS:
Intubated; eyes closed; not responding to voice or noxious.
CRANIAL NERVES:
II: No blink to threat. Pupil R 3-->2.5; L 2.5-->2.
III, IV, VI: eyes midline; oculocephalic reflex absent (no
dolls)
V: corneal present on R, not L; no response to nasal tickle.
VII: Face symmetrical.
VIII: -
IX: gag present.
XII: -
[**Doctor First Name 81**]: -
MOTOR SYSTEM: Normal bulk. Tone decreased throughout. No
adventitious movements, no tremor, no asterixis. No shaking. No
spontaneous movement. No response to noxious. No posturing.
SENSORY SYSTEM: Triple reflex in both LE to noxious. No response
in UE.
REFLEXES:
B T Br Pa Pl
Right 2 2 2 1 -
Left 2 2 2 2 -
Toes: mute bilaterally.
COORDINATION: deferred
GAIT: deferred
LABS and IMAGING:
Micro: [**12-30**]: BCx P; Scx PSEUDOMONAS AERUGINOSA, ENTEROBACTER
CLOACAE (pan [**Last Name (un) 36**]); UCx NG.
Imaging: [**1-4**]: C/A/P CT: Extensive bilateral pulmonary emboli.
Patchy opacities in the left upper lobe, right upper lobe, right
lower lobe, and left lower lobe. Mildly dilated loops of small
bowel with no obvious transition point. Followup recommended.
Infrarenal abdominal aortic aneurysm with maximal AP dimension
of
approx 4.1 cm. Fluid within the gallbladder fossa.
[**1-4**] LE U/S: R popliteal thrombus, not completely occlusive.
pH7.47 pCO236 pO295 HCO327 BaseXS2
Type:Art
freeCa:1.12 Lactate:1.4
144 112 19 AGap=11
------------< 130
4.4 25 1.2
Ca: 8.0 Mg: 1.8 P: 3.1
WBC12.4 PLT211 Hct26.5
PT: 14.8 PTT: 64.1 INR: 1.3
CT head [**1-6**]: There is no intracranial hemorrhage. There is no
midline shift, mass effect or hydrocephalus. The [**Doctor Last Name 352**]-white
matter differentiation is preserved. There are no fractures.
Incidental note is made of carotid artery calcifications and
scattered areas of mucosal thickening throughout the ethmoid and
maxillary paranasal sinuses.
IMPRESSION: No CT evidence of an acute infarct.
ASSESSMENT: The patient is a 75yo R-handed man with COPD, s/p
AAA repair, who was admitted [**12-28**] for an open CCY/Ventral
herniorrhaphy. On [**1-4**], he coded (x 20 minutes) and has
remained
comatose since that time. Workup revealed a saddle embolus and
R-popliteal embolus. He is maintained on a heparin drip. In
addition he is being treated for infection with cipro. In the
evening of [**1-5**], seizure activity was noted as the propofol was
being lowered, resolving after increase of propofol. On exam he
is comatose, with at least partially intact bs reflexes (not
taken off propofol as he was not loaded on AED). CT head does
not
show evidence of a hemorrhage and [**Doctor Last Name 352**]/white matter is
preserved.
Although little information has been documented regarding the
seizure, it is possible that he has been seizing due to anoxic
brain injury. Alternativly, he may have shown myoclonus which is
also frequently seen in this setting. Given the duration of PEA,
prognosis is guarded.
PLAN:
-load on dilantin 20mg per kg; check level; start dosing at
100mg
iv TID and continue to follow trough levels in am; please also
check albumin. Though propofol will work for now, he will need
other AED to be able to wean off vent.
-infectious/metabolic workup: please check LFTs (especially as
he
is being loaded on dilantin), and amylase, lipase; would
panculture
-please get bed side EEG; based upon the results may need to add
AEDs
-seizure precautions; ativan PRN seizures (once weaned off
propofol)
-treat fever aggressively with tylenol
-avoid fluoroquinolones and flagyl as these decrease seizure
threshold (pt currently on cipro which should be changed)
-MRI/MRA/MRV head once stable; MRV to rule out sinus thrombosis
in setting of recent thrombosis (DVT and PE); this would further
affect prognosis
-consider LP to rule out herpes encephalitis (as it is
treatable)
though rather unlikely
-will follow with you
Addendum:
bedside EEG; taken off propofol, had just been loaded on
dilantin; developing burst suppression pattern; then spike-slow
wave activity that increased in frequency, leading to pre-status
pattern. Clinically, started the initial spike waves co-incided
with head nods and bilateral arm jerks. These movements became
more prominent in line with increased activity on EEG.
Pt put back on propofol.
Further recs:
-keep pt on propofol over the weekend; may repeat bedside EEG on
[**1-8**]
-we will be available over the weekend if family would like to
discuss findings with us
[**First Name8 (NamePattern2) 39215**] [**Last Name (NamePattern1) **]
Neurology R-3
[**Numeric Identifier 90765**]
Disc with Dr. [**Last Name (STitle) **] [**Name (STitle) 467**], attending
Addendum by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD, PHD on [**2119-1-6**]:
I have seen Mr [**Known lastname 2470**] with Dr [**Last Name (STitle) 110494**] and agree with her note,
findings on exam, and recommendations. I have gone over the
details of the history, reviewed the EEG, and concur that most
likely Mr [**Known lastname 2470**] has sustained a hypoxic brain damage result in
current status epilepticus. However, even if unlikely, there are
some imperative diagnoses worth considering in the differential
as they are potentially treatable causes of the clinical picture
that have not been ruled out. First, the possibility of a CNS
infection is worth considering. A bacterial meningitis seems
most
unlikely given the history and the clinical picture. However, a
viral encephalitis might be worth considering. In this context
an
LP would help rule this out. Second, a vascular event, e.g. a
venous thrombosis, could be ruled out by MRI, including MRA and
MRV. An MRI would also help assess the damage caused by the
likely hypoxic insult.
In parallel to these considerations, a family conference to
address the poor prognosis of the present clinical situation and
obtain guidance regarding status seems important.
Thanks for the consultation. We will follow with you.
MRI of the brain
IMPRESSION: No definite evidence of dural sinus thrombosis. In
particular,
no definite signs of deep venous thrombosis
EEG
FINDINGS:
ABNORMALITY #1: Throughout the recording the background rhythm
remained
slow and of very low voltage in all areas. The low voltage
background
was punctuated by brief bursts of generalized slowing without
epileptiform features. After 10 minutes or so the slowing was
more
prominent and the background less suppressed. There were
frequent brief
jerks of the patient's head to the left (corroborated by video
recording). There were very brief sharp features at these times,
but
these appeared most likely to represent movement artifact. Jerks
became
more frequent after a few minutes, some appeared to involve
shoulder
muscles as well.
In addition, however, there were brief spikes with a
generalized distribution and bifrontal emphasis, as well though
these
did not correlate well with jerks.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: No normal waking or sleeping morphologies were seen.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: Markedly abnormal portable EEG due to the very
suppressed
background at the beginning of the recording and due to the
regular slow
background later, all with frequent myoclonic jerks and movement
artifact but also with independent and increasingly frequent
generalized
spikes later in the recording, as well. The background slowing
with
suppression suggests medication effect although widespread
cortical
dysfunction from anoxia can produce similar findings. The head
jerking
activity corroborated by video did not appear to be epileptic,
but it
was myoclonic and likely results from the same underlying
process,
presumed anoxia. Later in the recording there were other spikes
that
became more frequent. Thus, this tracing does not indicate
ongoing
seizures at the time but suggests that seizures could arise
later.
Also, the jerking activity appears most likely to represent
anoxic
myoclonus rather than a seizure, per se. The above movements did
not
appear epileptic in origin. They can be suppressed with some of
the
same medications used for seizures, if that is appropriate
clinically.
OBJECT: GENERALIZED SEIZURE ACTIVITY. STATUS POST CARDIAC ARREST
AND
PULMONARY EMBOLIS.
patient loaded with Dilatin, place on depakote. No improvement.
Family meeting called. Pt wishes expresed to proxy in the pass.
Pt made CMo expired on [**2119-1-13**] 330 am
Brief Hospital Course:
He was admitted for an Open CCY and Ventral Herniorrhaphy.
Resp: He had expiratory wheezes. He was ordered for nebulizer
treatments. On POD 2, he was noted to have some respiratory
distress consistent with an asthma attack. He was tachypnic and
using lots of accessory muscles. The Respiratory therapists was
called and the patient received nebulizer treatments and a
non-rebreather face mask. His RR was 24 and he was 96% on a NRB.
He received 100mg Hydroxcortizone.
He was transferred to the SICU for closer monitoring. A CXR
showed lung volumes are appreciably lower than they were on
[**12-23**], a finding that does not correspond to bronchospasm.
Mild cardiomegaly is worse. There is no pulmonary vascular
congestion. The asymmetric vascular distribution, with
deficiency in the right lung is longstanding. A Abd x-ray showed
no evidence of obstruction or free air.
A blood gas showed pO2146* pCO246* pH7.24*1 calTCO221 Base-7. He
acidosis ws persistent. He was started on Bipap PRN. His
respiratory acidosis began to correct slowly and he was
transfered to the floor on POD 5.
Abd: He had a midline abdominal incision. He had 3 JP drains in
the lower abdomen. His JP drains were hooked-up to wall suction.
His abdomen was still firm and slightly distended on POD 5 and
he reported -flatus.
Pain: Epidural was started initially. He then was on a PCA with
good pain control.
CV: In the PACu his HR was in the 70's and BP was 110-120/80's.
On POD 6, his HR was in the low 100's and he had a couple short
burst to the 170's; BP was 130/80. He was started back on his
home Lisinopril 10mg qd and Lopressor 25 mg [**Hospital1 **].
ID: He was started on Kefzol. A sputum sample from [**12-30**] showed
Pseudomonas A., and Enterobacter C. He was switched to from
Kefzol to Vanco/Levo.
FEN: He was started on sips on POD 1.
_
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________________________________________________________________
On [**2119-1-4**], he went to radiology for a CXR and Abdominal X-ray.
He was found by the radiologist unresponsive. A code was called
after he had been donw for 10 minutes. He did not have a pulse
and did not breath. Monitor showed PEA. After atropine and CPR
for 20 minutes, he developed a pulse. He was intubated at the
site.
Workup revealed a saddle embolus and R-popliteal embolus. He is
maintained on a heparin drip.
Since the code he has been remained intubated. His exam off
propofol per team showed intact bs reflexes, but otherwise no
response to noxious. When lowering the propofol in the evening
of [**1-5**], generalized tonic clonic seizure activity was noted.
This activity continued until the propofol was increased. A CT
head was obtained which did not show a hemorrhage or acute
pathology. He was loaded on an AED at that time.
Sputum cultures grew enterobacter and pseudomonas for which he
is being treated with cipro.
We are now called to further assist in management and workup of
seizures. No further seizure activity has been noted (but he has
remained on propofol).
[**1-4**] CT A/P: bilateral pulm emboli/saddle embolus in left main
pulm artery/right side. Athrosclerosis of Aorta/Coronary
arteries.
[**1-4**] BLE U/S: R popliteal vein thrombus, not completely
occlusive.
[**1-6**]: no CT evidence of acute infarct.
[**1-7**] MRI: ischemia, no DVT
Medications on Admission:
Albuterol prn, ASA 81' qd, Atrovent, Lisinopril 10', Zestril,
Advair, Verapamil, Alphagan eye drops, trusopt eye drops, multi
vit.
Discharge Disposition:
Expired
Discharge Diagnosis:
Cholecystitis
Ventral Hernia
Respiratory Distress
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Experied
Completed by:[**2119-1-13**]
ICD9 Codes: 5185, 4275, 5845, 496, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8777
} | Medical Text: Unit No: [**Numeric Identifier 77902**]
Admission Date: [**2191-3-11**]
Discharge Date: [**2191-4-12**]
Date of Birth: [**2191-3-11**]
Sex: F
Service: NB
HISTORY: This is a former 33 and [**4-1**] week infant admitted to
the NICU for issues of prematurity. The infant was born to a
33-year-old G1, P0, 2, 1 mother with past medical history notable
for hypothyroidism and prenatal screens as follows:
including 0 positive blood type, antibody negative, hepatitis
B surface antigen negative, RPR nonreactive, rubella immune,
unknown GBS status. Prenatal course was complicated by
initial IVF with twin conception dichorionic-diamniotic.
There was fetal demise of twin A at 26 weeks, where MRI
showed dextrocardia. The demised twin was also extremely
growth restricted at 431 grams and there was an unclear
etiology for the growth restriction. There was also a history
of subchorionic hematoma, and short cervix treated with magnesium
and nifedipine. The mother is status post betamethasone on
[**2191-1-7**]. She presented with vaginal bleeding with
question of abruption and contractions on the day of
delivery.
The infant was born on [**2191-3-11**] at 6:58 p.m. by C-
section due to unstoppable preterm labor and failure to descend
vaginally. Infant emerged with decreased respiratory
effort and was cyanotic. She received positive pressure
ventilation with quick improvement in color, but intermittently
continued to require some PPV. Oxygen saturation in the right arm
at delivery was 85%. Apgars of 5 at 1 minute and 7 at 5 minutes.
By 5 minutes of age, respiratory effort improved and infant was
transported to the NICU without respiratory support.
Rupture of membranes occurred at delivery with no maternal
fever. The mother was pretreated with antibiotics greater
than 4 hours prior to delivery. Birth weight was 1835 gram,
25 to 50th percentile. Head circumference 31.5 cm, 50 to 75th
percentile, length 44 cm 25 to 50th percentile.
PHYSICAL EXAMINATION ON DISCHARGE: Weight 2695g. very
well-appearing infant in no distress
HEENT AFSF; facies non-dysmorphic; palate intact; normocephalic;
no nasal flaring; red reflex normal
CHEST no retractions; good bs bilat; no adventitious sounds
CVS well-perfused; RRR; femoral pulses normal; S1S2 normal; no
murmur
ABD soft, non-distended; no organomegaly; no masses; bs active;
anus patent; three-vessel umbilical cord
GU normal female genitalia
CNS active, alert, resp to stim; tone normal and symm; MAE symm;
suck/root/gag intact; facies symm
INTEG normal
MSK normal spine/limbs/hips/clavicles
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. Respiratory. Upon arrival to the NICU the baby was in
room air. She remained stable in room air throughout
hospitalization without any active respiratory problems. She
did experience intermittent apnea/bradycardia, but did not
require medical treatment and had been free of significant events
for 5 days prior to discharge home.
2. Cardiovascular. She was stable throughout
hospitalization with normal cardiac examination.
3. Fluids, electrolytes, nutrition. Feeds were started on
day of life 1 and gradually increased. She tolerated the
feedings well. Upon discharge she has been tolerating
breast milk 24 calories/ounce ad lip with good weight
gain. Weight on discharge 2695 grams.
4. GI. The baby was treated with phototherapy during
hospitalization. Maximum bilirubin was 13.5/0.3 on day
of life 3. Hyperbilirubinemia persisted, with bilirubin 12.2
on DOL 28 and 12.4 (with a direct component of 0.4) on DOL 32.
Liver function tests on DOL 26 were normal, with ALT 14, AST 40
and alkaline phosphatase 275. Coombs test was negative and there
was no evidence of hemolysis or anemia. State screen was normal.
Risk for G6PD was considered minimal given female gender without
familial or ethic predisposition. Persistent jaundice was
attributed to breastmilk jaundice. Recommendation is made to
follow clinically and with repeat bilirubin, and consider further
investigation if bilirubin level increases.
5. Hematology. The baby did not require any blood
transfusions during hospitalization. She will be
discharged home on ferrous sulfate. Most recent hematocrit
was 49.2 on [**2191-3-23**] (DOL 12), at which point reticulocyte count
was 2.8. BLood group is O positive and Coombs direct antibody
test is negative.
6. Infectious disease. Blood culture was obtained on
admission to the NICU. CBC was benign. She was on
ampicillin and gentamicin empiric antibiotic therapy for
48 hours. There were no active infectious disease
issues.
7. Neurology. Stable throughout.
HOSPITAL COURSE:
1. Sensory
a. Audiology - hearing screening was performed with
automated auditory brainstem responses. Infant passed
bialterally.
b. Ophthalmology - Ophthalmology examination was not
indicated given gestational age and clinical course. Red reflexes
are present bilaterally.
2. Psychosocial - [**Hospital1 18**] Social Work was involved with the
family. The contact social worker can be reached at [**Telephone/Fax (1) 73590**].
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: [**Hospital **] Pediatrics. [**Telephone/Fax (1) 76908**]
CARE/RECOMMENDATIONS: Feeds at discharge will include breast
milk 24 calories/ounce with EnfaCare Powder.
MEDICATIONS: Ferrous sulfate iron and vitamin D
supplementation:
1. Iron supplementation is recommended for preterm and low
birthweight infants until 12 months corrected age.
2. All infants fed predominantly breast milk should receive
vitamin D supplementation at 200 international units
(may be provided as a multivitamin preparation) daily
until 12 months corrected age.
Car seat position screening was performed prior to discharge
and the baby passed.
State newborn screening has been negative.
IMMUNIZATIONS: Include hepatitis B vaccine on [**2191-3-31**].
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 4 criteria -
a. Born at less than or equal to 32 weeks - Born
between 32 and 35 0/7 weeks.
b. Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities
or school age siblings.
c. Chronic lung disease.
d. Hemodynamically significant CHD.
2. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age,
before this age (and for the first 24 months of the
child's life) immunization against influenza is
recommended for household contacts and out of home
caregivers.
3. This infant has not received rotavirus vaccine. The
American Academy of Pediatrics recommends initial
vaccination of preterm infants at or following discharge
from the hospital if they are clinically stable and at
least 6 weeks, but fewer than 12 weeks of age.
FOLLOW-UP APPOINTMENT SCHEDULED/RECOMMENDED: Appointment
with the pediatrician within 2 days of hospital discharge.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Rule out sepsis.
3. Hyperbilirubinemia.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Doctor Last Name 77903**]
MEDQUIST36
D: [**2191-4-1**] 15:47:31
T: [**2191-4-3**] 22:55:01
Revised [**2191-4-12**]
Job#: [**Job Number 77904**]
ICD9 Codes: 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8778
} | Medical Text: Admission Date: [**2175-3-31**] Discharge Date: [**2175-4-4**]
Date of Birth: [**2126-6-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catherization with placement of Drug Eluting Stent to
proximal LAD
History of Present Illness:
48M with a history of hyperlipidemia transferred from OSH with
chest pain found to have occlusion of LAD now s/p proximal LAD
stenting. The patient was in his usual state of health until
last evening when he developed severe chest pain while
exercising on an elliptical trainer at the gym. Pt states that
he has had both right and left shoulder pain in the past but has
not thought to associate that this with a cardiac etiology.
Last night, the pain was more severe than ever before, the
patient rates it a [**8-3**]. After he returned [**Last Name (un) **] from the gym, he
continued to have the chest pain so he called EMS and was
brought to an OSH.
.
At the OSH, initial vitals 113/68 93 18 98% on 3L. The patient
was given SL nitro and morphine with improvement of his symptoms
but not resolution. EKG notable for ST segment depressions in
V3-V5. This morning, he was transferred from the OSH to [**Hospital 61**] for positive cardiac markers and ongoing pain. Per
report, Pt bolused started on heparin and integrilin drips and
received 600mg Plavix, 25mg lopressor and 325mg aspirin prior to
transfer. CTA performed and negative for PE or other acute
intrathoracic process.
.
On arrival, vitals BP 106/78 HR 90. Cardiac cath showed 100%
occlusion of the LAD. A thrombectomy was performed with partial
removal of the occluding thrombus. A Cypher, drug-eluting stent
was placed in the mid LAD. PTCA of the diagonal was performed
with recurrent thrombus. The patient was plavix loaded at the
OSH and started on integrelin in the cath lab. The patient was
noted to have an elevated wedge pressure at 30 for which he
received 20mg IV lasix. Because the patient was uable to void,
a Foley catheter was placed with 1100 cc urine output.
.
On arrival to the CCU, vitals 98.4 109/58 86 95%2L. Patient
chest pain free. Denied any shortness of breath, palpitations,
or shoulder pain but did not feeling of severe gastric reflux.
.
ROS: As per HPI. In addition, back pain from lying flat.
Occasional dry cough, dry mouth, dysuria and occasional right
knee pain.
Past Medical History:
Gastroesophageal Reflux
Gout
Prostatitis
Hyperlipidemia
Borderline elevated blood glucose
History of palpitations with negaitve stress test and ECHO at
[**Hospital1 336**] one year ago
Hernia repair
Congenital Left lower Extremity deformity s/p multiple surgeries
as a child
Social History:
Married, one 14 year old son. Moved to US from [**Country 27587**] in
[**2164**]. Hydrologist, does computer modelling of climate change.
Quit smoking in [**2167**], smoked one pack per day for about 30
years. Drinks 1 glass wine 1-2 times per week. No illicits.
Has been eating a healthy diet with fish and minimal red meat.
Family History:
Mother - [**Name (NI) 3495**] Disease, Hypertension, Diabetes [**Name (NI) **]
Father - Deceased [**12-26**] [**Name2 (NI) **] cancer
Pertinent Results:
Admission labs:
[**2175-3-31**] 02:47PM BLOOD WBC-12.5* RBC-4.44* Hgb-12.6* Hct-36.5*
MCV-82 MCH-28.5 MCHC-34.6 RDW-14.3 Plt Ct-273
[**2175-3-31**] 02:47PM BLOOD PT-13.5* PTT-37.6* INR(PT)-1.2*
[**2175-3-31**] 02:47PM BLOOD Glucose-103 UreaN-12 Creat-1.3* Na-139
K-4.2 Cl-102 HCO3-27 AnGap-14
[**2175-3-31**] 02:47PM BLOOD ALT-96* AST-512* LD(LDH)-769*
CK(CPK)-4867* AlkPhos-54 TotBili-0.4
[**2175-3-31**] 02:47PM BLOOD CK-MB->500 cTropnT-10.33*
[**2175-3-31**] 02:47PM BLOOD Triglyc-191* HDL-37 CHOL/HD-5.9
LDLcalc-142*
[**2175-3-31**] 02:47PM BLOOD %HbA1c-5.8
.
Cardiac enzymes:
[**2175-3-31**] 02:47PM BLOOD ALT-96* AST-512* LD(LDH)-769*
CK(CPK)-4867* AlkPhos-54 TotBili-0.4
[**2175-3-31**] 11:26PM BLOOD CK(CPK)-3054*
[**2175-4-2**] 04:21AM BLOOD CK(CPK)-803*
[**2175-3-31**] 02:47PM BLOOD CK-MB->500 cTropnT-10.33*
[**2175-3-31**] 11:26PM BLOOD CK-MB-209* MB Indx-6.8*
[**2175-4-1**] 05:57AM BLOOD CK-MB-99*
[**2175-4-2**] 04:21AM BLOOD CK-MB-13* MB Indx-1.6
.
Cardiac cath ([**3-31**]):
Right Heart Catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 5 French pulmonary wedge pressure
catheter,
advanced to the PCW position through an 5 French introducing
sheath.
Cardiac output was measured by the Fick method.
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 5 French left [**Last Name (un) 2699**] catheter,
advanced
to the ascending aorta through a 6 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 5
French JL4 and a 5 French JR4 catheter, with manual contrast
injections.
Percutaneous coronary revascularization was performed using
placement of
drug-eluting stent(s).
Percutaneous coronary revascularization was performed using
thrombectomy.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.10 m2
HEMOGLOBIN: 13.6 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 22/21/19
RIGHT VENTRICLE {s/ed} 51/20
PULMONARY ARTERY {s/d/m} 51/30/40
PULMONARY WEDGE {a/v/m} 34/37/33
AORTA {s/d/m} 106/78/91
**CARDIAC OUTPUT
HEART RATE {beats/min} 90
RHYTHM SR
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 70
CARD. OP/IND FICK {l/mn/m2} 3.8/1.8
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 1516
PULMONARY VASC. RESISTANCE 147
**% SATURATION DATA (NL)
PA MAIN 55
AO 93
PTCA COMMENTS: Initail angiography revealed a proximally
occluded
LAD. We planned to treat this with PTCA and stenting. A 6 french
XB 3.5
guide provided good support for the procedure. Heparin,
integrilin,
aspirin and plavix were used as anticoagulation. A prowater wire
crossed
into the distal LAD with minimal difficulty. Thrombectomy was
performed
with an export catheter with minimal success. A 2.5 x 15 mm
balloon
dottered through the stenosis with minimal effect. A 5 French
temporary
pacing wire was inserted and thrombectomy with the angiojet was
perfoemd with moderate success. Angiography then revealed a
proximal LAD
stenosis involving the diagonal and thrombus in both the LAD and
the
diagonal. Another prowater wire was directed down the diagonal
and
angioplasty was performed in the diagonal with a 2.0 x 12 mm
voyager
balloon at 10 ATM. A 3.0 x 23 mm Cypher [**Last Name (un) **] was deployed in the
LAD at
18 ATM after removing the D1 wire. A choice floppy wire was then
redirected down the D1 adn the diagonal and LAD were dilated in
a
kissing fashion with a 2.0 x 12 mm quantum maverick in the
diagonal and
a 3.0 x 15 mm quantum maverick in the LAD at 10 ATM. Angiography
then
revealed recurrent thrombus in the LAD and diagonal.
Thrombectomy wasu
The diagonal was thenr edilated with a 2.0 x 12 mm balloon at 16
and teh
LAD was post dilated with a 3.25 x 15 mm quantum maverick
balloon at 20
ATM. There was a hazy opacity that persisted in the LAD stent
and IC
reopro was administered with little change. The LAD stent was
then post
dilated with a 3.25 x 15 mm powersail and a 3.5 x 15 mm
powersail
balloon at 20 ATM x multiple inflations. Final angiography
revealed
minor residual thrombus in the LAD stent and slow flow and
thrombus in
the D1 without a dissection.
COMMENTS:
1. Selective coronary angiography of thsi right dominant system
revealed
single vessel CAD. The LMCA had no nobstructive CAD. The LAD was
proximally occluded. The LCX had no angiographically visible
obstructive
lesions. The RCA was a dominant vessel without angiographically
obstructive CAD.
2. Resting hemodynamics revealed markedly elevated left and
right sided
filling pressures and a reduced cardiac index of 1.8 L/min/m2.
3. Left ventriculography was deferred.
4. Successful thrombectomy, PTCA and stenting of the LAD with a
3.0 x 23
mm cypher [**Last Name (un) **] which was postdilated with a 3.5 x 15 mm powersail
balloon
at high pressure. Final angiography revealed a minor residual
thrombus
in the LAD stent, no dissection and TIMI III flow in the LAD.
5. Unsuccessful PTCA of the diagonal with a 2.0 balloon. Final
angiography revealed slow flow and residual thrombus in the
diagonal and
no dissection. (see PTCA comments)
6. Right femoral arteriotomy site was closed with a 6 French
Angioseal
device.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Elevated left and right sided filling pressures.
3. Acute anterior myocardial infarction, managed by acute ptca.
PTCA of the LAD.
.
ECHO ([**3-31**]): The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. LV systolic function appears moderately-to-severly
depressed (ejection fraction 30 percent) secondary to akinesis
of the apex and anterior septum, and hypokinesis of the inferior
septum and anterior free wall. 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. Trivial mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
Discharge labs:
[**2175-4-4**] 06:05AM BLOOD WBC-7.2 RBC-4.00* Hgb-11.2* Hct-32.4*
MCV-81* MCH-28.0 MCHC-34.6 RDW-14.0 Plt Ct-212
[**2175-4-4**] 06:05AM BLOOD PT-29.3* PTT-91.2* INR(PT)-2.9*
[**2175-4-4**] 06:05AM BLOOD Glucose-92 UreaN-15 Creat-1.4* Na-138
K-4.8 Cl-103 HCO3-22 AnGap-18
[**2175-4-4**] 06:05AM BLOOD ALT-38 AST-29 AlkPhos-43 TotBili-0.4
[**2175-4-4**] 06:05AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.3
Brief Hospital Course:
48 year-old male with hyperlipidemia, borderline diabetes
[**Hospital **] transferred from OSH for [**Hospital 7792**] now s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] of
mid-LAD for occlusion. Hospital course was as follows.
1. [**Name (NI) 7792**] - Pt has risk factors including h/o hyperlipidemia,
borderline DM, positive family history and a 30 pack year
smoking history. Pt went to cath lab on [**3-31**] and was found to
have 100% occlusion of proximal LAD. He had [**Month/Day (4) **] of LAD and
unsuccessful PTCA of the diagonal. Post-cath ECHO showed EF of
30% with akinesis of the apex and anterior septum, and
hypokinesis of the inferior septum and anterior free wall. He
was Plavix loaded prior to cath then continued on heparin and
integrilin for 48 hours after intervention. Given the ECHO
results of apical akinesis with a depressed EF, he was started
on coumadin for 6 months for prophylaxis. He was started on a
beta blocker, ACE inhibitor, statin and low dose aspirin. He was
discharged with cardiac rehabilitation.
2. Prostatitis - Pt has history of prostatitis for which he
takes Bactrim and Flomax. Was unable to void post-cath
requiring Foley with greater than 1L urine output; the Foley was
subsequently removed without difficulty. He was continued on
Bactrim and Flomax.
3. Acute Renal Failure - Post cath creatinine 1.3 from a
baseline of 1.0. Got IV contrast with CTA at OSH and with
cardiac cath. Cardiac index also suppressed and EF now only
30%. His creatinine improved and was back to baseline at time of
discharge.
4. Borderline diabetes - Pt reports that he was told by PCP that
he had borderline blood sugars. He has been trying to eat heart
healthy diet. He had fasting value of 105 and hemoglobin A1c of
5.8%.
5. GERD - His proton pump inhibitor was discontinued as he was
started on Plavix; he was started on an H2 blocker.
6. Gout flare - Developed during hospital course; manifested
primarily right knee and left ankle. Patient had effusion in
left knee. Rheumatology was consulted. He felt this was very
similar to previous gout flares. He was started on colchicine.
NSAIDs were avoided given proximity to MI. Rheumatology
follow-up was scheduled.
Medications on Admission:
Omeprazole 20mg daily
Indomethacin 50mg daily prn gout flares
Bactrim DS 1 tablet [**Hospital1 **] for prostatitis and UTI proph
Flomax qhs
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): Stop taking if you get diarrhea, may resume when
diarrhea resolves. .
Disp:*90 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
Please check your PT/INR on Friday [**4-7**] and call results to
[**Hospital **] Clinic at [**Company 191**]: [**Telephone/Fax (1) 2173**]
10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
11. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
NST Elevation Myocardial Infarction
Hyperlipidemia
Apical akinesis
Acute gout flare
Discharge Condition:
Hemodynamically stable and afebrile
Discharge Instructions:
You were admitted to the hospital and found to have a heart
attack. You underwent cardiac catheterization which showed a
blockage in one of your arteries which was removed and a stent
placed.
There are multiple new medications from this hospital admission:
1) START Plavix (clopidogrel) 75mg daily - this needs to be
taken for at least one year, do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop
taking Plavix unless Dr. [**Last Name (STitle) **] tells you to.
2) START Aspirin 81mg daily - to be taken indefinitely
3) START Atorvastatin 80mg daily: to lower your cholesterol
4) START Metoprolol 25mg Twice daily: to lower your heart rate
5) START Lisinopril 2.5 mg daily: to lower your blood pressure
6) START Coumadin 2.5 mg daily: to prevent blood clots
7) START ranitidine 150mg twice daily
8) STOP omeprazole - this medication should not be taken while
you are taking plavix.
9) Colchicine: to treat your acute gout flare. Do not take
indomethecin until Dr. [**Last Name (STitle) **] tells you it is OK.
.
Your heart is weak because of the heart attack. You may find
that you retain fluid in your ankles or that you develop a cough
or trouble breathing. Please call Dr. [**Last Name (STitle) **] if this happens.
Please also wegh yourself every morning before breakfast and
record the weight in the graph. Call Dr. [**Last Name (STitle) **] if your weight
increases more than 3 pounds in 1 day or 6 ponds in 3 days.
Follow a low sodium (2000mg) diet
.
Please call Dr. [**Last Name (STitle) **] if you have any chest pain, trouble
breathing, nausea, vomiting, increasing fevers, dark stools,
sweating or any other concerning symptoms.
Followup Instructions:
Cardilology:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/time:
.
Primary care:
Dr. [**Last Name (STitle) 82165**] [**Name (STitle) **] Monday [**5-15**] at 10:30am
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4887**] [**4-14**] at 3:40pm. Both at [**Hospital Ward Name 23**] clinical
Center, [**Location (un) **], Central Suite. [**Hospital Ward Name 516**] [**Location (un) **],
[**Location (un) 86**].
.
Rheumatology:
Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 82166**] Date/Time: Monday [**5-15**]
at 9:00 am [**Hospital Unit Name **] [**Location (un) **] [**Hospital Unit Name **], [**Last Name (NamePattern1) 439**]
[**Location (un) 86**].
Completed by:[**2175-4-7**]
ICD9 Codes: 5849, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8779
} | Medical Text: Admission Date: [**2179-4-5**] Discharge Date: [**2179-4-14**]
Date of Birth: [**2102-1-24**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 22990**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
77 y/o F with hx of COPD on 2 L NC at home, DM II, and vascular
dementia who present to the ED with acute onset shortness of
breath the day prior to admission at around 2300. She had felt
like she was getting a "cold" or some type of URI. She was seen
in her PCP's office and started on a steroid taper with 60 mg
Friday and Sat and 40 mg on Sunday.
.
In the ED, initial vs were 97.8, 131, 194/80, 32, 100% on NRB.
Patient was given continuous nebulizer treatments, levofloxacin
and solumedrol for a COPD flare and possible PNA. She had a
clear CXR. She did not have good air movement on exam and had
pursed lip breathing. No bipap or cpap was tried at the time.
.
On the floor, patient is feeling better. She is on nasal canula.
Her daughters are at her bedside and think she is much improved.
She was not speaking in full sentences on presentation and now
is having mostly normal conversation.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
COPD on 2L home O2
DM2
Dementia
HTN
Dyslipidemia
Goiter s/p RAI
R breast nodule
RUL opacity on CT--thought to be scarring from pneumonia, but
ddx includes cancer
Social History:
She continued to smoke one to two packs of cigarettes/day until
[**Month (only) 404**] of this years. She is retired from the post office. She
no longer drinks alcohol but has a remote history of alcohol
abuse.
Family History:
The patient's father died at 71 of complications of diabetes.
She is the oldest of seven siblings of whom only four are
living. There is no history of known dementia in the family.
Physical Exam:
Vitals - T: 97.8 BP: 165/74 HR: 96 RR: 24 02 sat: 94% 2L NC
GENERAL: mild respiratory distress
HEENT: Sclera anicteric, MMM, OP without lesions
CARDIAC: RR, nl rate, no rubs, gallops or murmurs appreciated
LUNG: clear to auscultation bilaterally, no wheezes, rales or
rhonchi
ABDOMEN: soft, nontender, nondistended, bowel sounds present, no
organomegaly
EXT: WWP, 2+ pulses, without C/C/E
NEURO: Alert, confused, sensation grossly intact
DERM: No rashes appreciated
Pertinent Results:
[**2179-4-5**] 12:40AM WBC-8.1 RBC-3.61* HGB-10.0* HCT-32.6* MCV-91
MCH-27.7 MCHC-30.6* RDW-13.3
[**2179-4-5**] 12:40AM NEUTS-83.7* LYMPHS-11.1* MONOS-5.0 EOS-0.2
BASOS-0
[**2179-4-5**] 12:40AM PT-10.1* PTT-21.5* INR(PT)-0.8*
[**2179-4-5**] 01:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2179-4-5**] 12:40AM GLUCOSE-312* UREA N-29* CREAT-1.3* SODIUM-139
POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-33* ANION GAP-12
[**2179-4-5**] 12:46AM LACTATE-2.1*
[**2179-4-5**] 12:17PM CK-MB-NotDone cTropnT-0.01
[**2179-4-5**] 12:17PM CK(CPK)-75
CHEST, AP UPRIGHT PORTABLE FRONTAL VIEW: Blunting of the
costophrenic angles is new, due to small pleural effusions
developed over three days. Previous vascular engorgement has
resolved suggesting the pleural fluid is the residual of
improved CHF. Lungs are hyperinflated, clear of any
consolidation. Right upper lobe nodule is obscured by overlying
EKG lead. The heart size is normal. The aortic arch is
calcified. The descending thoracic aorta is tortuous.
IMPRESSION: New small pleural effusions remain after prior heart
failure. COPD. Right upper lobe nodule.
EKG: Sinus tachycardia. Occasional ventricular premature beats.
Compared to the previous tracing no definite change.
Brief Hospital Course:
77-year-old female with a history of COPD, on 2L NC home oxygen,
HTN, DM, vascular dementia who presents with shortness of
breath.
# COPD exacerbation: There is an unclear inciting event. The
patient didn't respond to home steroids or nebulizations.
Initially the patient was on up to 6L NC for oxygenation. The
patient was admitted to the hospital and improved with IV
steroids, levofloxacin and nebulizations. She completed 7 days
of levofloxacin. She was transitioned to oral prednisone and
given a 10 day taper. Her oxygen was weaned to 2L NC.
# RUL nodule: The patient has a known RUL nodule. This as been
previously followed as an outpatient. The most likely etiology
is scarring but malignancy cannot be ruled out. This will be
followed as an outpatient. Further management is up to her
primary care physician.
# Tachycardia: The patient has episodes of tachycardia which
were thought to be secondary to alberterol nebulizers. She was
switched to Xopenex with a decrease in the heart rate. She was
also given some IVF which decreased her heart rate as well. She
was encouraged to take PO fluids.
# Acute kidney injury: On presentation was 1.3 likely in the
setting of dehydration. With fluids her creatinine returned to
baseline.
# Elevated Cr: Cr up to 1.3 from baseline around 1.0 on
admission and mildly dry appearing on exam, likely from poor PO
intake over the weekend while having respiratory difficulties.
Creatinine resolved to baseline on second day.
# HTN: The patient was continued on verapamil. She was also
started on captopril (from lisinopril). Her blood pressure
remained well controlled.
# DM: The patient had elevated blood sugars in the setting of
steroids. She was taking oral diabetic medications. She was
started on NPH and insulin sliding scale. She was monitored
closely and her insulin scale was adjusted as needed. Her
aspirin was continued.
# Anemia: Stable during admission. She will need to be followed
as an outpatient.
# Dementia: Stable during admission. She has short term memory
problems. [**Name (NI) **] [**Name2 (NI) 97069**] was held because it causes "increased
confusion and aggitation" per family. Sertraline and trazadone
were continued.
# Hyperlipidemia: Continued on pravastatin.
# GERD: Continued on omeprazole.
Medications on Admission:
# Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler 2 puffs q6hr
# Advair Diskus 250-50 mcg/Dose Disk 1 puff [**Hospital1 **]
# Lisinopril 2.5 mg daily
# Pravastatin 20 mg daily
# Sertraline 25 mg qHS
# Spiriva with HandiHaler 18 mcg Capsule daily
# Trazodone 50 mg qHS
# Verapamil 180 mg Tablet Sustained Release daily
# Aspirin 81 mg daily
# Cholecalciferol (Vitamin D3) 400 unit [**Hospital1 **]
# Omeprazole 20 mg Capsule daily
# Humalog Sliding Scale, Humalin 34 u daily
# [**Hospital1 **] 10 mg qHS (new)
# Recently started steroid taper
Discharge Medications:
1. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Disp:*1 * Refills:*0*
2. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
Disp:*1 * Refills:*0*
3. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Sertraline 25 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
6. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
Disp:*1 * Refills:*0*
7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
8. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*0*
11. 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:*0*
12. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day for 15 doses: please take 30mg (3 tabs) for the next 2 days,
then take 20 mg (2 tabs) for 3 days, then take 10mg (1 tab) for
3 days, then stop.
Disp:*15 Tablet(s)* Refills:*0*
13. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: as
directed Subcutaneous every AM: 28 Units every morning, please
contact your primary care physician if your blood sugars are
difficult to control.
Disp:*1 * Refills:*0*
14. Insulin Aspart 100 unit/mL Insulin Pen Sig: as directed
Subcutaneous four times a day as needed for blood sugars: Please
use as directed, from the attached sheet.
Disp:*1 * Refills:*0*
15. oxygen
Please continue oxygen 2L via nasal canula as needed at home
16. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please start after your steroid taper. Continue this medication
and discuss with Dr. [**Last Name (STitle) **].
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
1. COPD exacerbation
2. Acute kidney injury
Secondary Diagnosis:
1. Diabetes mellitus
2. Hypertension
3. Anemia
4. Dementia
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted with a COPD exacerbation. You were treated
with steroids, antibiotics and breathing treatments. You
improved and your breathing was much better. Your oxygen level
was good on 2L of oxygen, which is your home level. Your
breathing treatments are spread out and you can continue to take
them at home. You steroids with be continued, although at
decreasing doses for the next 8 days. You will need to follow up
with your primary care physician [**Last Name (NamePattern4) **] [**1-23**] weeks-an appointment was
made below. You will continue to get home VNA and physical
therapy.
The following changes were made to your medications:
1. START: Prednisone 30mg for 2 days, then 20mg for 3 days, then
10mg for 3 days, then 5mg prednisone daily
2. CHANGE: Insulin NPH 28 units every morning
3. CHANGE: Insulin sliding scale - please see attached list
4. STOP: [**Date Range **] - please discuss with your primary care
physician
[**Name Initial (PRE) **] [**Name10 (NameIs) **] follow medications per the medication sheet
Your blood sugars may be high for the next few days. If your
blood sugars are running too high or too low please contact Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for recommendations on how to better control your
blood sugars.
Followup Instructions:
You will need to follow up with your primary care physician (Dr.
[**Last Name (STitle) **]. An appointment was scheduled for you on Wed. [**4-28**],
9:10 AM. In [**Hospital Ward Name 23**] Building [**Location (un) 895**]. Please call [**Telephone/Fax (1) 250**]
with any questions or to reschedule.
You will also need to follow up with pulmonary. The pulmonary
department will call you with an appointment time. If you do not
hear from them within a week please call [**Telephone/Fax (1) 612**] to
schedule an appointment.
Provider: [**Name10 (NameIs) **] SCAN
Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2179-6-15**] 1:00
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB
Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2179-6-28**] 2:10
ICD9 Codes: 5849, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8780
} | Medical Text: Admission Date: [**2159-6-8**] Discharge Date: [**2159-6-10**]
Service: [**Hospital Unit Name 196**]
CHIEF COMPLAINT: Unstable angina/chest pain
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 42205**] is an 85-year-old
man with a history of hypertension, diabetes mellitus, and
peripheral vascular disease. He was in his usual state of
health until several weeks ago when he started to experience
chest discomfort with exertion. The episodes resolved with
rest and the patient did not seek medical attention.
The day prior to admission, however, the patient experienced
worsening midsternal chest pain [**10-24**] while picking up the
trash. The symptoms were not associated with shortness of
breath, nausea, or diaphoresis. The symptoms resolved after
five minutes. The patient remained pain free until this
morning of admission when the patient again experienced 4/10
chest pain with minimal exertion walking, and presented to
[**Hospital3 1443**] Hospital, where he was given aspirin,
Lopressor, Heparin, nitroglycerin paste with relief of symptoms.
Electrocardiogram showed anterior ST-T wave changes, right
bundle branch block, biphasic T wave in V1 through V4. First
set of enzymes and troponin were negative. Patient was
transferred to [**Hospital1 69**] for
cardiac catheterization.
In the catheterization laboratory, the patient was found to
have three vessel coronary artery disease: left anterior
descending artery with 50% stenosis at D1, the small D1 with 80%
stenosis, ostial 50% left circumflex with 90% tubular lesion in
the OM1, and right coronary artery totally occluded with
antegrade collateral flow. No left ventriculogram was performed.
The 90% lesion in the OM-1 was successfully stented with a 2.5 X
15 mm BioDivysio stent. Pressure wire evaluation of the LAD
yielded a FFR of 0.81, indicating no limitation to flow. The
patient experienced Mobitz-II rhythm with adenosine during the
pressure wire study, but this resolved upon cessation of the
drug. At the conclusion of the procedure, the patient was pain
free and hemodynamically stable.
Coronary artery disease risk factors: ? Cholesterol,
hypertension, diabetes mellitus, negative family history,
negative tobacco.
PAST MEDICAL HISTORY:
1. Peripheral vascular disease, S/P AAA repair.
2. Hypertension.
3. Prostate cancer recently started radiation treatment.
PAST SURGICAL HISTORY:
1. Abdominal aortic aneurysm repair.
2. Status post appendectomy.
3. Cataract surgery.
ALLERGIES: No known drug allergies.
MEDICATIONS: The patient is unable to recall medications.
Daughter is to bring in medication list in from; per outside
hospital records:
1. Aspirin 325 mg po q day.
2. Proscar 5 mg po q day.
3. Hytrin 2 mg po q day.
4. Klonopin 0.1 mg po, ? dosing.
5. Lopressor 25 mg po bid.
6. Plavix 300 mg po given at outside hospital x1.
SOCIAL HISTORY: Lives with wife who has [**Name (NI) 2481**] disease.
Wife goes to daycare. Their three children assist with care
seven days a week, is a nonsmoker.
REVIEW OF SYSTEMS: Negative transient ischemic attack,
negative cerebrovascular accident, negative myocardial
infarction, negative claudication, negative gastrointestinal
bleeding.
INITIAL LABORATORY STUDIES: White blood cell count is 6.5,
hematocrit 41.6, platelets 245. Chem-7: Sodium 144,
potassium 4.1, chloride 107, bicarb 22, BUN 29, creatinine
1.5, which is his baseline, and glucose 161.
PHYSICAL EXAMINATION: General: Well-developed and
well-nourished male lying on stretcher in no apparent
distress, looks younger than stated age. Vital signs: Heart
rate 66, blood pressure 131/80, sat 99%. Neck without
bruits. Lungs clear anteriorly. Heart: Normal S1, S2,
regular, rate, and rhythm, no murmurs, rubs, or gallops.
Abdomen is soft, nontender, nondistended, mildly distended.
Right groin with arterial sheath in situ, no hematoma, no
ooze, and no flank tenderness. Dorsalis pedis and posterior
tibial pulses intact bilaterally. Extremities are warm.
No edema. He was on an Integrilin drip.
ASSESSMENT: This is an 85-year-old male with coronary artery
disease, peripheral vascular disease, hypertension, diabetes
mellitus, status post OM-1 stent placement.
HOSPITAL COURSE: Cardiovascular: Patient remained
hemodynamically stable while on the floor without Telemetry
events until the time of sheath pull. At the time of sheath
pull, the patient shortly afterwards developed hypotension
with a systolic blood pressure down to the 70s/30s and
bradycardia with a heart rate in the 30s. The patient was
given intravenous fluids and 2 mg of atropine (through what was
actually an infiltrated IV). The patient subsequently became
notably more somnolent. Although he was easily arousable and had
a nonfocal examination, he fell asleep easily (unlike before
sheath removal). The mental status changes were attributed to the
excessive atropine given essentially subcutaneously. He was
transferred for the CCU for observation, where he remained stable
wit a blood pressure of 126/66 with a heart rate of 80.
The patient was monitored in the Intensive Care Unit for
approximately five hours, and then was transferred back to
the [**Hospital Unit Name 196**] service for further observation. The patient
remained hemodynamically stable on the [**Hospital Unit Name 196**] service
throughout the rest of his hospital course with no Telemetry
events. The patient did not experience any more chest pain
or shortness of breath at any time. The patient had no
recollection of the episode which was deemed vasovagal
episode.
Followup laboratories were checked: Patient's CK was 110, MB
5. CK was down from prior CK of 127. ALT 18, AST 18.
Chem-7 unremarkable. Hematocrit 34.4 postprocedure and
stable. Total cholesterol 208, triglycerides 184, HDL 42,
LDL 124, for which atorvastatin was begun. Admission TnI was
6.3, consistent with a small non-ST elevation MI with normal MB.
Patient had an uneventful day of observation after vasovagal
episode, and was felt to be stable for discharge by the next
day. The patient's heart rate and blood pressure were stable
at all times after transfer from the CCU. Groin showed no
evidence of bleeding or hematoma, was soft, and there was no
bruit.
DISCHARGE DIAGNOSES:
1. Coronary artery disease with non-ST elevation myocardial
infarction (marker-positive unstable angina), now S/P stent
placement in OM-1.
2. Vasovagal episode upon sheath pull complicated by somnolence.
3. Peripheral vascular disease.
4. Hypertension.
5. Diabetes mellitus.
6. Chronic renal insufficiency with creatinine of 1.5. Of
note, creatinine was stable at 1.5 throughout his hospital
course, and discharge creatinine was 1.3.
7. Hypercholesterolemia.
DISCHARGE MEDICATIONS:
1. Nitroglycerin 0.3 mg tablets sublingually prn.
2. Finasteride 5 mg po q day.
3. Terazosin 2 mg po hs.
4. Metoprolol 25 mg po bid.
5. Aspirin 325 mg po q day (maintain 325 mg daily X 1 month
mininum, then consider 81 mg daily)
6. Plavix 75 mg po q day x 9 months.
7. Lipitor 10 mg po q day.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: To home.
FOLLOW-UP INSTRUCTIONS: The patient is to followup with his
cardiologist Dr. [**Last Name (STitle) **] at [**Hospital3 1443**] Hospital in two
weeks, and instructed if he is to have any chest pain, dizziness,
loss of consciousness, difficulty breathing, to call his doctor
or come to the Emergency Room.
[**Doctor First Name **] [**Name8 (MD) 20141**], M.D. [**MD Number(1) 7100**]
Dictated By:[**Name8 (MD) 6867**]
MEDQUIST36
D: [**2159-6-10**] 11:35
T: [**2159-6-14**] 08:33
JOB#: [**Job Number 42206**]
ICD9 Codes: 4111, 9971, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8781
} | Medical Text: Admission Date: [**2143-1-24**] Discharge Date: [**2143-1-28**]
Date of Birth: [**2101-11-13**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Doxycycline
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
41F HIV on HAART (compliant, CD4 350), HCV, DM2, chronic
neuropathic pain admitted [**1-24**] to MICU from [**Hospital **] clinic with
lethargy and AMS arousable only to sternal rub. Pt takes
fentanyl patch, dilaudid (pcp), gabapentin +/- oxycodone (has
scripts, denies taking) at home. Reports taking 4 tabs dilauded
before ID appoint + regular xanax and gabapentin. Explains that
woke up 5am day prior to admission in significant pain
(neuropathic) and took 3x her normal dose of dilaudid (usual
4mg, took 12mg) and 3x per normal dose of xanax (usual dose 2mg,
took 6mg). Then took her regular doses of both at noon before
going to her [**Hospital **] clinic at 1pm. At [**Hospital **] clinic she was noted to be
very lethargic and was sent to ED for further evaluation.
In the ED, initial vs were: T98.0 89 102/60 10 88% on RA. O2 sat
improved to mid 90s on 2L NC. Per ED report, she was very
lethargic and only responsive to sternal rub. Exam initially
felt notable for ?bilateral LE cellulitis. Multiple urine tox
screens positive (benzos, opiates, cocaine). UA with some WBCs
and nitrate. CXR with very poor inspiratory effort - limited
study but read as likely no infiltrate, though ED suspicious for
infiltrate. Patient was given ceftriaxone and vancomycin and
flagyl (though never appears to have received flagyl) and cipro
- coverage for UTI, pneumonia (aspiration), cellulitis. Came to
MICU because she was only responsive to sternal rub and
suspicion for hypoventilation from narcotic abuse. No ABG, no
narcan given. She brought with her a half-full bottle of xanax 2
mg tabs (#61 - 29 missing from bottle filled 2 weeks ago with
directions to take three times daily).
In the MICU, patient was arousable to loud voice but falls
asleep within seconds. Able to stay awake and answer some
direct questions, but unable to describe what happened today.
Denies IVDU, but does not answer when asked about other
ingestions. Says she takes a medication given to her by her PCP
for pain (?dilaudid) and wears a fentanyl patch. Endorses pain
but unable to specify where.
Review of systems on admission: unable to obtain.
Per discussion with PCP patient has long history of trying to
"stretch the system at both ends". Thinks legitimate pain but
likes her pain meds and tries to use her illness to get a lot
from the system. Of note, per PCP, [**Name10 (NameIs) **] was able to be placed on
hospice benefit within the last year which she outlived as she
was not actively dying of any illness (HIV+ but not with AIDS,
no OI, possibly placed due to liver disease which she is also
not dying of).
Past Medical History:
-HIV ([**2130**], compliant on HAART, last cd4 579 [**9-26**], nadir 43, OI
PCP [**2132**])
-multifactorial hypoxia w/ASD, OHS, OSA on bipap, baseline sat
~92ra%
-IDDM
-HCV (genotype 2B, bx [**5-23**] grade [**1-19**] inflammation, stage 3
fibrosis)
-chronic peripheral neuropathic pain [**2-19**] HIV, prior AZT,
exacerbated by DM
-Hypothyroidism
-HTN
-HepBcAb positive, sAb negative, sAg negative
-Diverticulitis w/hx of colovaginal fistula [**2136**]
-GERD
-Bipolar/anxiety
-genital HSV
-s/p TAH/BSO
Social History:
Has been living at home, has a PCA who visits her 30 hours per
week. Is currently smoking 6 cigs per day. No EtOH, no IVDU
since [**2133**]. She ambulates with the aid of either a walker or
cane depending on how she feels.
Family History:
The patient is adopted and is not aware of familial illnesses.
Physical Exam:
PHYSICAL EXAM ON ADMISSION TO MICU:
General: Somnolent, arouses to loud voice and tactile stimuli,
but falls back asleep within seconds. RR 10 when not
stimulated.
HEENT: PERRL 4->3, sclera anicteric, MMM, oropharynx clear
Neck: supple, JVD difficult to appreciate given obesity, no LAD,
excellent mobility.
Lungs: Clear bilaterally though with poor effort.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-distended, multiple incisional scars,
bowel sounds present, appears to be diffusely tender to deep
palpation though no apprent rebound tenderness or guarding.
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
pitting edema. Bilateral lower extremity erythematous
macular/micropapular rash from groin to shins, mostly medial
distribution. Slightly warm.
Neuro: Somnolent as above. Follows simple commands when asked
(moving all extrems, opens eyes and mouth to command), unable to
assess strength with formal testing.
PHYSICAL EXAM ON TRANSFER TO FLOOR:
VS: 96.3 109/58 79 16 99/2L FS 182 Wt 278.3
Gen: lethargic, somnolent
HEENT: dry MM, unable to assess JVP
Cardiac: RRR, unable to appreciate any murmurs
Lungs: clear anteriorly, unable to get pt to fully sit up
despite multiple attempts
Abdomen: obese, soft, very TTP LLQ with guarding but without
rebound, non-distended
Extremities: DP pulses 1+ bilaterally, unable to appreciate
other pulses
Neuro: CN II-XII grossly intact, moving all extremities,
sensation intact across upper and lower extremities, no
nystagmus appreciated, EOMI, pupils dilated ~6mm, equivocally
reactive to light
Skin: no rashes noted
Psych: denies SI
Pertinent Results:
Labs on Admission:
[**2143-1-24**] 04:40PM BLOOD WBC-6.7# RBC-4.88 Hgb-13.3 Hct-41.5
MCV-85 MCH-27.3 MCHC-32.1 RDW-14.7 Plt Ct-261
[**2143-1-24**] 04:40PM BLOOD Neuts-79.9* Lymphs-12.1* Monos-3.2
Eos-4.4* Baso-0.4
[**2143-1-24**] 04:40PM BLOOD Plt Ct-261
[**2143-1-24**] 04:40PM BLOOD WBC-6.7 Lymph-12* Abs [**Last Name (un) **]-804 CD3%-71
Abs CD3-571* CD4%-43 Abs CD4-349* CD8%-25 Abs CD8-200
CD4/CD8-1.8
[**2143-1-24**] 04:40PM BLOOD Glucose-216* UreaN-13 Creat-0.9 Na-140
K-3.8 Cl-96 HCO3-33* AnGap-15
[**2143-1-24**] 04:40PM BLOOD ALT-28 AST-22 CK(CPK)-59 AlkPhos-139*
TotBili-1.6*
[**2143-1-24**] 04:40PM BLOOD Lipase-22
[**2143-1-24**] 04:40PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2143-1-24**] 04:40PM BLOOD Albumin-4.4
[**2143-1-24**] 04:40PM BLOOD Osmolal-294
[**2143-1-24**] 04:40PM BLOOD TSH-1.9
[**2143-1-24**] 04:40PM BLOOD Free T4-1.2
[**2143-1-24**] 04:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2143-1-24**] 04:48PM BLOOD Lactate-1.6
Labs on Discharge:
[**2143-1-26**] 08:20AM BLOOD WBC-4.4 RBC-4.56 Hgb-12.8 Hct-39.4 MCV-87
MCH-28.1 MCHC-32.5 RDW-14.4 Plt Ct-223
[**2143-1-26**] 08:20AM BLOOD Plt Ct-223
[**2143-1-26**] 08:20AM BLOOD Glucose-309* UreaN-7 Creat-0.9 Na-137
K-3.5 Cl-95* HCO3-33* AnGap-13
[**2143-1-26**] 08:20AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.8
Blood Gases:
[**2143-1-25**] 04:56AM BLOOD Type-[**Last Name (un) **] Temp-36.7 Rates-/10 pO2-65*
pCO2-69* pH-7.38 calTCO2-42* Base XS-11 Intubat-NOT INTUBA
Comment-AXILLARY=9
[**2143-1-24**] 08:38PM BLOOD Type-ART Temp-36.3 pO2-44* pCO2-77*
pH-7.33* calTCO2-42* Base XS-10 Intubat-NOT INTUBA
Micro:
Blood Cultures ([**2143-1-24**]): NGTD
Urine Cultures ([**2143-1-24**]): E COLI, >100,000.
Sensitive to: ceftriaxone, cipro, cefepime, cerazolin, ceftax,
nitrofurantoin, [**Doctor Last Name **]/tazo.
Resistent to: ampicillin, amp/sulbactam, TMX/SMP.
IMAGING:
CXR: There is marked crowding of the bronchovascular structures
due to
the profoundly low lung volumes. An element of mild edema simply
cannot be
excluded on the basis of this examination. Additionally, there
is slightly
more confluent opacity at the left perihilum and in the left
lower lung.
While this may again be due to technical and patient factors, an
early
developing pneumonia cannot be excluded.
Brief Hospital Course:
41F with HIV, HCV, obesity, chronic pain, admitted to MICU with
altered mental status and decreased responsiveness concerning
for narcotic overdose, and ED concern for multiple infections.
# ALTERED MENTAL STATUS: [**2-19**] medication overdose. Somnolent and
obtunded without focal neurologic deficit on admission.
Evaluated for broad differential including toxic, infectious,
metabolic, all of which were negative except for a toxicology
positive for cocaine and a positive U/A. Patient history felt
most consistent with narcotic and benzodiazepine overdose, which
was confirmed once patient was alert and explained that she had
taken 3 times her normal doses of dilaudid and xanax on the
morning of admission. She had no metabolic acidosis or anion gap
and no ketonuria. Of note, patient was not given Narcan due to
her history of neuropathy. All sedating medications including
her pain meds and benzos were initially held with the exception
of her fentanyl patch. She gradually became more lucid and her
pain medications were gradually reintroduced. Psych was
consulted and she was started on long-acting benzodiazepines. By
the third day of hospitalization was noted to be consistently
awake and relatively lucid although still with intermittently
slurred speech. At the time of discharge she was felt to be
close to baseline.
# MEDICATION OVERDOSE: Patient readily admitted to excessive
narcotic and benzodiazepine use on the morning of admission in
infectious disease clinic prior to being sent to the ED. On
interview she repeatedly denied any intentions to harm herself,
stating that she took these medications only due to excessive
pain upon wakening that morning. Continued on home SSRI.
Discharged with referral for psychiatric outpatient follow up.
# PAIN REGIMEN: Admitted on home regimen of gabapentin,
oxycodone (Rx by ID), dilauded (Rx by PCP) a fentanyl patch as
well as Xanax 4mg q6 hours. Medications held and gradually
restarted as detailed above. Per discussion with PCP patient
tries to receive pain meds at multiple places. Per discussion
with PCP and ID fellow (Dr. [**First Name (STitle) **] it was agreed it was best if
from now on patient only received pain and sedating medications
from her ID fellow. Patient informed would be required to sign
narcotics contract.
# HYPOXIA: Hypoxia and hypoventilation/respiratory acidosis.
Reported baseline low O2 sats (baseline ~low 90s based on past
gases and elevated bicarb, likely multifactorial including known
ASD, OHS, chronic hypoventilation). ED with concern for PNA but
CXR consistent only with poor inspiratory effort. Sats initially
87-89% RA and 95% on 2L. Initial concern for PNA but CXR showing
only poor inspiratory effort. Patient was maintained on oxygen
to sats of 89-92% to prevent further hypercarbia. BiPAP was held
given mental status. Repeat CXR showed no clear evidence of PNA.
Saturating ~94% on room air at time of discharge.
# HIV: CD4 count 349 on admission, from > 500 [**9-26**]. Per notes
excellent HAART compliance. Her HAART regimen was continued
during her hospitalization. Phenergan was continued with her
HAART medications to avoid nausea.
# UTI: U/A on admission showed few WBCs, nitrate positive, many
bacteria. Patient asymptomatic and afebrile but with borderline
WBC count at ~12. Started on ceftriaxone. Urine cultures grew
out pan-sensitive e coli, and she was subsequently narrowed to
complete a 3-day course of ciprofloxacin. Afebrile, WBC ~5 at
time of discharge.
# DM-II: On metformin and glargine insulin at home. Metformin
held on admission and replaced with ISS. Glargine continued.
Patient refused a diabetic diet and was noted to have poor sugar
control during her hospitalization with blood [**Month/Year (2) 6801**] mostly
ranging in the 200s to 300s. Her metformin was restarted on
discharge.
# PANNICULAR RASH: recurrent, [**2-19**] habitus. Treated with nystatin
powder.
# HYPERTHYROID: Per documentation patient has history of very
high TSH but is not currently on levothyroxine. TSH + fT4 both
WNL during admission.
Medications on Admission:
- ABACAVIR-LAMIVUDINE 600 mg-300 mg Tablet once a day
- ALPRAZOLAM 2 mg twice a day
- CHLORHEXIDINE 0.12 % Mouthwash - swish and spit 15 cc [**Hospital1 **] as
needed
- FENTANYL - 50 mcg/hour Patch apply to skin every 72 hours
- FLUOXETINE ?30 mg daily
- FUROSEMIDE 80 mg daily as needed for swelling
- GABAPENTIN 900 mg three times daily
- ANUSOL-HC - 2.5 % Cream - cream rectally twice daily
- INSULIN GLARGINE 45 units q am
- METFORMIN 1,000 twice a day
- NYSTATIN - 100,000 unit/gram Powder twice a day
- OXYCODONE - 5 mg Tablet - 1-2 tabs q6 prn pain
- PHENERGAN - 25MG Tablet EVERY 6 HOURS AS NEEDED FOR NAUSEA
- REYATAZ - 400 mg once a day
- ASPIRIN - 81 mg once a day
- INSULIN REGULAR per sliding scale
Discharge Medications:
1. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for swelling.
2. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for nausea.
3. Atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
5. Fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO three times a
day for 2 weeks: Please see your infectious disease for refills.
Disp:*42 Tablet(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: please see your infectious disease
physician to have this continued past 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
8. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours) for 2 weeks.
Disp:*126 Capsule(s)* Refills:*0*
9. Epzicom 600-300 mg Tablet Sig: One (1) Tablet PO once a day.
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for skin irritation, rash.
12. Insulin Glargine 100 unit/mL Solution Sig: Forty Five (45)
units Subcutaneous every morning: as previously directed by your
physicians.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
1. Benzodiazepine overdose
2. neuropathic pain
3. IDDM
SECONDARY:
1. HIV
2. Obesity
3. Chronic hypoxia
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Lethargic but arousable
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted with altered mental status and difficulty
staying awake after taking too many of your pain and anxiety
medications. While you were here we adjusted some of your
medications. We also treated you for a urinary tract infection.
Please take all of your medications exactly as prescribed.
STOP taking your oxycodone.
STOP taking Xanax.
START taking clonezepam 1mg three times daily. This is a more
appropriate drug for your anxiety, and will act longer than your
Xanax did.
DECREASE your dose of dilaudid to 2mg every 6 hours.
From now on you will get all your pain prescriptions from your
infectious disease physician at [**Hospital1 1170**]. You will have to sign a narcotics contract with Dr. [**Last Name (STitle) **].
This will require you to promise not to receive pain medications
from anyone else, including your primary care physician. [**Name10 (NameIs) **] have
discussed this with your primary care physician and he agrees
that this is the best plan.
Please follow up with your primary care physician and your
infectious disease physicians within the next 2 weeks.
Followup Instructions:
ID
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2143-2-14**]
1:00
Schedule an appointment with your primary care doctor within 2
weeks of discharge.
GI
Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2143-4-8**] 12:10
ICD9 Codes: 5990, 2762, 3572, 2449, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8782
} | Medical Text: Admission Date: [**2192-7-29**] Discharge Date: [**2192-9-1**]
Date of Birth: [**2133-5-11**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
OSH transfer for evaluation and treatment of TTP
Major Surgical or Invasive Procedure:
Intubation and extubation
Bone Marrow Biopsy
HD line placed and removed
Liver biopsy [**8-8**]
History of Present Illness:
Patient is a 59 yo male who recently was hospitalized at [**Hospital1 18**]
after diagnosis of TTP. At that time no underlying cause could
be identified, he was treated with plasmapharesis and steroids,
and ultimately improved however remained HD dependant. On the
day of presentation patient fellt ill, and "passed out". He was
transferred to [**Hospital 945**] [**Hospital **] hospital.
.
In the OSH patient was found to be profoundly anemic and
hypocoaguable. he was given 4 units of FFP and transferred to
[**Hospital1 18**]
.
In the [**Hospital1 18**] ED, initial vs were: T 97.7 P 102 BP 134/92 R 22 O2
sat 95%4L. ED discussed the case with BMT fellow, 125 solumedrol
was given, 2 units of prbc were recomended by Heme fellow, non
cont abd contrast for abd pain obtainedm, 2mg iv morphine, and
10 mg of vit K given.
.
.
Patient reports that he felt overall well up until the day of
his presentation. He endorses no UOP over the past 8 hours. He
denies any fever/chills, or diarrhea, but endorses nausea and
abdominal pain.
Past Medical History:
- Asthma
- Hypercholesterolemia
- TTP unclear etiology
- Renal failure, was on HD Tue/Th/Sat
- Hemophagocytic lymphohistiocytosis
Social History:
Married and lives with his wife. [**Name (NI) **] retired from working as a
case manager. He denies chemical exposure.
- Tobacco: 25 pack year history, quit in [**2158**]
- Alcohol: rare
Family History:
Throat cancer in mom and uncle.
Physical Exam:
Vitals: T: 98.6 BP: 135/86 P: 103 R: 30 O2:92%
General: Alert, oriented, tired appearing
HEENT: Sclera icteric, MMM, oropharynx with no ulcers or lesions
Neck: supple, JVP moderately elevated, no LAD
Lungs: Slight bibasilar crackles
CV: Sinus rhythm, nl S1S2, no S3S4, no murmurs, rubs, gallops
Abdomen: soft, non tender, non-distended, bowel sounds present,
no rebound tenderness or guarding,
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, with
minimal dependent edema 1+ and pitting around the ankles
Neuro: CN II-XII intact, Upper extremitites shoulder shrug,
deltoid extension, bicep and tricep flexion and extension [**6-20**]
b/l, lower extremities hip flexion, Knee flexion/extension,
ankle flexion/dorsiflexion [**5-21**] b/l
Psych: mood and attitude appropriate
Pertinent Results:
DATA FROM LAST ADMISSION:
=========================
Blood cultures - [**7-8**], [**7-10**], [**7-13**] - no growth
CMV Ab - [**7-8**] - IgM negative, IgG positive
Catheter Tip - [**7-13**] - no growth
CMV Viral Load - negative
.
Leptospirosis - negative
Lyme serologies - negative
Sputum (OSH) - Pseudomanoas cultures, pan-sensitive to
Levofloxacin, Meropenem, Ceftriaxone, Ceftazidime, R to
Aztreonam
Stool cultures - negative for Salmonella, Shigella, Yersinia,
E. coli O157:H7 - negatve
B Glucan - negative
Galactomannan - negative
HIV - negative
.
Urine Gonorrhea/Chlamydia PCR - negative
Urine culture [**7-9**] - Enterococcus species (but contaminated
sample), [**7-17**] - Coag Negative Staph
Repeat urine cultures from [**7-12**], [**7-16**] negative
.
Hepatitis Titers:
Hep B sAb - negative
Hep B sAB - positive
Hep C Ab - negative
Hep A IgG - positive, IgM - negative
.
Parvovirus IgG positive, IgM negative
.
[**2192-7-12**] 02:07PM BLOOD Parst S-NEGATIVE
.
[**2192-7-11**] 07:31PM BLOOD HERPES SIMPLEX (HSV) 2, IGG- negative
[**2192-7-11**] 07:31PM BLOOD HERPES SIMPLEX (HSV) 1, IGG- postive
.
PPD normal from [**7-19**], read on [**7-21**]
.
Rheumatologic Work-up:
Anti-GBM Ab: negative
[**Doctor First Name **], ANCA - negative
Ceruloplasm - negative
.
[**2192-7-8**] 11:24AM BLOOD Lupus-NEG
[**2192-7-9**] 03:36AM BLOOD ACA IgG-4.1 ACA IgM-9.6
[**2192-7-8**] 11:23AM BLOOD ANCA-NEGATIVE B
[**2192-7-11**] 07:31PM BLOOD Smooth-NEGATIVE
[**2192-7-8**] 02:38PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2192-7-11**] 07:31PM BLOOD IgG-780 IgM-75
[**2192-7-10**] 04:39AM BLOOD C3-93 C4-13
.
Miscellaneous:
ADAMTS13 Activity and Inhibitor: 38%
[**2192-7-8**] 01:19AM BLOOD Fibrino-246
.
Serum Tox Screen:
[**2192-7-8**] 12:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
[**2192-7-12**] 01:01AM BLOOD COPPER (SERUM)- normal
Hereditary Hemochromatosis: Negative
.
ADMISSION LABS:
================
[**2192-7-29**] 10:05PM BLOOD WBC-8.8 RBC-1.95*# Hgb-6.2*# Hct-17.8*#
MCV-91 MCH-36.8*# MCHC-34.7 RDW-16.1* Plt Ct-53*#
[**2192-7-29**] 10:05PM BLOOD Neuts-77* Bands-3 Lymphs-17* Monos-1*
Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0 NRBC-1*
[**2192-7-29**] 10:05PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Schisto-1+
Stipple-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) **]1+
[**2192-7-29**] 10:05PM BLOOD PT-23.6* PTT-55.1* INR(PT)-2.2*
[**2192-7-29**] 10:05PM BLOOD Fibrino-81*#
[**2192-7-30**] 04:06AM BLOOD Fibrino-118*
[**2192-7-30**] 04:06AM BLOOD FDP-[**Telephone/Fax (1) 14007**]*
[**2192-7-30**] 04:06AM BLOOD QG6PD-11.5
[**2192-8-2**] 04:55PM BLOOD Gran Ct-1044*
[**2192-8-2**] 10:40PM BLOOD Gran Ct-1512*
[**2192-8-3**] 03:00AM BLOOD Gran Ct-328*
[**2192-7-30**] 04:06AM BLOOD Ret Aut-3.2
[**2192-7-29**] 10:05PM BLOOD Glucose-94 UreaN-59* Creat-3.4*# Na-132*
K-4.7 Cl-94* HCO3-18* AnGap-25*
[**2192-7-29**] 10:05PM BLOOD ALT-262* AST-614* LD(LDH)-3850*
AlkPhos-288* TotBili-17.6* DirBili-8.3* IndBili-9.3
[**2192-7-31**] 02:56AM BLOOD ALT-1393* AST-2319* LD(LDH)-5860*
AlkPhos-271* TotBili-30.7*
[**2192-7-31**] 08:03PM BLOOD ALT-1652* AST-2896* AlkPhos-411*
TotBili-27.1*
[**2192-7-29**] 10:05PM BLOOD Lipase-211*
[**2192-7-30**] 04:06AM BLOOD Lipase-585*
[**2192-7-31**] 02:56AM BLOOD Lipase-2627*
[**2192-7-31**] 01:37PM BLOOD Lipase-1399*
[**2192-8-1**] 01:57AM BLOOD Lipase-669*
[**2192-7-30**] 04:06AM BLOOD Calcium-8.2* Phos-4.0# Mg-1.5*
[**2192-7-30**] 04:06AM BLOOD Hapto-73 Ferritn-[**Numeric Identifier 85484**]*
[**2192-8-6**] 04:42AM BLOOD Ferritn-[**Numeric Identifier 85485**]*
[**2192-7-30**] 04:06AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE IgM
HAV-NEGATIVE
[**2192-7-31**] 09:03AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2192-7-31**] 01:37PM BLOOD ANCA-NEGATIVE B
[**2192-7-31**] 01:37PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2192-7-30**] 02:44PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2192-7-30**] 04:06AM BLOOD HCV Ab-NEGATIVE
[**2192-7-30**] 04:24AM BLOOD Lactate-7.2*
[**2192-7-30**] 09:15PM BLOOD freeCa-0.83*
MICROBIOLOGY:
==============
# ASPERGILLUS GALACTOMANNAN ANTIGEN: NEGATIVE
Test Result Reference
Range/Units
ASPERGILLUS ANTIGEN 0.1 <0.5
(Sera with an Index <0.5 are considered to be negative)
# B-GLUCAN- NO RESULT
Test
----
Fungitell (tm) Assay for (1,3)-B-D-Glucans
Results Reference Ranges
------- ----------------
No Result * Negative Less than
60 pg/mL
Indeterminate 60 - 79
pg/mL
Positive > OR
equal to
80 pg/mL
# RUBEOLA ANTIBODY, IGM: NEGATIVE
Test Result Reference
Range/Units
MEASLES ANTIBODY, (IGM) <1:10 <1:10 titer
# ADENOVIRUS PCR: NEGATIVE (No DNA Detected)
# HERPES 6 DNA PCR, QUANTITATIVE: <500
#HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY IGM
Test Name In Range Out of Range
Reference Range
--------- -------- ------------
---------------
Herpes Simplex Virus (HSV) [**2-18**] IgM Ab, IFA (Serum)
HSV 1 IgM, IFA <1:20
<1:20
HSV 2 IgM, IFA <1:20
<1:20
Interpretive Criteria
<1:20 Antibody Not Detected
> or = 1:20 Antibody Detected
#HERPES SIMPLEX (HSV) 1, IGG
Test Result Reference
Range/Units
HSV 1 IGG TYPE SPECIFIC AB >5.00 H index
HSV 2 IGG TYPE SPECIFIC AB <0.90 index
# [**2192-7-30**] 4:03 am MRSA SCREEN Nasal swab.
MRSA SCREEN (Final [**2192-8-1**]): No MRSA isolated.
# [**2192-7-30**] 4:06 am BLOOD CULTURE
Blood Culture, Routine (Final [**2192-8-5**]): NO GROWTH.
.
.
# [**2192-7-30**] 8:48 pm Blood (CMV AB) Source: Line-aline.
CMV IgG ANTIBODY (Final [**2192-7-31**]): POSITIVE FOR CMV IgG ANTIBODY
BY EIA.
227 AU/ML.
.
.
# [**2192-7-30**] 8:48 pm Blood (EBV) Source: Line-aline.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2192-8-1**]):
Test canceled and patient credited due to a prior EBV
panel sent on
[**2192-7-8**] indicating evidence of past infection (EBV
VCA-IgG positive,
EBNA IgG positive and EBV VCA-IgM negative). A repeat
panel is
unlikely to detect EBV reactivation. Serum will be held
for 3months.
.
# [**2192-7-30**] 8:48 pm Immunology (CMV) Source: Line-aline.
CMV Viral Load (Final [**2192-8-1**]): 650 copies/ml.
.
.
# [**2192-7-30**] 11:11 pm
BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
# [**2192-7-30**] 10:15 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2192-8-2**]**
GRAM STAIN (Final [**2192-7-31**]):
[**12-10**] PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2192-8-2**]):
RARE GROWTH Commensal Respiratory Flora.
.
# [**2192-7-31**] 2:56 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-aline.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
# [**2192-7-31**] 9:43 am
SEROLOGY/BLOOD CHEM # 09480W [**7-31**].
**FINAL REPORT [**2192-8-3**]**
VARICELLA-ZOSTER IgG SEROLOGY (Final [**2192-8-3**]):
POSITIVE BY EIA.
A positive IgG result generally indicates past exposure
and/or
immunity.
ICTERIC SPECIMEN.
[**Month (only) **] EFFECT PATIENT RESULTS.
INTERPRET RESULTS WITH CAUTION.
# [**2192-7-31**] 10:08 am Rapid Respiratory Viral Screen & Culture
Site: NASOPHARYNGEAL SWAB
**FINAL REPORT [**2192-8-2**]**
Respiratory Viral Antigen Screen (Final [**2192-7-31**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
Respiratory Viral Culture (Final [**2192-8-2**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
#[**2192-7-31**] 3:29 pm IMMUNOLOGY Source: Line-a-line.
HBV Viral Load (Final [**2192-8-2**]): HBV DNA not detected.
.
# [**2192-8-1**] 9:24 am URINE Source: Catheter.
URINE CULTURE (Final [**2192-8-2**]): NO GROWTH.
.
# [**2192-8-1**] 12:37 pm Immunology (CMV) Source: Line-a-line.
CMV Viral Load (Final [**2192-8-3**]): CMV DNA not detected.
.
# [**2192-8-4**] 10:49 am BLOOD CULTURE Source: Line-hd line SET
#2.
Blood Culture, Routine (Pending):
# [**2192-8-5**] 14:30
EBV PCR, QUANTITATIVE, WHOLE BLOOD Results Pending
# [**2192-8-6**] 11:32 am SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2192-8-6**]):
[**12-10**] PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2192-8-6**]):
TEST CANCELLED, PATIENT CREDITED.
FUNGAL CULTURE (Preliminary):
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
Specimen is only screened for Cryptococcus species. New
specimen is
recommended.
# CMV Viral Load (Final [**2192-8-29**]):
1,260 copies/ml.
# [**2192-8-29**] 09:45AM BLOOD WBC-6.2 RBC-2.86* Hgb-9.0* Hct-26.5*
MCV-92 MCH-31.4 MCHC-34.0 RDW-23.5* Plt Ct-63*
# [**2192-8-29**] 03:20PM BLOOD Na-129* K-4.7 Cl-95*
#[**2192-7-31**] 08:03PM BLOOD ALT-1652* AST-2896* AlkPhos-411*
TotBili-27.1*
[**2192-8-29**] 09:45AM BLOOD ALT-202* AST-50* AlkPhos-466*
TotBili-4.8*
# [**2192-8-6**] 04:42AM BLOOD Ferritn-[**Numeric Identifier 85485**]*
[**2192-7-30**] 04:06AM BLOOD Hapto-73 Ferritn-[**Numeric Identifier 85484**]*
# [**2192-8-29**] 09:45AM BLOOD Cyclspr-33*
IMAGES/STUDIES:
===============
[**2192-7-29**] 10:07:34 PM
Normal sinus rhythm. Possible left ventricular hypertrophy.
Non-specific
ST-T wave abnormalities. Compared to the previous tracing of
[**2192-7-9**]
QRS voltage in the left lateral leads has increased raising the
possibility of
left ventricular hypertrophy. Suggest clinical correlation and
repeat tracing.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
96 136 82 350/413 66 62 91
.
#[**2192-8-1**] 2:32:34 PM
Atrial fibrillation with rapid ventricular response. Left
ventricular
hypertrophy. Diffuse non-specific ST-T wave changes. Compared to
the previous tracing of [**2192-7-29**] atrial fibrillation with a rapid
ventricular response and diffuse ST-T wave flattening have
appeared.
TRACING #1
Intervals Axes
Rate PR QRS QT/QTc P QRS T
108 0 88 [**Telephone/Fax (2) 85486**]0
.
#Atrial fibrillation with rapid ventricular response. Diffuse
non-specific
ST-T wave flattening. Compared to the previous tracing of
[**2192-8-1**] no diagnostic interim change.
TRACING #2
Intervals Axes
Rate PR QRS QT/QTc P QRS T
115 0 86 342/438 0 67 80
# CHEST (PA & LAT) Study Date of [**2192-7-29**] 10:37 PMA double-lumen
catheter is seen with tip in the lower SVC.
Heart size is enlarged with the vascular pedicle more prominent
than on [**2192-7-15**]. There is an ill-defined opacificity overlying the
right mid lung.
There is no pleural effusion or pneumothorax.
IMPRESSION:
1. New cardiomegaly and enlarged vascular pedicle, suggestive of
fluid
overload.
2. Ill-defined opacity in the right mid lung could be pneumonia
or pulmonary hemorrhage in the appropriate clinical context.
.
#PATHOLOGY:
DIFFICULT CROSSMATCH AND/OR EVALUATION OF IRREGULAR
ANTIBODIES Study Date of [**2192-7-30**]
(ICD9 CODE: 999.7)
INDICATION FOR CONSULT: DIFFICULT CROSSMATCH AND/OR EVALUATION
OF IRREGULAR ANTIBODIES
INDICATIONS FOR CONSULT:
Difficult crossmatch and/or evaluation of irregular antibody (s)
CLINICAL/LAB DATA: Mr. [**Known lastname 74316**] is a 59 year old male who was
admitted
with renal and hepatic dysfunction, as well as a picture
concerning for
sepsis/DIC. A blood sample was sent for type and screen.
Laboratory Data:
Patient ABO/Rh: Group O, Rh positive
Antibody screen: Positive
DAT: 3+ IgG, 1+ C3
Eluate: panagglutination of all cells
Antibody identity: Panagglutinating antibody ([**Hospital1 18**]); anti-Jkb
identified by the American Red Cross reference laboratory after
performing heterologous adsorption [required due to recent
transfusion]
Antigen phenotype: performed [**2192-7-8**]- E, K, Jkb, Fya,
Fyb-antigen
negative
Transfusion history:
7 non-reactive red cell transfusions during previous admission
[**Date range (2) 85487**] (5 of 7 units retrospectively determined to be
positive
for Jkb)
Previous non-reactive plasma transfusions: 123 (in setting of
plasmapheresis)
Previous non-reactive platelet transfusions: 2
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mr. [**Known lastname 74316**] has a
new
diagnosis of Anti-Jkb antibody, in addition to his known warm
autoantibody. Jkb-antigen is a member of the Kidd blood group
system.
Jkb-antibody is clinically significant and capable of causing
hemolytic
transfusion reactions. During his last admission [**Date range (2) 85487**],
Mr.
[**Known lastname 74316**] received 5 units of Jkb positive blood. These units
will
likely be cleared more quickly than Jkb negative units. The ICU
team
was made aware that delayed hemolysis could be taking place,
although it
will be difficult to assess in the face of his other lab
abnormalities.
In the future, Mr. [**Known lastname 74316**] should receive Jkb-antigen negative
products
for all red cell transfusions. Approximately 26% of all ABO
compatible
blood will be Jkb-antigen negative. A wallet card and a letter
stating
the above will be sent to the patient.
.
# ECHO [**2192-7-30**]:
The left atrium is mildly dilated. 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 global left ventricular hypokinesis (LVEF
= 40-45 %). There is no ventricular septal defect. with
depressed free wall contractility. The ascending aorta 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 mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2192-7-9**],
biventricular systolic function now appears mildly depressed.
.
#CT OF THE ABDOMEN/PELVIS W/O INTRAVENOUS CONTRAST:
In the visualized thorax, there is septal thickening in the left
lower lobe that is consistent with pulmonary edema. Proximally
there are small nodular densities. There is mild basilar
atelectasis, worse on the left. There is no pleural effusion or
pneumothorax. The visualized heart is normal in size with a
trace pericardial effusion. Relative attenuation of the
ventricles relative to muscle suggests anemia.
Evaluation of the solid organs in the abdomen is limited without
intravenous contrast. Calcific foci are seen within the liver
and spleen suggesting prior granulomatous insult. A sliver of
fluid is seen between the hepatic parenchyma and the gallbladder
(series 2, image 25). There is no pericholecystic fat stranding.
The pancreas and adrenals appear normal.
There is a 1.7-cm diameter hypodensity within the lower pole of
the left
kidney and a second 1.2-cm hypodensity in the interpolar region,
incompetely characterized. Abdominal loops of small bowel appear
normal without distension or pericolonic fat stranding. There is
moderate fecal loading of the large bowel. The appendix is not
clearly visualized, but there are no secondary signs to suggest
appendicitis. There is no abdominal free air, free fluid, or
pathologic lymphadenopathy.
Pelvic loops of bowel appear normal. The bladder and distal
ureters appear
normal. The prostate measures to 5 cm.
MUSCULOSKELETAL: There is no suspicious osteolytic or
osteoblastic lesion.
Multilevel degenerative changes are seen with prominent
Schmorl's nodes at
L3-L4.
IMPRESSION:
1. Sliver of pericholecystic fluid adjacent to the hepatic wall
may reflect
liver pathology rather than acute cholecystitis given no
definitive
gallbladder wall edema or adjacent fat stranding. Nonetheless
recommend US
for further characterization.
2. Left renal cysts are incompletely characterized. These can be
evaluated
concurrently with gallbladder
3. Left lower lobe septal thickening and proximal nodularity are
consistent
with focal edema and an inflammatory/infectious process.
3. Moderate fecal loading.
4. Enlarged prostate.
5. Anemia
.
# [**2192-7-30**] 2:17 PM
LIVER OR GALLBLADDER US (SINGL; DUPLEX DOPP ABD/PEL)
Comparison is made to prior CT examination
dated [**2192-7-30**]. The echotexture of the liver is unremarkable
except for a
1.1-cm slightly hyperechoic lesion in segment VIII of the liver.
A similarly hyperechoic region is seen more medially in segment
VIII. This measures 1.3 cm. These areas do not demonstrate color
flow consistent with hemangiomas. There is gallbladder wall
edema; however, the gallbladder is not distended. There are no
stones in the gallbladder. No pericholecystic fluid is noted.
The gallbladder wall edema causes wall thickening up to 6.5 mm.
On color flow and Doppler images, there is normal flow in the
main portal vein. Adequate flow is also identified in the left
portal vein. There is normal flow visualized in the hepatic
veins, although it was difficult to obtain waveforms as the
patient was unable to hold his breath for a sufficiently long
period of time.
IMPRESSION:
1. Portal vein and its branches as well as hepatic veins are
patent.
2. Gallbladder wall edema, the presence of a non-distended
gallbladder most
consistent with hypoalbuminemia or liver disease.
3. Too small hyperechoic lesions in the liver are most
consistent with
hemangiomas.
.
# [**2192-8-4**] 4:08 AM CHEST (PORTABLE AP)
Cardiomediastinal contours are unchanged. Lungs are grossly
clear
except for a patchy area of opacity in the left retrocardiac
region, which has slightly improved when compared to an earlier
radiograph of 15th at 5:43 a.m. This is most likely atelectasis
and less likely an infectious pneumonia.
.
# [**2192-8-6**] 11:15 AM CHEST (PORTABLE AP):
New poorly well-defined round opacities and right mid and left
lower lung, concerning for infection such as septic emboli or
fungal
organisms. Consider chest CT for confirmation and further
characterization.
.
# [**2192-8-6**] CT CHEST W/O CONTRAST:
There has been partial resolution of the diffuse ground-glass
opacities since the previous CT with residual well-demarcated
ground-glass opacities which are predominantly in the right
upper lobe (2.27) and the right lung base, to a lesser extent.
The appearances of these abnormalities are similar to the
previous CT with no newly affected areas. Pleural surfaces are
smooth with no pleural effusion. Linear atelectasis is new and
mild in the lower lobes bilaterally with thickening of the left
major fissure due to mild atelectasis.
Several lung cysts which were accentuated by the ground-glass
opacities in the prior study are now separate to the lung
abnormality; these may represent sequelae of previous
hemorrhage, i.e. prior hematoceles. Paraseptal emphysema is
mild.
The pulmonary artery is enlarged at 37 mm, slightly larger than
on the
previous study suggesting pulmonary arterial hypertension. The
caliber of the aorta and heart size is normal,no pericardial
effusion. Relative hypodensity in the cardiac [**Doctor Last Name 1754**] in
comparison to the myocardium suggests anemia.
Although this examination was not designed for subdiaphragmatic
evaluation.
review of the upper abdominal organs is unremarkable. Punctate
calcification in the liver and spleen in addition to several
calcified mediastinal lymph nodes suggest prior granulomatous
exposure.
No destructive or sclerotic bone lesions are concerning for
malignancy.
IMPRESSION:
1)Partial resolution of the diffuse ground-glass opacities which
are
predominantly in the right upper lobe and right lower lobe to a
lesser extent. These abnormalities appear to have cleared over
several intervening chest radiographs and suggest recurrent
pulmonary hemorrhage, particularly given the coexistent
thrombocytopenia, other causes such as infection (PCP) are less
likely.
2)Liver, splenic and mediastinal lymph node calcifications
suggest prior
granulomatous exposure.
.
# [**2192-8-6**] CT HEAD W/O CONTRAST:
There is no intracranial hemorrhage, edema, mass effect, or
other
CT sign of acute major vascular territorial infarction. The
ventricles and
sulci are normal in size and configuration.
There are fluid levels within the left maxillary, right frontal
and bilateral sphenoid sinuses, as well as complete
opacification of left frontal sinus. Aeration of the ethmoid air
cells has improved since the prior study. Wall thickening in the
sphenoid and possibly also frontal sinuses suggests chronic
sinusitis. High-density material within the paranasal sinuses
suggests inspissated secretions, hemorrhagic secretions, or
fungal colonization. It is not clear whether there are
postsurgical changes in the incompletely evaluated nasal cavity.
IMPRESSION:
1. No intracranial hemorrhage or evidence of other acute
intracranial
abnormalities.
2. Chronic sinusitis. Fluid in the paranasal sinuses may
indicate the
presence of an acute component. High density contents within the
sinuses may reflect inspissated secretions, hemorrhagic
secretions, or fungal
colonization.
Labs results on 2 days prior to discharge:
[**2192-9-1**]
10:22a
Na 132 K4.9 Cl100 Cl 100 Bun 35 K 4.9 HCO3 100 creat 1
Ca: 7.9 Mg: 1.8 P: 3.0
CWBC 7.8 HCT 27.6 plts 60
[**2192-8-31**] Cyclspr: 70
ALT: 245 AP: 466 Tbili: 5.3 Alb: 2.7
AST: 50
Brief Hospital Course:
# HLH:
Clinical scenario consistent with HLH. Pt was admitted with
severe anemia and thrombocytopenia. He has had 4 days of ATG,
which was stopped early due to neutropenia - he later received
the 5th dose when neutropenia resolved. Pt was also placed on
high dose IV steriods, initially solumedrol 120mg [**Hospital1 **] that were
ultimately tapered to prednisone 40mg [**Hospital1 **] by beginning of [**Month (only) 205**].
Only possible cause of HLH that could be identified was ? of CMV
infection with two different viral load tests showing positive
viral load. Pt ended up getting two bone marrow biopsies ([**7-9**]
and [**8-14**]) which both showed evidence of some hemophagycytosis.
The liver biopsy on [**8-8**] showed no evidence of malignancy,
necrosis, or infections. The pathology present was predominantly
cholestatic and most consistent with drug induced changes. Pt
was held off other chemotherapeutic regimens for the first 6
weeks of the hospitalization because of his combined renal
failure and liver cholestasis. Once pt recovered renal function
and was declared by nephrology to no longer required
hemodialysis, he was started on low dose cyclosporine 50 mg [**Hospital1 **]
on the evening of [**8-23**]. Initial trough value was very low (<30)
two days later. His cyclosporine was gradually increased in
dose with the most recent dose being 175mg po BID. Cyclosporine
goal trough is 150-200 and should next be checked on [**2192-9-2**] and
should be checked every 48 hrs. Lab results should be faxed
every 48 hrs as soon as test results come back to Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 638**] and to Dr. [**Last Name (STitle) 85488**] [**Telephone/Fax (1) 85489**]. Along with these
you can fax CBC and chem 10 pls obtain as detailed on order
sheet. Pt started on standing magnesium given cyclosporine
results in magnesium wasting. Pt is also on predisone 40mg [**Hospital1 **].
Throughout admission pt continued to show evidence of red cell
and plt destruction on laboratory data (hgb/plts would drift
down, haptoglobin low, retics high). Initially numerous PRBC and
platelet transfusions were needed to stabilize pt while in the
ICU. Once he recovered enough to be on the floor, pt was
intermittently given PRBCs when his Hct was low enough that
there was concern for it causing symptoms. He only received plts
on the floor one time per IR before they pulled out the HD
catheter. He was followed closely by hematology while in the
hospital who recommend the following treatment for his HLH:
Unfortunately with HLH the patient's prognosis over the next
year is very poor.
# Sepsis/DIC: Mr. [**Known lastname 74316**] presented with hypotension, elevated
WBC, elevated lactate, decreased haptoglobin, elevated PT/PTT,
and elevated fibrinogen. No clear infectious source, possible
liver or lung. Upon presentation pt was treated empirically with
meropenem, levofloxacin from HAP with GN coverage since pt had
been hospitalized and was on immunosuppression. He ultimately
completed a 14 day course of meropenem. Culture data was
ultimately all negative with the only positive micro test being
a low CMV VL. ID started pt on Gancyclovir for ppx, and initial
Acyclovir was stopped. Pt then suffered from neutropenia thought
possible related to Gancyclovir vs ATG. Repeat CMV VLs were
negative and Gancyclovir was stopped. Histo was negative so also
okay to stop Ambisome. Pt had been on bactrim as an outpatient
for PCP prophylaxis while on steroids, but this was changed to
atovaquone due patients liver injury and concerns for bactrim
involvement. Later in hospital course, pt was restarted on
acyclovir for prophylaxis while on the steroids. Repeat CMV VL
from [**2192-8-22**] was positive for 1,630 copies and he was restarted
on Valganciclovir 900 mg PO BID with a plan for 3 weeks of
treatment total after discharge. His CBC will need to be
monitored daily to look for neutropenia, but has remained stable
after 4 days of treatment.
# Respiratory failure: Electively intubated on [**7-30**] and
extubated on [**8-3**]. Post extubation maintained oxygen sats on
nasal cannula and then on room air. Throughout admission pt
continued to have cough, occasionally productive, and somewhat
congested chest, but no evidence of infection was found and pt
was not treated with Abx for PNA after initial presentation. Pt
has hx of asthma and was previously on Advair. So neb tx and
advair were given throughout hospitalization. Pt had CT of chest
for f/u of new poorly well-defined round opacities and right mid
and left lower lung, concerning for infection such as septic
emboli or fungal. CT scans shows areas of opacity overall
improving when compared to prior image in [**Month (only) 116**]. As per above, ID
added Atovaquone for PCP [**Name9 (PRE) **] given that Bactrim can cause BM
suppression and liver damage.
# ATRIAL FIBRILLATION (AFIB): Pt developed A-fib on [**8-1**] which
then resolved on [**8-4**]. This was likely related infection and
respiratory distress. He was started on metoprolol 25mg [**Hospital1 **], he
converted to sinus. Currently NSR. Metoprolol 25mg PO BID was
continued throughout admission although pt did not have any more
incidences of documented afib while on hospital.
# Elevated LFTs: Uncertain about etiology initially, but after
liver bx results were final the leading likelyhood is
cholestatic drug induced liver injury [**3-20**] to bactrim. Overall
improvement in LFT??????s, but t.bili was significantly elevated (38
at one point). Tbili slowly came down over course of the next
month although ALT and Alk phos remained stably somewhat
elevated. The LFT improvement that was noted initially dis seem
to correlate with ATG treatment.
# Anemia: Hemolyzing. Schistocytes previously seen on smear.
Hemophagocytosis seen in BM. Pt was intermittently transfused as
noted above when Hct would get around 21 or when there was
concern that pt was getting symptomatic from his anemia. Epogen
was given with HD while pt was on dialysis. Once dialysis was
discontinued, it was given MWF (4k units). As pt clinically
stabilized, he was kept in the hospital by the concern that he
continued to show evidence of red cell destruction.
# Thrombocytopenia: Pt required plt transfusions in the ICU as
initially his plts were low and somewhat labile. He was also
transfused for liver biopsy. Once the patient was stable enough
for the floor his plts ranged from 20k-80k. On the floor he was
transfused plts once when IR took out the HD cath, but otherwise
his transfusion parameter was set at spontaneous bleeding. The
exact etiology of the low plts was never completely clear but it
is likely multifactorial and related to HLH, medications, and
overall health.
# Neutropenia: Pt became neutropnic after 4 doses of ATG and 2
doses of Gancyclovir which may have caused BM suppression.
Counts quickly resolving after stopping offending meds. Once
count improved pt was given last dose of ATG. Gancyclovir was
kept off until [**8-24**] when a repeat CMV viral load was again
suddenly positive. Low dose gancyclovir was restarted and WBC
counts should be monitored daily. Pt was then swtiched to
Galvancyclovir as per ID and his WBC have been monitored and
have been stable. Will monitor his WBC while in [**Hospital 3782**] rehab to
watch for recurrence of the neutropenia
# Coagulopathy: Related to liver disease, infection, HLH. Pt did
not need FFP. Pt was given vit K x 3 days early in admission.
INR was stable around 1 for most of admission.
# Renal failure: Received CVVHx 3 days. This was stopped on
[**8-2**]. He then had microfiltration on the same day to help with
diureses for extubation. He was started on HD [**8-4**]. Stayed on
HD until [**8-18**] with slow improvement of kidney function. After HD
was stopped, Cr was observed for a few days and when it
continued to show improvement down below 2, and pt continued to
make very good urine output, his HD line was pulled by IR on
[**8-23**]. Renal followed throughout course of disease and helped
manage electrolytes and guide HD therapy.
#Hyponatremia: Mr. [**Known lastname 74316**] developed hyponatremia on [**2192-8-28**]
when he was autodiuresis after his kidney recovered from his
ARF. His hyponatremia and autodiuresis is likely also related to
poor glc control. He made up to 6.5L of urine 3 days prior to
discharge. PLEASE FLUID RESTRICT TO 2.5L daily as his sodium
improved with free water fluid restriction.
# Hypertension: Pt had elevated BP that was worse with ATG
infusion. He initially required Nitro drip for better BP
control. This was discontinued quickly once control was achieved
and he was restarted on his home dose of amlodipine 7.5mg which
was then increased dose to 10mg Qday. HD also helped with BP
control. Some additional control was provided by the metoprolol
on which the patient was kept to control Afib.
#Hyperglycemia: Pt not a diabetic, but glucose was elevated in
the setting of high dose steroids and tube feeds. Managed with
NPH of varying AM and PM doses with humalog ISS. Once tube feeds
were stopped and oral intake restarted he again had to adjust
NPH and ISS to keep sugars in an acceptable range. He is being
discharged on NPH and an ISS.
# Delerium: After patient was transferred to the floor from the
ICU he developed delirium over the first weekend which
manifested as inappropriate and sometimes violent actions with
pt attempting to hit staff and spitting on staff. Pt had to be
restrained with leather restraints for parts of two days because
he was able to break out of the soft restraints despite his
deconditioning. The first night this occurred pt had to be given
haloperidol and ativan. Psych was then involved in care and
recommended giving quitiapene QHs with extra prn doses as
needed. Pt was on this regimen, with slow tapering of the QHs
dose for the next two weeks, although delirium never again was
an issue. Pt was intermittently mildly depressed about his body
weakness and how long he had been in the hospital.
.
# Lung nodule: New poorly well-defined round opacities and right
mid and left lower lung, concerning for infection such as septic
emboli or fungal organisms. Chest CT showed areas of opacity
overall improving when compared to prior image in [**Month (only) 116**] (when he
was previously admitted for what was thought to be TTP). This
was thought to be related to prior pulmonary hemorrhage that is
now resolving. Nodule will need follow-up as an outpatient after
discharge.
# HA: Early in admission, pt c/o bilateral frontal HA with no
focal neurological deficits found on exam, however this was a
new finding and given low platelet count this was concerning for
head bleed. Head CT showed no IC bleeding or other acute
process. HA resolved over next few days and was not an issue for
the rest of admission.
# Chest pain: pt had two episodes of epigastric pain which
raised concerns for chest pain. At each time EKGs were
unremarkable and cardiac enzymes did not show evidence of acute
MI (although troponin was stably elevated in context of renal
failure). Pt described pain as not unlike the GERD pain he
occasionally had in the past, and both times pain seemed to
resolve with a GI cocktail.
# Insomnia: He had difficulty with sleeping during his hospital
course and was started on trazodone qhs with good effect.
Medications on Admission:
1. Pantoprazole 40 mg PO once a day.
2. Zyprexa 5 mg PO at bedtime: while on steroids.
3. Fexofenadine 60 mg PO BID
4. Sulfamethoxazole-Trimethoprim 800-160 mg One Tablet PO MWF
5. Montelukast 10 mg PO DAILY
6. Prednisone 50 mg PO DAILY
7. Fluticasone-Salmeterol 500-50 [**Hospital1 **]
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule
9. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS
10. Amlodipine 7.5 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Polyethylene Glycol as needed for constipation.
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily).
3. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: hold for sedation or RR<12.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every four (4) hours as
needed for wheeze.
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
hold for SBP<110.
6. Atovaquone 750 mg/5 mL Suspension Sig: Two (2) servings
(total 1500mg) PO DAILY (Daily).
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for moderate pain.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) as
needed for GERD symptoms.
10. Labs and heme follow up
Most recent dose being 175mg po BID. Cyclosporine goal trough is
150-200 and should next be checked on [**2192-9-2**] and should be
checked every 48 hrs. Check 1/2 hr prior to AM dose but give am
dose after. Lab results including CBC and chem 10 should be
faxed every 48 hrs as soon as test results come back to Dr.
[**Last Name (STitle) **] [**Telephone/Fax (1) 638**] and to Dr. [**Last Name (STitle) 85488**] [**Telephone/Fax (1) 85489**].
11. Follow up
Needs transportation arranged for appointment at [**Hospital3 328**]
with Dr. [**Last Name (STitle) 85490**] on [**2192-9-3**] at 1:15pm
Needs transportation arranged for appointment with Dr.
[**Last Name (STitle) **]/[**Last Name (STitle) 85488**] at [**Hospital3 **] on [**9-6**] at 2:30pm
Needs transportation arranged for Infectious Disease appointment
at [**Hospital3 **] on [**2192-9-13**]
12. CMV viral load
Plase check CMV viral viral load each Thursday, pls check CBC
three x a week and chem 7 every other day for the next week and
then once weekly.
Pls fax CMV viral load and three x a week CBC and once a week to
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] infectious disease at [**Hospital1 **] or her RNS
at ([**Telephone/Fax (1) 1353**]
All questions regarding outpatient antibiotics should be
directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**]
13. Cyclosporine Modified 25 mg Capsule Sig: Three (3) Capsule
PO Q12H (every 12 hours).
14. Cyclosporine Modified 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): hold loose stool.
16. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) dose
Injection QMOWEFR (Monday -Wednesday-Friday).
17. Maalox
15ml po TID prn for gerd sx
18. Ondansetron 8 mg IV Q8H:PRN Nausea
19. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
20. Insulin
pls continue attached insulin SS, AM NPH increased from 26-28 to
start on [**2192-9-2**]
21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
22. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for Delerium and Agitation: has not been
needing recently.
23. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed for pruritis.
24. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
25. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): last dose expected to be [**2192-9-15**] unless told
otherwise by infectious disease doctor.
26. Magnesium 300 mg Capsule Sig: One (1) Capsule PO twice a
day: pls increase dosing if magnesium is low.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Primary Diagnosis:
-Hemophagocytic lymphohistiocytosis
-Acute on chronic renal failure
-Liver failure due to drug rxn
-Cytomegalovirus
Secondary Diagnosis:
- Asthma
- Allergies
- Hypercholesterolemia
Discharge Condition:
Alert and oriented x3
Unable to ambulate independently
Full code
Discharge Instructions:
Mr. [**Known lastname 74316**] as you know you had a difficult hospital course but
we are very pleased that you are well enough now to go to rehab.
You originally came in with low blood pressure, bleeding, renal
failure, liver failure, and hemolysis (destruction of your red
blood cells and platelets. You required intubation in the
intensive care unit and transfusions of blood and platelets.
Your liver biopsy ultimately showed your liver problems were due
to a drug reaction, likely bactrim so you were changed from
bactrim to atovaquone. Your liver has been slowly recovering.
Your kidney function has improved and you no longer require
hemodialysis. You are urinating a lot as a result of your
improved renal function which caused your sodium levels to
decrease. This improved with getting IV fluids.
You had 2 bone marrow biopsies that ultimately diagnosed
hemophagocytic lymphohistiocytosis which as you know is a very
serious disease. You were originally treated with ATG and
steroids but later switched to cyclosporine. Our hematologists
will give your rehab advice on how to continue treatment with
cyclosporine. You are also going to [**Hospital3 328**] on Monday for a
second opinion which we encourage you to do. You have this
appointment on [**2192-9-3**].
You currently have an infection called CMV which is being
treated with valgancyclovir which you will continue atleast
until [**2192-9-15**].
PLEASE TAKE ONLY THOSE MEDICATIONS FOUND ON THE ATTACHED LIST
Followup Instructions:
Please let Mrs. [**Known lastname 74316**] and the inpatient team know that I have
arranged for Mr. [**Known lastname 74316**] to be seen at [**Company 2860**] by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 85491**]
(expert in HLH wrote the uptodate card) on [**2192-9-3**] at 1:15, [**Location (un) **] of [**Hospital3 328**] Phone: [**Telephone/Fax (1) 85492**]
.
*We are working on an appointment for you to be seen in our
Dermatology department. The office will contact you with an
appointment. Please call ([**Telephone/Fax (1) 8132**] if you do not hear from
them.
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2192-9-6**] at 2:30 PM
With: [**First Name8 (NamePattern2) 25**] [**Last Name (NamePattern1) **], 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
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2192-9-6**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], 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
Department: INFECTIOUS DISEASE
When: THURSDAY [**2192-9-13**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10000**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 5849, 486, 2761, 2762, 5859, 2875, 2767, 2930, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8783
} | Medical Text: Admission Date: [**2130-8-18**] Discharge Date: [**2130-8-22**]
Service: NEUROSURGERY
Allergies:
Morphine / Codeine / Amoxicillin / Erythromycin Base /
Clindamycin / Nitrofurantoin
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
S/P Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI:
87yo right handed woman with HTN, prior stroke without residual
deficits, peripheral neuropathy, now presenting following a fall
with R SDH. Pt. was down the hallway into a movie when she
suddenly lost all tone fell flat on her face without protecting
herself with her arms. She was immediately awake following the
event, reportedly was very embarrassed and upset about falling.
However details of the fall itself are not available. She was
able to say where she was, who the president was. Daughter
brought her by car to her PMD's office where 10-15minutes
following the fall she was not speaking. She would be asked
questions, but only look around the car. She was taken to
[**Hospital **]
Hospital ED. Where head CT revealed R 5mm SDH layeringover the R
frontal lobe.
Past Medical History:
PMHx:
Hypertension
Prior cerebral infarction- presented with inability to
speak/transpose numbers that she read on palm pilot to dial her
phone. lasted a few hours, fully resolved. admitted at [**Hospital **]
hospital x 7 days. MRI with "small infarct" unclear exact
etiology. was on plavix, but did not tolerate.
Peripheral neuropathy
Chronic cystitis- likely secondary to pelvic radiation from
uterine cancer
Breast cancer- s/p mastectomy on late 70's early [**2101**]'s no known
recurrence
MVA ([**2102**])- ejected through the windshield, suffered leg fx,
multiple facial fractures, rib fx.
Asthma
Thoracic vertebral collapse- s/p kyphoplasty
h/o falls.
Social History:
Social Hx:
widowed, lives alone, she is a famed horticulturalist, never
smoker. no ETOH or illicits.
Family History:
Family Hx: NC
Physical Exam:
PHYSICAL EXAM: On Admission
O: T: 98 BP: 154/75 HR: 74 R 14 O2Sats 96% RA
Gen: in hard C-collar, NAD.
HEENT: R facial trauma, anicteric, MMM.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro: attends to examiner, does not answer questions, she is
inattentive, able to follow commands briefly- "hold up your
arms."
Cranial Nerves:
I: Not tested
II: L pupil is surgical and nonreactive, R is reactive from
2mm-1mm to light. Visual fields full to threat.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial sensation intact, R facial edema from trauma
VIII: Hearing intact to voice.
IX, X: unable to visualize in C-collar.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk. incr tone in bilat LE's. No abnormal
movements. No apparent pronator drift. She is able to hold her
arms antigravity briefly (limited d/t inattention). holds legs
antigravity.
Sensation: withdraws to light touch throughout.
Reflexes: B T Br Pa Ac
Right 3------> 0
Left 3------> 0
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Exam on Discharge:
A&O X 3, CN II-XII intact, Full strength all extremities and
following commands. Non-focal neurological exam.
Pertinent Results:
[**2130-8-21**] 05:40AM BLOOD WBC-7.7 RBC-2.89* Hgb-9.7* Hct-28.6*
MCV-99* MCH-33.6* MCHC-34.0 RDW-14.1 Plt Ct-265
[**2130-8-22**] 05:20AM BLOOD WBC-6.1 RBC-2.80* Hgb-9.0* Hct-28.1*
MCV-100* MCH-32.3* MCHC-32.2 RDW-14.1 Plt Ct-255
[**2130-8-22**] 05:20AM BLOOD Glucose-95 UreaN-11 Creat-0.7 Na-131*
K-4.2 Cl-100 HCO3-22 AnGap-13
[**2130-8-21**] 05:40AM BLOOD Glucose-115* UreaN-13 Creat-0.9 Na-132*
K-3.8 Cl-99 HCO3-21* AnGap-16
[**2130-8-22**] 05:20AM BLOOD Calcium-7.4* Phos-1.7* Mg-2.3
[**2130-8-22**] 05:20AM BLOOD Phenyto-13.9
[**2130-8-21**] 05:40AM BLOOD Phenyto-16.0
[**2130-8-19**] 02:09AM BLOOD Phenyto-19.9
[**2130-8-22**] 05:20AM BLOOD Glucose-95 UreaN-11 Creat-0.7 Na-131*
K-4.2 Cl-100 HCO3-22 AnGap-13
[**2130-8-22**] 05:20AM BLOOD Plt Ct-255
[**2130-8-22**] 05:20AM BLOOD Neuts-67.0 Lymphs-22.5 Monos-4.4 Eos-5.7*
Baso-0.4
HEAD CT [**8-18**]
INDICATION: Query worsening SDH.
COMPARISON: [**Hospital **] Hospital study from two hours prior.
TECHNIQUE: Non-contrast head CT with multiplanar reformats.
FINDINGS: Again seen is an acute right cerebral subdural
hematoma layering
over the right frontal convexity with maximal thickness of
11-mm, unchanged.
There is no significant shift of midline structures. Ventricles,
sulci and
cisterns are unchanged. Basal cisterns are preserved.
Periventricular white
matter changes likely reflect chronic microvascular disease.
Orbits appear
normal. Mastoid air cells appear clear. Again seen is a
retention cyst versus
polyp in the sphenoid sinus. There is ethmoidal and maxillary
sinus mucosal
thickening.
IMPRESSION: Stable right subdural hematoma.
C SPINE [**8-18**]
INDICATION: Status post fall.
COMPARISON: None available.
TECHNIQUE: Multiple MDCT axial images were obtained from the
base of the
skull through T1 without intravenous contrast. Multiplanar
reformats were
derived.
FINDINGS: There is no acute fracture. Prevertebral tissues
appear normal.
Atlantodental and craniocervical junction are normal. The
lateral masses of
C1 are well seated on C2. The dens appear normal. There is disc
space
narrowing and sclerosis of endplates at C3-4, C4-5, C5-6 and
C6-7. There is
multilevel facet hypertrophy that causes neural foraminal
narrowing at
numerous levels. The thyroid appears normal. The visualized lung
bases
demonstrate interlobular thickening suggestive of milg
congestion. A sinus
mucosal polyp versus retention cyst is seen in the sphenoid
sinus.
IMPRESSION:
1. No fracture of the cervical spine, but degenerative changes
predisposes
this patient to spinal cord injury with minor trauma. In the
appropriate
clinical context (for example myelopathy) consider MR for
further
characterization.
2. Smooth interlobular thickening of the lung apices suggests
pulmonary
congestion.
Head CT [**8-19**]
INDICATION: Patient is a 87-year-old female with prior
infarction, now with
right subdural hemorrhage and limited speech output. Please
evaluate for
interval change. On prior evaluation, initially protocol
requested for CTA
examination, however patient was unable to perform CTA secondary
to motion.
EXAMINATION: Non-contrast head CT.
COMPARISONS: Comparison to non-contrast head CT from [**2130-8-18**].
TECHNIQUE: Contiguous axial images were obtained through the
brain. No
intravenous contrast was administered.
FINDINGS: There is a stable appearance of 11 mm in transverse
dimension area
of high attenuation layering along the right frontal lobe with
characterizes
compatible with a subdural hemorrhage. There is no significant
associated
mass effect with no midline shift. No edema, masses or acute
infarction is
identified. The [**Doctor Last Name 352**]-white matter differentiation is preserved,
however,
study is extremely limited by patient motion. The ventricles and
sulci are
stably prominent compatible with age-related involutional
changes. There is
extensive periventricular hypodensity compatible with chronic
small vessel
ischemic changes. There is mucosal thickening involving the
ethmoid,
bilateral maxillary, and sphenoid sinuses. The mastoid air cells
are well
aerated.
IMPRESSION: Stable appearance of 11 mm right subdural
hemorrhage. CTA
examination to evaluate for vascular stenosis was unable to be
performed
secondary to patient motion. Extensive mucosal thickening of the
paranasal
sinuses not significantly changed since one day prior.
Brief Hospital Course:
87 yo female transferred to [**Hospital1 18**] from Outside Hospital s/p fall
at home. Initial CT Scan demonstrated 5mm SDH without a midline
shift. Hemodynamically stable with non focal neuro exam. Was
admitted to the ICU for observation of SDH and frequent neuro
checks. Following a short course in Intensive Care, she was
transferred to the step down unit, moving all extremities,
following simple commands, and with limited speaking capacity.
A repeat head CT was performed, which demonstrated stable
findings and no further or new bleeding.
On Hospital Day #4 she was transferred to the floor, where she
gained strength in all extremities and resumed normal speech.
Hydralazine was added to keep her SBP less than 160. She was A&O
X 3 on HD #4 and remained that way until discharge. She was
able to tolerate a general diet, urinate and stool
independently, ambulate with assistance, and had good pain
control. She incidentally was found to have hyponatremia, which
trended upwards during her hospitalization. Her most recent
level on [**8-22**] was 132. Salt tablets were started today on
[**2130-8-22**].
PT and OT saw the patient and determined her to need assistance
with ambulation/ADLS prior to discharge to home. She was deemed
appropriate for discharge to [**Hospital1 1319**] [**Hospital3 400**] facility
neurologically intact and in good condition.
Medications on Admission:
1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Aspirin 162 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.)
Discharge Medications:
1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Aspirin 162 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: DO NOT START THIS
MEDICATION UNTIL [**2130-9-5**].
7. Dilantin Extended 100 mg Capsule Sig: One (1) Capsule PO
three times a day for 5 days.
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours.
9. Heparin (Porcine) 5,000 unit/mL Syringe Sig: One (1)
Injection three times a day.
10. Sodium Chloride 1,000 mg Tablet, Soluble Sig: One (1)
Miscellaneous TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Right Sub Dural Hematoma
Hyponatremia
Discharge Condition:
Good/Stable
Discharge Instructions:
You may restart your aspirin in 2 weeks from discharge
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed for the next 7 days
and then stop.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow up with Dr [**Last Name (STitle) 548**] in 4 weeks with a head CT. Please call
[**Telephone/Fax (1) 1669**]
Completed by:[**2130-8-22**]
ICD9 Codes: 2761, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8784
} | Medical Text: Admission Date: [**2130-5-23**] Discharge Date: [**2130-5-29**]
Date of Birth: [**2101-10-19**] Sex: F
Service: OBS
HISTORY OF PRESENT ILLNESS: This is a 28 year old gravida
III, para I-0-I-I, at 27 weeks and 0 days who presents for
admission given significant cardiac history. The patient
reports ankle edema with her right side greater than the left
side and has decreased fetal movement. She denies
contractions or leakage of fluid or vaginal bleeding. She has
appropriate fetal movement, however, it has been
significantly less. She is complaining of shortness of breath
for about 1 week and no chest pain.
PRENATAL COURSE:
1. Estimated date of confinement [**2130-8-22**].
2. A positive, antibody negative, RPR nonreactive, hepatitis
surface antigen negative, rubella immune.
3. Normal fetal survey.
4. Multiple medical issues, seen by Dr. [**Last Name (STitle) **], cardiologist.
PAST MEDICAL HISTORY: Dilated cardiomyopathy. Was diagnosed
in her first pregnancy. Her ejection fraction is 25%.
She was actually counseled on the significant risk of
mortality, however, she elected to continue this pregnancy.
Chronic hypertension.
[**Doctor Last Name 13534**]/Parkinson/White syndrome.
Atrial septal defect repair as a child requiring antibiotic
prophylaxis.
Pacemaker.
Asthma.
LEEP for cervical dysplasia.
PAST SURGICAL HISTORY: Atrial septal defect which was
corrected in childhood.
DNE x1.
Cesarean section secondary to failure to progress.
Ablation of her [**Doctor Last Name 13534**]/Parkinson/White syndrome.
Pacemaker insertion.
Surgery as a LEEP.
MEDICATIONS ON ADMISSION:
1. Lasix 40 mg daily.
2. Hydralazine 50 mg q.i.d.
3. Toprol XL 100 mg daily.
4. Digoxin 0.5 mg daily.
5. Imdur 30 mg daily.
6. Lovenox 40 mg subcutaneously b.i.d.
7. Albuterol p.r.n.
8. Prenatal vitamins.
ALLERGIES: Penicillin gives her hives. Vancomycin gives her
hives.
SOCIAL HISTORY: No tobacco, alcohol or drugs. She was a
prior smoker and quit about 8 years ago. The father of the
baby is not involved.
PAST OBSTETRIC HISTORY: In [**2125**], she had a baby boy, full
term, had a cesarean section secondary to fetal distress and
failure to progress, 7 pound 6 ounce baby.
TAB at 8 weeks.
PHYSICAL EXAMINATION: Vital signs revealed temperature 98.8,
heart rate 84, respiratory rate 22, oxygen saturation 95 to
99% in room air, blood pressure 152/92, blood pressure was
repeated at 134/79. In general, she is in no apparent
distress, but she is stopping midsentence to take deep
breaths. Cardiovascular is regular rate, normal rhythm.
Pulmonary examination - She had some rales on the right side
and otherwise it was clear to auscultation. She had JVD. Her
abdomen examination was soft, gravid, nontender, morbidly
obese. Fetal heart tones 140s. Extremities showed 2+ pitting
edema at her ankles and bilateral symmetric calf swelling,
nontender calves. Fetal examination - Her EFW was 41%, 2
pounds 4 ounces, baby was vertex presentation. BPP was [**7-19**],
minus 2 for breathing and her fluid was normal.
HOSPITAL COURSE: Cardiovascular - The patient was found in
CHF. She had an echocardiogram which just showed an ejection
fraction of 25% to 30%. This was thought to be unchanged per
her cardiologist. She received 40 mg of Lasix and diuresed
well. She was taken to the intensive care unit. She was
placed on telemetry. She was ruled out for a heart attack
with cardiac enzymes. Her troponins I's were less than 0.1
and her CPK's were negative. She was maintained on telemetry
and started on Isordil 20 mg p.o. t.i.d., Hydralazine 25 mg
p.o. q.i.d., Digoxin 0.5 daily, Lasix IV b.i.d., IV Heparin
bolus, Toprol XL 100 mg daily. Her hematocrit at that time
was 30.0 and the rest of her laboratory examinations were
within normal limits. Her echocardiogram showed an ejection
fraction of 25% to 30% with her right atrium mildly dilated.
The left atrium was dilated. The left ventricle showed normal
wall thickness, severe global hypokinesis. Her mitral valve
showed 2+ mitral regurgitation. Tricuspid valve showed 1+
tricuspid regurgitation. There was moderate para-aortic
systolic hypertension. She was managed in the intensive care
unit with strict I's and O's and daily weight. Her cardiac
rhythm was normal. Her hypertension was well controlled in
the unit on her medications. The CHF service was consulted.
They noted that her JVP was significantly decreased over
time. They recommended keeping her on a cardiac diet, low
sodium diet and was continued on Lasix. She had a long
discussion with cardiology about the possibility of a cardiac
transplantation. Cardiology will be following for further
notice if her cardiac function starts to decline or she does
need a heart transplant. The cardiac surgery service was
consulted in case there was emergent care that was needed
throughout her hospital stay. There was some significant
concern about the time around her delivery that there would
be an issue of rapid cardiac decompensation as well as
pulmonary edema. Multiple team meetings between the
cardiologist, anesthesia, cardiac surgeons, intensive care
unit team were held. The decision was made to deliver the
patient at 28 weeks gestational age over on the [**Hospital Ward Name 517**]
and to be admitted to the coronary care unit immediately
after her delivery. Please see a final dictation summary for
her postpartum course. Prior to her delivery, she was typed
and crossed x4 units in case there was an issue. Her IV
Heparin was discontinued prior to her cesarean section, 24
hour period. However, she was kept on a Heparin drip
prophylactically.
Pregnancy - The patient had normal reassuring fetal testing.
Her EFW was 1025 grams which put her in the 41st percentile.
She had twice daily testing with NSTs as well as daily
biophysical profile. Her BPPs were always either [**7-19**] minus 2
for breathing or [**9-18**]. There was normal fluid that was noted.
Neonatology was consulted during this hospital stay and
discussed the risks of a premature delivery at 28 weeks with
the patient. The patient also received 2 doses of 12 mg of
betamethasone in order to mature the baby's lungs. She was
fairly complete prior to her cesarean section.
Asthma - The patient had no issues with her asthma during her
hospital stay. She was maintained on her albuterol p.r.n. and
had no issues of shortness of breath. Once she received
Lasix, she diuresed well and had no shortness of breath.
History of [**Doctor Last Name 13534**]/Parkinson/White syndrome - Electrophysiology
was consulted during her hospital stay. However, as she was
kept on telemetry monitor and there were no issues with
[**Doctor Last Name 13534**]/Parkinson/White, there were no arrhythmias noted. Her
magnesium and potassium were all within normal limits or if
they were low, they were repleted as necessary.
History of urinary tract infection - She was started on
Macrobid for 7 days starting on [**2130-5-24**]. She was
asymptomatic and had no issues.
Fluids, electrolytes and nutrition, GI - She was maintained
on a low sodium cardiac diet, kept NPO prior to her surgery.
Her fingersticks were obtained fasting and 2 hours
postprandial and were stable. She was maintained on insulin
sliding scale.
FOLLOW UP PLANS: Please see the next dictation for her
postpartum course for these plans.
DISCHARGE DIAGNOSES: Nonischemic dilated cardiomyopathy with
an ejection fraction of 25% to 30%.
Congestive heart failure.
Chronic hypertension.
[**Doctor Last Name 13534**]/Parkinson/White syndrome.
History of pacemaker and atrial septal defect repair.
Asthma.
Pregnancy, status post cesarean section.
Urinary tract infection.
MEDICATIONS ON DISCHARGE: Please see the next dictation for
a complete listing of her medications.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 23510**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2130-5-30**] 17:40:28
T: [**2130-5-30**] 21:14:44
Job#: [**Job Number 23511**]
ICD9 Codes: 4254, 4280, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8785
} | Medical Text: Admission Date: [**2200-2-7**] Discharge Date: [**2200-2-16**]
Date of Birth: [**2129-3-30**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Vancomycin / Cephalosporins
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70 year old female who was admitted to Dr [**First Name (STitle) 2819**] on [**2200-1-30**] for
gastroenteritis. Reports from the outside hospital included a
diagnosis of possible internal hernia and SBO. Repeat abdominal
CT at [**Hospital1 18**], however, demonstrated only wall thickening and fat
stranding of a 23cm segment of the mid small bowel. There was
no sign of SBO, and the patient had no peritoneal signs and she
was discharged with a running diagnosis of gastroenteritis on
[**2-3**]. She is on Coumadin for a mechanical valve and while in
the hospital she was on a heparin drip. She was discharged from
the hospital on 5 mg of Coumadin daily and taking Lovenox. She
was told by her [**Hospital 197**] clinic that her last dose of Lovenox
was to be taken yesterday. She denies any trauma. She comes in
because she was having similar abdominal pain. She was having
lower abdominal which was similar to her previous symptoms. She
denies nausea or vomiting. Last bowel movement was two days ago.
She is passing flatus. Denies melena or bright red blood per
rectum.
Past Medical History:
PMHx: 1st degree AV block and episodes of 2nd degree AV block
(Wenckiebach); HTN; hemolytic anemia; question of TIA when
she had endocarditis 18 yrs ago; Hypothyroidism; Hyperlipidemia,
HTN, OA, Hashimoto thyroiditis.
.
PSHx: CABG, mechanical MVR [**2175**], reoperative MVR St. [**Male First Name (un) 923**] [**2194**],
open tubal ligation.
Social History:
Married. Has 4 daughters, has grandchildren. Family involved.
Lives with husband in [**Name (NI) 392**]. Retired. Like to go down to a
nearby beach with her husband. Denies smoking, alcohol, drugs.
Safe at home.
Family History:
Non-contributory
Physical Exam:
On Admission:
Vitals: 97.0, 128/88, 78, 18, 95% RA.
General: Alert, oriented, no acute distress, conversational.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, click heard with S1
at LLSB, harsh systolic murmur IV/VI heard throughout precordium
Abdomen: soft throughout other than firmness at the midline and
slightly to the left of midling in the infraumbilical region,
+bs in surrounding regions but not auscultated over that firm
region, non-distended, ttp+ at midline/infraumbilical region but
not TTP elsewhere, no rebound or guarding. no organomegaly. No
bruises.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Significant purple/blue bruising ranging from 2cm x 2cm to
6cm x 6cm lesions (not TTP) over the arms bilaterally.
Neuro: Grossly intact.
Pertinent Results:
Admission CBC, chemistry panel, coags:
[**2200-2-6**] WBC-9.2# RBC-3.79* Hgb-10.6* Hct-33.2* MCV-88 MCH-27.9
MCHC-31.9 RDW-15.1 Plt Ct-322
[**2200-2-6**] PT-41.3* PTT-34.9 INR(PT)-4.4*
[**2200-2-6**] Glucose-114* UreaN-17 Creat-0.8 Na-139 K-3.7 Cl-104
HCO3-25 AnGap-14
.
Cardiac enzymes:
[**2200-2-6**] 11:45PM cTropnT-0.06*
[**2200-2-7**] 09:10AM cTropnT-0.03*
.
[**2200-2-7**] 2:02AM CT abdomen and pelvis with contrast:
1. Interval development of new bilateral rectus abdominis
hematomas. Superinfection of these fluid collections cannot be
excluded. Linear hyperdensity in between fluid-fluid level of
one of the hematomas is identified and may represent active
extravasation. If clinical concern for active extravasation
exists, repeat delayed imaging or angiography should be
performed.
2. Small amount of high-density fluid in the right paracolic
gutter, similar in appearance.
3. Mild biliary prominence, unchanged.
4. Renal and splenic hypodensities, incompletely characterized.
Dedicated renal/spleen ultrasound is recommended on nonurgent
basis.
5. Interval improvement in small bowel wall thickening as
compared to prior exam.
.
[**2200-2-7**] 1:39PM ABD/PELVIC CT W/CONTRAST:
1. There is increase in size of the left rectus sheath hematoma
in both transverse, AP and craniocaudal dimension with an
increase of the extraperitoneal pelvic pre- and perivesical
component of the hematoma.
2. Unchanged small amount of fluid in the paracolic gutters
bilaterally.
3. No additional foci of bleeds including no retroperitoneal
bleeding.
.
[**2200-2-8**] ABD/PELVIC CT W/CONTRAST:
1. Active extravasation idicating arterial bleeding into left
rectus hematoma from a branch of the left epigastric artery.
Multiple rectus sheath abdominal wall hematomas, in a different
configuration although not significantly changed in size.
Hematoma in the extraperitoneal pelvic pre- and perivesical
space, unchanged.
2. Hemoperitoneum adjacent to the liver and in paracolic
gutters, slightly increased when compared to prior exam.
3. Right basilar atelectasis.
.
MICROBIOLOGY:
[**2200-2-8**] MRSA Screen: Negative.
[**2200-2-10**] MRSA Screen: Negative.
Brief Hospital Course:
70 year old female with h/o MVR on coumadin, with recent
admission from [**1-30**] to [**2-3**] for gastroenteritis treated with
cipro and flagyl, now with recurrent abdominal pain and found to
have a new large rectus hematoma, which likely formed
spontaneously in the setting of a supratherapeutic INR (likely
secondary to coumadin plus antibiotic use). Also, the abdominal
pain could include a component of the patient's resolving
colitis.
.
The patient presented with decreased blood pressure and
increased tense abdomen on [**2-7**] with a repeat CT scan showing an
enlarging restus hematoma. Anticoagulation was held. The patient
was transfused a unit of blood, and the HCT did not bump
significantly. A subsequent repeat CT scan showed active
bleeding, for which the patient given a unit of FFP and planned
for Interventional Radiology to embolize the bleed. Cardiology
was consulted. Based on risk/benefits of embolizing a patient
with an elevated INR (3.3 at that time), the embolization was
not performed. The patient remained hemodynamically stable, but
with more tense/painful abdomen. As such, patient was then
admitted to the SICU and transferred to the Surgical Service for
further management.
.
In the SICU, The patient was given Vitamin K 2mg IV, 5units of
FFPs, and 2units PRBC. A (R)IJ CVL was placed. On [**2-8**], she went
to Interventional Radiology, where attempts to perform selective
catheterization were unsuccessful, as the left inferior
epigastric artery was found to be tortuous, thus no prophylatic
embolization was performed. Of note, no active extravasation was
seen on arteriogram. On [**2-9**], she received another unit of PRBC
for a HCT of 22.6. Lasix was given to prevent fluid overload.
Serial HCTs remained stable. On [**2-10**], Cardiology was consulted
regarding anticoagulation recommendations, and a Heparin drip
was started. Coagulation studies were closely monitored. Tha
patient was transferred to the inpatient floor on [**2-11**], at which
time Coumadin was restarted at 4mg in the evening.
.
The patient was continued on a Heparin drip, which was adjusted
regularly according to routine PTT, until the INR became
therapeutic again on Coumadin prophylaxis. Once the INR became
therapeutic, the Heparin was discontinued. INR goal 2.5-3.5.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care.
Labwork was routinely followed; electrolytes were repleted when
indicated.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. She will follow-up with her PCP to further manage
her Coumadin prophylaxis. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
Lipitor 80mg qday
Lovenox 120mg qday
HCTZ 12.5mg qday
Levothyroxine 125mcg qday
Lisinopril 20mg qday
Metoprolol Tartrate 50mg [**Hospital1 **]
Cipro 250mg [**Hospital1 **] until [**2-5**]
Metronidazole 500mg [**Hospital1 **] until [**2-5**]
Coumadin 5mg alternating with 7.5mg daily
ASA 81mg daily
Discharge Medications:
1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO QMON,
TUES, THURS, FRI, SAT and 2 tab PO QWED. and SUN.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: Over-the-counter.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
4. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain: Do NOT exceed 4gm (4000mg)
acetaminophen daily.
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
7. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Spontaneous rectus sheath hematomas.
2. Left epigastric artery bleed.
3. History of mechanical mitral valve replacement on Coumadin
prophylaxis.
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and **drink adequate amounts of fluids.**
Please follow-up with your Primary Care Provider (PCP) and
The [**Hospital 197**] Clinic as advised.
If you experience any of the following, please call your doctor
or come to the emergency department:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Coumadin information:
Coumadin (Warfarin):
What is this medicine used for?
This medicine is used to thin the blood so that clots will not
form.
How does it work?
Warfarin changes the body's clotting system. It thins the blood
to prevent clots from forming.
What you should contact your healthcare provider [**Name Initial (PRE) **]:
Signs of a life-threatening reaction. These include wheezing;
chest tightness; fever; itching; bad cough; blue skin color;
fits; or swelling of face, lips, tongue, or throat, severe
dizziness or passing out, falls or accidents, especially if you
hit your head. Talk with healthcare provider even if you feel
fine, significant change in thinking clearly and logically,
severe headache, severe back pain, severe belly pain, black,
tarry, or bloody stools, blood in the urine, nosebleeds,
coughing up blood, vomiting blood, unusual bruising or bleeding,
severe menstrual bleedin, or rash.
Call your doctor if you are unable to eat for several days, for
whatever reason. Also call if you have stomach problems,
vomiting, or diarrhea that lasts more than 1 day. These problems
could affect your Coumadin??????/warfarin dosage.
Coumadin (Warfarin) and diet:
Certain foods and beverages can impair the effect of warfarin.
For this reason, it's important to pay attention to what you eat
while taking this medication.
Until recently, doctors advised [**Name5 (PTitle) **] taking warfarin to avoid
foods high in vitamin K. This is because large amounts of
vitamin K can counteract the benefits of warfarin. However,
recent research shows that rather than eliminating vitamin K
from your diet, it is more important to be consistent in your
dietary vitamin K intake.
These foods contain vitamin K:
Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli,
Cabbage, [**Location (un) 2831**] sprouts, Green onions, Asparagus, Cauliflower,
Peas, Lettuce, Spinach, Turnip, collard, and mustard greens,
Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver.
Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins,
Soybeans and Cashews.
Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage
but it does not mean you must avoid all alcohol. Serious
problems can occur with alcohol and Coumadin??????/warfarin when you
drink more than 2 drinks a day or when you change your usual
pattern. Binge drinking is not good for you. Be careful on
special occasions or holidays, and drink only what you usually
would on any regular day of the week.
Monitoring:
The doctor decides how much Coumadin??????/warfarin you need by
testing your blood. The test measures how fast your blood is
clotting and lets the doctor know if your dosage should change.
If your blood test is too high, you might be at risk for
bleeding problems. If it is too low, you might be at risk for
forming clots. Your doctor has decided on a range on the blood
test that is right for you. The blood test used for monitoring
is called an INR.
Use of Other medications:
When Coumadin??????/warfarin is taken with other medicines it can
change the way other medicines work. Other medicines can also
change the way Coumadin??????/warfarin works. It is very important to
talk with your doctor about all of the other medicines that you
are taking, including over-the-counter medicines, antibiotics,
vitamins, or herbal products.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD (PCP). Phone: [**Telephone/Fax (1) 457**].
Location: [**Doctor First Name **], STE GB, [**Location (un) **],[**Numeric Identifier 2260**].
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8318**], MD Phone:[**Telephone/Fax (1) 2359**]
Date/Time:[**2200-2-20**] 10:00. Location: [**Hospital Ward Name **] 3, [**Last Name (NamePattern1) 439**],
[**Hospital1 18**] [**Hospital Ward Name 517**].
ICD9 Codes: 2851, 4589, 2449, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8786
} | Medical Text: Admission Date: [**2192-6-25**] Discharge Date: [**2192-7-3**]
Date of Birth: [**2140-6-16**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Acute liver failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 15674**] is a 52 year old male with a pmh of DMII, EtOH abuse,
and Crohn's disease who presented to an OSH after a night of
partying with friends where they had wine and raw oysters. He
went home and slept until he awoke with acute N/V/D and fevers.
At the OSH he was found to be in ALF with AST of >5000, ALT >
3000 INR of 3.2 and platelets of 62. Given his history of EtOH
abuse he was given a dose of steroids, covered for vibrio with
doxycycline and ceftriaxone, and started on NAC drip (Tylenol
level <15). Per report, U/S was negative at the OSH ED. After
acute worsening of his liver failure and development of
encephalopathy/withdrawal, he was transferred to [**Hospital1 18**] for
ongoing care.
Prior to transfer he had received a total of 16mg Ativan, 2mg
Haldol for agitation and withdrawal. QTc on arrival is 410.
On arrival to the MICU, he is extremely agitated. Thrashing in
the bed trying to break free of restraints kicking the bed.
Easily redirectable for short periods of times. Initially vitals
were with HR in 120s, BP 110s/60s, RR 16 and temp of 102.3.
However, he became acutely agitated and BP elevated to 210/120s,
HR in 150s. Given 2mg IV ativan, 5mg IV haldol. Fan and cooling
blanket being used to help cool patient.
Review of systems:
(+) Per HPI - Unable to obtain.
Past Medical History:
DMII complicated by neuropathy
Narcotic Agreement
Asthma
HL
HTN
GERD
Alcohol Abuse
Crohn's Disease
Barrett's Esophagus
Social History:
- Tobacco: Never
- Alcohol: Yes documented as abuse and "heavy" but not
quantified.
- Illicits: Denies
Family History:
Unable to obtain.
Physical Exam:
Vitals: T:102.3 BP:113/55 P:121 R:22 O2: 97% on RA
General: Agitated, thrashing in bed.
HEENT: Sclera icteric, dry MM, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic
Lungs: Clear to auscultation anteriorly
Abdomen: soft, non-tender, non-compliant from exam
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Very warm. Erythema over chest and face
Neuro: Unable to cooperate
Pertinent Results:
ADMISSION
[**2192-6-25**] 08:59AM URINE MUCOUS-RARE
[**2192-6-25**] 08:59AM URINE GRANULAR-6*
[**2192-6-25**] 08:59AM URINE RBC-3* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2192-6-25**] 08:59AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-300 KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2192-6-25**] 10:54AM FIBRINOGE-196
[**2192-6-25**] 10:54AM PT-38.7* PTT-29.1 INR(PT)-3.8*
[**2192-6-25**] 10:54AM PLT SMR-VERY LOW PLT COUNT-58*
[**2192-6-25**] 10:54AM NEUTS-90.0* LYMPHS-7.0* MONOS-2.7 EOS-0
BASOS-0.1
[**2192-6-25**] 10:54AM WBC-5.2 RBC-3.89* HGB-11.9* HCT-37.5* MCV-96
MCH-30.6 MCHC-31.7 RDW-12.5
[**2192-6-25**] 10:54AM HCV Ab-NEGATIVE
[**2192-6-25**] 10:54AM IgG-620* IgA-248 IgM-114
[**2192-6-25**] 10:54AM AMA-NEGATIVE Smooth-NEGATIVE
[**2192-6-25**] 10:54AM HBsAg-NEGATIVE HBs Ab-NEGATIVE HAV
Ab-POSITIVE
[**2192-6-25**] 10:54AM IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2192-6-25**] 10:54AM calTIBC-265 HAPTOGLOB-108 FERRITIN-[**Numeric Identifier 112216**]*
TRF-204
[**2192-6-25**] 10:54AM ALBUMIN-3.7 CALCIUM-8.4 PHOSPHATE-1.7*
MAGNESIUM-1.6
[**2192-6-25**] 10:54AM IRON-214*
[**2192-6-25**] 10:54AM ALT(SGPT)-5735* AST(SGOT)-[**Numeric Identifier 20965**]*
LD(LDH)-[**Numeric Identifier 112217**]* ALK PHOS-132* TOT BILI-3.4*
[**2192-6-25**] 10:54AM GLUCOSE-211* UREA N-21* CREAT-1.1 SODIUM-137
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-21* ANION GAP-22*
[**2192-6-25**] 11:04AM LACTATE-7.8*
.
DISCHARGE
[**2192-7-3**] 04:47AM BLOOD WBC-6.3 RBC-3.48* Hgb-10.7* Hct-34.3*
MCV-99* MCH-30.7 MCHC-31.0 RDW-13.9 Plt Ct-90*
[**2192-7-3**] 04:47AM BLOOD PT-14.9* PTT-32.3 INR(PT)-1.4*
[**2192-7-3**] 04:47AM BLOOD Glucose-105* UreaN-20 Creat-1.5* Na-136
K-4.1 Cl-102 HCO3-25 AnGap-13
[**2192-7-3**] 04:47AM BLOOD ALT-279* AST-101* AlkPhos-359*
TotBili-7.4*
[**2192-7-3**] 04:47AM BLOOD Albumin-3.3* Calcium-8.7 Phos-2.8 Mg-1.5*
.
MICRO
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2192-6-28**]): POSITIVE BY
EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2192-6-28**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2192-6-28**]):
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
[**2192-6-27**] 5:45 pm STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2192-6-29**]**
C. difficile DNA amplification assay (Final [**2192-6-28**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final [**2192-6-29**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2192-6-29**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2192-6-28**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final [**2192-6-29**]): NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final [**2192-6-29**]): NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2192-6-28**]):
NO E.COLI 0157:H7 FOUND.
CMV, HCV VL negative
Urine cx [**7-2**] no growth
Blood cx [**6-25**], [**7-2**] no growth to date
OSH blood cx no growth
.
[**2192-6-25**] Echocardiogram:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta and aortic arch are mildly dilated. 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. No mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. Mild pulmonary artery hypertension. Mildly dilated
thoracic aorta.
CLINICAL IMPLICATIONS:
Based on [**2187**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
[**2192-6-25**] LIVER/GALLBLADDER ULTRASOUND:
IMPRESSION:
Increased liver echogenicity, compatible with fatty deposition.
However, more advanced types of liver disease,
fibrosis/cirrhosis cannot be excluded. No discrete hepatic
lesion. Hepatic vasculature is patent.
.
[**2192-6-25**] CXR:
NG tube tip is in the stomach. Heart size is top normal. There
is prominence of the right pulmonary artery, most likely
asymmetric due to patient rotation. Mild vascular edema is
present, but no overt consolidations to suggest infectious
process are seen.
.
[**2192-6-25**] CT ABDOMEN and PELVIS with CONTRAST:
IMPRESSION:
1. Fatty liver.
2. No evidence of colitis or intra-abdominal abscesses.
3. Small left lower lobe consolidation, might represent
subsegmental
atelectasis, still, infection cannot be ruled out.
.
[**2192-6-26**] RENAL ULTRASOUND:
FINDINGS: The right kidney measures 12.3 cm and the left kidney
measures 11.2 cm. There is no hydronephrosis. No cyst or stone
or solid mass is seen in either kidney. No perinephric fluid
collection is identified. The bladder is collapsed on a Foley
catheter.
IMPRESSION: No hydronephrosis.
.
[**7-2**] Liver U/S
1. Gallbladder wall edema is likely related to underlying
fulminant hepatitis and low albumin levels. No son[**Name (NI) 493**]
evidence of acute cholecystitis, as the gallbladder is
nondistended. The above findings are new since [**2192-6-25**] exams.
2. Echogenic liver, compatible with fatty deposition.
3. Splenomegaly.
Brief Hospital Course:
52 year old male with a pmh of DMII, EtOH abuse with past
hospitalizations for withdrawal, on chronic pain medications who
is transferred from an OSH for worsening hepatic function.
# Liver Failure: DDx includes acute EtOH hepatitis, acute viral
hepatitis, autoimmune hepatitis, obstruction, toxin (statin or
tylenol), and vascular compromise of the liver with portal
thrombosis. The patient was acutely agitated and delirious at
admission with significant synthetic dysfunction with an INR of
5.5, AST >[**Numeric Identifier 3301**] and ALT >5000. He was initially treated with 18
mg of Ativan and 7 mg of Haldol for acute agitation and presumed
alcohol withdrawal. The patient also apparently ingested 20
Percocet prior to the acute onset of his nausea/vomiting. Given
his ingestion, toxic consumption with delayed presentation is
most likely (chronology of patient's history is likely not
reliable) though alcoholic hepatitis could also have been
contributing. Given the patient's clinical story, Vibrio was
also a possibility so he was started on doxycycline until
cultures returned negative. Hepatitis, HSV, CMV, and EBV
serologies were negative as were [**Doctor First Name **], [**Last Name (un) 15412**], AMA, Alpha-1, and
iron studies. Per Infectious Disease, he was covered with
ceftazidime empirically until blood cultures from OSH returned
negative. The patient was also evaluated by Hepatology who
recommended treating the patient per NAC protocol for presumed
acetaminophen ingestion and acute liver injury. The patient's
LFTs and coag labs downtrended continuously during this
hospitalization and his mental status improved so that he was
oriented and appropriate by discharge. His statin was held at
discharge and patient was advised to stay away from tylenol and
alcohol.
.
# Fevers: Given history of raw oyster consumption, he was
presumptively started on doxycycline and ceftaz empirically for
vibrio and enteric coverage which was discontinued once cultures
returned negative. Given his negative abdominal imaging (RUQ U/S
and CT abdomen), fever is most likely in response to
inflammation associated with the patient's liver disease.
.
#Renal failure: Patient's Creatinine peaked at at 3 on [**6-27**].
Given the patient's history of Percocet ingestion and his last
urinalysis showing urine casts, ATN secondary to toxic ingestion
was the most likely etiology. Patient had also received some IV
contrast during his admission likely contributing to his renal
decline. However, the patient was treated with IV fluids and
maintained adequate urine output during his hospitalization with
improvement of his Cre to 1.5 at discharge.
.
#Thrombocytopenia: The patient was thrombocytopenic at
admission with platelets of 58. The patient remained
thrombocytopenic throughout his hospitalization. This finding
was likely associated with alcohol abuse. DIC was less likely
given his normal FDP and normal PTT.
.
# Delirium/Hallucinations: The patient's mental status seemed a
combination of EtOH withdrawal and hepatic encephalopathy
secodnary to acute liver failure. The patient at admission was
combative and agitated. However, he was kept on CIWA with
Ativan and his mental status improved. His mental status
continued to improve during his hospital course so that he was
appropriate at discharge.
.
#Narcotic withdrawal: The patient normally takes 6 Percocet/day
with increased ingestion over the weekend immediately prior to
onsest of acute nausea and vomiting. The patient initially
experienced abdominal pain and hypertension but this resolved
over the course of his stay. Given his likely withdrawal, he
was started on oxycodone PRN for pain.
.
#Hypertension: The patient has a history of hypertension, but
his systolic BPs ran in the 180s. His BP initally may have been
more elevated given his abdominal pain as well as withdrawal
symptoms. His pain was controlled with Dilaudid and then
switched to oxycodone PRN. Given [**Last Name (un) **], his home lisinopril was
held and he was started on labetalol. This was uptitrated during
his stay to achieve BPs in the 150s at discharge. His ACE was
held but can likely be restarted once his creatinine fully
normalizes.
.
# Diabetes: Insulin SS while in house. His blood sugars remained
elevated in the 200s with an A1c of 8.4. He was discharged on
glipizide. His metformin was held but this can likely be
restarted once his creatinine normalizes.
.
# Neuropathic pain: Patient complained of neuropathic pain in
his feet. Had been on percocet at home but this was switched to
oxycodone. His gabapentin was decreased as well so that it was
renally dosed.
TRANSITION ISSUES:
1. Recheck ferritin, TIBC after resolution of acute liver injury
to screen for hematochromatosis and if elevated would send
genetic testing
2. Hold statin until liver function tests normalize; hold
metformin and ACE until renal function normalizes
3. Continue to advocate for abstinence from alcohol
Medications on Admission:
Oxycodone-Acetaminophen 7.5-325 PO Q4H prn pain
Gabapentin 300mg tabs; 2 tabs PO TID
Glipizide 5mg; 1 tab PO daily
Metformin 500mg; 2 tabs PO daily
Lorazepam 1mg; 1 tab PO daily
Omeprazole 20mg caps; 1 cap PO daily
Simvastatin 40mg tabs; 1 tab QHS
Lisinopril 10mg tabs; 1 tab PO daily
Discharge Medications:
1. Gabapentin 600 mg PO TID
2. Lorazepam 1 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg daily Disp #*30 Tablet Refills:*2
5. Labetalol 200 mg PO BID
hold for SBP<100 or HR<55 and inform H.O.
RX *labetalol 200 mg twice a day Disp #*60 Tablet Refills:*2
6. Lactulose 30 mL PO QID
hold for BM > 4
RX *lactulose 20 gram/30 mL four times a day Disp #*3600
Milliliter Refills:*0
7. Multivitamins 1 TAB PO DAILY
RX *Daily Multi-Vitamin daily Disp #*30 Tablet Refills:*2
8. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg daily Disp #*30 Tablet Refills:*2
9. OxycoDONE (Immediate Release) 7.5 mg PO Q6H:PRN pain
RX *Oxecta 7.5 mg every six hours Disp #*12 Tablet Refills:*0
10. GlipiZIDE 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute liver failure
tylenol overdose
opioid abuse
acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care Mr. [**Known lastname 15674**]. You
were admitted with nausea and vomiting. You were found to have
acute liver failure likely due to tylenol overdose from taking
too many percocets. You need to stop abusing prescription
medications and you cannot drink any alcohol as this can
severely damage your liver.
Continue your home medications with the following changes:
1. STOP percocet and START oxycodone instead
2. STOP lisinopril until your kidney function can be rechecked
3. STOP metformin until your kidney function can be rechecked
4. STOP simvastatin until your liver function returns to normal
Followup Instructions:
When: THURSDAY, [**7-5**] at 11:00AM
Name: [**First Name4 (NamePattern1) 4134**] [**Last Name (NamePattern1) **] (nurse practictioner of [**Last Name (LF) **],[**First Name3 (LF) 177**] M)
Location: [**Hospital 20086**] MEDICAL GROUP
Address: [**Street Address(2) 20087**], STE 3C, [**Hospital1 **],[**Numeric Identifier 20089**]
Phone: [**Telephone/Fax (1) 7164**]
Department: LIVER CENTER
When: FRIDAY [**2192-7-13**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 5845, 2930, 2875, 3572, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8787
} | Medical Text: Admission Date: [**2131-12-30**] Discharge Date: [**2132-1-3**]
Service: [**Doctor Last Name 1181**]
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is an 87-year-old
Vietnamese woman with numerous medical problems (noted
below), who was residing at [**Hospital3 2558**] when she fell on
[**2131-12-29**]. Reportedly, the patient did not sustain
any injuries at that time, and her vital signs were stable.
The patient fell again at approximately 1 A.M. on [**2131-12-30**]. At 4:45 P.M. that same day, she was found
unresponsive, lethargic, and hypotensive (blood pressure
90/60), with room air saturations of 54% (she subsequently
had saturations of 75% on 4 liters of oxygen). EMS was
called, and the patient was brought to the [**Hospital1 346**] Emergency Department, where her
blood pressure was 96/41, and her finger stick was 384. The
patient was also noted at that time to be in wide complex
tachycardia. She was given calcium chloride, which for a
time converted her QRS to a narrow complex, however, it
subsequently reverted back to wide complex. The patient was
intubated at approximately 5:30 P.M. on [**2131-12-30**], for
hypoventilation and respiratory failure. The patient's
admission laboratories were notable for hyperkalemia to 9.3.
This specimen was felt to be hemolyzed, and a subsequent
potassium was found to be 7.5. The patient was also found to
be in acute renal failure, and hyperglycemic to 402, with a
sodium of 117.
As noted, the patient has numerous medical issues. Also she
has had hyperkalemia on three prior hospitalizations over the
past year. The exact etiology of this (and her
hyponatremia), with acute renal failure, is unknown. Past
ACTH stim test was normal on a recent admission.
The patient was admitted initially to the Intensive Care
Unit. There, her course went fairly smoothly, and she showed
marked improvement. The patient was extubated on [**2132-1-1**]. She subsequently had an episode of post-extubation
stridor, which resolved after the administration of steroids,
nebulizers, and racemic epinephrine.
The patient continued to do well and, on [**2132-1-2**],
she was transferred to the Medicine floor, [**Doctor Last Name **] firm.
PAST MEDICAL HISTORY:
1. Diabetes mellitus Type 2
2. Coronary artery disease status post rest Thallium with
anterior and apical defects, which were fixed
3. Congestive heart failure, ejection fraction of 20%, focal
hypokinesis of the right ventricle, severe regional left
ventricular dysfunction, 1 to 2+ aortic insufficiency, 2+
mitral regurgitation, 2+ tricuspid regurgitation, moderate
pulmonary hypertension
4. Complete heart block/? sick sinus syndrome, status post
DDD pacemaker placement
5. Chronic renal insufficiency, creatinine running between
1.2 and 1.6, status post hemodialysis for acute renal failure
in [**2131-7-28**]
6. Dementia
7. Depression
8. Hyponatremia, episode in [**2131-3-27**] felt secondary to
serum-inappropriate antidiuretic hormone
9. ? upper gastrointestinal bleed in [**2131-7-28**],
nasogastric lavage negative
ALLERGIES: No known drug allergies.
OUTPATIENT MEDICATIONS:
1. Bactrim double strength one by mouth twice a day
2. Trazodone 25 mg as needed
3. Glipizide 2.5 mg once daily
4. Niferex
5. Isordil 5 mg three times a day
6. Hydralazine 10 mg four times a day
7. Aricept 5 mg once daily
8. Protonix 40 mg once daily
9. Enteric-coated aspirin
10. Insulin sliding scale
SOCIAL HISTORY: The patient is Vietnamese. She has no
tobacco or alcohol history. She has been a resident of
[**Hospital3 2558**] Nursing Home.
PHYSICAL EXAMINATION: On presentation, per Medical
Intensive Care Unit house staff, vital signs: Blood pressure
195/75, heart rate 70, respirations 90, oxygen saturation
100% while intubated. General: Sedated, intubated. Head,
eyes, ears, nose and throat: Pupils pinpoint bilaterally,
right greater than left (1.5 mm). Neck: Without jugular
venous distention. Chest: Examination revealed right-sided
rhonchi and left side clear to auscultation. Cardiovascular:
Regular rate, positive systolic ejection murmur heard
maximally at the apex. Abdomen: Soft, nontender,
nondistended, positive bowel sounds. Extremities: Without
edema, toes dry. Neurologic: Corneal reflexes sluggish
bilaterally, patient winces with very deep painful stimuli,
moves all extremities and does so symmetrically; deep tendon
reflexes 1+ throughout.
LABORATORY DATA: On presentation, CBC revealed a white
count of 11, hematocrit 36.5. Chem 7 revealed a sodium of
117, potassium initially 9.3 (subsequently 7.5), chloride 88,
bicarbonate 17, BUN 35, creatinine 2.4, glucose 402. CK was
137, with an MB fraction of 5, troponin less than .1. Coag
studies revealed an INR of 1.2, PT 13.0, PTT 32.6. Calcium
was 9.4, magnesium 2.3, phos 7.2. Arterial blood gas
revealed a pH of 7.22, PCO2 47, PO2 458. Urinalysis was
negative.
HOSPITAL COURSE: As noted above, the patient was intubated
and subsequently admitted to the Intensive Care Unit. She
did well in the Intensive Care Unit and, on [**2132-1-1**],
was extubated. She experienced a brief episode of
post-extubation stridor, which resolved following the
administration of steroids, nebulizers, and racemic
epinephrine. The patient continued to improve and, on
[**2132-1-2**], she was transferred to the Medicine floor,
[**Doctor Last Name **] firm.
It should be noted, as mentioned above, that the patient
during at least three prior hospitalizations over the past
year, has had hyperkalemia (she has also had hyponatremia).
The exact etiology for these electrolyte disturbances remains
unclear. A past ACTH stim test was normal on a recent
admission. It should be noted that, at the time of this
discharge, the patient has renin levels and aldosterone
levels which are pending. This has been discussed with Dr.
[**Last Name (STitle) 5762**], who will follow up on the results following the
patient's discharge.
CONDITION ON DISCHARGE: Vital signs stable, afebrile.
DISCHARGE DIAGNOSIS:
1. Acute renal failure/chronic renal insufficiency
2. Hyperkalemia
3. Dementia
4. Coronary artery disease
5. Diabetes mellitus Type 2
6. Congestive heart failure
7. Status post DDD pacemaker placement
DISCHARGE MEDICATIONS:
1. Colace 100 mg by mouth twice a day
2. Zantac 150 mg by mouth twice a day
3. Regular insulin sliding scale
4. Albuterol nebulizer every four hours as needed
5. Atrovent nebulizer every four hours as needed
6. Tylenol 650 mg by mouth every six hours as needed
FOLLOW UP: The patient is to be discharged back to [**Hospital3 7511**], where she will continue to be followed by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 5762**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 9755**]
Dictated By:[**Last Name (NamePattern1) 1550**]
MEDQUIST36
D: [**2132-1-3**] 00:22
T: [**2132-1-3**] 01:03
JOB#: [**Job Number 33217**]
ICD9 Codes: 5849, 2767, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8788
} | Medical Text: Admission Date: [**2117-1-16**] Discharge Date: [**2117-1-20**]
Date of Birth: [**2072-7-1**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Patient admitted with bright red blood from rectum and
dizziness.
Major Surgical or Invasive Procedure:
Status Post EGD
History of Present Illness:
44 M s/p open gastric bypass in [**9-20**] c/b stenosis and dilation
post-op now p/w with maroon stools x 3 days. he states that he
recently started taking aspirin the past month. Had syncopal
episode at home. HCT at OSH was 25, got 1 unit PRBC and now
here
his HCT was 23.8. NGT placed by ED resident [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3827**]
as
instructed by his attending revealed a mildly positive lavage,
not gross blood though. He was diaphoretic and very pale. He
got 2 units of PRBC through a level one with good improvement in
symptoms. SBP also increased from 80s to 100s, color and
diaphoresis improved.
Past Medical History:
PMH: hypertension, dyslipidemia, OSA on CPAP
PSH: ankle fx, wisdom teeth
Social History:
He denies tobacco or recreational drug usage, has 12-14 beers a
week and drinks can of caffeine-free diet soda 6 days a week. He
is employed as a sales manager traveling 1000 miles per week. He
is married living with his wife age 41 and their 2 children ages
10 and 8.
Family History:
Family history is noted for both parents living father age 65
with heart disease, hyperlipidemia, arthritis and obesity;
mother age 67 with hyperlipidemia and arthritis. There is strong
family h/o asthma.
Physical Exam:
PE: 97.8 94 80s->110 systolic after 2 units 16 94
AAOx3, diaphoretic and pale
RRR
CTAB
soft NT/ND, well healed scar
Grossly positive blood on rectal, no masses or hemorrhoids felt,
no BRB but more red than melena
no edema, extrem warm
Pertinent Results:
[**2117-1-15**] 11:35PM BLOOD WBC-5.6 RBC-2.58*# Hgb-8.7*# Hct-23.8*#
MCV-92 MCH-33.6* MCHC-36.4* RDW-13.6 Plt Ct-183
[**2117-1-16**] 03:31AM BLOOD WBC-7.2 RBC-3.22* Hgb-10.2* Hct-28.5*
MCV-89 MCH-31.7 MCHC-35.8* RDW-14.0 Plt Ct-149*
[**2117-1-16**] 11:26AM BLOOD Hct-21.6*
[**2117-1-17**] 02:07AM BLOOD WBC-3.0*# RBC-2.24*# Hgb-7.1*# Hct-20.3*
MCV-91 MCH-31.4 MCHC-34.7 RDW-14.8 Plt Ct-105*
[**2117-1-18**] 06:50AM BLOOD Hct-26.5*
Brief Hospital Course:
Patient admitted with bright red blood per rectum with
dizziness. Patient was given 2 units of packed cells in the
emergency room with improved symptoms. A nasogastric tube was
placed and lavaged. He was transferred to the intensive care
unit where he was closely monitored. He had an EGD on [**2117-1-16**]
which revealed an ulcer at the GJ anastomosis that was injected.
His current hematocrit level is 26.5. He was advanced to a
Bariatric stage 3 with tolerance.
On discharge he is tolerating bariatric stage 5 and hct is
stable at 27.3. He will follow up with Dr. [**Last Name (STitle) **] in 2 weeks
and then have a follow up EGD on [**2-25**].
Medications on Admission:
VALSARTAN [DIOVAN] - (Prescribed by Other Provider) - 160 mg
Tablet - one Tablet(s) by mouth per day
Medications - OTC
CALCIUM - (Prescribed by Other Provider) - 500 mg Tablet - one
Tablet(s) by mouth daily
CYANOCOBALAMIN [VITAMIN B-12] - (Prescribed by Other Provider) -
Dosage uncertain
MULTIVITAMIN - (Prescribed by Other Provider) - Tablet -
Tablet(s) by mouth twice a day
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
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. Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal Bleed
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Please call your doctor or return to the emergency room if you
have 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.
* 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.
Followup Instructions:
Dr. [**Last Name (STitle) **] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Building [**Location (un) **] -
[**Telephone/Fax (1) 3201**] - Appointment at [**2-4**] at 9:45 and then
again on [**3-11**] at 9:15.
You will be having your endoscopy on [**2-25**] at 12:30, all
information regarding this procedure will be mailed to you.
Completed by:[**2117-1-20**]
ICD9 Codes: 4589, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8789
} | Medical Text: Admission Date: [**2156-1-8**] Discharge Date: [**2156-1-20**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**Doctor First Name 1402**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Intubation.
History of Present Illness:
[**Age over 90 **] yo male with pmhx significant for Type 2 Diabetes Mellitus
and coronary artery disease was admitted from the ED for [**2-14**]
days of shortness of breath. Patient is a poor historian but
reports that he has a [**2-14**] day history of shortness of breath,
"wobbly on my feet," and generally "wasn't feeling good." He
then called his PCP who recommended that patient call EMS to be
taken to the hospital. On ROS, patient notes that he sleeps in a
chair but denies leg swelling, PND, or palpitations. Patient
reports that he takes his medications regularly but does
occasionally "cheat" with his diabetic diet. On additional ROS,
patient reports diffuse abdominal pain for 2-3 days, decreased
appetite for several days, and URI 5 days ago which has
improved. Patient otherwise denies dysuria, hematuria, diarrhea,
constipation, fevers, chills, or night sweats.
.
Patient was brought to the ED by EMS where he was given 3x NTG
and 180mg lasix IV. In the ED, VS were HR 120s / BP 125/72 / RR
28 / 98% on NRB / 1900 total UOP. Patient was initially placed
on BiPap and then lowered to 4.5L NC. Received aspirin 325mg and
was admitted.
.
Of note, patient was previously admitted to the hospital in
[**2155-11-12**] with a similar episode of shortness of breath with
dry cough. At that time, he was thought to have a CHF
exacerbation secondary to medication noncompliance and underwent
diuresis with improvement in SOB. Patient was discharged with
outpatient cardiology follow-up but did not follow-up.
Past Medical History:
1. Adult-onset diabetes mellitus.
2. Coronary Artery Disease - MI per report
3. Prostate cancer, [**Doctor Last Name **] 6 out of 10, diagnosed in [**Month (only) **]
[**2141**], no metastases, status post XRT.
4. Hiatal hernia.
5. External hemorrhoids.
Social History:
No hx of drugs or EtOH. Did recently take codeine.
Family History:
n/c
Physical Exam:
PE:
T 95.8 / HR 126 / BP 132/78 / RR 28 / PO2 96% on 4L
Gen: lying comfortably in bed, no acute distress
HEENT: Clear OP, MMM
NECK: Supple; shoddy, nontender cervical LAD; JVP to jaw
CV: tachycardic but regular rate. NL S1, S2. No murmurs, rubs or
gallops
LUNGS: bibasilar crackles with increased crackles on the left
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP/PT pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. alert and
oriented x 3; hard of hearing with somewhat better hearing on
the right side; slowed speech with difficulty with word-finding
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Admission Labs: [**2156-1-8**] 10:13AM:
GLUCOSE-155* UREA N-28* CREAT-1.1 SODIUM-141 POTASSIUM-4.2
CHLORIDE-105 TOTAL CO2-26 ANION GAP-14
.
WBC-11.4* RBC-3.83* HGB-11.3* HCT-32.4* MCV-85 MCH-29.5
MCHC-34.9 RDW-14.7
PLT COUNT-374 NEUTS-71.2* LYMPHS-22.3 MONOS-3.8 EOS-2.0
BASOS-0.6
.
PT-12.1 PTT-24.4 INR(PT)-1.0
.
[**2156-1-8**] 10:13AM CK(CPK)-78 CK-MB-NotDone proBNP-3382*
cTropnT-0.02*
[**2156-1-8**] 07:40PM CK(CPK)-60 CK-MB-NotDone cTropnT-0.04*
[**2156-1-9**] 06:20AM CK(CPK)-64 CK-MB-NotDone cTropnT-0.03*
.
[**2156-1-8**] CXR:
CHEST, ONE VIEW: Comparison with chest radiograph of [**2155-11-19**] and chest CT, [**2155-11-19**]. There are bilateral
moderate pleural effusions, similar to the previous exam.
Bilateral lower lobe opacities can represent atelectasis,
aspiration, or pneumonia. Cardiac, mediastinal, and hilar
contours are unchanged. No pneumothorax. Osseous structures are
unchanged.
IMPRESSION: Similar appearance of bilateral lower lobe
atelectasis/aspiration/pneumonia and bilateral moderate pleural
effusions.
.
[**2156-1-10**] Echo:
Conclusions:
The left atrium is normal in size. The estimated right atrial
pressure is
11-15mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity is moderately dilated. An echodensity
suggestive of a large apical mural thrombus is seen in the left
ventricle. Overall left ventricular systolic function is
severely depressed (ejection farction 20 percent) secondary to
severe hypokinesis of all walls except the lateral wall. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. There is no aortic valve stenosis. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2155-11-21**], the left ventricular ejection fraction is
further reduced, the mitral regurgitation appears reduced
(although it may not optimally have been displayed on the
present study), and the presence of an echodensity in the left
ventricle suggestive of an apical mural thrombus is now noted.
.
[**2156-1-19**] XRay right foot: IMPRESSION:
1. Curvilinear calcification located medially to the navicular
bone could represent vascular calcification, but an avulsion
injury cannot be excluded.
2. Os naviculare.
.
[**2156-1-20**] CT right foot: read from MS fellow: no fracture.
Brief Hospital Course:
[**Age over 90 **] yo male with CAD, DMII admitted with CHF exacerbation who had
flash pulmonary edema requiring intubation. He improved, was
extubated. Hospital course complicated by new tachycardia and
delirium. Now with right foot pain.
#. Cardiac
A. Rhythm: Patient has a question of new diagnosis of atrial
tachycardia, although P waves apear to be similar to old EKGs
ddx also included benzo withdrawl despite family's insistence
that he was not taking valium more than once a month. The
tachycardia is thought to be the precipitating factor for this
admission's CHF. His Toprolol was titrated up from 25mg to
200mg QD. We called his PCP's, Dr. [**Last Name (STitle) 172**], office for old EKGs;
Old EKG showed rate in 70's with no obvious difference in P wave
morphology. He had some ectopy thought to be a variant of this
atrial tachycardia (SVT with aberrancy).
.
B. Cardiomyopathy: Pt with h/o CHF with EF 25-30% and 2+ MR. [**Name13 (STitle) **]
had an acute CHF exacerbation with flash pulmonary edema. DDx
flash edema includes includes worsening MR, atrial tach, HTN [**2-13**]
holding lisinopril in setting of MR [**First Name (Titles) **] [**Last Name (Titles) **]. Pt ruled out for
MI and had no new EKG changes suggestive of ischemia. Also
lisinopril was restarted at a lower dose 2.5mg (home dose was
20mg QD) because of need to increase beta blocker for
tachycardia. Patient had decreased intake because of clearing
delirium at discharge. He was euvolemic at discharge. He is on
20mg lasix daily.
- Patient needs to be weighed every day. If he gains more than
2 lbs he should take 40mg of lasix (his home dose).
.
C. Coronaries: Patient with a presumed CAD and prior MI,
although no records here. No current chest pain or acute
ischemic changes on EKG. CE neg. Medical management with home
doses of atrovastatin 20mg, plavix 75mg. His metoprolol was
increased for rate control with compensatory decrease in
lisinopril to maintain blood pressure. Restarted aspirin 81mg
(has listed GI bleed as allergy).
.
# ARF: Patient had episode of ARF with Creatinine bump to 1.4,
from baseline 1.0, thought to be pre-renal from low CO. ACE I
was held during renal failure.
.
# PNA: Completed a 7 day course on [**2156-1-16**] of zosyn for
pneumonia. Patients white count and fevers decreased and he was
afebrile at discharge.
.
#. Type 2 Diabetes Mellitus-- He was discharged on Lantus dose
22U (on half doses for NPO and poor PO intake). As he began
eating we added back Humalog at meals (3U) and covered with
insulin sliding scale.
.
# Right foot pain-- Patient with 3 days of right foot pain.
redness and minimal swelling in medial ankle/foot arch. Thought
to be secondary to a mechanical trauma. No break in the skin.
Ddx is bruise/fracture/osteo. Right foot x-rays and CT showed
no fracture. Continue tylenol for pain control.
.
5. Anemia: Baseline--Unclear etiology for patient's anemia,
thought likely secondary to iron deficiency anemia. Baseline Hct
32-35. Colonoscopy and EGD in [**4-15**] demonstrated no significant
findings. Ferritin in [**3-15**] was 14 and most recent ferritin in
[**8-15**] was 42. We continued ferrous sulfate 325mg PO daily.
.
6. Delirium: Likely multifactorial from infection, age and ICU
delirium, medications. He was treated for pneumonia.
geriatrics was consulted. We encouraged normalizing behavior
(OOB to chair), had his hearing aids brought in. We treated
agitation with low dose ativan (0.25mg Q6PRN) preferentially
then zyprexa 2.5mg PRN. He uses minimal-moderate diazepam at
home and there was concern for withdrawl. Patient did not have
any seizures or DT. For the last few days of admission, he had
a clear sensorium and did not require any ativan or zyprexa.
.
10. CODE: DNR. Agrees to intubation for reversible causes but
would not like prolonged intubation. Confirmed with family on
[**2156-1-19**].
.
11 COMM:
Wife [**Name (NI) **] [**Name (NI) 101256**] - [**Telephone/Fax (1) 101257**]
Daughter - [**First Name4 (NamePattern1) 717**] [**Last Name (NamePattern1) **] - [**Telephone/Fax (1) 101258**]
PCP [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**] - [**Telephone/Fax (1) **]
Medications on Admission:
Aspirin 81mg PO daily
Atorvastatin 20mg PO daily
Lisinopril 20mg PO daily
Clopidogrel 75mg PO daily
Toprol XL 25mg PO daily
Lasix 40mg PO daily
Diazepam 5mg PO qhs
Ferrous Sulfate 325mg PO daily
Nitroglycerin .4mg SL prn
Lantus 22U SC qhs
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Insulin Glargine 100 unit/mL Solution Sig: 22U Subcutaneous
at bedtime: This is his normal home dose. .
8. Insulin Lispro (Human) 100 unit/mL Solution Sig: Three (3)
Units Subcutaneous QAS, with meals.
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Heparin (Porcine) 5,000 unit/mL Syringe Sig: One (1)
Injection three times a day: if not ambulating.
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 12414**] Healthcare Center - [**Location (un) 12415**]
Discharge Diagnosis:
Primary
Atrial tachycardia
CHF with EF of 30%
Coronary artery disease
Diabetes Mellitus type II
Delirium
Pneumonia
acute renal failure
Seconday
Iron deficiency anemia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for congestive heart failure. You had to be
intubated to help you breath. This was what you and your family
agreed should be done during such circumstances.
You must be weighed everyday. If you gain more than 2 lbs, you
should take your 40mg of Lasix and call your doctor.
Followup Instructions:
Please follow up with the facility physician at the rehab
facility.
.
After leaving there, please see your primary care doctor, Dr.
[**Last Name (STitle) 172**], in the next week.
.
You should have your labs checked on Thursday [**2156-1-22**]- please
check a potassium and magnesium and replace as needed.
Completed by:[**2156-1-20**]
ICD9 Codes: 4280, 4240, 4254, 5849, 486, 2930, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8790
} | Medical Text: Admission Date: [**2121-2-5**] Discharge Date: [**2121-2-11**]
Service: Trauma
ADMISSION DIAGNOSIS:
Bilateral pulmonary contusion
Abdominal wall hematoma
Left patellar fracture
DISCHARGE DIAGNOSIS:
Bilateral pulmonary contusion
Abdominal wall hematoma
Left patellar fracture
Osteoporosis, status post pacemaker and hypertension
HISTORY OF PRESENT ILLNESS: This is an 84 year old female
involved in a motor vehicle accident, low speed. She was a
restrained driver. [**Location (un) 2611**] coma scale is 15. No loss of
consciousness. She was transferred from an outside hospital
complaining of right chest pain and right rib pain, no
shortness of breath and no dizziness.
PAST MEDICAL HISTORY: Osteoporosis, hypertension.
PAST SURGICAL HISTORY: Pacemaker.
OUTPATIENT MEDICATIONS: Norvasc, Hydrochlorothiazide,
Atenolol, and calcium.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Vital signs on admission were 99.8/65/
blood pressure 149/79, 100% on oxygen.
LABORATORY DATA: Admission laboratory data revealed complete
blood count 10.7/36.7/148. Chemistry, 140/3.6/105/23/
22/0.5/133. Coags 13.4/21.4/1.2.
Admission radiographic studies - Admission chest x-ray showed
cardiac enlargement, mild right lung opacity. A computerized
tomography scan of the pelvis and abdomen showed right lower
quadrant abdominal wall hematoma. Computerized tomography
scan of the chest with and without contrast showed asymmetric
areas of mural plaqing in the thoracic aorta, right middle
lobe consolidation likely from pulmonary contusion and
hematoma, anterior to the right anterior, superior iliac
spine with evidence of active bleeding, also showed multiple
hepatic cysts and fracture of the anterior fifth through
tenth ribs on the right side. Thoracic and lumbar spine
films showed an old T7 compression fracture. The left knee
showed a transverse patella fracture, right forearm films
were negative. Cervical spine was obtained and was negative.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit for q. 4 hour hematocrit checks. Her hematocrit
remained stable while in the Intensive Care Unit in the low
30s. She did not require blood transfusion during her
hospital stay. She remained afebrile with stable vital signs
while she was in the Intensive Care Unit. She was
transferred to the floor late on hospital day #2. She was
taken to the Operating Room on hospital day #3 for her left
patellar open reduction and internal fixation by Dr. [**Last Name (STitle) 9694**].
The patient tolerated the procedure well. Postoperatively
while in the Post Anesthesia Care Unit her saturations were
in the high to mid 80s on only nasal cannula. This was
disturbing as she was only 92% on nasal cannula and shovel
mask cannulation. Repeat chest x-ray was performed and this
showed a new left basilar collapse and/or consolidation with
probable left pleural effusion and no change in the right mid
zone opacity. We felt that this likely represented a
collapse of the left lower lobe. She was placed on a short
period of BiPAP in order to expand the lung. Serial arterial
blood gases were obtained. Her pCO2 was as high as 60 with a
pO2 only in the 70s and she has had a respiratory acidosis
during this time. During this time she was alert and awake
and she was hemodynamically stable. Cardiac enzymes were
obtained and they were normal. Electrocardiogram was
obtained which showed questionable T wave inversions in V6
and 1. After a short period of BiPAP and the patient's
arterial blood gases improved and CO2s went down towards the
normal range, repeat chest x-ray showed improvements of the
left lower lobe and of the effusion, the patient was
transferred from the Post Anesthesia Care Unit to the
Vascular Intensive Care Unit where she remained on Telemetry
and arterial blood gases were sent serially with no
significant deterioration in her respiratory status. She was
then transferred to the floor where her Foley catheter was
discontinued and she was able to urinate fine on her own.
She was able to tolerate a regular diet. She was out of bed
with physical therapy, weightbearing as tolerated on the left
side where her patellar fracture was and the knee
immobilizer. At the time of this dictation the nurse
reported a slightly foul-smelling urine. A urinalysis was
sent which is pending at the time of this dictation. If it
appears that the urinalysis is positive for infection, she
will be treated with Levofloxacin for a few days as an
outpatient, however, we do not suspect this will be the case.
The patient has been afebrile with a normal white count for a
period of time. Her hematocrit remained stable. She did
have some slight electrolyte abnormalities which were
repleted. Repeat electrocardiogram showed no significant
change. She was willing and excited to go to a
rehabilitation facility upon discharge.
DISCHARGE INSTRUCTIONS: She should call or return to the
Emergency Room if she has any difficulty breathing or if she
has pus coming from the wound of her patella fracture
fixation or if she has a fever. She will follow up in Trauma
Clinic in approximately two weeks and with Dr. [**Last Name (STitle) 9694**] in
approximately one week.
DISCHARGE MEDICATIONS:
Percocet as needed for pain
Colace as needed for constipation
Senna as needed for constipation
Aspirin 81 mg q.d.
Atenolol 50 mg q.d.
Protonix 40 mg q.d.
Ferrous Sulfate per day
Ascorbic acid per day
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2121-2-11**] 16:27
T: [**2121-2-11**] 16:43
JOB#: [**Job Number 53251**]
cc:[**Hospital3 53252**]
ICD9 Codes: 5180, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8791
} | Medical Text: Admission Date: [**2195-7-3**] Discharge Date: [**2195-7-29**]
Date of Birth: [**2123-12-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Diuril
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
71yoW s/p AVR(#19 [**Company 1543**] Mosaic)CABGx2(LIMA-LAD,SVG-RCA)[**7-16**]
Right internal jugular line and PA catheter
Bilater thoracentesis
History of Present Illness:
71 y/o female with CAD, AS, and PVD who presented to [**Hospital 1474**]
hospital on [**2195-7-2**] with dyspnea for one month, worse over the
preceeding week with cough but no clear fevers. Vitals were
98.7, 124/69, 91, and 94% on 2L/M O2 on presentation. CXR showed
cardiomegaly with mild [**Date Range 1106**] congestion. Labs showed a WBC
count of 19.2 with 89% neutrophils. HCT was 24.6. ABG was
7.41/52/63. She was tried on BIPAP unsuccessfully and then
intubated for respiratory distress. She became transiently
hypotensive, requiring dopamine drip. She became tachycardic,
and so was changed to levophed. Initial labs showed BNP of 880,
BUN of 28, Cr of 1.2, CK 100 to 84 to 540, troponin 0.01 to 0.4
to 14.2. EKG had ST depressions in I, II, V4-V5 which were more
pronounced with tachycardia
Past Medical History:
Hypertension
CAD s/p RCA stenting [**2193**] (Cypher stent x 2 to ostial and mid
RCA, two bare metal stents to distal RCA)
Bilateral carotid artery disease
Aortic stenosis [**Location (un) 109**] 1.1cm and mean gradient 37
LE claudication
Possible COPD
Obstructive sleep apnea (not on CPAP)- uses 2 liters O2 at night
Diabetes
Hyperlipidemia
Left LE ORIF c/b infection
Glaucoma
GERD
s/p cataract surgery of right eye with lens replacement
Percutaneous coronary intervention, in [**2193**] anatomy as follows:
Cypher stent x 2 to ostial and mid RCA, two bare metal stents to
distal RCA
Social History:
Husband died in [**2192-3-17**] of cancer. She lives alone and has
three children who are very helpful. Her son is [**Name (NI) 4468**] [**Name (NI) **] and
her daughter [**Name (NI) **] [**Name (NI) **]. [**Doctor First Name 4468**] can be reached at
[**Telephone/Fax (1) 64736**]. [**Doctor First Name **] can be reached by cell phone at
[**Telephone/Fax (1) 64737**]. Patient has smoked >50 years. She used to smoke
two and a half to three packs a day. Currently smoking half a
pack a day. Min EtoH. Used to work as a bookeeper.
Family History:
(+) FHx CAD. Mother had CAD. Father had MI and died at 52.
Physical Exam:
PHYSICAL EXAMINATION:
.
T 99.3 BP 105/50 HR 100 Vent TV500 Rate14 PEEP5 FiO250% Sat 100%
General: Intubated, able to follow simple commands, appears
comfortable. Pale skin throughout.
HEENT: Pupils equal and reactive. Pale conjunctiva.
NECK: Unable to determine JVP. Late peaking pulses.
LUNGS: Mild Wheezes bilaterally. No crackles.
HEART: Regular rhythm. S1 and S2 with harsh late peaking
systolic creshendo/decreshendo murmur.
ABD: Obese, soft, NT, ND, normal active bowel sounds.
EXT: Pitting edema to
SKIN: Generally warm with cool feet. Weak femoral, popliteal,
and DP/TP pulses.
.
Pertinent Results:
[**2195-7-6**] Cardiac Cath:
COMMENTS:
1. Coronary angiography in this right-dominant system
demonstrated
2-vessel disease. The LMCA had 50% stenosis at its origin with
noted
dampening of pressure. The LAD had moderate diffuse disease.
The LCx
was a non-dominant vessel without critical lesions. The RCA was
a
dominant vessel with previous stent origin 90% stenosis.
2. Resting hemodynamics revealed elevated left-sided filling
pressures
with LVEDP of 40. There was moderate pulmonary arterial
systolic
hypertension with PASP of 58. The cardiac output was preserved
at 5.71
L/min.
3. There was severe aortic stenosis with a peak to peak
gradient of 60
mmHg, mean gradient of 41 mmHg and aortic valve area of 0.8 cm2.
4. The aortic root and arch were noted to have significant
calcifications.
.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Severe aortic stenosis.
3. Elevated left-sided filling pressures and moderate pulmonary
artery
systolic hypertension.
.
[**2195-7-4**] Echo:
Conclusions:
The estimated right atrial pressure is 11-15mmHg. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. There is mild to moderate global left
ventricular hypokinesis (LVEF = 40 %). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. There
is severe aortic valve stenosis (area <0.8cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is no pericardial effusion.
.
[**2195-7-9**] Chest CT:
IMPRESSION:
1. Bilateral moderate to large dependent simple pleural
effusions.
2. Bilateral dependent pulmonary opacities, which may be due to
a combination of atelectasis and provided history of pneumonia.
A 1.5 cm diameter rounded lucency in superior segment left lower
lobe may represent underlying pneumatocele or bulla, but a focus
of necrotizing pneumonia is difficult to exclude given adjacent
pleural effusion and absence of intravenous contrast. If
warranted clinically, a followup contrast enhanced chest CT
could be considered, ideally following thoracentesis, for more
complete evaluation of this region.
3. Emphysema.
4. Coronary artery and aortic valvular calcifications.
[**2195-7-29**] 02:50AM BLOOD WBC-12.4* RBC-3.48* Hgb-10.1* Hct-31.2*
MCV-90 MCH-29.2 MCHC-32.5 RDW-15.9* Plt Ct-410
[**2195-7-28**] 02:22AM BLOOD WBC-11.8* RBC-3.61* Hgb-10.3* Hct-32.5*
MCV-90 MCH-28.6 MCHC-31.8 RDW-16.1* Plt Ct-412
[**2195-7-27**] 02:15AM BLOOD WBC-8.9 RBC-3.51* Hgb-10.2* Hct-31.2*
MCV-89 MCH-29.1 MCHC-32.7 RDW-16.1* Plt Ct-292
[**2195-7-29**] 04:43AM BLOOD PTT-81.5*
[**2195-7-29**] 02:50AM BLOOD Plt Ct-410
[**2195-7-29**] 02:50AM BLOOD PT-12.9 PTT-101.3* INR(PT)-1.1
[**2195-7-29**] 02:50AM BLOOD Glucose-66* UreaN-24* Creat-1.1 Na-141
Cl-96 HCO3-38*
Brief Hospital Course:
Ms. [**Known lastname 4223**] was admitted to the CCU for invasive monitoring and
mechanical ventilation. She was started on levofloxacin,
vancomycin and zosyn for CAP. She was transfused for a
hematacrit of 22. She was seen by renal for likely atn and
contrast nephropathy from cath. She was started on tube feeds.
Cardiac cath on 8.20 showed 50% LM, moderate diffuse LAD
disease, 90% RCA. She was seen by cardiac surgery for AVR/CABG,
and awaited diuresis, plavix washout and possible extubation
prior to surgery. Cautious diuresis was attempted given her
severe AS. On [**7-9**] she underwent thoracentesis. Pressure support
trial was unsuccessful as was steroid taper and she remained
intubated. On [**7-16**] she ws taken to the operating room where she
underwent a CABG x 2 and AVR (porcine). She was transferred to
the ICU in critical but stable condition on epi, neo, propofol
and insulin. She remained intubated. She ws startd on amiodarone
for post op atrial fibrillation. She was seen by general
surgery for abdominal pain, increased pressor requirement and
increased LFTs. She did not require surgery, and her LFTs
improved. She continued on tube feeds postoperatively.
Aggressive diuresis continued. She was weaned from her
vasoactive drips. She was seen by thoracic surgery for trach and
PEG, which was performed on [**2195-7-24**]. The ventilator was weaned
and she was screened for rehab. She was ready for discharge to
rehab on [**2195-7-29**].
Medications on Admission:
asa, plavix, atenolol, vytorin, spiriva, metformin 500'',
glyburide 5', timolol, avndia, aciphex, MVI
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
6. Albuterol 90 mcg/Actuation Aerosol Sig: 4-6 Puffs Inhalation
Q4H (every 4 hours).
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 4-6 Puffs
Inhalation Q4H (every 4 hours).
8. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day) as needed.
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed.
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
16. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
17. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Prevacid 30 mg Susp,Delayed Release for Recon Sig: One (1)
PO once a day.
19. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
20. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
AS
CAD
PMH: DM, Dyslipidemia, HTN, PVD s/p Right Carotid stent s/p
stenting of aortic bifurcation, Hemorrhoids, GERD, Anemia, COPD
Discharge Condition:
Stable.
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.
Followup Instructions:
Dr. [**Last Name (STitle) **] after discharge from rehab.
Dr. [**Last Name (STitle) 17887**] after discharge from rehab.
Dr. [**Last Name (STitle) **] after discharge from rehab.
Already scheduled appointments:
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2195-9-29**]
10:00
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2195-9-29**]
11:00
Completed by:[**2195-7-29**]
ICD9 Codes: 4241, 4280, 496, 5849, 486, 4439, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8792
} | Medical Text: Admission Date: [**2149-9-27**] Discharge Date: [**2149-10-2**]
Service: SURGERY
Allergies:
Demerol / Codeine / Percocet / Darvocet-N 50 / Sulfa
(Sulfonamides)
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85 yo female with multiple medical problems include recent
stroke,
[**Name (NI) 7792**] s/p with fall at [**Hospital3 **] facility, found down,
+LOC, doesn't recall details of fall. She is on Coumadin and
Plavix for A fib. She was transported to [**Hospital1 18**] for further care.
Past Medical History:
Type II DM
HTN
Hypothyroid
H/o TIA
Ehrlos Danlos
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
Family history of Ehrlos Danlos. There is no family history of
premature coronary artery disease or sudden death.
Physical Exam:
Upon exam:
Gen: In hard collar
HEENT: significant swelling and ecchymosis R face, R eye,
bleeding cut near R eye
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date..
Language: Speech fluent with good comprehension and repetition.
Cranial Nerves:
II: unable to see right eye due to swelling, L eye PERRL, 5 to
3mm.
III, IV, VI: L Extraocular movements intact, R could not assess.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-9**] throughout. No pronator drift
Sensation: Intact to light touch, bilaterally.
Toes downgoing bilaterally
Pertinent Results:
[**2149-9-27**] 10:20PM GLUCOSE-158* UREA N-16 CREAT-0.7 SODIUM-140
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-29 ANION GAP-15
[**2149-9-27**] 10:20PM CK(CPK)-81
[**2149-9-27**] 10:20PM CK-MB-NotDone cTropnT-<0.01
[**2149-9-27**] 10:20PM CALCIUM-8.8 PHOSPHATE-3.7 MAGNESIUM-1.5*
[**2149-9-27**] 10:20PM WBC-8.7 RBC-3.04* HGB-8.1* HCT-23.6* MCV-78*
MCH-26.7* MCHC-34.4 RDW-14.0
[**2149-9-27**] 10:20PM PLT COUNT-284
[**2149-9-27**] 10:20PM PT-14.5* PTT-26.6 INR(PT)-1.3*
Head CT scan - [**2149-9-28**]
FINDINGS: The previously noted region of high attenuation,
representing clot,
in the right lateral ventricular body is now slightly smaller,
measuring 6 x
22 mm compared to prior 5 x 29 mm. There is a small amount of
blood layering
dependently in bilateral lateral ventricular occipital horns and
atria, more
represent interval redistribution of blood, rather than true
additional
hemorrhage. There are no other foci of intra- or extra- axial
hemorrhage.
There is no edema, mass effect, or shift of normally midline
structures.
Multifocal low attenuation in the bilateral periventricular and
subcortical
white matter, unchanged, likely represent chronic small vessel
ischemic
changes.
Again is noted mucosal thickening in bilateral ethmoid air cells
and air-fluid
level in the right sphenoid sinus. The right maxillary sinus and
orbital floor fractures are not included in the field of view or
well-
depicted in the current study. There is persistent swelling in
the right
periorbital region. The known right zygomatic arch fracture is
only partially
visualized.
IMPRESSION:
1. Slight reduction in size of the right lateral ventricular
thrombus, likely
adherent to choroid plexus, with some blood in the bilateral
occipital horns
and atria, likely representing redistribution of
intraventricular hemorrhage
rather than interval progression.
2. Persistent opacification of bilateral ethmoid air cells and
air-fluid
level in the right sphenoid sinus. The known facial fractures
are not
completely visualized on the current study. Please refer to
prior report
of dedicated maxillofacial CT for details.
3. Unchanged periorbital soft tissue swelling and preseptal
thickening.
Repeat head CT scan - [**2149-9-29**]
NON-CONTRAST HEAD CT: Compared to prior exam, right
intraventricular hematoma
is minimally decreased in size. Small amount of blood is seen
layering in the
dependent portions of the lateral ventricle, unchanged. No new
focus of
hemorrhage is identified. There is no hydrocephalus, shift of
normally
midline structure or evidence of major [**Month/Day/Year 1106**] territorial
infarct. The
[**Doctor Last Name 352**]-white matter differentiation is preserved. Hypodensities in
the
periventricular and subcortical white matter reflect chronic
microvascular
ischemic change. The cavernous carotid show atherosclerotic
calcification.
Again noted are ethmoid mucosal thickeninge, air-fluid level in
the right
sphenoid sinus and complete opacification of the right maxillary
sinus. Right-
sided facial fractures are better evaluated on dedicated CT from
[**2149-9-27**].
IMPRESSION: Compared to prior exam from [**2149-9-28**], there
is minimally
decreased size of right intraventricular hematoma. Small amount
of blood
layering within the dependent portion of the ventricle is
unchanged. No new
hemorrhage is identified.
[**2149-9-27**] CT SINUS/MANDIBLE/MAXIL
FINDINGS: Marked right-sided facial swelling and preseptal
swelling has been
evident. There is a depressed fracture involving the lateral
wall of the
right maxillary sinus by approximately 3 mm. There are several
comminuted
fractures of the lateral wall as well. An inferior maxillary
sinus fracture
is also evident. Comminuted fracture involving the medial wall
of the
maxillary sinus is noted. Hemorrhage and foci of emphysema fill
the right
maxillary sinus. Hemorrhage extends in to the ethmoid sinus at
the level of
the fracture of the medial wall. A comminuted fracture also
involves the
superior wall of the maxillary sinus. The right orbit appears
intact. No
fracture of the lamina papyracea is appreciated. The left
maxillary sinus is
intact. A small amount of high-attenuation material is also
noted within the
right sphenoid sinus and may indicate extension of right-sided
facial
fractures into the level of the sphenoid sinus. An acute
fracture of the
right zygomatic arch is again noted. No left-sided facial
fractures are
identified.
IMPRESSION: Right -sided facial fractures with hemorrhage
filling the right
maxillary sinus and extending into the right ethmoid and
sphenoid sinuses.
Fractures involving all walls of the maxillary sinus, including
the inferior
orbital wall. The right globe appears otherwise intact. There is
no evidence
of muscle entrapement but right inferior rectus is thicked
indicating trauma.
Brief Hospital Course:
She was admitted to the Trauma service. Her INR was reversed in
the Emergency room and her anticoagulants were withheld.
Neurosurgery and Plastic surgery were consulted. Her injuries
were non operative. She was taken to the Trauma ICU for close
monitoring. Serial neuro exams and head CT scans were performed.
There were no new areas of intracranial hemorrhage noted on
repeat scans. It is being recommended that her anticoagulants
not be restarted.
She was eventually transferred to the regular nursing unit.
Geriatrics was also consulted given her age and mechanism of
injury. Several recommendations were made pertaining to her
medications. She has a known history of hypertension and has
been on several medications to control this. Her systolic blood
pressures have ranged between 160-170's; she was previously on
Norvasc amongst her other blood pressure medications (see
Medications at home section) and this was resumed. Her PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] was contact[**Name (NI) **] and he reports that her baseline systolic
blood pressure ranges between 130-140's and has recommended to
increase the Norvasc from 2.5 mg to 5 mg.
She was noted to be delirious and it was recommended that she be
started on Zyprexa which has improved her mental status. Of
note, there have not been any behavioral issues.
Social work was consulted for patient and family emotional
support.
Medications on Admission:
Lidocaine 5% Patch 1 PTCH TD Q 24H
Chlorothiazide 500 mg PO DAILY
Meclizine 12.5 mg PO Q24H Order date: [**3-26**] @ 2301
Vytorin
Metformin 500mg [**Hospital1 **]
Levothyroxine Sodium 50 mcg PO DAILY
Lisinopril 20 mg PO DAILY
Atenolol 25mg QD
Vesacare
Allergies- Demerol / Codeine / Percocet / Darvocet-N 50
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. Lisinopril 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for HR <130; HR <60.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Solifenacin 5 mg Tablet Sig: Two (2) Tablet PO daily ().
10. Amlodipine 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): hold fro SBP<130.
11. Hydrochlorothiazide 12.5 mg Capsule Sig: Three (3) Capsule
PO DAILY (Daily).
12. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO Q6PM: hold
for increased sedation.
14. Erythromycin 5 mg/g Ointment Sig: One (1) APPL Ophthalmic
TID (3 times a day) for 2 days: Apply OD.
15. Nevanac 0.1 % Drops, Suspension Sig: One (1) GTT Ophthalmic
TID (3 times a day): Apply OS.
16. Moxifloxacin 0.5 % Drops Sig: One (1) GTT Ophthalmic TID (3
times a day): Apply OS.
17. Omnipred 1 % Drops, Suspension Sig: One (1) GTT Ophthalmic
TID (3 times a day): Apply OS.
18. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
19. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5481**]
Discharge Diagnosis:
s/p Fall
Maxillary sinus fracture
Inferior orbital wall fracture
Intraventricular head bleed
Coagulopathy secondary to elevated INR
Discharge Condition:
Hemodynamically stable, pain adequately controlled
Discharge Instructions:
AVOID any anticoagulants (except for Heparin SQ) until follow up
in 2 weeks with Neurosurgery.
Followup Instructions:
Follow up in 1 week with Plastic surgery for your facial
fractures, call [**Telephone/Fax (1) 5343**] for an appointment.
Follow up next week in [**Hospital 8095**] Clinic next week, call
[**Telephone/Fax (1) 253**] for an appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) 548**], Neurosurgery. Call
[**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will
need a repeat head CT scan for this appointment.
The following appointments were made prior to this
hospitalization:
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2149-10-14**]
11:00
Provider: [**Last Name (NamePattern5) 7224**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2149-10-14**]
12:00
Completed by:[**2149-10-2**]
ICD9 Codes: 2930, 4019, 2449, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8793
} | Medical Text: Admission Date: [**2149-3-15**] Discharge Date: [**2149-3-28**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old
male with a history of coronary artery disease, CABG in [**2136**],
hypertension, and GERD, who presented to an outside hospital
on [**2149-3-14**] with chest pain occurring at rest. The
chest pain was substernal radiating to the jaw, and as well
to both arms. He denied nausea, vomiting or diaphoresis. As
well, he denied shortness of breath. At the outside
hospital, he received aspirin, Nitroglycerin x 5, morphine 2
mg IV, and the chest pain resolved. However, he did have
persistent neck and arm pain. The patient was started on
heparin and received Nitro spray.
At the outside hospital, his vitals were blood pressure
96/62, pulse 79, respiratory rate 20, 99% on 2 liters. Labs
at the outside hospital revealed a CK of 144, MB 7.9, index
5.5, as well as troponin of 0.5. His EKG, by report, was
normal sinus rhythm, poor R wave progression, nonspecific
ST-T wave changes. No changes compared to an EKG on [**2149-3-9**]. The chest x-ray showed an elevated left hemidiaphragm
which had been seen on the previous chest x-ray since
[**2148-12-1**]. The patient reports being relatively
pain-free since his CABG. His last episode of chest pain was
approximately one year ago.
Upon arrival at [**Hospital1 18**], blood pressure 106/60, pulse 73. He
was given Lopressor 25 po x 1, sublingual Nitroglycerin x 1,
heparin drip, nitropaste. His chest pain went from being
[**1-10**] on arrival to being chest pain-free. His EKG showed a
normal sinus rhythm, left axis deviation, poor R wave
progression, T wave inversions in III, T wave flattening in
II and AVS.
The patient was admitted with unstable angina, non-ST
elevation MI. He was continued on aspirin, beta blocker, IV
Nitroglycerin, nitropaste, heparin drip, and started on
Integrelin.
PAST MEDICAL HISTORY: CAD, status post CABG x 4 in [**2136**],
hypertension, GERD complicated by Barrett's esophagus,
Paget's disease, DJD, trigeminal neuralgia, frequent falls,
restless leg syndrome.
MEDICATIONS ON ADMISSION: 1) aspirin 325 qd, 2) Lipitor, 3)
calcium, 4) Klonopin, 5) thiazide, 6) Celexa, 7)
multivitamin, 8) vicodin, 9) Prilosec, 10) valium 2.5 [**Hospital1 **].
MEDICATIONS ON TRANSFER FROM CT SURGERY SERVICE TO THE CCU
SERVICE: 1) albuterol nebs q 6 prn, 2) calcium carbonate
1,000 [**Hospital1 **], 3) Haldol 2 mg IV q 4 prn, 4) heparin IV, 5)
regular sliding scale insulin, 6) pantoprazole 40 qd, 7)
amiodarone 1 mg qd, 8) metoprolol 25 [**Hospital1 **], 9) furosemide 40 IV
bid, 10) Neo drip, 11) aspirin 325 qd, 12) albuterol MDI, 13)
colace 100 [**Hospital1 **], 14) Plavix 75 mg qd, 15) percocet.
SOCIAL HISTORY: He is retired. He has two children. He is
a lawyer whose healthcare proxy is [**Name (NI) **] [**Name (NI) 49438**], his lawyer.
The patient smokes a pipe. No alcohol use or illicit drug
use.
PHYSICAL EXAM ON ADMISSION: Heart rate 73, 106/61 blood
pressure, 12 respiratory rate, 92%/2 liters. A&Ox3. Cranial
nerves II through XII intact. Bilateral surgical pupils,
anicteric. OP clear. Moist mucous membranes. No JVD
appreciated. Lungs clear to auscultation. Cardiovascular -
regular rate and rhythm, no murmurs, rubs or gallops.
Abdomen - nontender, nondistended, positive bowel sounds.
Stool guaiac negative. Extremities - no edema, clubbing or
cyanosis, [**5-5**] lower extremity strength and upper extremity
strength.
LABS ON ADMISSION: Hematocrit 33.7, hemoglobin 11.2, white
count 6.6, platelets 224, sodium 141, potassium 4.3, chloride
103, bicarb 30, BUN 25, creatinine 1.1, glucose 138, CK 144,
MB 7.94, MB 5.5, troponin .........
IMPRESSION: This is an 85-year-old male admitted with
unstable angina with a significant CAD history, for non-ST
elevation MI.
HOSPITAL COURSE: The patient was continued on aspirin, beta
blocker, nitropaste, heparin drip, and started on Integrelin.
He remained chest pain-free, and on the [**2149-3-17**], he
underwent a cardiac catheterization. His peak CK was 617, MB
3, index 13.5, troponin 34.9. These were from the [**2149-3-15**].
On cardiac catheterization, he had a right atrial pressure of
20, mid RCA 100% lesion, acute marginal 60% lesion, proximal
LAD 100%, midcircumflex 60%, OM 80%. His grafts, SVG1 to the
PDA had a 90% discrete midlesion. The SVG2 to OM, as well as
the left LAD to LIMA, were patent.
The patient underwent PCI of the SVG to PDA. The procedure
was complicated by perforation of the SVG/RV. A GelMed stent
was placed in the perforated region. The patient continued
to leak dye distal to the GelMed stent. An additional GelMed
stent was placed distally. The graft was occluded using a 3
mm balloon.
At that time, the patient was noted to have severe chest
pain, and also became hypotensive. STAT echo revealed a
hemopericardium with pericardial tamponade. Physiology
pericardiocentesis performed, complicated by RV perforation.
The patient was intubated and went emergently to cardiac
surgery on dopamine and neo-synephrine. The surgery portion
of the vein from the lower leg was harvested.
Stroke monitoring was performed and a moderate amount of
blood from the RA was drained. There was no bleeding found
from the RA graft with perforation present in the lower
aspect of the RV which was cauterized. Two drains were
placed. The patient had severe biventricular failure despite
inotropic support. He spiked a temperature to 101.8 on
[**3-18**]. He was started on vancomycin, as well as heparin and
Plavix. He was weaned off pressors. Epi was weaned on
[**3-19**]. Levo was weaned on [**3-20**]. He was extubated on [**3-19**].
Chest tube removed [**3-21**].
Per nurse's report, the patient's course has been complicated
by delirium in the Cardiothoracic Unit. He had atrial
fibrillation on the 20th. He was started on amiodarone drip
and heparin and converted to normal sinus rhythm on the 21.
He had 18 hours total of atrial fibrillation. He had another
episode the evening of the 23 into the 24 that lasted four
hours. Since then, he has been in normal sinus rhythm. He
was transferred to the CCU for management on the [**3-21**].
PHYSICAL EXAMINATION: On the day of discharge, the patient's
exam revealed a blood pressure of 112/57, heart rate 70, 96%
on 5 liters nasal cannula. He was in no acute distress,
sitting up in chair, answering questions appropriately, A&O x
3. Surgical pupils. EOMI. Poor dentition. Dobbhoff NG tube
in left nostril. JVD approximately 8-9 cm. Cardiovascular -
regular rate and rhythm, distant heart sounds, no murmurs,
rubs or gallops. Crackles - one a quarter the way up
bilaterally. Abdomen - soft, normoactive bowel sounds, no
tenderness. Extremities - no edema. His left leg harvest
site had mild erythema. Cranial nerves II through XII were
intact. He had 4/5 strength. Able to ambulate a small
number of steps with assistance from bed to chair.
LAB DATA DAY OF DISCHARGE: Hematocrit 33.9, hemoglobin 11.3,
platelets 199, white blood cell 8.3, sodium 135, potassium
3.7, chloride 107, bicarb 28, BUN 25, creatinine 0.9, calcium
7.8, phosphorus 3.3, magnesium 1.8. The patient had a
negative HIT antibody.
The patient had blood cultures on the 21 and urine cultures
on the 21 that have no growth. One out of four bottles on
the blood culture showed the Staph epi. The patient has been
afebrile since his transfer to the CCU, with a normal white
count.
An echocardiogram on [**3-24**] showed a 5x2 cm mass extending to
the left atrium that was compressing the left atrium. The
left atrium was mildly dilated. The right atrium was normal
size. Mild depressed LV. No reliable measure of EF. Right
ventricular chamber size was normal. Trivial MR and 1+ TR.
No tamponade. No effusion. The patient had oropharyngeal
swallowing study on the [**3-25**]. Nonfunctional
swallowing ability with aspiration of pureed foods and nectar
thickened liquids after the swallow.
It is anticipated that when the patient gets a little bit
stronger and gets out of the unit, can safely swallow on
clear and secretions, he should be able to eat and swallow.
Reassessment should be done at that time. Recommendations of
tube feeds and videoscope in which the patient was found to
just have problems clearing secretions and collecting
secretions, with likely ability to improve his function in a
short period of time.
The patient is an 85-year-old male with CAD, status post
coronary artery bypass graft in [**2136**], hypertension,
hypercholesterolemia who presents with non-ST elevation
myocardial infarction, status post SVG perforation, RV
perforation, with pericardial tamponade requiring emergent
cardiac surgery for drainage. Postop atrial fibrillation
approximately x 8 hours. Currently in normal sinus rhythm,
....................ischemia. He was continued on aspirin
and Plavix, as well as beta blocker. Blood pressure ran low
at times, as low as maps around 60 to high-50s. The patient
never required pressors, although his Lopressor dose was
decreased to 12.5 [**Hospital1 **] with his heart rate steadily in the
60s-70s.....................
The patient had a cycle in the CCU of being volume overloaded
and then being aggressively diuresed with 40 lasix IV bid and
then being dehydrated with low blood pressure. The echo, as
previously stated, showed mildly depressed EF without
specific EF. This should probably be followed up as an
outpatient with a repeat echo at a later date. On the [**3-24**], the patient had a Swan placed, a right IJ Cordis and
Swan. The patient was A&O x 3 and was consented for the
Swan. This was done without complication. CVP was
approximately 12, RV pressure was approximately 40/18, PA was
approximately 38/26, and his wedge was approximately 18.
On the day of discharge, the patient was being converted to
two-day medicine staggered, Zestril 2.5 pm, Toprol XL 25 q am
with 40 po lasix qd. This will allow for maximization of his
blood pressure while placing him on cardioprotective and
anti-CHF medication. On the day of discharge, the patient is
in mild, compensated fluid overload. He is receiving 20 of
IV lasix. The patient should have weights qd and strict in's
and out's to the best of his ability, and be followed up at
the [**Hospital 1902**] Clinic here at [**Hospital1 **], and have his
regimen adjusted based on his weights.
RHYTHM: The patient had 18 hours of atrial fibrillation
postop. He has been normal sinus rhythm. He has had guaiac
positive stools. The heparin was DC'd, as well as the
amiodarone. He has maintained normal sinus rhythm with the
exception of four hours on the evening of the 23. He is
maintained with beta blocker to help control his heart rate.
ID: Despite the episode of fever prior to his transfer to
the CCU, the patient had no leukocytosis, no fever during his
time in the ICU, and no clear tissue source of infection. He
was empirically treated with Levaquin for seven days. It is
unclear whether the patient had pneumonia, and he also was
being treated with clindamycin for a course of 10 days for
cellulitis around his vein harvest site. On the day of
discharge, the site was much improved. The patient was
afebrile with a normal white count. The patient should have
periodic stools sent for C. diff following the use of the
clindamycin. If he should develop diarrhea, a C. diff test
should be sent and treated with Flagyl appropriately.
GI: The patient was continued on Protonix for GERD.
MENTAL STATUS: Although the patient was experiencing
delirium prior to his transfer to the CCU, his course has
been one of generally improving mental status, and on the
days prior to admission the patient was alert and oriented x
3, sitting up in a chair, joking, and resembling himself
prior to his hospitalization.
PSYCH: He gets Klonopin for restless leg syndrome and
Celexa. The patient did not require Haldol at all for
agitation in the CCU.
FLUIDS, ELECTROLYTES AND NUTRITION: The patient had a low
albumin, but also had the failed swallowing study secondary
to secretions. He had an NG tube placed with tube feeds.
The patient was receiving ....................with fiber 70
cc/h and has reached his goals. He has a Dobbhoff feeding
tube. The patient will require a follow-up swallowing study.
I anticipate that within a week he should be able to return
to PO.
HEME: The patient has had guaiac positive stools. His
hematocrit has been stable since he has been off the heparin.
The guaiac positive stools were in the context of
anticoagulation. He will require follow-up in this matter.
As an outpatient his hematocrit has been stable since
receiving a transfusion.
DISCHARGE DIAGNOSES: 1) Coronary artery disease status post
coronary artery bypass graft. 2) Non-ST elevation myocardial
infarction, status post catheterization with perforation of
his saphenous vein graft and puncture of his right ventricle
resulting in tamponade and requiring open surgical
intervention. 3) Hypertension. 4) Gastroesophageal reflux
disease complicated by Barrett's esophagitis. 5) Paget's
disease. 6) Degenerative joint disease. 7) Trigeminal
neuralgia. 8) Restless leg syndrome. 9) Frequent fall
history.
DISCHARGE CONDITION: Good.
DISCHARGE MEDICATIONS: 1) lasix 40 mg po qd, 2) lisinopril
2.5 mg po q pm, 3) metoprolol XL 25 mg po q am, 4)
lansoprazole oral solution 30 mg po NG qd now and when the
patient is taking POs this can be converted to a pill; 5)
clindamycin 300 mg po q 6 h should be continued until [**4-1**], 6) aspirin 325 qd, 7) heparin 5,000 U subcu q 12 h and
this may be discontinued when the patient is ambulating, 8)
Flovent 110 mcg 2 puffs inhaled [**Hospital1 **], 9) salmeterol 1-2 puffs
inhaled [**Hospital1 **], 10) Dorzolam 2%, timolol 0.5% ophthalmic drops 1
drop OU [**Hospital1 **], 11) clonazepam 0.5 mg po tid, 12) Atrovent nebs
1 neb q 6 h and held prn shortness of breath; he is currently
getting them q 6 h, 13) Pravachol 20 mg po qd, 14) calcium
carbonate 1,000 mg po bid, 15) colace 100 mg po bid, 16)
Plavix 75 mg po/NG qd, 17) Tylenol 325-650 mg po/q 4-6 h prn.
FOLLOW-UP: The patient should have follow-up with the [**Hospital 1902**]
Clinic approximately one week following discharge. He should
have daily weights, and I's and O's to the best of his
ability tracked to monitor the patient's fluid status. The
patient should have a swallowing study repeated within the
week after his discharge to rehabilitation to see if he is
able to resume po intake. He will require nutritional
supplements for calories and protein. The patient will also
require follow-up with CT surgery. The number will be
enclosed, and a call should be made to follow-up.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Last Name (NamePattern1) 1659**]
MEDQUIST36
D: [**2149-3-28**] 12:28
T: [**2149-3-28**] 11:28
JOB#: [**Job Number 49439**]
ICD9 Codes: 9971, 2765, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8794
} | Medical Text: Admission Date: [**2123-10-20**] Discharge Date: [**2123-10-23**]
Date of Birth: [**2065-5-25**] Sex: F
Service: CICU
HISTORY OF PRESENT ILLNESS: Patient is a 58-year-old female
with a past medical history significant for coronary artery
disease, status post multiple interventions, type 2 diabetes
mellitus, and hypercholesterolemia who was transferred from
an outside hospital for management of unstable angina.
Patient presented to the outside hospital with a complaint of
recurrent weakness and dizziness with a three day history of
progressive chest pressure and difficulty breathing.
Patient reports a several week history of intermittent dizzy
spells, often occurring in the afternoon while at rest. The
patient's atenolol dose was decreased from 150 to 100 one
week prior to presentation which, by report, seemed to help
for several days. However, the dizziness returned the day of
presentation.
The patient also reports a three day history of chest
pressure with shortness of breath and generalized fatigue,
which prompted the patient to seek evaluation. At baseline,
the patient experiences angina "at rest". Typical anginal
symptoms include chest tightness without radiation or
associated symptoms, relieved with 1-2 sublingual
nitroglycerin. The patient reports anginal symptoms
reportedly worsening over the course of three days.
On the day of admission, the patient reports [**5-26**] chest
pressure described as "weight on my chest", unrelieved with
two sublingual nitroglycerins. The chest pressure was
accompanied by vomiting, tightening around the lower lip,
shortness of breath, and fatigue. The patient reports two
pillow-stable orthopnea, and medical compliance, and denies
new medications, paroxysmal nocturnal dyspnea, cough, fever,
chills, and increasing edema.
At the outside hospital, the patient was found bradycardic
(heart rate in the 40s) and hypotensive (systolic blood
pressure 60-80) with persistent mild chest pain. The patient
was started on dopamine and nitroglycerin drip, and became
chest pain free with stabilization of her blood pressure.
The patient was transferred chest pain free to [**Hospital1 346**] for further management.
In the [**Hospital1 69**] Emergency
Department, the patient has remained chest pain free on
nitroglycerin drip. The dopamine was weaned from 30
mcg/kg/hour to 5 mcg/kg/hour. The patient's
electrocardiogram on admission to [**Hospital1 190**] demonstrated normal sinus rhythm with no acute
ST-T wave changes, and evidence of prior anterior wall
myocardial infarction.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post multiple interventions
including [**2117-3-17**] percutaneous intervention with stents
placed in the left anterior descending artery and right
coronary artery, [**2117-6-17**], status post PTCA of the left
anterior descending artery instent stenosis, [**2117-7-18**],
status post PTCA of right coronary artery instent stenosis,
[**2117-8-17**] anterior wall myocardial infarction status
post coronary artery bypass graft with each graft from the
left internal mammary artery to the left anterior descending
with inferior epigastric graft (subsequently failed), [**2118-1-15**] redo coronary artery bypass graft with [**Year (4 digits) **] to the left
anterior descending artery and saphenous vein graft to the
right coronary artery, [**2119-6-17**] percutaneous intervention
with status post PTCA of the left anterior descending artery
via the [**Last Name (LF) **], [**2122-2-15**] status post PTCA of the D1
branch, [**2122-6-17**] status post cardiac catheterization
with no intervention, patent [**Year (4 digits) **] to the left anterior
descending artery.
2. Type 2 diabetes mellitus.
3. Hypercholesterolemia.
4. Morbid obesity.
MEDICATIONS ON ADMISSION:
1. Atenolol 100 mg po q day.
2. Enteric coated aspirin 325 mg po q day.
3. Reglan 10 mg po tid.
4. Nitropaste (dose unknown).
5. Zocor 40 mg po q day.
6. Ambien 10 mg po q day.
7. Amaryl 4 units po q day.
8. Glucophage 1,000 mg po bid.
9. Folic acid 1 mg po q day.
10. Tiazac 360 mg po q day.
11. Nexium 20 mg po q day.
12. Neurontin 600 mg po bid.
13. Zoloft 200 mg po q day.
14. Lasix 40 mg po bid.
15. Potassium chloride 20 mEq po q day.
16. Plavix 75 mg po q day.
17. Celebrex 200 mg po q day.
18. Xanax (dose unknown).
ALLERGIES: Dye allergy with a reaction of severe vomiting.
SOCIAL HISTORY: The patient is married and lives with her
husband, patient denies tobacco as well as recreational drug
use, and reports rare alcohol use.
FAMILY HISTORY: Notable for coronary artery disease with
father dying of a myocardial infarction at the age of 49.
PHYSICAL EXAM ON ADMISSION: Temperature of 97.0, blood
pressure 100/60, heart rate 64, oxygen saturation 99% on 2
liters nasal cannula. In general, the patient is alert and
pleasant, morbidly obese female in no acute distress. HEENT
examination: Normocephalic, atraumatic, anicteric sclerae,
clear oropharynx, dry mucous membranes. Neck examination:
Supple, no jugular venous distention, jugular venous pressure
to the angle of the jaw. Pulmonary examination: Clear to
auscultation bilaterally with no wheezes, rales, or rhonchi.
Cardiovascular examination: Regular, rate, and rhythm,
normal S1, S2, no S3, S4 noted. Soft systolic murmur noted
at the right upper sternal border. Abdominal examination is
soft, obese, normoactive bowel sounds, nontender,
nondistended. Extremities: Warm and well perfused, 2+
dorsalis pedis and posterior tibial pulses, no edema noted,
no femoral bruit noted.
LABORATORIES AND STUDIES ON ADMISSION TO [**Hospital1 **]: Complete blood count with a white
blood cell count of 10.9, hematocrit 31.3 and platelets of
246. Chem-7 with a sodium of 136, potassium 5.2, chloride
103, bicarb 20, BUN 34, creatinine 1.8, and glucose of 273.
Coags with a PT of 13.2, INR of 1.2, and PTT of 28.2.
Remainder of the hospital course to be continued.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Name8 (MD) 4935**]
MEDQUIST36
D: [**2123-11-25**] 17:14
T: [**2123-11-26**] 07:53
JOB#: [**Job Number 96620**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8795
} | Medical Text: Admission Date: [**2176-1-23**] Discharge Date: [**2176-1-31**]
Date of Birth: [**2122-1-31**] Sex: M
Service: MEDICINE
Allergies:
Lactose-Free Food
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Metformin & Levothyroxine overdose
Major Surgical or Invasive Procedure:
Intubation and Mechanical Ventilation
[**First Name9 (NamePattern2) 95229**] [**Last Name (un) **]-Venous hemodialysis
History of Present Illness:
This is a 54 year old man with history of depression and prior
suicide attempts who presents following overdose on multiple
medications. Recent hospitalization at [**Hospital 8**] Hospital. Had
been hording meds. Told his psychiatrist he wanted to kill
himself - patient referred to OSH ED, overdosed on grounds of
the OSH. Took metformin, levothyroxine, and several of
antidepressants ~10:30pm. Initially lucid, then progressively
"groggy." Had witnessed tonic-clonic seizure while on bedside
commode. Intubated there, given charcoal and ativan then
transferred to [**Hospital1 18**]. He apparently aspirated a "substational
amount" of charcoal at the OSH.
In the ED, vitals were 98 97 96/41 99% on 100% AC, on peripheral
dopa. FAST was negative, pump function appeared adequate.
Persistent hypotension as low as 70's. Neo and levophed were
added. Right groin line placed. OG tube placed. Has received
nearly 8L of fluid total. Toxicology was consulted and he was
started on bicarbonate per their recommendations. No history of
CCB ingestion. EKG with QRS of 106 and upright R in avR. CT head
without evidence of bleed or mass. Current vitals 102 92/40 16
97%. Got empiric vancomycin in ED (did not get zoysn ordered).
Past Medical History:
Depression, h/o suicide attempts
-- Has PACT team, followed in [**Location (un) 538**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Rehab
Baycove Pact [**Telephone/Fax (1) 95230**] caseworker [**Female First Name (un) 21105**] Dr. [**Last Name (STitle) 95231**],
[**Telephone/Fax (1) 95232**]
-- [**Hospital1 8**] psych emergency service [**Telephone/Fax (1) 95233**] contact
[**Telephone/Fax (1) 95234**] pager [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Bipolar disorder (prior dx of schizoaffective per psych)
Aspergers
Hypothyroidism, h/o [**Doctor Last Name 933**]
Diabetes
Cardiomyopathy EF 40% MIBI [**2169**]
HTN
Hyperlipidemia
Social History:
history of smoking per OMR
Family History:
non-contributory
Physical Exam:
Vitals 95.2 102 105/57 17 96% on AC 550x22, 1.0
General Intubated and sedated obese man +charcoal in ET tube
HEENT Pupils dilated to ~5mm but reactive, charcoal draining
from OGT
Neck Unable to assess JVP secondary to habitus
Pulm Lungs with bronchial breath sounds bilaterally, no wheezing
or rales
CV Regular S1 S2 no m/r/g
Abd Obese nontender +bowel sounds soft
Extrem Warm well perfused full distal pulses
Neuro Sedated
.
Lines/tubes/drains R femoral line
Pertinent Results:
CT Head [**2176-1-23**]: No acute intracranial hemorrhage or fracture.
ECHO [**2176-1-23**]: 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. There is an anterior space
which most likely represents a fat pad.
LENI [**1-28**] No DVT.
CXR - [**1-29**]:
FINDINGS: Heart size is normal. Aorta is mildly tortuous. Marked
improvement in aeration of the lungs with near complete
resolution of
bibasilar opacities with some residual bronchial wall thickening
in the
perihilar and basilar regions. Questionable small left pleural
effusion on
lateral view. IMPRESSION: Near resolution of bibasilar
opacities. Residual bronchial wall thickening and questionable
small left effusion.
cbc:
[**2176-1-23**] 08:10AM BLOOD WBC-19.9* RBC-4.10* Hgb-12.9* Hct-39.3*
MCV-96 MCH-31.5 MCHC-32.8 RDW-14.4 Plt Ct-295
[**2176-1-30**] 01:00PM BLOOD WBC-10.9 RBC-3.96* Hgb-12.6* Hct-36.1*
MCV-91 MCH-31.9 MCHC-35.0 RDW-14.0 Plt Ct-334
chemistries:
[**2176-1-23**] 08:10AM BLOOD Glucose-336* UreaN-19 Creat-1.9* Na-142
K-4.9 Cl-116* HCO3-12* AnGap-19
[**2176-1-25**] 03:24PM BLOOD Glucose-169* UreaN-33* Creat-3.3* Na-136
K-5.1 Cl-103 HCO3-25 AnGap-13
[**2176-1-30**] 01:00PM BLOOD Glucose-153* UreaN-14 Creat-1.1 Na-137
K-4.1 Cl-98 HCO3-30 AnGap-13
lfts:
[**2176-1-23**] 08:10AM BLOOD ALT-20 AST-15 CK(CPK)-163 AlkPhos-55
TotBili-0.2
[**2176-1-23**] 06:46PM BLOOD CK(CPK)-278*
[**2176-1-23**] 08:10AM BLOOD Lipase-33
[**2176-1-26**] 03:00AM BLOOD Lipase-66*
[**2176-1-28**] 03:26AM BLOOD Lipase-124*
iron studies:
[**2176-1-23**] 02:46PM BLOOD calTIBC-239* VitB12-257 Folate-13.1
Ferritn-53 TRF-184*
[**2176-1-27**] 02:57AM BLOOD Hapto-262*
tfts:
[**2176-1-23**] 08:10AM BLOOD TSH-8.0*
[**2176-1-28**] 03:26AM BLOOD TSH-6.2*
tox screen:
[**2176-1-23**] 08:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2176-1-23**] 02:46PM BLOOD Ethanol-NEG
abg/lactate:
[**2176-1-23**] 08:40AM BLOOD Lactate-7.0*
[**2176-1-23**] 08:40AM BLOOD Type-ART pO2-119* pCO2-44 pH-7.10*
calTCO2-14* Base XS--15 -ASSIST/CON Intubat-INTUBATED
[**2176-1-28**] 05:23AM BLOOD Type-ART Temp-36.6 Rates-/18 FiO2-100 O2
Flow-15 pO2-122* pCO2-43 pH-7.42 calTCO2-29 Base XS-3
Intubat-NOT INTUBA Comment-NEBULIZER
[**2176-1-23**] 11:43AM BLOOD BETA-HYDROXYBUTYRATE-Test (< 0.3)
Brief Hospital Course:
This 54 year old man with history of depression presents
following overdose of Metformin and Levothyroxine with seizure.
1. Overdose/ Suicide Attempt: Through contacting outside
sources it appears that Mr. [**Known lastname **] [**Last Name (Titles) **] Metformin,
Levothyroxine and available antidepressants in a suicide
attempt. Has been diagnosed with dysthymic disorder and
dependent personality disorder in the past, and wife recently
passed away. He was intubated at outside hospital for airway
protection. Once admitted to the MICU he was started on a
bicarbonate drip with Toxicology, Psychiatry and Renal
following. CVVH was started for rising creatinine and
electrolyte abnormalities. The patient's laboratory values
normalized before transfer from the MICU. He was monitored with
a 1:1 sitter and on Haldol. His other psychiatric medicines
were held in the MICU. He was started oral risperidone with
supervision on the floor. His lamictal and wellbutrin were held
during the stay for suspicion of overdose with antidepressants.
These medications may be resume per psychiatric evaluation. The
patient was transferred to an acute psychiatric facility on
discharge.
2. Hypoxic Respiratory Failure: The patient was witnessed
aspirating charcoal at OSH. He was intubated for airway
protection and hypoxic respiratory failure. He did not develop
signs of bacterial pneumonia. He was successfully extubated and
transferred on 3L Nasal Canula. There was a concern for
pulmonary embolus based on a chest x-ray read, but ultrasound
was unable to find a deep vein thrombosis. His hypoxia resolved
after extubation. Repeat CXR on [**1-29**] showed near resolution of
bibasilar opacities.
3. Hypotension/Hypertension: The patient developed hypotension
secondary to overdose. He was started on Levophed &
Neosynephrine for support. A TTE ruled out cardiac etiology. He
was successfully weaned and actually developed hypertension from
agitation which was controlled with a nitroglycerin drip. The
patient was started on Amlodipine on transfer. He was weaned off
of the nitroglycerin drip, and his hypertension was controlled
on amlodipine and ACEi on discharge.
4. Acute renal failure: The patient developed acute renal
failure secondary to Metformin overdose. He was started on
continuous renal replacement therapy which was well tolerated.
His urine output and renal function returned spontaneously and
were stable on discharge. Metformin was restarted for diabetes
control.
5. Ileus: The patient did not stool while intubated. He vomited
once while extubated. Enemas placed after extubation were
successful in mobilizing his impacted charcoal.
6) Leukocytosis: The patient was found to have a Leukocytosis
on admission, attributed to a combination of acute stress
response from overdose and probably aspiration pneumonitis. No
cultures grew positive and no antibiotics were continued in the
MICU and his white count resolved.
7) Anemia: The patient was found to have an anemia with unknown
baseline that trended down with repeated fluid hydration. No
evidence of iron deficiency. B12 levels were low normal.
Hemolysis labs were negative. Hematocrit was stable at 36 on
discharge.
8) Hypothyroidism: The patient's Levothyroxine was held in the
acute post-overdose situation. It was restarted when he showed
clinical improvement.
Medications on Admission:
Albuterol 2puffs q4h pnr
Colace 100mg qhs
Lamictal 50mg qhs
Metformin 500mg [**Hospital1 **]
Risperdal 2mg [**Hospital1 **]
Synthroid 112mcg daily
Wellbutrin 100mg [**Hospital1 **]
Zestril 20mg daily
Discharge Medications:
1. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for agitaiton.
3. Amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
6. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-12**] Inhalation four
times a day as needed for shortness of breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1680**] [**Hospital **] Hospital
Discharge Diagnosis:
1' Diagnosis
Medication Overdose
Acute renal failure
Diabetes Mellitus
Discharge Condition:
stable
Discharge Instructions:
You were admitted with a diagnosis of overdosing on your
medications metformin, levothyroxine, and anti-depressants. You
were admitted to the ICU for closer monitering and then
transitioned to the general floor as your clinical condition
improved. You will be discharged to a psychiatric facility.
Please take your medications as directed. We did not give you
your lamictal and wellbutrin in the hospital.
Please return to the ED or call your primary care physician if
you experience any of the following symptoms: chest pain,
shortness of breath, palpitations, light-headedness or loss of
consciousness, thoughts of wanting to hurt yourself or other
people, or any other symptoms not listed here that warrant
physician [**Name Initial (PRE) 2742**].
Followup Instructions:
with your PCP [**Name9 (PRE) **],[**First Name3 (LF) **] [**Name Initial (PRE) **] [**Telephone/Fax (1) 80088**] within 1-2 weeks
after discharge.
with psychiatry as directed by your psychiatric facility.
Completed by:[**2176-2-1**]
ICD9 Codes: 5845, 2762, 4254, 2859, 4019, 2724, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8796
} | Medical Text: Admission Date: [**2196-12-5**] Discharge Date: [**2196-12-11**]
Date of Birth: [**2130-8-30**] Sex: M
Service: MICU Oange Team#58
HISTORY OF PRESENT ILLNESS: Patient is transferred from
[**Hospital3 **] for hypoxemic respiratory failure. He is a
66 year-old man with known past medical history but who has
not brought medical care for many years who was brought to
[**Hospital3 **] [**12-2**] of shortness of breath times several
weeks. Upon arrival patient was found to have an oxygen
saturation in the 70s, was cyanotic, discovered on imaging to
have a large right sided pleural effusion with white-out of
the right hemithorax. Patient also had a white blood cell
count of 20.5 with 89 percent polys. A right chest tube was
placed after intubation with greater than 4 liters of
serosanguinous fluid drained. Subsequent CT of the chest
showed complete obstruction of the right main stem bronchus
with right effusion and total right lung collapse. He also
had a left effusion of moderate size with atelectasis of the
left lung posteriorly at lingula. Patient also was severely
hypercapnic on presentation with pCO2 of 85 and a pH of 7.2.
After CT patient underwent bronchoscopy with confirmation of
right main stem total occlusion. Patient also had
endobronchial biopsies of this right main stem lesion.
Pathology and cytology from the bronchoscopy was sent.
Patient's oxygenation and ventilatory status were stabilized
and he was transferred here for further evaluation and
management and possible stenting procedure of his right main
stem bronchus.
PHYSICAL EXAMINATION: Temperature 98.6, blood pressure
105/62, heart rate 94, respirations 16, oxygen saturation 94
percent on 50 percent FIO2. Vent was SIMV mode 500 cc, 12
breaths per minute, pedal volumes are about 350 cc, pressure
support was 8, PEEP was 10, FIO2 50 percent. Generally he is
an obese plethoric male intubated but alert and responding to
questions. Head, eyes, ears, nose and throat: plethoric
edematous face, anicteric, pupils equal, round, reactive to
light. Neck is supple, extremely large, unable to assess
jugular venous pressure. Cardiovascular: Regular rate and
rhythm, normal S1, S2, no murmurs, rubs or gallops. Chest:
bandage at right chest tube site, clean, dry and intact.
Decreased breath sounds over entire right side, and decreased
breath sounds at the left base. No wheezes, rhonchi or
rales. Abdomen: question of paradoxical abdominal movements
with respiration. Soft, nontender, nondistended, normal
active bowel sounds. Extremities: Edematous hands but
nonedematous feet, cyanosis cool fingers bilaterally.
Patient with clubbing of his toes bilaterally.
Neurologically he is alert, answering questions and writing
appropriately. Moving all extremities symmetrically.
LABORATORY DATA: At the outside hospital - white count 11.9,
hematocrit 32.5, platelets 358, 89 percent polys, 4 percent
lymphocytes. INR 0.9. PTT 26.8. Sodium 131, potassium 5.5,
chloride 93, bicarbonate 33, BUN 16, creatinine 0.6, glucose
141, albumin 2.1, total protein 6.1, total bilirubin 0.6,
direct bilirubin 0.1, alkaline phosphatase 97, ALT 34, AST
30, LDH 139. CK peak was 95, 26 upon transfer. CEA was 1.9.
Troponin I was initially 0.15 with a peak of 2.0 which
decreased back down to 0.9 upon transfer. Pleural fluid:
glucose72, LDH 139, amylase 27, total protein 3.9, pH 8.0,
hazy, white blood cell count [**Pager number **], red blood cells 3,850, 82
percent polys, 16 percent lymphocytes, 2 percent monocytes.
CT of the chest showed extremely large right sided pleural
effusion with right lung collapse suspicious for underlying
tumor, right chest tube in place, moderate size left pleural
effusion with subsequent atelectasis, posterior left lung and
lingula. Small pericardial effusion, no evident pulmonary
embolism and small ascites. Chest x-ray shows significant
change from prior films with large right pleural effusion
opacifying entire right hemithorax. Small left effusion and
an endotracheal tube and orogastric tube in satisfactory
positions. Electrocardiogram showed diffusely low voltage,
normal sinus rhythm at 65, flat T waves throughout, T waves
in V1 through V3. Pathology from right main stem
endobronchial biopsy at [**Hospital3 **] came back positive
for nonsmall cell lung cancer, poorly differentiated.
Cytology from 3 cc of pleural fluid came back negative for
malignancy.
HOSPITAL COURSE: 1) Right main stem bronchial obstruction.
Patient transferred from [**Hospital3 **] for stent of right
main stem bronchus. Endobronchial biopsy performed at
[**Hospital1 **] - 3 cc of right effusion sent for cytology which was
negative for malignancy. Right main stem bronchial biopsy
came back positive for nonsmall cell lung cancer, poorly
differentiated. His right main stem lesion was debulked and
the right main stem bronchial stent was placed although his
right lung remained collapsed [and his right chest tube
drainage increased slightly but his right effusion remains
large. He also had a moderate size left effusion, status
post left thoracentesis drainage of 1800 cc. Laboratory
analysis of his left effusion is pending. He is to have a
pleurodesis of his right lung Monday [**12-12**]. Radiation
oncology is consulting for possible palliative radiation
therapy to reinflate his right lung.
2) Nonsmall cell lung cancer newly diagnosed, likely stage 4
as CT scan shows left adrenal fullness. Hematology oncology
and radiation oncology were consulted for possible palliative
treatment. Head CT was negative. Bone scan to be done [**12-12**]
for full staging procedure. Chest CT showed evidence of left
adrenal fullness and superior vena cava syndrome with
associated nonobstructing superior vena cava clot. Radiation
oncology will leave final recommendations for possible
radiation therapy treatment to reinflate right lung.
Pleurodesis planned for right lung [**12-12**]. Heparin drip
started for evidence of clot in the superior vena cava and
possible clot in the right atrium on CT scan.
3) Coronary artery disease. Patient with episode of 22 beats
of ventricular tachycardia and multiple recurrent episodes of
stable ventricular tachycardia. He underwent catheterization
prior to stenting procedure which revealed non-intervenable
three vessel disease. He was continued on aspirin, beta
blocker and ACE inhibitor. He continued to have several
episodes of stable ventricular tachycardia and his potassium
and magnesium were repleted aggressively. Electrocardiogram
upon transfer here showed new Q waves in leads 1 and AVL and
cycle troponins were decreasing here. Electrocardiograms
have remained unchanged since transfer.
4) Code status: The patient is a Do Not Intubate as per him
and his wife.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Last Name (NamePattern1) 5819**]
MEDQUIST36
D: [**2196-12-11**] 16:51
T: [**2196-12-11**] 17:56
JOB#: [**Job Number 53752**]
ICD9 Codes: 486, 4271, 5180, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8797
} | Medical Text: Admission Date: [**2132-10-28**] Discharge Date: [**2132-10-28**]
Date of Birth: [**2053-3-26**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
ID: Transfer from OSH with acute blast crisis
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
79 yo male presented to OSH with fever, fatigue and found to
have WBC 200,000 with 99% Blasts. Was to be transferred to
[**Hospital1 18**] emergently for leukopheresis. En route, he developed
respiratory arrest and EMS returned to OSH, where pt was
intubated. He was also noted at that time to have [**Location (un) 2611**] Coma
Scale of 3 with fixed, dilated pupils. He was then Med-Flighted
directly to [**Hospital1 18**] [**Hospital Ward Name 332**] ICU. En Route he had PEA arrest x 2
which responded to epinepherine.
He arrived intubated and unresponsive.
Past Medical History:
unknown
Social History:
unknown
Family History:
unknown
Physical Exam:
Gen: intubated, nonsedated and unresponsive.
HEENT: pupils fiexed, dilated. No gag reflex. No withdrawal to
noxious stimuli. Gross bleed suctioned from ETT.
Chest: rhonchorous Ant/lat
Cards: Tachy reg no rgm
Abd: diminished bowel sounds
Extr: diffuse petichiae and purpura.
Pertinent Results:
[**2132-10-28**] 08:32AM WBC-199.7* RBC-UNABLE TO HGB-8.4* HCT-25.5*
MCV-UNABLE TO MCH-UNABLE TO MCHC-31.1 RDW-UNABLE TO
[**2132-10-28**] 08:32AM NEUTS-0 BANDS-2 LYMPHS-2* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-1* OTHER-94*
[**2132-10-28**] 08:32AM PLT COUNT-32*
Brief Hospital Course:
79 yo male presented to OSH with fever, fatigue and found to
have WBC 200,000 with 99% Blasts, then with respiratory arrest
and GCS 3, transferred to [**Hospital1 **] [**Hospital Unit Name 153**] intubated and unresponsive.
Upon arrival, patient's family updated on his condition:
prognosis for any neurologic recovery given his underlying blast
crisis at age 79 is bleak. Family felt that patient would never
have wanted any mechanical ventillation, especially given bleak
prognosis for any recovery of neurologic function. Patient was
placed on T-tube oxygenation and expired within minutes.
Medications on Admission:
unknown
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Acute Blast Crisis
Death
Discharge Condition:
Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 2875, 4019, 2724, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8798
} | Medical Text: Admission Date: [**2120-7-5**] Discharge Date: [**2120-7-24**]
Date of Birth: [**2070-3-5**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 20506**]
Chief Complaint:
Jumping eyes and not making sense
Major Surgical or Invasive Procedure:
Brain Biopsy([**2120-7-10**])
History of Present Illness:
50 yo, female, with no pmh, p/w headache and jumping eyes.
10 days prior to admission the patient developed a throbbing
headache noted in the bifrontal area. A fever was noted at that
time to be as high as 103. The headache at that time began to
get progressively worse in intensity. The patient was
reportedly
seen at an OSH where a CT scan was negative. The fever and
headache continued. 2 days prior to admission the patients
family members noted that she was very weak and unstaedy on her
feet, requiring assistance with daily tasks. At that point the
patient was no longer sleeping due to the intensity of the pain.
On the day of admission the patient was barely walking and at
that point the family noted that her eyes started jumping and
she
couldn't look to her right. At that point the patient came in
to
the ED.
The family notes taht [**Known firstname **] originally had problems swallowing
and had sores in her mouth for over a month before the fever
began. They also note that while the patient did have headaches
off and on over the last few months they were never as intense.
[**Known firstname **] has no recent travel although she was living in [**Country 4574**]
until [**2099**]. Her cousin notes that she had always been well as
child. They also note that she works as a nurse and takes care
of many sick people including a child with a chronic illness.
They are unaware of any particular illness that she may have
been
in contact with.
Upon arrival the patient was noted to have altered mental
status with leftward eye deviation with nystagmus. A CT showed
edema. The CSF showed highly elevated protein and WBC. An MRI
was
done showing FLAIR signal
hyperintensity and patchy enhancement involving the right
thalamus, mid brain, splenium of the corpus callosum,
inferomedial temporal lobe and right cerebellum with associated
leptomeningeal enhancement in the right cerebellum. Broad
spectrum antibiotics were begun at that time and the patient was
sent to the ICU. In the ICU CT scans showed improvement of the
edema. Patient was transferred to step down.
Past Medical History:
none
Social History:
From [**Country 4574**], in US for 16 years, works as NP, married, 1
child, denies alcohol, tobbaco or illicit drug use
Family History:
Father died in an accident; mother is [**Name2 (NI) 54843**]; siblings are
healthy
Physical Exam:
Gen: patient lying in bed, opens eyes to verbal and tactile
stimulation.
HEENT:MMM, no adenopathy,positive Brudzinski,
CV: NL S1/S2, RRR
Lungs: CTA b/l
Neuro:Mental Status: patient is lethargic and drowsy, arrousable
to stimulation, patient will follow commands, opens eyes,
responds to questions, oriented to month and year,
CN: left [**Hospital1 **] eye deviation, right beat nystagmus, pupils 2 mm,
minimally reactive, left facial droop, corneal reflexes intact,
Motor: left arm weakness, strength 2/5 in [**Hospital1 **] and tri, moves
lower
extremities to command but does not cooperate for strength exam,
left up going toe.
Sensory: unable to evaluate.
Cb: unable to test due to mental status.
DISCHARGE EXAM:
Mental status intact, knows [**Doctor Last Name 1841**] backwards easily. Speech,
naming, repetition, [**Location (un) 1131**] intact.
CN: EOMI with some increased effort to look right, horizontal
nystagmus with rightward gaze, few beats then fatigues. Left
downward skew deviation. Left facial droop sparing the upper
face. Otherwise intact.
Motor: 5- in left delt, tri, 4 in left
Pertinent Results:
ADMISSION LAB STUDIES: SERUM
WBC-11.7*# RBC-4.37 HGB-12.1 HCT-36.3 MCV-83 MCH-27.8 MCHC-33.4
RDW-13.7
NEUTS-79.7* LYMPHS-15.5* MONOS-4.0 EOS-0.4 BASOS-0.4
PLT COUNT-409
SED RATE-99* PARST SMR-NEGATIVE
[**2120-7-5**] 11:16AM LACTATE-2.2*
[**2120-7-5**] 11:05AM GLUCOSE-135* UREA N-6 CREAT-0.7 SODIUM-129*
POTASSIUM-3.6 CHLORIDE-92* TOTAL CO2-24 ANION GAP-17
[**2120-7-5**] 11:05AM estGFR-Using this
[**2120-7-5**] 11:05AM LD(LDH)-252*
[**2120-7-5**] 11:05AM CRP-43.1*
NEGATIVE SERUM TESTS: aspergillus, B-glucan, Bartonella,
[**Location (un) **], EEE, West [**Doctor First Name **], Ehrlichia, anaplamsa, MS profile,
mycoplasma, anti-[**Doctor Last Name **], anti-Yo
PENDING: Quantiferon gold, LCMV, BRUCELLA
URINE:
[**2120-7-5**] 01:30PM URINE UCG-NEGATIVE
[**2120-7-5**] 01:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.003
[**2120-7-5**] 01:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2120-7-5**] 01:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2
CSF:
1st LP:
WBC-1510 RBC-110* Polys-30 Lymphs-67 Monos-2 Atyps-1
TotProt-262* Glucose-19
2nd LP:
WBC-1550 RBC-0 Polys-90 Lymphs-6 Monos-4
TotProt-136* Glucose-43 LD(LDH)-60
3rd LP: (TUBE 4)
WBC-46 RBC-41* Polys-0 Lymphs-97 Monos-3
TotProt-63* Glucose-51 LD(LDH)-19
CSF NEGATIVE STUDIES:
TB PCR x 2, CMV, EEE, EBV, EV, HSV, [**Doctor First Name **], TOXO, varicella, west
[**Doctor First Name **]
IMAGING:
MRI/MRV [**2120-7-5**]:
1. FLAIR signal hyperintensity and patchy enhancement involving
the right
thalamus, mid brain, splenium of the corpus callosum,
inferomedial temporal lobe and right cerebellum with associated
leptomeningeal enhancement in the right cerebellum. These
findings may reflect an encephalitis of viral, bacterial or
fungal etiology versus ADEM. Given the time course of
presentation of symptoms, lymphoma or a glial neoplasm is
thought to be less likely.
2. Punctate foci of restricted diffusion within the right
thalamus, most
likely caused by a secondary vasculitis causing punctate foci of
infarction
secondary to surrounding inflammatory process.
3. Normal MRV without evidence of venous sinus thrombosis.
MRI [**2120-7-16**]:
Mild interval decrease in enhancement within the splenium of the
corpus
callosum and right cerebellum with slightly increased prominence
of
enhancement in the right thalamus, with unchanged persistent
FLAIR signal
abnormalities within the right thalamus, mid brain, medial
temporal lobe, and cerebellar hemisphere compared to the prior
study. Unchanged foci of slow diffusion are again demonstrated.
These findings remain nonspecific in appearance. Findings may
reflect encephalitis, with a viral etiology favored, including
entities such as Eastern equine encephalitis. Mycobacterial,
typical bacterial and fungal etiologies are thought to be less
likely. Differential diagnoses also includes neoplasms such as
glioma and inflammatory etiologies such as vasculitis.
CT CHEST/AB/PELV
1. No intrathoracic, intra-abdominal, or intra-pelvic mass or
lymphadenopathy
detected.
2. Enlarged uterus, with slight heterogenous enhancement of the
myometrium.
Findings could represent adenomyosis and/or intramural fibroids,
but CT is
limited in its ability to evaluate the uterus and therefore
pelvic ultrasound
is recommended for further evaluation if clinically indicated.
3. Pulmonary nodular density adjacent to the left major fissure
is unchanged
from [**2119-5-22**].
DISCHARGE LABS:
[**2120-7-22**] 09:37AM BLOOD WBC-9.5 RBC-4.31 Hgb-11.9* Hct-37.1
MCV-86 MCH-27.6 MCHC-32.0 RDW-16.3* Plt Ct-340
[**2120-7-22**] 09:37AM BLOOD Glucose-178* UreaN-12 Creat-0.7 Na-137
K-3.7 Cl-100 HCO3-24 AnGap-17
Brief Hospital Course:
HOSPITAL COURSE:
Upon arrival the patient was noted to have altered mental
status with leftward eye deviation with nystagmus. A CT showed
edema. The CSF showed highly elevated protein and WBC. An MRI
was
done showing FLAIR signal hyperintensity and patchy enhancement
involving the right
thalamus, mid brain, splenium of the corpus callosum,
inferomedial temporal lobe and right cerebellum with associated
leptomeningeal enhancement in the right cerebellum. Broad
spectrum antibiotics were begun at that time and the patient was
sent to the ICU.
ICU:
# Neuro:
Patient was admitted with headache, fever and altered mental
status. There was initially a broad differential that included
brain abscess and meningoencephalitis. Head CT and MRI showed
multiple FLAIR and enhancing hyperintensities throughout the
brain (R thalamus, corpus callosum, midbrain). LP was extremely
significant for WBC 1150.
ID was consulted. Patient was started on vancomycin, CTX,
ampicillin, and acyclovir. Numerous bacterial, viral, parasitic
and fungal studies were sent from blood and CSF. PPD was placed
and was negative. HIV was negative.
Patient continued to wax and wane, and remained somnolent on
exam. She was started on mannitol, which did not improve her
exam very much, it was stopped [**7-11**] for increasing sodium
levels.
ID recommended treating empirically for TB and mycoplasma. All
other empiric antibiotics and antivirals were discontinued once
cultures were negative for 48 hours and HSV PCR was negative.
Patient was started on RIPE and moxifloxacin. They also
recommended dexamethasone to treat the inflammation that could
be associated with TB meningoencephalitis. Consecutive CT scans
showed improvement of cerebral edema.
Step Down:
Neuro:
Patient's mental status began to improve significantly after
decadron was started on [**7-9**]. Since that time the patient is
more awake and alert. A repeat LP showed stable pleocytosis but
no improvement. An extremely extensive workup was pursued for
infectious and inflammatory causes in the serum and CSF. All of
these studies were negative. CT of the torso was done to look
for underlying malignancy, and was negative. There was no sign
of intrapulmonary TB. Opthomology performed an eye exam to look
for tubercles which would suggest TB and/or malignant cells in
the vitreous representing lymphoma. The eye exam was normal.
We continued to treat the patient empirically with
dexamethasone, RIPE and moxifloxicin. She continued to improve
in terms of neurologic exam. Her left sided weakness improved
significantly, however she continued to have neglect of that
side making activity difficult for her. At discharge, her gaze
preference and skew deviation was improved, and nystagmus was
minimal. Her left facial droop was mild compared to initial
exam. Motor strength was 5- in left deltoid, tricep, wrist and
finger extensors and IP, otherwise full strength.
Repeat LP showed significant improvement in pleocytosis at this
point. MRI on day of discharge showed decreased inflammation and
decreased size and intensity of the prior lesions, although
radiology read is still pending.
Brain biopsy was considered at several points, however it was
felt that the patient was improving clinically and the biopsy
would not be without risks. It was determined that we would
continue to treat empirically for possible TB
meningoencephalitis and monitor clinical and radiologic status.
She will continue on dexamethasone at current dose. She will
begin to taper the steroids in 1 week. If she continues to
improve with steroid taper, we will not plan on biopsy. However,
if she does not continue to improve in the following 4-6 weeks
on current regimen, we will discuss with neurosurgery and pursue
a biopsy.
She passsed speech and swallow bedside evaluation. She began to
work with PT/OT but requires significant reconditioning and
teaching to improve her left neglect and motor planning. She
will be discharged to [**First Name9 (NamePattern2) 24759**] [**Hospital1 656**] acute rehab.
Patient will follow up with neurology in 4 weeks. She will
follow up with ID in 3 weeks. She will continue current abx
including RIPE and moxifloxacin. She will taper steroids in 1
week, with a 4 week taper. She will get monthly safety labs
faxed to ID office.
Medications on Admission:
motrin/tylenol; started on azythromycin for 01 day
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Rifampin 300 mg Capsule Sig: Two (2) Capsule PO Q24H (every
24 hours).
7. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Pyrazinamide 500 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Ethambutol 400 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours): continue until [**7-29**] at this dose,
then taper as follows:
[**7-29**] (week 1 of taper)- 2g q6h
[**8-5**] (week 2)- 2g q6h
[**8-12**] (week 3)- 2g q8h
[**8-19**] (week 4)- 2g q12h
then STOP.
13. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale units Injection QHS: QHS sliding scale only
FS 150-200= 2 units
FS 200-250= 4 units
FS 250-300= 6 units
FS 300-350= 8 units
FS 350-400= 10 units.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1122**] Center - [**Hospital1 3597**]
Discharge Diagnosis:
encephalitis
Discharge Condition:
Stable
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neurologic Exam: Mental status intact. EOMI intact with
horizontal beating nystagmus on rightward gaze, left downward
skew. Left facial droop. Left sided weakness and inattention,
distal worse than proximal. Sensation intact but with variable
extinction to DSS on the left. Coordination intact. Reflexes 2+,
toes downgoing.
Discharge Instructions:
It was a pleasure taking care of you. You were admitted with
fever, headache, and confusion. You were found to have elevated
white blood cells in your spinal fluid. You were found to have
areas in your brain that appeared inflammed on MRI, although the
cause of these lesions was not clear. You were tested for many
possible causes for your symptoms and these findings, but all
testing has been negative so far. Your spinal fluid white count
improved, and your MRI now looks improved as well. You were
treated empirically for tuberculosis with antibiotics. You were
also given steroids to treat the inflammation in your brain. You
improved greatly and will continue to improve with physical and
occupational therapy in rehab.
You will continue all these antibiotics and steroids for now.
You will follow up with infectious diseases, who will determine
the final antibiotics treatment.
Followup Instructions:
Appointment 1
Infectious Disease
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6137**]
Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2120-8-12**] 9:30
[**Last Name (NamePattern1) **]. [**Hospital Unit Name **]
Appointment 2
Neurology
Dr. [**Last Name (STitle) 1968**] and Dr. [**Last Name (STitle) 1206**]
Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2120-8-20**] 2:30
[**Hospital Ward Name 23**] Building [**Location (un) **]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8799
} | Medical Text: Admission Date: [**2192-8-14**] Discharge Date: [**2192-8-15**]
Service: ICU
HISTORY OF PRESENT ILLNESS: This is an 82-year-old female
with a history of osteoporosis and compression fracture,
cerebrovascular disease, and chronic anemia who was
transferred from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital for further management
of Clostridium difficile colitis with toxic megacolon,
sepsis, renal failure, and disseminated intravascular
coagulation.
The patient had recently been on antibiotics for a urinary
tract infection. On [**8-7**], she presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Hospital after sustaining a fall. The patient complained of
back pain and it was discovered she sustained a new
compression fracture at T11. Her hematocrit was noted to be
24% at that time. An abdominal CT with intravenous contrast
revealed no evidence for abdominal aortic aneurysm. She was
initially reported to be guaiac-negative on her presentation.
She received several transfusions. Over the subsequent days,
she developed diarrhea accompanied by abdominal distention.
Abdominal films were suggestive of a dilated colon. Stool
studies proved positive for Clostridium difficile toxin times
two, and the patient was begun on Flagyl. The patient
subsequently underwent colonoscopy on [**8-12**] which revealed
diffuse colitis with pseudomembranes consistent with
Clostridium difficile colitis. She has concomitant
leukocytosis from 11,000 to greater than 30,000 over her
hospital admission and with this noted to have a fall in
platelets as well as evaluated PT/PTT consistent with a DIC
pattern. The patient became increasingly unstable, later
developing hypotension and mental status changes. This was
accompanied by acute-on-chronic renal failure, culminating in
anuria. She was also found to have methemoglobinemia to 18%,
presumably as an adverse drug effect related to dapsone. She
required intubation and was transferred to the [**Hospital1 346**] for further management.
On presentation, the patient was noted to be obtunded,
responding only to painful stimuli. She was ventilated on
assist control on pressor support with phenylephrine. Her
urine output had only been 33 cc over the past 24 hours prior
to her presentation.
PAST MEDICAL HISTORY:
1. Cerebrovascular accident in [**2192-2-17**].
2. Osteoporosis with back pain and multiple compression
fractures at L1 and T11.
3. Peripheral edema.
4. Bullous pemphigoid, for which she was treated with
dapsone and prednisone for many years.
5. Chronic anemia.
6. Echocardiogram in [**2192-3-16**] with a normal ejection
fraction.
7. Status post hysterectomy.
8. Status post appendectomy.
MEDICATIONS ON TRANSFER: Medications on transfer included
Flagyl 500 mg t.i.d., Protonix 40 mg p.o. q.d.,
Neo-Synephrine drip, hydrocortisone 20 mg intravenously
q.6h., ceftriaxone, and levofloxacin.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married. The family
describes a declining quality of life in recent months
following ischemic stroke she sustained in [**2192-2-17**].
She suffered several falls following this incident, and the
family also related evidence of cognitive decline consistent
with early dementia.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on presentation revealed an elderly white female who was
intubated and in moderate discomfort. She was not responsive
to voice. Temperature was 97.6, heart rate was 100, blood
pressure was 84/70 on a Neo-Synephrine drip at 27 mcg per
minute. She was on assist control ventilation at 12
respirations per minute with total volumes of 600 with an
actual respiratory rate of 22, and FIO2 of 0.4, a positive
end-expiratory pressure of 0. Arterial blood gas on these
settings showed a pH of 7.37, a PCO2 of 25, a PO2 of 163, and
an estimated bicarbonate of 15. Head, eyes, ears, nose, and
throat revealed pupils were equally round and reactive to
light. Corneal reflex was intact. Mucous membranes were
dry. Lungs revealed mild inspiratory crackles at the bases.
Heart sounds were tachycardic, regular, and distant. The
abdomen was grossly distended with absent bowel sounds,
profusely tenderness to palpation. The patient would wince
with palpation of the abdomen. Extremities revealed 1+
peripheral edema.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission revealed white blood cell count was 35.9,
hematocrit was 30.9, platelets were 20 (neutrophils of 70%,
bands of 14%, lymphocytes of 11%, monocytes of 3%). PT
was 21.4, INR was 3.2, PTT was 74.8. FDP was 40 to 80.
D-dimers were greater than [**2190**]. Fibrinogen was 291. Sodium
was 127, potassium was 5.6, chloride was 90, bicarbonate
was 16, blood urea nitrogen was 85, creatinine was 3.4, blood
glucose was 64. Calcium was 5.5, a free calcium of 3.82,
albumin was 1.1, phosphate was 8.4, magnesium was 2.4, AST
was 418, ALT was 104, alkaline phosphatase was 96, total
bilirubin was 1.5, direct bilirubin was 1.2, amylase was 60,
lipase was 48. Arterial lactate was 11.4.
RADIOLOGY/IMAGING: Electrocardiogram showed sinus
tachycardia at around 100 beats per minute with a
first-degree AV conduction delay, left axis deviation, with
left anterior vesicular block, T wave flattening in I and
aVL.
A chest x-ray showed left lower lobe atelectasis with small
bilateral effusions.
Abdominal films revealed dilated sigmoid colon estimated
greater than 8 cm in diameter.
HOSPITAL COURSE: This is an 82-year-old woman with recent
antibiotic exposure who developed severe Clostridium
difficile colitis and toxic megacolon complicated by
overwhelming sepsis and disseminated intravascular
coagulation. In addition, she had developed acute renal
failure with anuria and profound metabolic derangement with
lactic acidosis and shock requiring treatment with pressors.
Her prognosis, given her age, comorbidities, and presentation
was extremely grim. The patient received massive volume
resuscitation and was weaned off of Neo-Synephrine with
upward titration norepinephrine. She was continued on
intravenous metronidazole and levofloxacin. In addition,
oral vancomycin was added to her regimen. Her electrolytes
were repleted.
A surgical consultation was obtained urgently. It was
determined that she would need a total abdominal colectomy
and ileostomy for toxic Clostridium difficile colitis;
however, given her current level of systemic decompensation,
it was determined that she would not survive the procedure
and that it would be futile. The patient's husband and
children were immediately called in to the hospital in the
early morning hours shortly after the patient's arrival and
were informed of her grave prognosis.
Given her overall situation and overall extremely low
probability of meaningful recovery, the family chose to
withdraw further support. Their wishes were honored.
Shortly thereafter, the patient was extubated and support
with pressors was withdrawn. Her pain was controlled. The
patient expired at 0453 on [**2192-8-15**]. Her husband and
family were present at the bedside. An autopsy was declined.
DISCHARGE DIAGNOSES:
1. Clostridium difficile colitis with toxic megacolon.
2. Sepsis.
3. Disseminated intravascular coagulation.
4. Acute renal failure.
5. Lactic acidosis.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Last Name (NamePattern1) 23338**]
MEDQUIST36
D: [**2192-8-15**] 14:46
T: [**2192-8-22**] 07:34
JOB#: [**Job Number 12990**]
ICD9 Codes: 5849, 2767 |
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