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train · 498k rows

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{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8800 }	Medical Text: Admission Date: [2175-4-1] Discharge Date: [2175-4-5] Service: MEDICINE Allergies: Lipitor / Lisinopril Attending:[First Name3 (LF) 348] Chief Complaint: Hematemesis and bloody stools Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 4143] is an 87 year old gentleman with a past medical history significant for CVA, AF, DM, and a recent admission for Influenza treated with oseltamavir, clinda, and levofloxacin now admitted for GIB. The patient was admitted to [Hospital1 18] from [Date range (1) 79037] for hypoxemic respiratory distress found to have Influenza treated with oseltamavir (completed on [3-29]), clindamycin, and levofloxacin (completed on [3-31]). At that time, he was discharged as DNR/DNI/DNH, comfort measures only. Patient now sent into the ED today for increasing lethargy over the past few days after family decided to reverse DNH. . In the [Hospital1 18] ED, initial VS 97.0 80 103/52 16 99%2L nc. The patient had a CXR that was negative for focal consolidation, with labs notable for a hct 22.5 from 41.8 on [3-26]. An NGT was attempted 3 times, and then the family declined any further interventions. He received vancomycin and pip/tazo, and was admitted to the MICU for further management. . Currently, the patient is somnolent, minimally responsive. Past Medical History: Past Medical: -Gout -Left CVA with residual aphasia -GERD -AF -DM -Depression -Hyperlipidemia -Recent admission ([2175-3-7]) for Influenza Past Surgical: -open cholecystectomy Social History: Lives at [Location 1188] house, no alcohol/smoking, daughter works at [Company ] house. VERY supportive family. Pt has a very pleasant routine at [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] involving gardening, and gets around mostly with WC or 1-assist ambulation. Family History: nc Physical Exam: ADMISSION: VS: 96.5 110 138/92 19 93%RA Gen: NAD HEENT: pupils 3->2mm reactive. MM dry. CV: Irregular S1+S2 Pulm: CTAB Abd: S/NT/ND +bs Rectal: OB brown + in ED Ext: No c/c/e. Neuro: Minimally responsive. DISCHARGE: VS: afebrile, 125-142/58-70, 60-85, 20@96-100%%(RA) Gen: NAD, excited to go home, smiling, answering Y/N questions HEENT: PERRLA, mmm CV: Irregular S1+S2, no m/r/g Pulm: CTAB Abd: S/NT/ND +bs Ext: No c/c/e. Neuro: Aphasic. Follows commands. At baseline, per family members. Pertinent Results: RELEVANT AND REPRESENTATIVE LABS: CBC and coags: -[2175-4-1] 12:22PM BLOOD Hgb-7.9* calcHCT-24 -[2175-4-1] 12:00PM BLOOD WBC-18.1# RBC-2.11# Hgb-7.7# Hct-22.5# MCV-107* MCH-36.2* MCHC-34.0 RDW-19.1* Plt Ct-558# -[2175-4-3] 07:55AM BLOOD WBC-16.4 RBC-2.59* Hgb-9.2* Hct-26.6* MCV-103* MCH-35.5* MCHC-34.6 RDW-18.2* Plt Ct-520* -[2175-4-5] 06:00AM BLOOD WBC-14.7* RBC-2.58* Hgb-8.8* Hct-26.8* MCV-104* MCH-34.2* MCHC-32.9 RDW-17.6* Plt Ct-643* . [2175-4-1] 12:00PM BLOOD PT-21.0* PTT-28.6 INR(PT)-1.9* [2175-4-5] 06:00AM BLOOD PT-14.1* INR(PT)-1.2* . Chem: -[2175-4-1] 12:00PM BLOOD Glucose-107* UreaN-24* Creat-0.9 Na-140 K-3.4 Cl-104 HCO3-26 AnGap-13 -[2175-4-4] 08:00AM BLOOD Glucose-89 UreaN-10 Creat-0.7 Na-137 K-4.1 Cl-103 HCO3-26 AnGap-12 . Misc: -[2175-4-1] 12:00PM BLOOD LD(LDH)-227 TotBili-0.7 -[2175-4-1] 12:00PM BLOOD Hapto-313* -[2175-4-1] 12:22PM BLOOD Lactate-1.6 Na-138 K-3.3* Cl-100 calHCO3-27 CXR, [2175-4-1], IMPRESSION: Persistent retrocardiac atelectasis or consolidation. ECG: AF with RVR. non-specific ST-T wave changes. Brief Hospital Course: Mr. [Known lastname 4143] is an 87 year old gentleman with a past medical history significant for CVA (on anti-coagulation), AF (on coumadin), DM, and a recent admission for Influenza treated with oseltamavir, clinda, and levofloxacin now re-admitted with a GI bleed requiring ICU level of care. # GI bleed: Guaiac positive stools on admission in the context of a dramatically lowered Hb/HCT. Multiple discussions were held with family regarding patient's wishes for care/intervention, and it came to pass that the patient had refused previous endoscopic procedures, even in the context of a history of GI bleed. This, no endoscopic procedure was pursued, consistent with patient's past expressed wishes. In addition, HCP (wife) felt that patient would not want an NGT or further GI eval. However, blood transfusion was done--which patient tolerated well--and coumadin-induced coagulopathy was also reversed. All anti-coagulation agents were held. Patient was started on a twice daily PPI, and was discharged with this new medication. Warfarin, ASA, and Plavix were discontinued, and will defer restarting these medications to outpatient providers. The risk of holding these medications, especially given patient's past stroke history and A-fib, were discussed in full with the family, but the family and team felt that risk of re-bleeding in the short term was higher than risk of stroke. # Leukocytosis: Potential etiologies include GI bleed, aspiration, or infectious process including post-Influenza pneumonia. However, patient not tachypneic, and oxygen saturations remained within normal limits. Labs were trended, and leukocytosis was continuing to resolve at the time of discharge. Leukocytosis is being attributed to a stress response in the context of acute major illness. # H/O cerebrovascular accident with residual aphasia: As discussed above, all anticoagulants were held in the context of GI bleed. As a result of his aphasia, it was difficult to communicate with the patient. Thus, even though patient was made aware of diagnoses and plan, the primary team deferred mostly to family to indicate patient preferences. # A-Fib: As discussed above, all anticoagulants were held in the context of GI bleed. Antihypertensives were reintroduced once patient's Hb/HCT were stable. # DM: although patient had an insulin sliding scale during admission, he required very little insulin. No standing insulin ordered, and on no oral hypoglycemics as an outpatient. Pt can likely be managed by diet alone. # HLD: Statin was initially held, but restarted at time of discharge. # Code/Goals of Care: Multiple conversations were had with the family given patient's baseline aphasia. DNR/DNI status was re-confirmed, and patient's family desired no escalation of care (including invasive diagnostics or therapies). However, symptom relief with blood transfusions were consistent with goals of care. Medications on Admission: -MVI -ASA 81 daily -Pilocarpine 2% eye drops Q6H -Polyvinyl alchohol 1.4% prn -Paroxetine 10 mg daily -Plavix 75 daily -HCTZ 25 daily -Travatan 0.004% daily -Allopurinol 150 daily -Atrovent -Coumadin 1 mg daily -Metoprolol 25 mg po tid. Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day. 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Tablet, Delayed Release (E.C.)(s) 3. Atrovent Nasal 4. allopurinol 300 mg Tablet Sig: 0.5 Tablet PO once a day. Tablet(s) 5. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 6. paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 7. pilocarpine HCl 2 % Drops Sig: One (1) drop to eyes Ophthalmic every six (6) hours. 8. polyvinyl alcohol 1.4 % Drops Sig: One (1) drop to eyes Ophthalmic every 4-6 hours as needed for dry eyes. 9. multivitamin Tablet Sig: One (1) Tablet PO once a day. 10. Travatan Z 0.004 % Drops Sig: One (1) drop to eyes Ophthalmic once a day. Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] - [Location (un) 538] Discharge Diagnosis: Primary: -Gastrointestinal bleeding Secondary: -Stroke with residual aphasia -GERD -Atrial fibrillation -Diabetes Mellitus 2 (not medically treated) Discharge Condition: Mental Status: Follows directions and usually able to answer yes/no, but aphasic at baseline. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were seen in the hospital for anemia (a low blood count) which was most likely due to bleeding in your digestive tract. You received a blood transfusion, and we discontinued your Warfarin (Coumadin), as well as other blood-thinning medications. Now the bleeding seems to have slowed down/stopped and your blood levels are stable. Changes to your medications: -START pantoprazole 40mg twice a day; you should take this medication for 4-6 weeks to protect your stomach lining, then discuss with your physician about whether to stop or decrease the dose of the medication -STOP Coumadin; this medication may need to be restarted in the future, but in the short term, the risk of re-bleeding is greater than the risk of stroke -STOP Plavix, but as above, this medication may be restarted in the future -STOP Aspirin, but as above, this medication may be restarted in the future Followup Instructions: Please make an appointment to see your PCP, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at ([Telephone/Fax (1) 8417] in [1-8] weeks. Department: VASCULAR SURGERY When: TUESDAY [2175-5-2] at 8:15 AM With: VASCULAR LMOB (NHB) [Telephone/Fax (1) 1237] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: VASCULAR SURGERY When: TUESDAY [2175-5-2] at 9:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1244], MD [Telephone/Fax (1) 1237] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage ICD9 Codes: 5789, 2851, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8801 }	Medical Text: Admission Date: [2175-3-7] Discharge Date: [2175-3-19] Date of Birth: [2111-11-23] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 9554] Chief Complaint: DOE Major Surgical or Invasive Procedure: none History of Present Illness: 63 yo woman with CAD s/p CABG [3-/2164] (LIMA->LAD, SVG->D1, SVG->PDA), CHF secondary to diastolic dysfunction, CRI=1.7, anemia admitted for CHF management and ultrafiltration. Past Medical History: 1. Hypertension. 2. Diabetes mellitus with last hemoglobin A1C of 8.7 in 12/[2172]. 3. Chronic renal insufficiency baseline creat 1.7-2.0 . 4. Coronary artery disease status post coronary artery bypass graft in [2163] (LIMA to LAD, SVG to D1 and PDCA), last cath [3-/2164] with elev R and L filling pressures, PTCA of RCA and 2 VD; last ETT-MIBI [6-22] 6 min on [Doctor Last Name 4001] protocol, no reversible defects. 5. Hypothyroidism. 6. Depression. 7. Osteoarthritis. 8. Hyperlipidemia. 9. CHF with EF 45-50% on last echo [10-21], mild LV systolic dysfunction, mildly depressed LV function, inf and mid inf HK, mild 1+MR. 10. Anemia - unclear etiology; baseline Hct 29-31, last iron studies nl [7-22]; per pt, has never had EGD or colonoscopy Social History: SH: lives with her boyfriend at home, retired; previous tob user 2ppdx20 yrs, quit [2155]; no ETOH Family History: FH: sig for father who deceased in his 50s from cirrhosis secondary to alcoholism; 1 brother deceased from MI in his 40s; other brother who died of lymphoma in his 50s Physical Exam: 98.6 56 150/70 18 96% RA Gen: in NAD HEENT: MMM, OP clear. CV: RRR, + SEM at RUSB. Lungs: + slight crackles at bases L>R. Abd: S/NT/ND, +BS. Ext: + chronic changes from edema, 2+ pitting edema B with erythema. Neuro: A&Ox3. Pertinent Results: [2175-3-7] 10:45PM URINE HOURS-RANDOM TOT PROT-33 [2175-3-7] 10:45PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO [2175-3-7] 10:45PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.014 [2175-3-7] 10:45PM URINE BLOOD-NEG NITRITE-POS PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [2175-3-7] 10:00PM PTT-78.4* [2175-3-7] 03:20PM GLUCOSE-172* UREA N-69* CREAT-2.1* SODIUM-140 POTASSIUM-4.8 CHLORIDE-111* TOTAL CO2-22 ANION GAP-12 [2175-3-7] 03:20PM ALT(SGPT)-68* AST(SGOT)-39 LD(LDH)-247 ALK PHOS-76 TOT BILI-0.6 [2175-3-7] 03:20PM proBNP-[Numeric Identifier 9555]* [2175-3-7] 03:20PM TOT PROT-6.8 ALBUMIN-4.2 GLOBULIN-2.6 CALCIUM-9.0 PHOSPHATE-3.8 MAGNESIUM-2.0 IRON-57 [2175-3-7] 03:20PM calTIBC-322 FERRITIN-122 TRF-248 [2175-3-7] 03:20PM [Doctor First Name ]-POSITIVE TITER-1:320 [2175-3-7] 03:20PM TSH-0.13* [2175-3-7] 03:20PM [Doctor First Name ]-POSITIVE TITER-1:320 [2175-3-7] 03:20PM PEP-NO SPECIFI [2175-3-7] 03:20PM WBC-5.2 RBC-3.56* HGB-10.6* HCT-32.6* MCV-92 MCH-29.8 MCHC-32.5 RDW-16.9* [2175-3-7] 03:20PM NEUTS-75.5* LYMPHS-16.1* MONOS-5.4 EOS-2.7 BASOS-0.3 [2175-3-7] 03:20PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ [2175-3-7] 03:20PM PLT COUNT-159 [2175-3-7] 03:20PM PT-13.9* PTT-28.7 INR(PT)-1.2 MRA ABD: 1. No evidence of significant renal artery stenosis. Small amount of atherosclerotic plaque within the proximal left renal artery ( <50% narrowing). 2. Poor corticomedullary differentiation of both kidneys, on pre-contrast sequences, suggest of chronic renal parenchymal disease. Clinical correlation is recommended. Brief Hospital Course: # Cardiac: a) pump/CHF: Pt came in with sig vol overload (JVD to angle jaw, 3+ LE pitting edema). Pt was entered in the UNLOAD trial and was randomized to Ultrafiltration (UF). Over 2 days ~17 L of fluid was taken off, at 500 cc/hour. Lasix was held while on UF, and actos was d/c'd (can lead to retention of fluid). However, after 2 days the pt's Cr [Known firstname ] and UF was stopped. Afterwards, no further diuresis was attempted and the pt was fluid restricted while Cr recovered. On [3-18] restarted lasix at low doses 20 [Hospital1 ] (previously had been 80 tid at home). Weights: [3-8] 129.6 on initiation .....[3-9] 118.9 am .....[3-12] 115.2 .....[3-15] 116 .....[3-18] 114.8 before discharge. . b) CAD- h/o CAD s/p CABG. Pt was continued on a Statin, beta blocker, and ASA was started. . c) Hypertension: On admission to the CCU pt's atenolol was changed to Toprol XL 50. d/c'd hydralazine and Imdur, started norvasc 5 qd initially. Continued valsartan at 80 qday and clonidine patch was weaned off. As ultrafiltration removed a great deal of fluid, the pt's BP decreased significantly and as ARF ensued, her BP meds were taken off and ultrafiltration was stopped. By [3-15], she was having hypertension during the night so her toprol was increased to toprol 25mg [Hospital1 ] for more even-action throughout the day. BP meds were added back on as kidney function improved and on [3-18] valsartan 40 was added back and lasix was restarted at low dose. Her BP remained high and so Isosorbide Dinitrate 20 mg TID was started as well as Hydralazine 50 mg TID. Lasix was titrated up to 40mg daily. These will be adjusted further as an outpatient. . d) Rhythm- Sinus. On tele. . # Renal failure: baseline Cr is 1.8-2.0. Creatinine [Known firstname ] with ultrafiltration to as high as 4.0 on [3-13]. This was likely due to over-diuresis with the ultrafiltration leading to volume depletion and pre-renal renal failure. Her antihypertensive regimen was also down-titrated as her BP droped with rapid volume correction. Urine lytes were consistent with ATN. Urine eosinophils were negative. MRA look for renal artery stenosis was positive for plaque but radiology did not feel this would be physiologically signficant. The pt's creatinine trended down to baseline with time and on discharge it was 2.1. She was restarted on the [Last Name (un) ] and lasix which will be adjusted as an outpatient. . # Anemia: Hct dropped from 32.6 on admission to 27 after admission. Iron (iron 57, ferritin 122), B12 ok. epo level was high-normal. Thus, her anemia was felt to be likely anemia of chronic disease. On [3-14], she was transfused 1 u PRBC. Hct bumped to only 29.8. Stool was guiac negative. Subsequently, however, her Hct improved without further transfusion and on discharge Hct was 31.2. . # Endocrine: History of type II diabetes mellitus and hypothyroidism. Her admission TSH was 0.13 (on levothyroxine 175) and HgbA1c 6.2. Levoxyl was decreased back to 150mcg. Actose was held and pt was maintained on Lantus and Humalog. . # Depression: pt was felt to have a depressed affect and was started on Celexa in house. Her mood improved slightly near her discharge. Discharge Medications: 1. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain,fever. 3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 4. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed. 6. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 8. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO BID (2 times a day). Disp:60 Tablet Sustained Release 24HR(s) Refills:2 9. Hydralazine HCl 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 10. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 12. Insulin Glargine 100 unit/mL Solution Sig: Twenty Six (26) units Subcutaneous once a day. Disp:1 month supply Refills:0 13. Humalog 100 unit/mL Solution Sig: per scale Subcutaneous three times a day. Disp:1 month supply Refills:2 Discharge Disposition: Home Discharge Diagnosis: Congestive heart failure type II diabetes mellitus acute on chronic renal failure Coronary artery disease s/p CABG Discharge Condition: Stable, afebrile. Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5L Please take your medications as directed. Followup Instructions: 1) Provider: [Name10 (NameIs) 1576],[Name11 (NameIs) 9119] [Name12 (NameIs) 9120] MEDICINE (PRIVATE) Where: ADULT MEDICINE UNIT [Hospital3 ] HEALTHCARE - 1000 [Location (un) ] - [Location (un) 2352], [Numeric Identifier 9121] Phone:[Pager number ] Date/Time:[2175-4-13] 10:30 2) Please see Dr. [Last Name (STitle) ] in [11-20] weeks for followup. You will be called with an appointment. If you do not get called in [11-20] days, please call [Telephone/Fax (1) 3512] to arrange an appointment. [First Name8 (NamePattern2) 2064] [Last Name (NamePattern1) ] MD [MD Number(2) 2139] ICD9 Codes: 5849, 4280, 2720, 2449, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8802 }	Medical Text: Admission Date: [2139-2-15] Discharge Date: [2139-3-4] Date of Birth: [2116-9-7] Sex: M Service: SURGERY Allergies: Ceclor Attending:[First Name3 (LF) 371] Chief Complaint: s/p Motor vehicle crash - multi-trauma Major Surgical or Invasive Procedure: [2139-2-16] ORIF posterior pelvic ring bilaterally, ORIF anterior pelvic ring on right side, I&D elbow open fracture, ulnar nerve expliration and placment of external fixation [Doctor Last Name 1005] [2139-2-18] 1. I AND D RIGHT ELBOW. ORIF RIGHT ELBOW,IVC filter [Location (un) ] [2139-2-23] I AND D RIGHT ELBOW WITH BONE GRAFTING History of Present Illness: 22M was unrestrained driver s/p motor vehicle crash, unknown rate of speed or mechanism but ejected from vehicle approx 100ft. Cardiac arrest on scene, received CPR in ambulance. Large volume rescucitation, and bilateral chest tube placement in ED during code, no blood or air return. FAST neg x2. Pulses returned w/o epinephrine or shocks. Past Medical History: none PSHx: ureter correction age 8 Social History: Parents involved in care. Family History: Noncontributory Pertinent Results: [2139-2-15] 11:16PM GLUCOSE-164* UREA N-21* CREAT-1.3* SODIUM-143 POTASSIUM-5.2* CHLORIDE-114* TOTAL CO2-20* ANION GAP-14 [2139-2-15] 11:16PM CALCIUM-7.1* PHOSPHATE-4.1 MAGNESIUM-1.9 [2139-2-15] 11:16PM WBC-13.8* RBC-4.18* HGB-12.5* HCT-35.4* MCV-85 MCH-29.8 MCHC-35.3* RDW-14.2 [2139-2-15] 11:16PM PLT COUNT-182 [2139-2-15] 09:21AM PLT COUNT-188 [2139-2-15] 09:21AM PT-12.0 PTT-28.4 INR(PT)-1.1 IMAGING: [2-16] CT head: Stable multicompartmental intracranial hemorrhage including small globus pallidus and medial temporal lobe intraparenchymal hemorrhage and minimal hemorrhage in occipital [Doctor Last Name 534] of left lateral ventricle. A tiny focus of hemorrhage may not be visualized in the occipital [Doctor Last Name 534] of the right lateral ventricle suggestive of redistribution. No new hemorrhage or shift in midline structures. Right parietal subgaleal hematoma with associated laceration and staples overlying. . [2-18] LENIs: no evidence of DVT in b/l LE . [2-19] CXR: Low lung volumes persist. Bibasilar atelectasis larger on the left are unchanged. Lines and tubes are in standard position. There is no pneumothorax or pleural effusion. Left subcutaneous emphysema has improved. . [2-21] Abd CT: No evidence of infection in chest, abdomen, and pelvis, to account for the patient's fever. The study is not tailored for evaluation of pulmonary embolism; however, within this limitation, filling defects in left lower lobar and segmental arteries, is concerning for pulmonary embolus. Extensive thoracic and abdominal pelvic fractures, with interval fixation of pelvic fractures in near anatomic alignment. New mild widening of the right sacroiliac joint. Known right renal lacerations, with mild interval decrease in the hematoma in the perinephric space. Stable high-density fluid layering in the right paracolic gutter and anterior pelvis. No new interval intra-abdominal or pelvic bleed. . [2-23] Chest PTA r/o PE: Intraluminal filling defects c/w pulmonary emboli are visualized in distal left lower lobe pulmonary artery and extend into anteromedial, lateral and posterior basal segmental pulmonary arteries. No evidence of right heart strain. Brief Hospital Course: Mr. [Known lastname 27003] was noted to have lost pulses in the ambulance on arrival to the ED. He was intubated in the field. He was actively coded while bilateral chest tubes were placed, a Cordis was placed in his right groin and a central line was placed in his left subclavian. He regained pulses before losing them approximately 10 minutes later, and was coded for an additional amount of time prior to regaining his pulses and remaining stable thereafter with several units of blood and crystalloid being infused. His FAST was negative and he was noted to have an open fracture of his right distal humerus as well as pelvic instability. There was concern for urethral injury and a catheter was not placed at this time. Given persistent hemodynamic instability he was sent to the Angio suite with interventional radiology where they embolized the bilateral internal iliacs with Gelfoam. They also performed a retrograde urethrogram at this time which demonstrated an intact urethra and placed a Foley catheter at this time. Between the ED and IR, he received 9 units of PRBCs, 4 units of blood and 4 L of crystalloid. He returned to the Trauma ICU stable not on pressors, but intubated and sedated. Stable, he was taken to radiology for further radiologic workup revealing the following injuries: Left intraparenchymal hemorrhage basal ganglia Posterior scalp laceration Right parietal subgaleal hematoma Right distal humerus and olecranon fractures Right renal lacerations with subcapsular hematoma Right posterior 11th rib fracture L2-4 transverse process fracture Right iliac crest fracture Bilateral superior and inferior pubic rami fractures Left SI joint diastasis He was taken to the or on [2139-2-16] by the orthopedic team for ORIF right hip/acetabular fracture as well as I&D and ex-fix of his right elbow. He returned to the OR on [2-18] for another washout of his elbow with ORIF and concomitantly had an IVC filter placed. His hospital course by systems as follows: Neuro: Neurosurgery was consulted early on due to his brain injuries - seizure prophylaxis was started, serial exams and head CT scans were followed as well. His repeat head scans remained stable. He was kept intubated and sedated through his initial days in the TSICU. His sedation was weaned for extubation on [2-19] and he was treated with IV Dilaudid for pain control. He was mildly confused after extubation. Given his altered mental status his cervical-collar was not able to be cleared at first. As his mental status improved we were able to obtain an adequate physical exam and removed the cervical collar. At time of discharge he is awake and answers questions and follows commands. He was started on Trazodone at HS to help regulate his sleep/wake cycle given his brain injury and this has seemed to help. CV: After initial hemodynamic instability, he stabilized and remained stable throughout his hospital course. His Hcts were trended and stable. He was initially tachycardic after extubation and intermittently after transfer out of the ICU remained tachycardiac. He was stated on beta blockers which has brought his heart into the 80's-90's range. Resp: Initially placed chest tubes were removed on [2-17] (right side) and [2-18] (left) without complication. He had no pneumo or hemothorax. He was extubated on [2-19]. After transfer to the floor on [2-20] he was transferred back to the ICU on [2-21] for respiratory distress and for a fever. CT Chest/Abdomen/Pelvis did not reveal an obvious source of fever but he was placed in the ICU, antibiotics were broadened and he recovered well. On re-review, radiology could not exclude a pulmonary embolism in the left lower lobe. This was followed with a CTA on [2-23] which confirmed this finding in the left lower lobe basilar segments and he was started on a heparin drip. He was transitioned to Coumadin; his dose was held on [3-3] for INR 4.1 after having received 5mg the night before. We are recommending that he be given 2.5 mg on [3-4] for INR 2.4 repeating INR on [3-5]. GI: Initially started on tube feeds via OGT then advanced to a regular for which he is tolerating much better now with improved mental status. GU: His Foley catheter was found to be placed in the urethra with balloon expansion in the urethra on MRI after Foley placement in IR. The catheter was advanced. He was also noted to have a right sided renal laceration and subcapsular hematoma. Urology was following for both of these issues and recommended conservative management wit keeping Foley in place for 3-4 weeks and repeating urethrogram at the end of that time. He will follow up in [Hospital 159] clinic as an outpatient. ID: He maintained on broad spectrum antibiotic coverage (Ancef/Levo/Flagyl) for his open fractures and after placement of orthopedic hardware given high risk of infection. The antibiotics were eventually stopped. He is afebrile and his WBC on [3-3]. Heme: An IVC filter was placed given his multiple fractures. Afterwards was deemed okay for heparin (per neurosurgery) and was started on heparin SQ as prophylaxis which was maintained throughout the hospitalization. He was started on a heparin drip on [2-23] to treat a pulmonary embolism in the left lower lobe basal segments. And now on Coumadin as mentioned previously. MSK: He has an external fixation on his right arm and is non weightbearing. He is also non weight bearing on his lower extremities due to his pelvic fractures. Follow up films of his pelvis due to complaints of increased pelvic pain were done on [3-4] to assess the hardware and it was noted that there were no issues. He will follow up as an outpatient in [Hospital 1957] clinic. He was evaluated by Physical and Occupational therapy and is being recommended for rehab after his acute hospital stay. Medications on Admission: Denies Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 6. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO three times a day as needed for constipation. 8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. warfarin 5 mg Tablet Sig: One (1) Tablet PO every evening: dose daily based on INR goal of 2.0-3.0. 12. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO dose daily based on INR: please adjust dose daily based on maintaining goal INR range . Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: s/p Motor vehicle crash Injuries: Left intraparenchymal hemorrhage basal ganglia Posterior scalp laceration Right parietal subgaleal hematoma Right distal humerus and olecranon fractures Right renal lacerations with subcapsular hematoma Right posterior 11th rib fracture L2-4 transverse process fracture Right iliac crest fracture Bilateral superior and inferior pubic rami fractures Left SI joint diastasis Pulmonary embolus Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital following a motor vehicle crash where you sustained multiple injuries that required several operations. You also developed a blood clot in your lung over the course of your hospital stay requiring treatment with a blood thinner called wafarin (Coumadin) - you will be on this medication at least for 6 months and possibly longer. Due to the extent of your injuires you are being recommended to go to a rehabilitation facility. Followup Instructions: * Department: ORTHOPEDICS When: TUESDAY [2139-3-17] at 9:25 AM With: ORTHO XRAY (SCC 2) [Telephone/Fax (1) 1228] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: TUESDAY [2139-3-17] at 9:45 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235], MD [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: GENERAL SURGERY/[Hospital Unit Name 2193] With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 853], MD When: MONDAY [2139-3-23] at 2:30 PM With: ACUTE CARE CLINIC [Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: RADIOLOGY When: THURSDAY [2139-3-26] at 1:15 PM With: CAT SCAN [Telephone/Fax (1) 327] Building: CC CLINICAL CENTER [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: NEUROSURGERY When: THURSDAY [2139-3-26] at 2:15 PM With: [Name6 (MD) ] [Last Name (NamePattern4) 7746], MD [Telephone/Fax (1) 3666] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage We are working on a follow up appointment for you to see one of our physicians in urology within the next 2-4 weeks. You will be called at rehab with the appointment information. If you have questions or have not heard, please call [Telephone/Fax (1) 92004] to inquire about the appointment. Name: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 85521], MD Specialty: Internal Medicine 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. Completed by:[2139-3-10] ICD9 Codes: 4275
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8803 }	Medical Text: Admission Date: [2173-12-9] Discharge Date: [2173-12-10] Date of Birth: [2111-12-29] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2704] Chief Complaint: s/p L Carotid Stent Major Surgical or Invasive Procedure: Stenting for Carotid Artery Stenosis History of Present Illness: This is a 61-year-old gentleman with a history of HTN, PVD, CVA and CAD (s/p BMS-LCx and [Name Prefix (Prefixes) ]-[Last Name (Prefixes) ] in [12-16]) now admitted to CCU s/p stenting of the left carotid artery. During workup for several months of anginal symptoms that included cath showing 3 vessel disease, pt underwent carotid doppler study on [12-6] that showed complete occlusion of the R ICA and >70% occlusion of the L ICA, though the pt c/o no HA, TIA, vision, dizziness or other neurologic sx. Angiography on [12-9] showed 100% R ICA occlussion, 80% occlusion (ulcerated plaque)of the L ICA with filling of ipsilateral and contralateral ACA, MCA via L ICA. A Protege stent was placed in the L ICA. The procedure was completed without complication and without evidence of distal embolization. On arrival in CCU, pt was maintained on .3mcg/kg/min of phenylephrine and pt was without complaints. Past Medical History: CAD: -BMS to LCx, DES to 1st diagonal in [12-16] -3 vessel disease on cath on [12-6]--99% mid RCA, 85% prox LAD, 80% OM1 -scheduled for CABG on [12-13] CVA '[68] HTN HPLD BPH B/l inguinal herniorraphies Basal Cell Cancer s/p resection Lumbar radiculopathy Social History: Married, 2 children. Works in construction. Denies smoking, drugs. Drinks 1 glass of wine per day Family History: CAD-Father, MI 80yo Physical Exam: VS: T=97 BP=107/67 HR=66 RR=26 O2 sat=97 on RA GENERAL: WDWN, NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM NECK: Supple with JVP of 8 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. Dressing CDI. No femoral bruits, hematomas. SKIN: Decreased hair over distal LE. No livedo reticularis or necrosis over toes. PULSES: 2+ DPs, R>L Neuro: A+Ox3, CNII-XII grossly intact. No pronator drift, [6-14] b/l in proximal and distal UE muscles. [6-14] gastroc strength b/l. (other leg muscles not tested following femoral puncture). Sensation, reflexes, coordination equal b/l. Pertinent Results: 139 106 17 AGap=12 -------------< 91 4.0 25 0.8 Ca: 8.8 Mg: 2.0 13.8 7.9 >----< 253 38.7 CARDIAC CATH REPORT 1. Access via left femoral artery (as right femoral had been accessed two days prior for coronary angiography). 2. Limited hemodynamics with BP 144/80 with HR 62 in sinus. 3. Angiography of the aortic arch with a pigtail catheter in ascending aorta showed a Type 1 arch without lesions. 4. Angiography of the right carotid artery with Berenstein catheter in right common carotid artery showed patent right external with occluded right internal carotid artery. 5. Angiography of the left carotid artery with Berenstein catheter in the left common carotid artery showed the left common and external to be normal. The left internal carotid had a ulcerated 80% lesion best seen in LAO 45 view. This left internal carotid fills the ipsilateral and contralateral ACA and MCA. The posterior circulation was not fed by the left internal carotid. 6. Given severity of lesion and upcoming surgery we elected to proceed with stenting. We exchanged for a Shuttle sheath 6F into the left common carotid and started heparin with therapeutic ACT. We crossed easily with a SpartaCore wire and exchanged for a 5mm Spyder filter. We predilated with a Quantum Maverick 2.75x20 at 14 atm. We then stented with a self expanding Protege 8-6 mm x40 mm tapered stent. We post dilated the stent at the lesion with a Quantum Maverick 4.5x20mm balloon at 12atm Final angiography with 10% residual and normal flow. The filter was recovered without incident and presence of small amount of atheromatous material. Final cerebral angiography without evidence of embolization or vessel occlusion. 7. The LFA arteriotomy was closed with a Mynx device. FINAL DIAGNOSIS: 1. Occluded right internal carotid artery. 2. 80% stenosis of left internal carotid artery. 3. Stenting of left internal carotid artery with distal protection. Brief Hospital Course: 61 yo HTN, HPLD, CAD admitted to the CCU s/p L ICA stent. He was doing well, and was admitted to CCU for BP management. He was requiring fluids, phenylephrine on admission. # CAROTID STENOSIS s/p STENTING and HYPOTENSION: Pt tolerated stenting procedure well and was neurologically intact. After admissin, he required phenylepherine up to 0.7 mcg/kg/min to maintain SBPs>100 and he received 2.5 L of IV fluids. He was weaned off by midnight and had stable blood pressures in the 100-120 SBP range throughout the morning. He continued to have good neurological status. Prior to discharge, an echo was done to evaluate pre-op EF. Last recorded ef was 51%. The read of this was pending at discharge. He was discharged off blood pressure medications with instructions to restart them on Sunday. . # CORONARIES: He is s/p BMS, DES in '[71], 3 vessel disease on cath [12-6]. He was continued on ASA 81 and plavix . # PROPHYLAXIS: -DVT ppx with sq heparin 5000u tid -Bowel regimen-standing colace, senna prn CODE: full Medications on Admission: ASA 81mg 3x daily Plavix 75mg po daily atenolol 50mg po daily lisinopril 10mg po daily lipitor 80mg po daily isosorbide 60mg po daily flomax .4mg po daily finasteride 5mg po daily loratadine 10mg po daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Will restart on Sunday: 4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atenolol 50mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 10mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: CAROTID ARTERY STENOSIS HYPOTENSION Coronary Artery Disease Discharge Condition: Stable, Ambulating, Blood pressure 119/76 systolic, HR 62 off pressors. Discharge Instructions: You were admitted with carotid stenosis. A stent was placed in your carotid artery to improve blood flow to your brain. You were admitted to the CCU while you were on a medication to keep your blood pressure elevated. You were slowely taken off this medication. You did well, and were discharged from the ICU. You sould complete your pre-operative testing after you are discharged from the CCU. This is to be completed on the [Location (un) ] of the clinical center. Your blood pressure and heart rate were improving but still somewhat low at the time of discharge. You should wait to resume your blood pressure medications, Lisinopril and Atenolol until Sunday. You should also wait until Sunday to restart your Flomax as this medication can also lower blood pressure. Please call your PCP or go to the emergency room if you have symptoms of low blood pressure such as feeling faint, lightheaded, weak or dizzy. Followup Instructions: Please attend your pre-operative testing Your surgery is scheduled for next week Completed by:[2173-12-10] ICD9 Codes: 4019, 4439, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8804 }	Medical Text: Admission Date: [2180-5-16] Discharge Date: [2180-5-18] Date of Birth: [2101-7-29] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern4) 290] Chief Complaint: dyspnea and hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 77 year old man with metastatic melanoma (to lungs, spleen and adrenals), severe aortic stenosis (valve area 0.8 cm2) with recent valvuloplasty [4-/2180], CAD, systolic CHF with EF 30-35%, who presents with dyspnea. He was diagnosed with melanoma in [2180-3-2] after an enlarging right axillary lesion was noted on pre-op workup for valvuloplasty. Biopsy showed BRAF V600E mutated melanoma. He has been admitted several times in the preceeding months ([3-/2180], [4-/2180], and most recently [2180-5-4] - [2180-5-12]) to the cardiology service for dyspnea thought to be due to pulmonary edema and CHF exacerbations secondary to his worsening aortic stenosis. He had valvuloplasty [4-/2180] with improvmement in valve area 0.6 -> 0.8cm2. His most recent admission for dyspnea was thought to be due to pulmonary edeam, but also pulmonary metastatic disease. He was diuresed and discharged on home lasix with follow up in heme/onc clinic to discuss treatment options for his metastatic melanoma. Upon follow up in heme/onc clinic today to evaluate candidacy for systemic chemotherapy, he appeared ill with dyspnea 94% on 3L and hypotension BP: 76/52. His left arm appeared intervally larger. PIV was placed and he was transferred to the ED. In the ED, initial VS were: 97.7 84 98/67 20 91% 4L. SBP subsequently dropped to 60s, given 2L NS with rapid improvement in SBP to 90-100s. CVL placed. Labs notable for WBC 64 (near recent baseline), K 2.7, BUN 50, Cr 0.9, BNP 9469, trop 0.01, INR 3.7, lactate 5.4 -> 4.5 after fluids. UA without RBCs or WBCs. CXR showed innumberable metastases in bilateral lungs. CT-A chest confirmed diffuse and significant burden of metastases without clear evidence of consolidation, edema or effusion, NO PE. He was placed on Bipap for increased work of breathing and tachypnea. Most recent vital signs afib HR 95 102/58 99% 24-28 on BiPap. . On arrival to the MICU, he is on Bipap 10/5 which has improved his SOB, sats 94% on 50% FIO2. He has not been feeling well lately because of poor appetite (has not been able to eat anything for days due to anorexia). He has had increased dyspnea and cough. Continues to take his medications which include lasix. Denied fever, chills, headache. No abdominal pain, diarrhea, dysuria. He has ongoing right axillary arm pain at the area of his mass. Past Medical History: Past Oncologic History: Metastatic melanoma BRAF V600E mutated - [2-/2180] Scheduled to undergo AVR but was delayed for unexplained leukocytosis. During his pre-op workup, he noted pain and a "bump" in his right shoulder/axilla. ID consult and follow up felt this was not infectious - [2180-3-21] Noted increasing size of R axillary lesion. Initial concern for a pseudoaneurysm. CTA Chest/R arm with runoff showed 6.2 x 5.8 mass in the right axillary region with mild enhancement and mild surr fat stranding. Unchanged in size from non-con CT scan on [2180-3-8] (Hounsfield units 25 on prior non-con scan) - [2180-3-23] Biopsy of the R axillary mass and a pigmented R deltoid lesion revealed melanoma, BRAF V600E mutated - [4-/2180] Multiple admission for symptomatic CHF due to AS, underwent valvuloplasty. Not yet started on systemic chemotherapy (vemurafanib could be considered in future should his cardiac disease stablize and he is hemodynamically stable). . Past Medical History: - CAD with RCA artherectomy in [2167], BMS to LAD in [2177] - Coronary artery disease s/p myocardial infarction in [2169], [2177] - Aortic stenosis s/p valvuloplasty in [2180-4-2] - Hypertension - Systolic and diastolic congestive heart failure - Benign prostatic hypertrophy - Prostate cancer- s/p cryotherapy - Bladder cancer- s/p chemoteherapy - Atrial Fibrillation - Hyperlipidemia - GERD . Past Surgical History: -s/p Back surgery -s/p Appendectomy Social History: Married for 57 years, retired firefighter after 35 years. Lives at home in [Location (un) 3320] with wife. 4 children, 5 grandkids. Denies smoking, ETOH, drug use. Family History: +Premature coronary artery disease. Father died of an MI at age 51. Physical Exam: Admission Exam Vitals: 97F, 86, 109/62 on norepi, 21, 99% on Bipap 10/5 50% Fio2 General: Alert, oriented, no acute distress, using accessory muscle of respiration HEENT: Sclera anicteric, oral mucus membranes moist, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly 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, finger-to-nose intact Pertinent Results: Labs: [2180-5-16] 04:30PM BLOOD WBC-64.6* RBC-3.88* Hgb-11.0* Hct-36.6* MCV-94 MCH-28.3 MCHC-30.0* RDW-16.3* Plt Ct-213 [2180-5-16] 04:30PM BLOOD Neuts-97.1* Lymphs-1.6* Monos-1.2* Eos-0 Baso-0.1 [2180-5-16] 04:30PM BLOOD PT-38.0* PTT-34.7 INR(PT)-3.7* [2180-5-16] 04:30PM BLOOD Glucose-111* UreaN-50* Creat-0.9 Na-147* K-2.7* Cl-101 HCO3-27 AnGap-22* [2180-5-16] 04:30PM BLOOD proBNP-9469* [2180-5-16] 04:30PM BLOOD cTropnT-0.01 [2180-5-17] 05:27AM BLOOD cTropnT-0.03* [2180-5-17] 12:55PM BLOOD CK-MB-2 cTropnT-0.02* [2180-5-16] 10:39PM BLOOD Calcium-7.2* Phos-3.9 Mg-1.9 [2180-5-17] 12:55PM BLOOD Cortsol-35.2* [2180-5-16] 11:18PM BLOOD Type-ART pO2-71* pCO2-38 pH-7.45 calTCO2-27 Base XS-2 [2180-5-17] 01:03PM BLOOD Type-ART pO2-42* pCO2-44 pH-7.38 calTCO2-27 Base XS-0 [2180-5-16] 04:47PM BLOOD Lactate-5.2* [2180-5-16] 10:45PM BLOOD Lactate-4.5* [2180-5-17] 05:43AM BLOOD Lactate-4.6* [2180-5-17] 01:03PM BLOOD Lactate-5.5* [2180-5-16] 11:18PM BLOOD O2 Sat-95 [2180-5-17] 01:07AM BLOOD O2 Sat-72 [2180-5-17] 09:44AM BLOOD O2 Sat-67 Imaging: [2180-5-16] CXR: IMPRESSION: Extensive bilateral nodular opacities in lungs suspicious for progression of metastatic disease. No definite pulmonary edema or new confluent consolidation, although subtle changes may be missed due to extensive burden of metastatic disease. [2180-5-16] CT chest: IMPRESSION: 1. No evidence of pulmonary embolism. 2. Significant increase in innumerable pulmonary metastases. 3. Large right necrotic axillary metastasis and increasing intrathoracic lymphadenopathy. 4. Enlarging T10 and T11 vertebral metastases, with cortical breakthrough. 5. Right adrenal metastasis. 6. Resolving perisplenic hematoma/seroma. ECHO [2180-5-17]: IMPRESSION: Severe aortic valve stenosis. Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w multivessel CAD. Compared with the prior study (images) reviewed ([2180-4-11]), the severity of aortic stenosis has progressed and regional left ventricular systolic dysfunction is more apparent. Brief Hospital Course: 77 year old man with metastatic melanoma (to lungs, spleen and adrenals), severe aortic stenosis (valve area 0.8 cm2) with recent valvuloplasty [4-/2180], CAD, systolic CHF with EF 30-35%, who presented with dyspnea and hypotension. Henodynamic shock was likely hypovolemic in etiology given poor oral intake while taking lasix, low CVP and normal SvO2. Fluid resuscitation was complicated by pulmonary edema secondary to his systolic dysfunction and aortic stenosis. Imaging (CXR and CT chest) showed rapid progression of melanoma with extensive pulmonary involvement. Echocardiogram showed increased severity of aortic stenosis and worsening left ventricular systolic function. Oncology was consulted and recommended initiation of vemurafinib. He intermitttently required Bipap for respiratory support. The patient together with his family expressed desire to transition care to comfort measures only. He was started on morphine drip, his pressor was slowly discontinued and he died with his family at the bedside. Autopsy was declined. Medications on Admission: 1. aspirin 81 mg daily 2. oxycodone 5-10 mg PO Q8H PRN 3. omeprazole 40 mg daily 4. digoxin 125 mcg daily 5. Lasix 40 mg [Hospital1 ] Discharge Medications: deceased Discharge Disposition: Expired Discharge Diagnosis: Metastatic melanoma Severe aortic stenosis Systolic congestive heart failure Respiratory failure Hypovolemic shock Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2180-5-18] ICD9 Codes: 2760, 5849, 2762, 412, 4019, 2724, 4241, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8805 }	Medical Text: Admission Date: [2182-1-28] Discharge Date: [2182-2-1] Date of Birth: [2125-6-3] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 12174] Chief Complaint: confusion Major Surgical or Invasive Procedure: none History of Present Illness: 56 year old male with HCV cirrhosis (on transplant list), c/b portal HTN, hepatic encephalopathy, peripheral edema, and ascites, managed with diuretics and albumin infusions Q4wks, transferred from OSH on [1-28] with altered mental status requiring intubation for airway protection. He was admitted to [Hospital1 18] SICU for further management. . Upon transfer to [Hospital1 18] ED, CT Head/Neck were without acute process. In the SICU, the patient was treated with lactulose and rifaximin for presumed hepatic encephalopathy. The patient was extubated on [1-29] after improvement in his mental status. A precipitant for his symptoms remains unclear as family indicated strict compliance with medication regimen. Infectious work-up was initiated, though all cultures have revealed no growth to date. No diagnostic paracentesis was performed, though only trace ascites was visualized in the abdomen. . The patient had a recent admission ([Date range (1) 43171]) for hepatic encephalopathy. The day prior, he underwent an EGD for which he was premedicated with fentanyl and versed, believed to have caused his confusion. His mental status significantly improved and his home meds were restarted at discharge. Currently, the patient reports that his thinking is much more clear. He cannot remember exaclty how he arrived to the hospital or the circumstances leading up to this admission, but he does recall being in an ambulance. Per his nurse, he has been somewhat "off" this evening (still not always making sense), but this is a significant improvement since admission. He is unsure what may have precipitated this episode and reiterates that he was taking his medications as prescribed. . On ROS, he denies pain other than his baseline MSK complaints. He denies any recent fevers/chills or other localizing symptoms. He does endorse some recent SOB, though this is not bothering him now. He has no CP or palpitations. He would like his Foley out; otherwise no urinary complaints. He reports recent [3-3] BM at home with lactulose as is his goal. Sore throat and hoarse voice since extubation. Otherwise ROS negative. Past Medical History: - HCV cirrhosis (VL [7-/2180] of 262,000), s/p IFN+ribavirin in [2175], genotype 1 - grade II non-bleeding varices - thrombocytopenia - Cervical lumbar herniated discs on chronic narcotics - Obstructive sleep apnea on home CPAP - Hematuria status post recent cystoscopy - Plantar fasciitis - Meniscal tear status post repair [2174] - Bilateral shoulder injuries Social History: He formerly worked for the Mass Water Resource in sewage and as a painter; currently he is not working (disability paperwork has just gone through per patient; he states this is more due to shoulder issues than his liver disease). He lives with his girlfriend. Denies history of tobacco abuse. He drank approx one six-pack daily x 10 yrs, but has been sober since [2158] when he was diagnosed with hepatitis C. H/o IV drug use in high school, but has not used any illicit drugs since that time. Family History: His mother died at 82 from pancreatic cancer. Father died at age 78 with type 2 diabetes and colon cancer. The patient is one of eight children. His sister died of melanoma. Two brothers with diabetes. One brother with esophageal cancer. Nephew who died suddenly from a blood clo Physical Exam: EXAM ON ADMISSION TO FLOOR VS: Afebrile, HR 87, BP 136/63, O2 sat 97% on RA GENERAL: Awake, cooperative with exam. Oriented to place [Hospital1 18], day of week Tuesday, year [2181]. Some tangential speech noted and some difficulty naming month/day. Vocal hoarseness noted. HEENT: Sclera faintly icteric. PERRL (pupils large at baseline, 5-6mm but reactive), EOMI. NECK: Supple with low JVP CARDIAC: RRR, S1 S2 clear and of good quality without murmurs, rubs or gallops. No S3 or S4 appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, moving air fairly well and symmetrically. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender to palpation. No ascites/fluid wave by exam. No HSM or tenderness. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+ DP pulses bilaterally, trace edema (wearing pneumoboots). . DISCHARGE EXAM VS: Tc-96.5 HR 59, BP 116/64, 20 O2 sat 98% on RA GENERAL: Awake, sitting up in a chair, A+O x3, less confused . HEENT: Sclera faintly icteric. PERRL (pupils large at baseline, 5-6mm but reactive), EOMI. NECK: Supple with low JVP CARDIAC: RRR, S1 S2 clear and of good quality without murmurs, rubs or gallops. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender to palpation. No ascites/fluid wave by exam. No HSM or tenderness. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+ DP pulses bilaterally, trace pedal edema Pertinent Results: ADMISSION LABS [2182-1-28] 07:15PM BLOOD WBC-4.9 RBC-4.04* Hgb-13.8* Hct-38.7* MCV-96 MCH-34.1* MCHC-35.6* RDW-14.0 Plt Ct-37* [2182-1-28] 07:15PM BLOOD Neuts-80* Bands-0 Lymphs-12* Monos-8 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2182-1-28] 07:15PM BLOOD PT-16.6* PTT-31.9 INR(PT)-1.6* [2182-1-28] 07:15PM BLOOD Glucose-127* UreaN-15 Creat-0.7 Na-138 K-4.1 Cl-112* HCO3-19* AnGap-11 [2182-1-28] 07:15PM BLOOD ALT-200* AST-155* AlkPhos-137* TotBili-3.2* [2182-1-28] 07:21PM BLOOD Type-ART pO2-207* pCO2-25* pH-7.48* calTCO2-19* Base XS--2 Intubat-INTUBATED [2182-1-28] 07:21PM BLOOD Lactate-1.9 [2182-1-28] 11:42PM BLOOD Lactate-2.2* . DISCHARGE LABS [2182-2-1] 12:55PM BLOOD WBC-3.0* RBC-3.62* Hgb-12.6* Hct-35.5* MCV-98 MCH-34.8* MCHC-35.5* RDW-13.6 Plt Ct-40# [2182-2-1] 06:20AM BLOOD PT-16.0 PTT-43.2* INR(PT)-1.5* [2182-2-1] 06:20AM BLOOD Glucose-121* UreaN-16 Creat-0.7 Na-135 K-4.2 Cl-105 HCO3-25 AnGap-9 [2182-1-31] 06:40AM BLOOD ALT-160* AST-135* LD(LDH)-237 AlkPhos-77 TotBili-3.1* . URINE STUDIES [2182-1-28] 07:15PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.025 [2182-1-28] 07:15PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [2182-1-28] 07:15PM URINE RBC-5* WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 [2182-1-28] 07:15PM URINE CastHy-2* [2182-1-28] 07:15PM URINE Mucous-MOD [2182-1-28] 07:15PM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . MICROBIOLOGY URINE CULTURE (Final [2182-1-30]): NO GROWTH. GRAM STAIN (Final [2182-1-29]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS IN SHORT CHAINS. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI. RESPIRATORY CULTURE (Final [2182-2-1]): SPARSE GROWTH Commensal Respiratory Flora. MORAXELLA CATARRHALIS. MODERATE GROWTH. STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH. PRESUMPTIVELY PENICILLIN SENSITIVE BY OXACILLIN SCREEN. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS PNEUMONIAE \| PENICILLIN G---------- S . Blood culture- pending . STUDIES EKG-Baseline artifact. Sinus tachycardia. Cannot rule out ST-T wave abnormalities but much of it may be artifact. Since the previous tracing of [2181-7-12] the rate has increased. . CXR Single supine AP portable view of the chest was obtained. Endotracheal tube is seen, terminating approximately 5.5 cm above the level of the carina. There are low lung volumes. Patchy right upper lobe opacity could relate to low lung volumes and artifact, although an underlying consolidation can be present. No additional consolidation is seen. The right costophrenic angle is not included on the image. There is no pleural effusion or pneumothorax. The cardiac and mediastinal silhouettes are likely accentuated by supine, AP technique. No overt pulmonary edema. Gaseous distention of the colon is incidentally noted. . CT C-SPINE No acute fracture or malalignment. . CT HEAD No acute intracranial process . Abdominal US IMPRESSION: Scant trace of ascites seen in the abdomen. . ECHO The left atrium is mildly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber sizeand wall motion are normal. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is borderline pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Biatrial enlargement. Normal left ventricular cavity size and wall thickness with preserved global and regional biventricular systolic function. No clinically significant valvular disease. Normal pulmonary artery systolic pressure. Some late bubbles are appreciated with Valsalva maneuver, but given that this was after the third injection of saline contrast it is unlikely that they represent clinically significant pulmonary shunting. Brief Hospital Course: ASSESSMENT AND PLAN: 56M with HCV cirrhosis on the transplant list who was admitted with an episode of confusion/altered mental status which required intubation for airway protection. He was initially admitted to the SICU. Mental status improved significantly with aggressive lactulose. . ACTIVE ISSUES . # Altered Mental Status: Mental status changes likely due to hepatic encephalopathy. As above he required intubation for airway protection and admission to the SICU. He was started lactulose and rifaximin with improvement in his mental status. He was successful extubated and transferred to the floor. Precipitant was initially unclear (as the patient had no evidence of active infection or new metabolic derangement). Blood and urine cultures were negative. The patient only had minimal ascites making spontaneous bacterial peritonitis unlikely. However, on further questioning of the patient's girlfriend reported he has been having a productive cough a few days prior to presentation. CXR did show a small area concerning for consolidation and sputum culture grew S. pneumonae and Moraxella Catarrhalis. He was started on levofloxacin for a planned 5 day course. His home cyclobenzaprine and gabapentin were also held. The patient's mental status was at baseline at the time of discharge. Patient was instructed to consider a vegetarian diet should instances of encephalopathy continue. . # ? Pneumonia- As above sputum showing moraxella and s. pneumo. Original CXR concerning for possible RUL infiltrate. Given patient was having low grade temps, cough, and a positive sputum cough he was started on levofloxacin for a 5 day course. . # Ear pain- Patient complained of R sided ear pain. Otoscopic exam was unremarkable. It was felt pain might be reflective of TMJ. Pain was controlled with Tylenol. . STABLE ISSUES . # HCV Cirrhosis: Patient is on the transplant list. Course has been complicated by hepatic encephalopathy (on lactulose and rifaximin), peripheral edema and ascites (managed with diuretics and albumin infusions Q2wks) and grade varices II (on nadolol). Patient was continued on his home diuretics, nadolol, lactulose and rifaximin as above. . # Thrombocytopenia: This was felt to likely be due to liver disease. Platelets remained stable throughout admission. . # Muscle Spasms: Patient has a history of muscle spasms for which he receives infusions of 50 g of IV albumin every 2 weeks. The patient received this infusion while hospitalized. . # Dyspnea- Patient was scheduled for an echo as an outpatient. He was scheduled of an echo. Therefore study was performed while the patient was in-house. Echo was notable only for biatrial enlargement. . # OSA: On CPAP at home . # Back, shoulder pain: Patient has chronic pain on narcotics, gabapentin and cyclobenzaprine at home. These medications were initially held give confusion. His home oxycodone was restarted with caution on discharge. The patient was instructed to minimize use of narcotics. Gabapentin and cyclobenzaprine were held at the time of discharge. . TRANSITIONAL ISSUES - Blood cultures were pending at the time of discharge - Patient will follow-up at the liver center - Patient was full code throughout this hospitalization Medications on Admission: furosemide 20 mg PO DAILY gabapentin 300 mg PO QHS. lactulose 10 gram/15 mL Syrup 30 ML PO twice a day nadolol 20 mg Tablet PO DAILY omeprazole 20 mg Capsule daily oxycodone 5 mg q6h cyclobenzaprine 5 mg Tablet PO PRN rifaximin 550 mg Tablet [Hospital1 ] spironolactone 200 mg PO DAILY tolterodine 2 mg Tablet PO DAILY zinc sulfate 220 mg PO DAILY Calcium Citrate + D 315-200 mg-unit Tablet tabs Qam 1tab Qpm multivit-min-FA-lycopen-lutein 0.4-2-250 mg-mg-mcg magnesium 250 mg Tablet 4 Tablet PO once a day ensure TID albumin, human 25 % 1 infusion Intravenous q2 weeks Discharge Medications: 1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:3 Tablet(s) Refills:0 3. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO twice a day. 5. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. oxycodone 5 mg Capsule Sig: One (1) Tablet PO every six (6) hours as needed for pain. 9. tolterodine 2 mg Tablet Sig: One (1) Tablet PO once a day. 10. zinc sulfate 220 mg Tablet Sig: One (1) Tablet PO once a day. 11. Calcium Citrate + D 315-200 mg-unit Tablet Sig: One (1) Tablet PO once a day. 12. multivit-min-FA-lycopen-lutein 0.4-2-250 mg-mg-mcg Tablet Sig: Four (4) Tablet PO once a day. 13. albumin, human 25 % 25 % Parenteral Solution Sig: Fifty (50) gram Intravenous q 2 weeks. 14. Ensure Liquid Sig: One (1) PO three times a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hepatic encephalopathy Community acquired pneumonia Hepatitis C Cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname 54184], It was a pleasure participating in your care while you were admitted to [Hospital1 69]. As you know you were admitted because you were having confusion. We feel this was most likely caused by an infection in your lungs resulting in hepatic encephalopathy. You were given increased doses of lactulose which improved your mental status. You were also given antibiotics for the infection in your lungs which you will need to continue for 3 more days. We made the following changes to your medications 1. Start levofloxaxin 750 mg daily for 3 more days 2. Stop cyclobenzaprine (flexeril) 3. Stop gabapentin It is important that your take all other medications as instructed. Please feel free to call with any questions or concerns. Followup Instructions: Department: TRANSPLANT When: THURSDAY [2182-2-7] at 11:20 AM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 673] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Name: [Last Name (LF) ],[First Name3 (LF) ] C Location: [Location (un) 2274]-[Location (un) ] Address: 111 [Doctor Last Name ] DR, [Location (un) ],[Numeric Identifier 17464] Phone: [Telephone/Fax (1) 17465] *The office is working on an appt for you in the next [12-31**] weeks and will call you at home with an appt. If you dont hear from them by Monday, please call them directly to book. ICD9 Codes: 486, 5715, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8806 }	Medical Text: Admission Date: [2139-10-5] Discharge Date: [2139-10-16] Date of Birth: [2073-8-5] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 598] Chief Complaint: s/p fall down stairs Major Surgical or Invasive Procedure: [2139-10-9] 1. Open reduction internal fixation of left parasymphysis fracture of the mandible. 2. Extraction of teeth numbers 4, 5, 11, 12, 13, 14, and 23. 3. Alveoplasty of upper right quadrant and upper left quadrant. History of Present Illness: 66F transfer from outside hospital after patient found down in front of her staircase. Patient had multiple signs of trauma including subarachnoid hemorrhage and orbital blowout fracture. Patient had alcohol onboard with alcohol level in the 200s. Patient was transferred for further care. Fall was unwitnessed, ?LOC. But responsive at the scene. GCS reportedly 15 at the scene. Intubated in the ED for airway protection 2/2 blood in the airway. Past Medical History: PMH: breast CA PSH: CCY [2112], lumpectomy [2133] Social History: 1ppd smoker almost 50 years, alcoholism 14-15 shots per day with recent detox, lives at home Family History: noncontributory Physical Exam: On arrival to [Hospital1 18]: Constitutional: Somnolent HEENT: Left facial bruising and ecchymosis Multiple dental fractures as well as intraoral laceration Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Nontender, Soft GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema Skin: Warm and dry Neuro: Speech fluent, moving all 4 extremities Pertinent Results: [10-5] CT OSH: Comminuted Rt ramus and left parasymphyseal mandible fractures Rt ant and med maxillary wall fx with alveolar ridge Left tetrapod type fracture with ant/med/lat wall fractures of maxillary sinus, L zygoma fracture, and L orbital floor non-displaced fx. L orbital rim fx. Comminuted nasal bone fx with minimal displacement. No c-spine injury per radiology. MR SPine [10-6] IMPRESSION: 1. At least partial tear of the cervical nuchal ligament with small amount of surrounding fluid/edema. No evidence of deeper posterior ligamentous or multicolumn injury, as associated with cervical instability. 2. Significant multilevel cervical degenerative disease, as described, but no cord signal abnormality. 3. No MR evidence of acute lumbar spine injury. 4. Multilevel lumbar degenerative disease, most marked at the L5-S1 level, with facet arthrosis and synovial effusion, and gap measuring up to 3.5 mm, which may be associated with instability. [2139-10-5] WBC-11.2* Hct-38.6 Plt Ct-137* [2139-10-7] WBC-4.5 Hct-25.1* Plt Ct-90* [2139-10-9] WBC-4.2 Hct-23.4* Plt Ct-91* [2139-10-10] WBC-3.4* Hct-22.7* Plt Ct-123* [2139-10-11] WBC-4.1 Hct-20.5* Plt Ct-162 [2139-10-11] Hct-24.0* [2139-10-11] Hct-23.6* [2139-10-12] WBC-4.6 Hct-24.3* Plt Ct-257# [2139-10-5] Creat-0.5 Na-142 K-4.0 [2139-10-12] Creat-0.4 Na-145 K-4.0 Brief Hospital Course: 66 F s/p fall down stairs in the setting of EtOH. She suffered multiple injuries including a small R SAH, Bil mandible fx, Bil ant/med maxillary wall fx, L zygoma, L orbital floor/rim fxs and a nasal bone fracture. She was intubated in the trauma bay as she was not protecting her airway and subsequently admitted to the TSICU. The patient was evaluated by neurosurgery upon admission who reccomended seizure prophylaxis with dilantin for seven days. Her course is now completed. She was seen by plastic surgery for her facial fractures who deferred care to the OMFS team. She was taken to the OR on [10-9] for open reduction internal fixation of left parasymphysis fracture of the mandible; extraction of teeth numbers 4, 5, 11, 12, 13, 14, and 23; and alveoplasty of upper right quadrant and upper left quadrant. Initially she had symptoms of alcohol withdrawl and required hourly ativan. An MRI of the C/L spine was preformed and showed no evidence of fracture or injury. While in the ICU she spiked mulitple fevers and was diagnosed with a LLL pneumonia. Bronchoscopy showed purulent thick secretions, and culture grew SERRATIA LIQUEFACIENS >100,000 ORGANISMS/ML and ENTEROBACTER CLOACAE ~4000/ML. She was started on a 10 day course of antibiotics for this. When she returned from the OR with OMFS she was extubated but rapidly re-intubated given desaturations. Much of this was thought to be secondary to edema. Upon resolution of the edema she was easily extubated but failed speech and swallow so was initiated on tube feeds. Foley catheter was discontinued but replaced shortly thereafter due to urinary retention. She was started on flomax. Mrs. [Known lastname ] remained hemodynamically stable and mentation continued to improve so she was transferred to the floor. On [2139-10-14] she was transferred to the surgical floor where she continued to remain hemodynamically stable without respiratory compromise. Her mental status continued to improve and she was alert and oriented x 3 at the time of discharge. Prior to discharge, occupational therapy evaluated her cognitive status given the TBI and follow up with cognitive neurology was recommended. She remained afebrile and incentive spirometry and pulmonary toileting were continually encouraged. At the time of discharge, her O2 saturation was stable on room air and her IV ceftriaxone for VAP was transitioned to PO ciprofloxacin, course to be completed on [10-19]. Her WBC count remained within normal limits. She was evaluated by speech and swallow therapy, who said she was okay to take both thin and thick liquids; therefore PO's were encouraged and her tube feeds were discontinued. Her foley was removed after starting on flomax and she was able to void without difficulty there after, with no further evidence of urinary retention. Physical therapy also evaluated her her recommended discharge to an extended care facility for continued acute PT. Social work was also consulted at the time of her admission and continued to follow the patient and provide support for her family given the trauma and history of alcohol use. Medications on Admission: Anastrozole 1mg QD, Armidex 1 mg QD, Fluoxetine 20mg QD, Citalopram 40mg QD, Campral 333mg 2 tabs QD 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 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 4. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. anastrozole 1 mg Tablet Sig: One (1) Tablet PO QD (). 7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day). 10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for GERD. 13. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 14. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Cipro 500 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 3 days. 16. bacitracin 500 unit/g Ointment Sig: One (1) application Topical twice a day: Please apply to left submental incision . Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: Primary: s/p fall Injuries: Small Right SAH Bilateral mandible fracture Bilateral ant/med maxillary wall fracture L zygoma, L orbital floor/rim fractures Nasal bone fracture Secondary: Ventilator associated 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: You were admitted to the hospital after suffering a fall down stairs. You sustained multiple injuries including multiple facial fractures and a traumatic injury to your brain. You developed pneumonia while you were intubated, for which you are receiving antibiotics. You are now being discharged to an extended care facility to continue rehabilitation from your accident. Please follow up as instructed below. It is important that you keep all of your follow up appointments. Continue to take a liquid diet. It is important that you take the supplements recommended by nutrition as you will be on a liquid diet for 6 weeks. You are being given a prescription for narcotic pain medication. Take the medication as needed. Do not drink alcohol or drive while taking narcotics. Narcotics can cause constipation so continue to take an over the counter stool softener such as colace while taking narcotics, and increase your fluid and fiber intake if possible. Followup Instructions: Department: Oral and Maxillary Facial Surgery Notes: Please call the office number to make a hospital follow up appointment for 4-8 days after your hospital discharge. [Hospital6 ] [Location (un) 24902] Yawkey Building [Location (un) ] [Location (un) 86], [Numeric Identifier 13108] Phone: [Telephone/Fax (1) 91002] Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: TUESDAY [2139-11-3] at 3:00 PM With: ACUTE CARE CLINIC [Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: COGNITIVE NEUROLOGY UNIT When: MONDAY [2139-11-9] at 3:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6403], MD [Telephone/Fax (1) 1690] Building: Ks [Hospital Ward Name 860] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage Department: [Hospital3 1935] CENTER When: TUESDAY [2139-11-10] at 10:45 AM With: [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2334], M.D. [Telephone/Fax (1) 253] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601] Completed by:[2139-10-16] ICD9 Codes: 2762, 2930, 2760, 3051, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8807 }	Medical Text: Admission Date: [2143-4-17] Discharge Date: [2143-5-1] Service: MED Allergies: Aspirin Attending:[First Name3 (LF) 783] Chief Complaint: syncope and bright red blood per rectum Major Surgical or Invasive Procedure: none History of Present Illness: 86yo male with gastrointestinal stromal tumor diagnosed in [2142-11-5] after he presented with a lower GI bleed and was found to have a 17x17 cm abdominal mass, with a negative EGD and colonoscopy. He required multiple transfusions at that time, and was started on gleevec, which was subsequently stopped secondary to lower extremity edema and diarrhea. It was restarted on [4-5], with some shrinkage in tumor. He was then readmitted to [Hospital1 18] on [2143-4-17] after he presented with bright red blood per rectum. He was admitted to the MICU, and transfused as needed. No further oncologic management was felt necessary, nor possible, and he was subsequently transferred to the regular floor with the goal of comfort and support with blood transfusions until the rest of his family arrived. Past Medical History: GIST-unresectable, manifested with LGIB RBBB PNA CRF chronic lower extremity edema Social History: Retired Laoatian general with 13 kids. He denies alcohol or tobacco use. Family History: noncontributory Physical Exam: Gen-chronically ill-appearing male, fatigued, nad HEENT-op with thrush, mmm, eomi, perrl, no scleral icterus Neck-supple, no jvd or [Doctor First Name ] Pulm-cta bilaterally CV-regular, no m/r/g Abd-distended, hyperactive bowel sounds, large right-sided mass that was nontender Ext-2+ edema to knees bilaterally, trace distal pulses Pertinent Results: [2143-4-19] 05:30PM BLOOD WBC-11.4* RBC-3.50* Hgb-10.6* Hct-29.5* MCV-84 MCH-30.2 MCHC-35.8* RDW-14.7 Plt Ct-180 [2143-4-19] 05:30PM BLOOD Plt Ct-180 [2143-4-19] 02:42AM BLOOD Glucose-86 UreaN-13 Creat-1.0 Na-140 K-3.9 Cl-113* HCO3-19* AnGap-12 [2143-4-19] 02:42AM BLOOD Calcium-7.5* Phos-3.2 Mg-1.8 Brief Hospital Course: Briefly, Mr. [Known lastname 53885] was transferred to the floor with the goal of comfort and blood transfusions and fluid as needed for support until further family members could arrive. He received multiple transfusions as he was having [2-7] large bloody bowel movements per day. He required approximately [1-9] transfusions/day. On [4-25], a family meeting was held at which time it was decided to withdraw support with the feeling that he would pass away within hours, and with a change in the goals of care to comfort, with no further support with transfusions, etc. After withdrawing support, he was placed on multiple medications for comfort, and became unresponsive. He remained alive for days longer than the team had anticipated. He continually appeared comfortable, and was intermittently tachypnic, requiring morphine. The patient passed away on [5-1] at 2:30 am. His family was at his bedside and he appeared comfortable throughout. Medications on Admission: tylenol prn protonix 40qd Discharge Medications: none Discharge Disposition: Home with Service Discharge Diagnosis: inoperable gastric stromal cancer Discharge Condition: n/a Discharge Instructions: n/a Followup Instructions: n/a [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799] Completed by:[2143-5-1] ICD9 Codes: 5789, 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8808 }	Medical Text: Admission Date: [2143-8-21] Discharge Date: [2143-8-28] Date of Birth: [2073-4-4] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 443] Chief Complaint: Dyspnea. Major Surgical or Invasive Procedure: Cardiac Cath. History of Present Illness: Pt is a 70 y.o Vietnamese speaking male, nursing home resident, with h.o HTN, PVD, DM, ESRD on HD (M/W/F) who became SOB yesterday after HD. Pt returned to his NH and was given 80mg lasix and xeroxlyn. SOB worsened over 24 hrs, sats found to be 80-90's, 92% on 5L. Pt sent to [Hospital3 8834] where troponins found to be elevated from "baseline" of 0.05 to 0.68. CPK 548, MB 10. BNP found to be 43,000. ST elevations in V1-V3 that were reportedly "new" compared to prior EKG. Pt started on heparin, given [Hospital3 ] 325mg and lopressor 5mg IV and intubated due to increased work of breathing. Vitals at OSH HR 64, BP 123/57, RR 30, 02 99-100% on NRB. On Vent 7.42/52.5/76 . In [Hospital1 18] [Name (NI) ], pt given 300mg [Name (NI) 4532], 20mg lipitor, and 325mg [Name (NI) ] per cardiology fellow. Cardiology was consulted. Also given valium for sedation. . Unable to obtain current cardiac ROS including CP, DOE, PND, orthopnea, palpitations, syncope or other such as h.o stroke, TIA, DVT, PE, bleeding, myalgias, joint pains, cough, claudication. Past Medical History: ESRD on HD BPH h/o MRSA sepsis legally blind PVD s/p multiple toe amputations h/o osteomyelitis chronic nonhealing ulcer of left foot . Cardiac Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension Cardiac History: no known history of CABG. No known PCI or pacemaker. Social History: Pt lives at home w/his wife, he has ?60pack year smoking hx, but quit 5years ago. nondrinker. Retired officer from [Country 3992]. Family History: n/a Physical Exam: PHYSICAL EXAMINATION: Vital signs stable Gen: NAD, able to ambulate with assistance. HEENT: impaired visual function CV: S1S2 RRR, no audible M/R/G Chest: GAEB, CTAB Abd: +bs in 4Q, soft, NT/ND Ext: No c/c/e. No femoral bruits, no signs of groin hematoma. L.foot with metarsal ambutation. Skin: No rash Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Pertinent Results: Admission labs: [2143-8-21] 01:30AM WBC-11.4* RBC-2.67* HGB-8.3* HCT-25.3* MCV-95 MCH-31.3 MCHC-33.0 RDW-16.4* [2143-8-21] 01:30AM NEUTS-86.9* LYMPHS-6.8* MONOS-5.9 EOS-0.2 BASOS-0.2 [2143-8-21] 01:30AM PLT COUNT-168 [2143-8-21] 01:30AM GLUCOSE-230* UREA N-45* CREAT-7.4* SODIUM-140 POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-30 ANION GAP-18 [2143-8-21] 01:30AM CALCIUM-9.1 PHOSPHATE-3.3 MAGNESIUM-2.6 [2143-8-21] 01:30AM PT-15.4* PTT-143.9* INR(PT)-1.4* [2143-8-21] 01:30AM CK(CPK)-724* [2143-8-21] 01:30AM CK-MB-62* MB INDX-8.6* [2143-8-21] 01:30AM cTropnT-0.95* [2143-8-21] 01:41AM LACTATE-2.0 [2143-8-21] 09:15AM CK(CPK)-648* [2143-8-21] 09:15AM CK-MB-60* MB INDX-9.3* cTropnT-2.17* [2143-8-21] 04:50PM ALT(SGPT)-31 AST(SGOT)-79* LD(LDH)-398* CK(CPK)-455* ALK PHOS-87 TOT BILI-0.4 [2143-8-21] 04:50PM CK-MB-44* MB INDX-9.7* . Discharge labs: [2143-8-28] 08:30AM BLOOD WBC-9.0 RBC-3.02* Hgb-9.3* Hct-28.4* MCV-94 MCH-30.8 MCHC-32.8 RDW-16.9* Plt Ct-290 [2143-8-28] 08:30AM BLOOD Glucose-155* UreaN-50* Creat-8.6* Na-138 K-4.9 Cl-96 HCO3-28 AnGap-19 [2143-8-27] 06:50AM BLOOD CK(CPK)-40 [2143-8-28] 08:30AM BLOOD Calcium-9.5 Phos-5.4* Mg-2.2 . Microbio data: [2143-8-22] 12:08 am SWAB Source: anterior left foot. FINAL REPORT [2143-8-26] GRAM STAIN (Final [2143-8-22]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2143-8-26]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. STAPH AUREUS COAG +. SPARSE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN G---------- =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [2143-8-26]): NO ANAEROBES ISOLATED. . Imaging: ECG: Cardiology Report ECG Study Date of [2143-8-27] 7:38:28 AM Sinus rhythm Consider left ventricular hypertrophy Anterolateral ST-T changes are nonspecific Since previous tracing of [2143-8-26], no significant change Read by: [Last Name (LF) ],[First Name3 (LF) 900] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 80 172 82 [Telephone/Fax (2) 79003]04 Cardiac Cath: Cardiology Report C.CATH Study Date of [2143-8-26] COMMENTS: 1. Selective coronary angiography of this right dominant system revealed two vessel coronary artery disease. The LMCA had a 20% distal stenosis. The LAD had no angiographically apparent stenosis but the first diagonal had an 80% lesion. The Lcx had moderate disease thoughout. The OM1, OM2, and OM3 each had 50% lesions at their ostia. The distal RCA had a 90% ulcerated lesion. 2. Limited resting hemodynamics demonstrated normal systemic pressure with a central aortic pressure of 130/56/63 mmhg. 3. Succseeful POBA of an ulcerated mid RCA lesion. Unable to pas a stent to the affected segment due to calcified and tortuous vessl. Final angiography revealed Type A dissection without flow limitation and 30% residual stenosis. No angiographically-apparent distal emboli was noted. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Normal systemic pressure. 3. Successful POBA of the mid RCA with Type A dissectiona nd 30% residual stenosis. 4. Reopro gtt overnight without a bolus. Cardiac Echo: Portable TTE (Complete) Done [2143-8-23] at 9:52:56 AM FINAL The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %) with basal to mid inferior hypokinesis and midinfero-septal hypokinesis. The apex is not well seen. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. 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. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2143-8-21], the LVEF has improved. Brief Hospital Course: 70 yo M w/ PMH significant for DM/ESRD on HD, HTN, DMII, peripheral [Year (4 digits) 1106] insufficiency who presented [8-21] in respiratory failure with inc enzymes and EKG changes suggestive of ACS. Had cardiac cath Monday [8-26] with successful POBA of an ulcerated RCA. . # CAD/ ISchemia: s/p cath on [8-26] showing 2VD, D1 with 80% stenosis, RCA with distal 90% ulcerated lesion, POBA of mid RCA but unable to pass stent to affected segment due to Ca/tortous vessel. Type A dissection w/o flow limitation. [Last Name (LF) ], [First Name3 (LF) ], and statin were continued as well as an ace inhibitor and a beta blocker as tolerated. . # Pump: Presented with Heart Failure likely [2-16] to volume overload with ? ACS. BNP elevated at [Numeric Identifier ] unclear [Name2 (NI) ] given renal failure. Respiratory exams were clear, the goal was for even status -- Hemodialysis was done during his stay to remove fluid. . # Rhythm: Patient was in normal sinus rhythm post catheterization. . # Valves: The patient has no known valvular disease . # HTN: Has intermittant elevations to SBP's 160, patient was continued on home meds of BB, ACE-I, his CCB was held . # Respiratory failure: Resolved, o2 sats >95 on RA, the patient was continued on levofloxacin for total of 14 days for question of PNA va. sepsis picture. (day 1 was [8-21]). . # Left Foot ulcer/Osteo: Pt has known foot ulcer w/ + MRSA culture. On vanco for ?2 month course to end on [9-3]. Vascualar evaluation (Non invasives arterial studies) scheduled as outpatient with follow-up in clinic. . #ESRD: Patient undergoes hemodialysis on mondays, wednesdays, and fridays, no change in schedule during stay. Medications on Admission: glipizide Sr 5mg daily Lantus 12 units QHS prandin 2mg TID protonix 40mg daily nephrocaps 1 cap daily flomax 0.4mg daily renagel 800mg daily omeprazole 20mg daily simvastatin 20mg daily amlodipine 10mg daily toprol XL 150mg daily lisinopril 20mg daily tylenol MOM Discharge Medications: 1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 8 doses. Disp:8 Tablet(s) Refills:0 2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed. 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 4000-[Numeric Identifier 2249] units Injection PRN (as needed) as needed for line flush: for dialysis. 7. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) cc PO BID (2 times a day) as needed. 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14) units Subcutaneous at bedtime: titrate up for high blood sugars. Disp:1 bottle Refills:2 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 13. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 14. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 15. Restoril 15 mg Capsule Sig: One (1) Capsule PO at bedtime as needed for insomnia. 16. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every four (4) hours as needed for pain. Disp:30 Capsule(s) Refills:0 17. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 18. Renagel 800 mg Tablet Sig: Two (2) Tablet PO three times a day. 19. Prandin 2 mg Tablet Sig: One (1) Tablet PO three times a day: with meals. 20. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous HD PROTOCOL (HD Protochol) for 6 days: End date [9-3]. Disp:6 Recon Soln(s) Refills:0 21. ACCUZYME 830,000-10 unit/g-% Ointment Sig: One (1) Topical once a day: Apply thin layer to the periwound tissue with each drsg [Name5 (PTitle) ]. . Disp:1 tube Refills:1 22. Insulin Syringes (Disposable) 1 mL Syringe Sig: One (1) syringe Miscellaneous once a day. Disp:30 syringes Refills:2 Discharge Disposition: Home With Service Facility: Caregroup Discharge Diagnosis: Reason for Admission: Respiratory failure secondary to acute diastolic heart dysfunction. Past Medical History: Stage IV end stage renal disease on hemodialysis, hypertension, advanced Type II diabetes, peripheral [Name5 (PTitle) 1106] insufficiency, blind. Discharge Condition: Stable. Labs on discharge: Glucose 71 UreaN 36 Creat 6.4 Na 141 K 4.7 Cl 98 HCO3 30. HCT 29.2. Discharge Instructions: Mr. [Known lastname ], you were admitted at the [Hospital1 18] in [Location (un) 86] for respiratory failure which appears to have been secondary to acute dyastolic heart dysfunction in the setting of a myocardial infarction (a heart attack). At the time of your presentation to the hospital, we could not rule out an infection and so we began you on Levofloxacin, an antibiotic with good coverage for community aquired pneumonia. We are discharging you with an additional 8 days of Levofloxacin 250 mg PO DAILY so you will have completed a 14 day course. We continued your Vancomycin which from the [Hospital1 ] chart appears to have been for MRSA osteomyelitis diagnosed on [2143-7-7] so that you would have completed 6 weeks total. You will need to continue to get the vancomycin at hemodialysis until [2143-9-3]. As well, given your cardiac dysfunction, we are giving you Clopidogrel 75 mg PO DAILY, Aspirin EC 325 mg PO DAILY, Lisinopril 5 mg PO DAILY, and Atorvastatin 80 mg PO DAILY. You will continue to follow with the [Hospital 79004] healthcare team at [Location (un) 2199]. In summary, we added the following medications to your current regimen: 1) Clopidogrel 75 mg PO DAILY 2) Aspirin EC 325 mg PO DAILY 3) Lisinopril 5 mg PO DAILY 4) Levofloxacin 250 mg PO DAILY for 8 days 5) Lantus insulin 14 units SC daily at bedtime We changed the following medications: 1) Changed Zocor to Atorvastatin 80 mg PO DAILY 2) Discontinued Norvasc 3) Redosed the Metoprolol XL to 50 mg PO on discharge (to be titrated up for a goal HR of 60-70 as tolerated) Other medications were continued. Action ambulance phone: [0-0-] will pick you up at 10:15am on Friday [8-30] to take you to dialysis and will continue every Monday/Wednesday and Friday. Followup Instructions: 1) Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Doctor Last Name 5858]/Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] (Cardiology, [Telephone/Fax (1) 62]) on [9-10] at 2:00pm, [Hospital Ward Name 23] 7 [Hospital Ward Name ]: 2) Dr. [Last Name (STitle) 47598] Phone: ([Telephone/Fax (1) 79005] [Doctor First Name ] from Dr.[Name (NI) 79006] office will call you at home for an appt at the hospital . Primary Care: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 11622], MD Phone: [Telephone/Fax (1) 250] Date/Time: [10-14] at 2:00 pm. [Hospital Ward Name 23] clinical Center, [Location (un) 448]. Provider: [Name10 (NameIs) ] [Apartment Address(1) 871] ([Doctor First Name ]) [Doctor First Name ] LMOB (NHB) Phone:[Telephone/Fax (1) 1237] Date/Time:[2143-9-11] 2:45 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2143-9-11] 3:15 . [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], PA: works at [Company 2199] dialysis and coordinates care for him there, he has been updated and will give vancomycin with dialysis runs. pager: [Telephone/Fax (1) 79007] Completed by:[2143-8-29] ICD9 Codes: 5856, 486, 4280, 4240, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8809 }	Medical Text: Admission Date: [2189-3-29] Discharge Date: [2189-4-16] Date of Birth: [2121-5-9] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 783] Chief Complaint: headache Major Surgical or Invasive Procedure: none History of Present Illness: This is a 67 year old with a history of hypertension, type II diabetes mellitus, CRI who initially presented on [2189-3-29] with headache following mechanical falls at home 2 weeks ago. His wife notes that he has had three falls in the last 2 weeks. His first fall was two weeks ago while he was being weighed on a scale. He lost his balance, fell backwards and hit the back of his head on a shelf. His second fall was one week ago, he was on his way to the bathroom with his walker and fell on the left side of his head. His third fall was three days prior to admission, he was on his walker when his wife noted that his legs buckled. No head trauma was noted following this third fall. His wife reports witnessing these falls and denies LOC, associated chest pain, SOB, palpitations, and lightheadedness. He walks with a walker at baseline. His wife notes that in the last two weeks, she has noticed a deterioriation in his mental status. She has found him increasingly confused and tired. He has also been reporting headaches for the last two weeks. 3 days prior to admission, he also began to have nausea and vomitting along with the headache. His last INR at home was 4.3 five days prior to admisison. He was brought to the [Hospital ] Hospital ED on [2189-3-30] where he was noted to have a SDH. . He received 5 mg vitamin K at the OSH prior to transfer to the [Hospital1 18]. At [Hospital1 18] ED, he [Last Name (un) ] given FFP x 4 units. He also received Lasix IV and Dilantin. He was seen by the neurosurgury team who recommended NSICU and he was subsequently transferred to the ICU. He was deemed stable from a neurosurgical perspective on [3-30] and there were plans for his discharge. However early morning on [3-31], he began to have black guaiac positive stools and had atrial fibrillation with RVR to the 130s. His coumadin has been held and he received 10mg SC vitamin K on presentation ([2189-3-29]) and an additional 10mg SC vitamin K on [3-31]. Additionally, he received 1 unit FFP on [2189-3-31]. INR is currently 1.7. . Of note, he has been on home hospice for heart failure since 3 weeks ago. On review of systems, his wife denies fever, chills, cough, weight loss, abdominal pain, and diarrhea. Past Medical History: 1. Atrial fibrillation on anticoagulation 2. Congestive Heart Failure (per Med c/s note, diastolic with relatively preserved EF 50%, dry weight around 285 to 290 lbs, uses metolazone 2.5 mg when weight increase to 190 lbs. On standing K repletion). 3. Hypertension 4. Type II Diabetes Mellitus 5. Chronic renal insufficiency (most recent baseline Cr 3) 6. Gout Social History: Lives at home with wife, on hospice for CHF, No tobacco, alcohol, IVDU Family History: DM, CAD Physical Exam: T: 100.4 at 8 AM, T 99.6 BP: 150/60 HR: 88 (88-102) R: 16 O2Sats: 99% 4L Gen: Sleeping, somnolent but arousable, falling asleeping throughout the exam HEENT: Pupils: R 3-2 mm, L 2-1.5 EOMs intact Neck: Supple. Lungs: Clear to ascultation anteriorly Cardiac: irregular, irreg. S1/S2. Abd: Soft, NT, BS+, obese Extrem: LE venous stasis changes bilaterally. Neuro: CNII-XII grossly in tact. Moves all extremities freely. Neurological exam limited by somnolence. [2189-3-29] CT head: 1. Acute right-sided subdural hematoma, stable when compared to outside study. 2. Bilateral superior ophthalmic vein enlargement, left greater than right. These findings can be seen with carotid cavernous fistula and/or cavernous sinus thrombosis. Clinical correlation is suggested. . [2189-3-31] CT head: Stable appearance of right-sided acute subdural hematoma. Unchanged left greater than right superior ophthalmic vein enlargement. . [2189-4-10] CXR: In comparison with study of [3-30], the pulmonary vessels now appear to be essentially within normal limits. Enlargement of the cardiac silhouette persists. No evidence of acute focal pneumonia at this time. Pertinent Results: [2189-3-29] CT head: 1. Acute right-sided subdural hematoma, stable when compared to outside study. 2. Bilateral superior ophthalmic vein enlargement, left greater than right. These findings can be seen with carotid cavernous fistula and/or cavernous sinus thrombosis. Clinical correlation is suggested. . [2189-3-31] CT head: Stable appearance of right-sided acute subdural hematoma. Unchanged left greater than right superior ophthalmic vein enlargement. . [2189-4-10] CXR: In comparison with study of [3-30], the pulmonary vessels now appear to be essentially within normal limits. Enlargement of the cardiac silhouette persists. No evidence of acute focal pneumonia at this time. Brief Hospital Course: 67 y/o male with a history of type II DM, congestive heart failure (class IV), atrial fibrillation, hypertension, chronic renal insufficiency, who was admited with a supratherapeutic INR and SDH following fall, complicated by intermittent seizure activity. . SDH with opthal vein engorgement: His repeat CT scan was stable on [3-31]. However, he was found to have new seizures on [4-3], with focal motor activity of LUE, suggesting that SDH may be progressing. We attempted to reimage his head on [4-3], and onward, but due to his tenuous respiratory status and severe orthopnea, repeat CT was unfeasible. Per extensive discussion with his wife about pt's comfort, decision was made to provide supportive care with management of seizure activity and pain. He was continued on valproic acid for seizure prophylaxis. He was given ativan 0.5 prn for persistent seizure activity lasting for a prolonged period of time (>2-3 mins). . Pain: He had continued headaches and back pain throughout this hospitalization. As noted above, goals of care shifted towards focusing on pt's comfort, even if it meant that this would be at the cost of increased sedation. He was started on concentrated morphine. He has a peripheral IV if morphine gtt in case morphine gtt is required. . GIB: There were concerns of melanic stools during this hospitalization and likely UGIB on [3-31] on the neurosurgical service. He does have a long standing history of epistaxis, this may explain his guaiac positive stools. He remained hemodynamically stable otherwise. EGD could not be done on [3-30] due to desats when lying flat. On the evening of [3-30] with hct drop to 24 from baseline of 27-28. He received 1 unit pRBC on [3-30] with appropriate response. As above, with changes in goals of care, lab draws were discontinued on [4-10]. . CHF: Based on OSH echo results, mainly diastolic, with relatively preserved EF. Prior to admission, at home with hospice for class IV HF. At home on lasix 80 mg [Hospital1 ] and metolazone. Diuretics were held in the setting of metabolic abnormalities (primarly hypernatremia) and GIB. He appeared fluid overloaded on [4-4] and in respiratory distress and his home regimen of lasix reintroduced. On [4-14], diuretics were discontinued following meetings with his wife who expressed her wishes to discontinue all medications that could potentially prolong his life. Diuretics and anti-hypertensives were discontinued at this time. . Atrial Fibrillation: On admission he was rate controlled on digoxin, CCB, and BB. However, due to change in goals of care, his rate control agents were discontinued. . Pt is DNR/DNI, with comfort measures only. His current medications include keppra for seizure prophylaxis, ativan for prolonged seizures, and morphine for comfort. Medications on Admission: Insulin SS Lantus 45U QPM Potassium 20 Meq [Hospital1 ] Lasix 80 MG [Hospital1 ] Metolazone 2.5 mg sliding scale Levothyroxine 175 mcg Daily Alopurinol 100 mg daily Colchicine 0.6 mg daily digoxin 0.125 mg QPM Renal Caps Daily Diltiazem SR 180 mg QAM Coreg 25 mg [Hospital1 ] Coumadin 7.5 as directed Clarinex 5mg QPM Iron 300 mg [Hospital1 ] Lyrica 100 mg TID Lidoderm patch 12 hrs QPM Klonopin 0.5-1 mg QID Celexa 10 mg QPM Percocet [12-17] Q4-6 hrs PRN Procrit 15,000 U QMonday Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: One (1) PO Q1H (every hour) as needed. 2. Morphine Concentrate 20 mg/mL Solution Sig: One (1) PO Q4H (every 4 hours). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 4. Lorazepam 0.5 mg IV Q4H:PRN 5. Valproic Acid 250 mg Capsule Sig: Three (3) Capsule PO every six (6) hours. Discharge Disposition: Extended Care Discharge Diagnosis: Primary Subdural hemorrhage Gastroinstestinal bleeding Congestive heart failure Atrial fibrillation Focal motor seizure Secondary Chronic renal insufficiency Gout Hypothyroidism Discharge Condition: poor, tachycardic, 89-90% RA Discharge Instructions: You were admitted with a bleed in your head. You were evaluated by our neurosurgical staff. You also had bleeding in your gastrointestinal tract. You were seen by the gastrointestinal doctors and were [Name5 (PTitle) ] blood transfusions. Your bleeding could not be further assessed on CT scan due to your respiratory status. It is possible that your bleed is progressing. You also had seizures during this admission. You are currently receiving comfort care. Your medications include keppra for seizure prophylaxis, ativan for prolonged seizures, lidocaine for pain and morphine for comfort. If you have any of the following symptoms, you should return to the emergency room: Worsening headache, blurry vision, worsening drowsiness/sleepiness, loss of consciosness, chest pain, shortness of breath or any other serious concerns. Followup Instructions: n/a [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799] Completed by:[2189-4-16] ICD9 Codes: 5789, 5849, 4280, 5859, 2749, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8810 }	Medical Text: Admission Date: [2154-4-30] Discharge Date: [2154-5-3] Date of Birth: [2092-11-28] Sex: F Service: MEDICINE Allergies: Percocet Attending:[First Name3 (LF) 12] Chief Complaint: fever, chills, rigors Major Surgical or Invasive Procedure: Arterial line placement History of Present Illness: 61F w/ sign PMH for UC s/p colectomy, Stage II breast cancer presented on day 13 of second cycle of chemotherapy with fever to 100.6 at home w/ severe rigors. She took two Ibuprofen at home and then went to onc clinic today where she was then referred to the ED for admission. She stated that for the past two days she has noticed an increasing amount of stool output in her ostomy bag but denies abdominal discomfort or blood in her stool. She has had nausea but similar to how she has felt in the past with chemo. She also mentioned that she recently cut her finger in the garden on Sunday which is now red and slightly tender to the touch. She otherwise denies any vomiting, rash, rhinorrhea, dysuria, cough, SOB or abdominal discomfort. She denies any recent travel or sick contacts as well. . In the ED inital vitals were, Temp: 101 ??????F (38.3 ??????C), Pulse: 93, RR: 16, BP: 77/38, O2Sat: 94, O2Flow: RA. Her labs were notable for WBC of 0.7 and PMN count of 21. Her U/A was bland and two blood cultures were obtained and are pending. His CXR did not show definitive source of infection either. She was started on Cefepime for neutropenic fever. While in the ED she developed hypotension not responding to IVF boluses, the pt denied CVL placement and required the initiation of phenylepherine peripherially in order to maintain SBPs in the 90s-100s. She did not have a change in her mentation during these episodes of hypotension. . On arrival to the ICU, she was mentating normally and answering questions appropriately. She was in NAD. . Review of systems: (+) Per HPI (-) Denies current chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies vomiting, constipation, abdominal pain. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes. Past Medical History: Ulcerative colitis s/p Total colectomy with hartmanns pouch in [2147-11-26] Ileostomy revision for ileocutaneous fistula. Chronic back pain Right leg pain for which she underwent exploration for a possible reflex sympathetic dystrophy at [Hospital 13] Hospital. basal cell carcinoma of her right shoulder Left Colles fracture Depression Breast Cancer Diagnosed in [1-31] w/ biopsy currently in cycle 2 of Docetaxel (Taxotere) + Cyclophosphomide, completed cycle 1 in [4-1] Social History: Lives alone, works for non-profit. - Tobacco:denies - Alcohol: denies - Illicits: denies No tob, Etoh. Patient lives alone in a 2 family home w/ a friend. She is an administrative assistant Family History: Mother had breast cancer in 70s. brother w/ ulcerative proctitis, mother w/ severe arthritis, father w/ h/o colon polyps and GERD Physical Exam: ADMISSION EXAM: Vitals: T:99.2 BP:78/34 P:71 R: 13 O2:94% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear no tonsilar exudate Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, ileostomy in place in RLQ no erythema or tenderness to palpation on exam GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, left fourth finger has erythematous area of skin measuring approx 2cm in diameter surrounding an scabbed over skin lesion, no swelling or purulent drainage noted DISCHARGE EXAM: Physical Exam: Vitals: 97.9 106/60 78 20 97%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear no tonsilar exudate Neck: supple, JVP 6-8, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, ileostomy in place in RLQ no erythema or tenderness to palpation on exam GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, left fourth finger has erythematous area of skin measuring approx 1cm in diameter surrounding an scabbed over skin lesion, no swelling or purulent drainage noted Pertinent Results: [2154-4-30] 10:45AM BLOOD WBC-0.7# RBC-3.19 Hgb-9.7* Hct-28.8* MCV-90 MCH-30.3 MCHC-33.5 RDW-13.1 Plt Ct-233 [2154-4-30] 11:43AM BLOOD WBC-1.0* RBC-3.10* Hgb-9.1* Hct-27.5* MCV-89 MCH-29.5 MCHC-33.2 RDW-12.9 Plt Ct-209 [2154-5-1] 04:12AM BLOOD WBC-2.3# RBC-2.59 Hgb-7.8* Hct-23.8* MCV-92 MCH-30.0 MCHC-32.7 RDW-13.2 Plt Ct-165 [2154-5-1] 05:36PM BLOOD WBC-4.2# RBC-2.70* Hgb-8.5* Hct-24.4* MCV-90 MCH-31.3 MCHC-34.7 RDW-13.6 Plt Ct-178 [2154-5-2] 03:49AM BLOOD WBC-5.6 RBC-2.77* Hgb-8.7* Hct-25.1* MCV-91 MCH-31.4 MCHC-34.6 RDW-13.2 Plt Ct-177 [2154-5-3] 09:00AM BLOOD WBC-4.9 RBC-3.02* Hgb-8.9* Hct-27.3* MCV-90 MCH-29.3 MCHC-32.5 RDW-13.6 Plt Ct-221 [2154-4-30] 10:45AM BLOOD Neuts-3* Bands-0 Lymphs-27 Monos-69* Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 [2154-4-30] 11:43AM BLOOD Neuts-7* Bands-1 Lymphs-53* Monos-32* Eos-1 Baso-0 Atyps-6* Metas-0 Myelos-0 [2154-5-1] 04:12AM BLOOD Neuts-16* Bands-7* Lymphs-38 Monos-37* Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0 [2154-5-2] 03:49AM BLOOD Neuts-67 Bands-0 Lymphs-22 Monos-11 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2154-5-3] 09:00AM BLOOD Neuts-77* Bands-0 Lymphs-14* Monos-7 Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0 [2154-4-30] 11:43AM BLOOD Glucose-112* UreaN-18 Creat-1.1 Na-137 K-4.5 Cl-105 HCO3-23 AnGap-14 [2154-5-1] 04:12AM BLOOD Glucose-106* UreaN-12 Creat-0.9 Na-142 K-3.6 Cl-115* HCO3-20* AnGap-11 [2154-5-2] 03:49AM BLOOD Glucose-97 UreaN-13 Creat-0.9 Na-140 K-3.9 Cl-114* HCO3-21* AnGap-9 [2154-5-3] 09:00AM BLOOD Glucose-92 UreaN-10 Creat-0.9 Na-143 K-4.0 Cl-115* HCO3-22 AnGap-10 Galactomannan - negative B-d-glucan - negative Cdiff - negative BCX - pending Brief Hospital Course: Ms. [Known lastname 14] is a 61 yo w/ Stage II breast cancer who was admitted on day 13 or cycle 2 of Docetaxel (Taxotere) + Cyclophosphomide who developed fever to 100.6 at home with associated rigors in the setting of neutropenia. . #Neutropenic Fever- On presentation the pt's PMN count was 21 most likely from her most recent chemotherapy cycle and lack of Neulasta use. Two possible sources of infection existed including pulmonary or from a laceration on her finger suffered while gardening. She was broadly covered with Vancomycin and cefepime to cover both possible sources, as well as flagyl to cover for cdiff as the patient mentioned that she had increased ostomy output. When cdiff returned negative, flagyl was discontinued. Blood cultures were sent and a U/A was not concerning for infection. We also sent off galactomannan antigen and beta-D-glucan labs initially as part of her neutropenic fever workup which were negative. The following day after admission her WBC rose significantly and she no longer was neutropenic. As her WBC rose she started to develope a cough and he CXR became concerning for an infiltrate. She was continued on Vanc/Cefepime until afebrile and with ANC>1000 for greater than 48 hours, after which she was switched to PO levofloxacin to complete an 8 day total course for community acquired pneumonia. . # Hypotension- In the [Name (NI) ] pt's SBP dropped to 70s, not responding to IVF boluses. She refused central line placement in the ED and peripheral pressors were initiated. This is most likely related to her underlying infectious process. She was not administered any medications recently that could be accounting for her hypotension. Looking through OMR her baseline blood pressures are sbp of 90s-100s. An a-line was obtained which showed higher BP than what was being recorded by the blood pressure cuff. She was given several liters of IV fluid boluses and weaned off pressors the night of admission to the ICU. Her cuff and a-line pressures correlated after fluid resuscitation and the a-line was discontinued. . # Breast Cancer- currently in cycle 2 of Docetaxel (Taxotere) + Cyclophosphomide. Most likely this current episode of neutropenia is due to the fact that Neulasta was not given during this cycle of chemo per pt's request, however due to the rapid rise in her WBC count myelosuppression from sepsis was also a possibility. . # Depression / Anxiety- Continue Duloxetine and clonazepam at home doses. . # Nausea- Continued compazine and PO zofran prn. Medications on Admission: CLONAZEPAM - 1 mg Tablet - 1 (One) Tablet(s) by mouth once a day anxiety DULOXETINE [CYMBALTA] - 20 mg Capsule, Delayed Release(E.C.) - 2 Capsule(s) by mouth daily LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for nausea or insomnia METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg Tablet - 1 (One) Tablet(s) by mouth twice a day as needed PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for nausea ZOLPIDEM - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth at bedtime as needed for insomnia Medications - OTC CALCIUM [CALCIO [Doctor First Name 15] [Month (only) 16]] - (Prescribed by Other Provider) - 500 mg Tablet - Tablet(s) by mouth Total daily dose 1200 mg CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - (Prescribed by Other Provider) - Dosage uncertain MULTIVITAMIN - (Prescribed by Other Provider) - Dosage uncertain OMEPRAZOLE - (OTC) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day Discharge Medications: 1. clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:4 Tablet(s) Refills:0 5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for insomnia. 6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. 7. zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 8. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 9. Vitamin-D + Omega-3 350 mg- 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 10. multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: 1) Neutropenic fever 2) Community acquired pneumonia 3) Severe sepsis 4) Anemia 5) Stage II breast cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [Known firstname 17], It was a pleasure to take care of you here at [Hospital1 18]. You were admitted for low white cell (neutrophil count), fever, and pneumonia. You required monitoring with blood pressure supporting medications and IV antibiotics in the intensive care unit. Fortunately, your counts improved and you responded nicely to the antibiotics. Please continue to take levofloxacin to treat your pneumonia for a total of 8 days (last dose on [2154-5-7]). As we discussed if you notice fever, worsening breathing problems, or any other concerning symptoms to return to the emergency room immediately. We have made the following changes to your medications: START levofloxacin 750mg by mouth daily for 4 more days ([2154-5-7]) You should discuss with Dr. [Last Name (STitle) 19] the possibility of restarting neulasta with your next chemotherapy cycle. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [2154-5-9] at 10:30 AM With: [First Name11 (Name Pattern1) 20] [Last Name (NamePattern1) 21], M.D. [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 [2154-5-9] at 10:30 AM With: [First Name8 (NamePattern2) 25] [First Name4 (NamePattern1) 26] [Last Name (NamePattern1) 27], NP [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 [2154-5-9] at 12:00 PM With: [Name6 (MD) 26] [Name8 (MD) 28], RN [Telephone/Fax (1) 22] Building: [Hospital6 29] [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage ICD9 Codes: 0389, 486, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8811 }	Medical Text: Admission Date: [2185-11-2] Discharge Date: [2185-11-19] Date of Birth: [2103-5-27] Sex: F Service: MEDICINE Allergies: Erythromycin / Tramadol / Simvastatin Attending:[First Name3 (LF) 2290] Chief Complaint: Nausea/Vomiting Major Surgical or Invasive Procedure: Truncal vagotomy, antrectomy, retrocolic Billroth II gastrojejunostomy and omentectomy History of Present Illness: This is an 82 yo F transfered for workup of a stomach mass. She was admitted to OSH on [10-26] with 5 weeks of nausea and foreful brownish/blackish emesis, appx 1 pint/day. She associated this with recently starting warfarin, but symptoms returned even after stopping warfarin. She had no prior issues with nausea or vomiting. Also with 8-10# wt loss over this time. At OSH, noted to be in rapid afib. HR improved with IVF and dilt drip (now in 80s-90s). Warfarin was held and she was continued on enoxaparin. Underwent EGD which showed gastric mass. Biopsy performed with pathology "inconclusive". NG tube was refused (pt does not recall this). Surgery was consulted and recommended CT scan, with results below. She did require blood transfusions for anemia, as well. She was also on levofloxacin, then bactrim, for pansens E coli UTI. Sent to [Hospital1 18] for possible EUS with bx, and likely surgical intervention. Vitals from transfer call-in: T: AF BP: 132/91 HR: 80s-90s RR: 20 O2 Sat: 99% 2 L/min O2. . On the floor, patient notes that she has been on a regular diet, but not eating much solid. Her nausea is bad in the am, with spitting up phlegm, but abates after ~1pm. . . Past Medical History: Diabetes Hypertension Coronary artery disease s/p MI, 3 stents Osteoporosis Emphysema Atrial fibrillation Chronic back pain - spinal stenosis CHF? Anemia Hx of pancratitis Hx bilateral knee replacement and L shoulder replacement from OA Social History: Lives alone in [Location (un) 5028]. Former secretary. No tobacco, no etoh, no illicit drug use Family History: Father with [Name2 (NI) 499] cancer resected in his 80s; daughter diagnosed with breast cancer at age 48 Physical Exam: Vitals: T: 96.0 BP: 120/82 P: 101 R: 18 O2: 96,2L Glc: 142 General: Alert, no acute distress HEENT: MMM Neck: SCMs tight, no LAD Lungs: Crackles throughout left lung (patient lying with left lung down), otherwise clear CV: Irregularly irregular, no murmurs, rubs, gallops Abdomen: soft, mild LUQ and R mid abd TTP without rebound or guarding, mildly distended with tympany, bowel sounds present Ext: Warm, well perfused, no edema Pertinent Results: [2185-11-3] 06:10AM BLOOD WBC-5.5 RBC-3.44* Hgb-10.4* Hct-31.7* MCV-92 MCH-30.3 MCHC-32.9 RDW-13.2 Plt Ct-213 [2185-11-3] 06:10AM BLOOD PT-13.1 PTT-25.7 INR(PT)-1.1 [2185-11-3] 06:10AM BLOOD Glucose-122* UreaN-9 Creat-0.5 Na-136 K-3.9 Cl-96 HCO3-35* AnGap-9 [2185-11-3] 06:10AM BLOOD ALT-17 AST-18 AlkPhos-77 TotBili-0.4 [2185-11-3] 06:10AM BLOOD Albumin-3.4* Calcium-9.0 Phos-3.4 Mg-1.9 [2185-11-3] 06:10AM BLOOD PT-13.1 PTT-25.7 INR(PT)-1.1 [2185-11-5] 05:22AM BLOOD Triglyc-113 [2185-11-7] 06:13AM BLOOD PT-13.3 PTT-24.6 INR(PT)-1.1 [2185-11-8] 05:32AM BLOOD PT-13.3 PTT-28.3 INR(PT)-1.1 [2185-11-10] 02:37AM BLOOD PT-14.6* PTT-42.7* INR(PT)-1.3* [2185-11-17] 04:16AM BLOOD PT-13.9* INR(PT)-1.2* . Labs on discharge: [2185-11-19] 01:37PM BLOOD WBC-6.4 RBC-2.95* Hgb-8.9* Hct-26.9* MCV-91 MCH-30.2 MCHC-33.2 RDW-14.3 Plt Ct-327 [2185-11-19] 04:37AM BLOOD PT-15.4* INR(PT)-1.4* [2185-11-19] 04:37AM BLOOD Glucose-59* UreaN-12 Creat-0.5 Na-134 K-4.3 Cl-99 HCO3-31 AnGap-8 [2185-11-19] 04:37AM BLOOD Calcium-8.0* Phos-4.1 Mg-2.0 . [2185-11-3] 6:10 am SEROLOGY/BLOOD HELI ADDED TO ACC#[Serial Number 87019]Z. FINAL REPORT [2185-11-4] HELICOBACTER PYLORI ANTIBODY TEST (Final [2185-11-4]): NEGATIVE BY EIA. (Reference Range-Negative). . [2185-11-4] ECG: Atrial fibrillation with a ventricular rate of 126. Low voltage in the standard leads. Early transition. No other diagnostic abnormality. No previous tracing available for comparison. . [2185-11-3] EUS: Large amount of yellow liquid with large solid particles were noted in the stomach, it could not be completely suctioned out due to the large particles occluding suction channel An irregular, circumferential, friable mass was found in the antrum causing obstruction of the gastric outlet Cold forceps biopsies were performed for histology after EUS examination and FNA. EUS was performed using a radial echoendoscope at 7.5 MHz frequency, however, a full examination was not able to be performed due to the presence of large amount of fluid in the stomach: There was marked thickening of the stomach wall in the antrum, demarcation between mucosa, submucosa and muscularis propria was lost. These findings are consistent with an infiltrative type of gastric neoplasm, such as: linitis plastica, lymphoma, amyloidosis, syphillis, etc. Celiac axis was examined and no lympadenopathy was noted. . [2185-11-4] EUS Biopsy: Gastric mucosa, antrum: Antral mucosa with focal intestinal metaplasia. Note: Special stains for fungi are negative . [2185-11-3] Antrum wall cytology report: SUSPICIOUS FOR ADENOCARCINOMA. Scantly cellular specimen with scattered highly atypical glandular epithelial cells with high N:C ratio, prominent nucleoli, and vacuoles; one signet-ring appearing cell seen. . [2185-11-19] CXR: Left lower lobe opacity is a combination of pleural effusion and probably atelectasis. This is unchanged since [11-4]. Small right pleural effusion is probably unchanged. The right lobe otherwise is clear. There is no evidence of pneumothorax. Multiple thoracic vertebral body compression fractures are noted. . [2185-11-19] CTA chest: Final Report FINDINGS: There is a left trans-subclavian PICC in place with the tip in the junction ofSVC and right atrium. There is no sign of acute or chronic pulmonary embolism or pulmonary hypertension. There is no mediastinal, hilar or axillary adenopathy. There are diffuse three-vessel coronary calcifications. Cardiac [Doctor Last Name 1754] are unremarkable. Aorta demonstrates mild atherosclerotic burden without aneurysm with conventional branching of arch vessels. There is a left pleural effusion. There is consolidation in the left lower lobe adjacent to the pleural effusion which may be due to compressive atelectasis versus pneumonia. There is a smaller right pleural effusion. There is a 3.2 cm bulla in the right middle lobe. No nodule or mass. Bronchi and trachea are unremarkable. There are compression fractures in the T8 and T9 vertebra with approximately 50% height loss without breach of posterior cortex or retropulsion, stable from [2185-11-4]. There are also significant degenerative changes involving the right shoulder joint. IMPRESSION: No acute or chronic pulmonary embolism. Left pleural effusion with adjacent consolidation, atelectasis versus pneumonia. T8 and T9 vertebral body compression fractures with 50% height loss, stable from [2185-10-12]. Brief Hospital Course: This is an 82 yo F transferred for workup of a stomach mass, which presented with nausea and vomiting. The patient was initially admitted to general medicine, but was transferred to the Acute Care Service for a planned subtotal gastrectomy. Subsequently, a truncal vagotomy, antrectomy, retrocolic Billroth II, gastro-jejunostomy and omentectomy was performed on [2185-11-8]. The patient was transferred to the surgical intensive care unit post-operatively, where she remained stable. The patient was transferred to the surgical [Hospital1 ] on Post-operative day #4. # Gastric mass: presented with mass from OSH. Partially obstructing, concerning for malignancy. EUS performed on [11-4] confirmed mass, with concern for linitis plastica vs. lymphoma. Was deemed H. pylori negative. Biopsies returned positive for intestinal metaplasia without any signs of overt malignancy. NGT was eventually needed for the pt as she began vomiting gastric secretions on [2185-11-6]. The patient was evaluated by surgery and deemed intermediate to high risk candidate based on her cardiovascular risk factors and history of an MI in the past. She was scheduled for surgery and a truncal vagotomy, antrectomy, retrocolic Billroth II gastrojejunostomy and omentectomy was performed on [2185-11-8]. Oncology was asked to evaluate the patient due to a final pathologic diagnosis of T4aN2. The patient will follow-up with [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1852] as an outpatient on [2185-11-25]. . # Afib: Pt. presented with atrial fibrillation with rapid ventricular response. Her warfarin was discontinued out of necessity for future surgical intervention. Her ASA was initially held but restarted on [2185-11-7] at 81 mg daily due to her risk of restenosis of her prior cardiovascular stents. Rate control was poorly achieved, initially with IV metoprolol and po diltiazem. However, after her NGT was placed, oral medications were stopped and the patient was continued on IV metoprolol 20 mg q4hr with her heart rate ranging between 80-90 BPM. However, on post-operative day # 5 the patient triggered for a sustained heart rate in the 130s. The patient received 5 mg of intravenous metoprolol x 3 with an improved heart rate into the 100s. The patient remained asymptomatic throughout the event. On post-operative day #6 her home regimen of po metoprolol and diltiazem was resumed. She remained in atrial fibrillation with a persistently elevated ventricular rate ranging between the 80's-120's. General medicine was consulted to optimize management. Recommendations included adjusting the timing of diltiazem with an increase in her atenolol dose. She was transfered to medicine for further rate control of her a fib and ultimately discharged on diltiazem 180mg sustained release and atenolol 50mg [Hospital1 ]. She had a CT scan of your chest to look for a blood clot causing irritation of your heart. This was negative for evidence of a blood clot although the final read of this study is pending at your time of discharge. She was discharged on coumadin with an INR of 1.4 on the day of discharge. . # Anemia: Required transfusions at outside hospital. Upon transfer to [Hospital1 18] no further transfusions were needed. . # DM: Blood glucose levels were intermittenly elevated with a regular insulin sliding scale and glyburide early in the admission. At the time of transfer to medicine she has occasional low blood sugars and her glyburide was reduced to 2.5mg daily. # HTN: The patient came in on oral anti-hypertensives which were resumed once the patient was able to take po. Her systolic blood pressures ranged between 90-120s on diltiazem and atenolol. Her lisinopril 10mg daily was held in order to uptitrate her A fib medications. Her lisinopril should be restarted by your primary care doctor when her blood pressure allows. # Coronary artery disease s/p MI, 3 stents: She was initially off ASA for procedures but placed back on low dose ASA on [2185-11-7]. She was continued on her beta-blocker and statin. Her lisinopril was held as detailed above. . # Emphysema: She was continued on her fluticasone-salmeterol and nebs prn. . # Pain: Her standing APAP and methadone were converted to intravenous morphine and then a Dilaudid PCA while NPO. The patient resumed oral methadone and was transitioned to oral Percocet once tolerating po with well-controlled abdominal pain. She continued to have right shoulder and back pain throughout the course of her hospital stay. She also developed severe constipation during her hospitalization and was discharged on an aggressive bowel regimen of senna, colace, and miralax. . # FEN: The patient was kept NPO and maintained on total parenteral nutrition until her [Last Name (un) ]-gastric tube was discontinued and tolerance to a regular diet was established. At discharge, the patient was tolerating a diabetic/ consistent carbohydrate diet. . # Prophylaxis: She was on heparin sc during her hospitalization. . # Rehabilitation: The patient was evaluated by both physical and occupational therapy prior to discharge. Physical therapy recommended home follow-up to improve endurance. Occupational therapy without recommendations. Medications on Admission: Home meds: ASA 81mg daily Glyburide 5mg daily Lipitor 10mg daily Lisinopril 10mg daily Atenolol 50mg daily Methadone 15mg qam, 10mg qnoon, 10mg qpm Combivent 2 puffs QID Advair 2 puffs daily Oxycodone APAP 5/325 prn . Medications (from [Hospital3 26615]): Atenolol 50mg [Hospital1 ] Lisinopril 2.5mg daily Diltiazem CD 120mg daily Atorvastatin 10mg daily Lovenox 40 units daily Ferrous sulfate 325mg [Hospital1 ] Insulin SS Methadone 15mg qam, 10mg qnoon, 10mg at 2200 Reglan 5mg IV TIDAC Zofran 8mg IV TIDAC Oxycodone APAP 1-2 tabs q6h prn pain Protonix 40mg daily Bactrim 1 tab [Hospital1 ] Salmeterol Fluticasone 1 inh [Hospital1 ] Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Methadone 5 mg Tablet Sig: Three (3) Tablet PO qam. 4. Methadone 10 mg Tablet Sig: One (1) Tablet PO q noon and qhs. 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 6. 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 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:2 8. diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:30 Capsule, Sustained Release(s) Refills:2 9. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 10. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. Disp:60 Tablet(s) Refills:0 12. warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day: pls adjust as needed to maintain an INR of [3-16]. Disp:150 Tablet(s) Refills:0 13. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 14. diltiazem HCl 180 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. Disp:30 Capsule, Sust. Release 24 hr(s) Refills:2 15. Miralax 17 gram/dose Powder Sig: One (1) PO once a day as needed for constipation. 16. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: Obstructing gastric antral carcinoma with small notch of implants in the gastric colic omentum and the serosa of the first portion of the duodenum and the antrum. 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 transferred to the [Hospital3 ] from an outside hospital and found to have gastric cancer. You had surgery which you are healing well from. You were seen by oncology and will follow up with them as an outpatient to determine your treatment plan. You remained in the hospital because you developed atrial fibrillation with a rapid heart rate. Your dose of atenolol was increased and you were started on diltiazem. You had a CT scan of your chest to look for a blood clot causing irritation of your heart. This was negative for evidence of a blood clot although the final read of this study is pending at your time of discharge. Please follow up with your primary care provider to obtain the final read of your chest CT scan. You have been started on a bowel regimen. Please contact your primary care doctor if you stop moving your bowels or if you stop passing gas. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [6-20] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. The following medications were started: -Diltiazem 180mg sustained release daily for a fib -colace 100mg twice a day as needed as a stool softner -senna 1 tab twice a day as needed for constipation -calcium 500mg twice a day The following medications were changed in dose: -atenolol was increased to 50mg twice a day -glyburide was decreased to 2.5mg daily The following medications were stopped: -lisinopril 10mg daily (should be restarted by your primary care doctor if your blood pressure is not too low) -pericolace (separate colace and senna was started) The following medications were continued at their previous doses: -ASA 81mg daily -Lipitor 10mg daily -Methadone 15mg in the am, 10mg at noon, 10mg before bed -Combivent 2 puffs four times a day -Advair 2 puffs daily -Oxycodone APAP 5/325 as needed for pain -Miralax as needed for constipatiion Followup Instructions: Please call the Acute Care Service at [Telephone/Fax (1) 600] to make an appointment within 2-3 weeks for surgical follow up. . Please call Dr. [Last Name (STitle) 14879] at [Telephone/Fax (1) 32949] to make an appointment within 3 days to have your INR checked and your heart rate checked. . Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [2185-11-25] at 1:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 6050], MD [Telephone/Fax (1) 8770] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2185-12-23] ICD9 Codes: 5990, 5180, 4019, 2859, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8812 }	Medical Text: Admission Date: [2176-11-12] Discharge Date: [2176-11-18] Date of Birth: [2099-7-15] Sex: F Service: MEDICINE Allergies: Morphine / Iodine; Iodine Containing / Lipitor / Phenothiazines Attending:[First Name3 (LF) 2387] Chief Complaint: 77-yo-woman with DM2, CRI, HTN, CHF, CAD called out of MICU to floor, awaiting permacath placement [11-14] for dialysis. Had been admitted to MICU for mgmt of acidosis in the setting of ARF. Major Surgical or Invasive Procedure: Placement of right inferior jugular tunneled catheter for hemodialysis History of Present Illness: Presented to ED [11-12] w/ tremor for 3 days, decreased appetite, also urinary frequency x 1 week. See original MICU admission H&P for full history and review of systems. In the [Name (NI) ], pt was found to have ARF w/ creatinine 6.1, K 4.8, and bicarb 10. ABG was 7.1/36/99 on room air. Pt was admitted to the MICU for management of acidosis/uremia. Past Medical History: Primary: Bronchitis Anemia of Chronic Renal Disease Possible Mastitis Secondary: CAD/CHF s/p CABGx3 -- multiple caths, 3 stents [5-31], [9-30], [11-30] HTN IDDM CRI (Cr 2.4-2.7) Hypothyroid OA Wheelchair bound [1-31] left knee removal right THR, left TKR Polycythemia d/t erythropoetin, d/c'd [2175-7-30] Social History: No ETOH, NO Tobacco, NO drugs. [Name (NI) 1094] husband and children present and supportive. Family History: non-contributory Physical Exam: 131/43 61 15 100% on 2.5L Gen: morbidly obese woman, NAD, A+Ox3 conversing fluently HEENT: anicteric, EOMI, MMM, no JVD CV: RRR, +S3, +Systolic murmur loudest at apex Pulm: CTAB Abd: obese, +BS, soft, NT, ND Ext: warm, palpable DP pulses B, + non-pitting edema to mid-leg, venous stasis skin changes; ecchymosis over forearms bilaterally Neuro: A+O x 3. + Asterixis bilaterally Guaiac negative Pertinent Results: [2176-11-12] 07:48PM GLUCOSE-164* UREA N-110* CREAT-5.8* SODIUM-143 POTASSIUM-4.6 CHLORIDE-113* TOTAL CO2-12* ANION GAP-23* [2176-11-12] 07:48PM CK(CPK)-28 [2176-11-12] 07:48PM cTropnT-0.05* [2176-11-12] 04:15PM ABG PO2-99 PCO2-36 PH-7.10* TOTAL CO2-12* BASE XS--17 [2176-11-12] 04:15PM LACTATE-0.7 NA+-142 K+-4.3 CL--115* [2176-11-12] 04:15PM HGB-11.6* calcHCT-35 [2176-11-12] 04:15PM freeCa-1.23 [2176-11-12] 03:48PM WBC-6.2 RBC-4.01# HGB-12.8# HCT-42.8# MCV-107# MCH-31.9 MCHC-29.9# RDW-16.6 [2176-11-12] 03:48PM NEUTS-75.3* BANDS-0 LYMPHS-16.8* MONOS-3.8 EOS-3.0 BASOS-1.2 [2176-11-12] 03:48PM PLT COUNT-132* [2176-11-12] 01:55PM URINE COLOR-Straw APPEAR-Cloudy SP [Last Name (un) 155]-1.014 [2176-11-12] 01:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2176-11-12] 01:55PM URINE RBC-[6-7]* WBC->1000 BACTERIA-MANY YEAST-NONE EPI-0 [2176-11-12] 01:25PM GLUCOSE-111* UREA N-113* CREAT-6.1# SODIUM-142 POTASSIUM-4.5 CHLORIDE-112 TOTAL CO2-10* ANION GAP-25* [2176-11-12] 01:25PM CK(CPK)-32 [2176-11-12] 01:25PM CK-MB-NotDone cTropnT-0.06* [2176-11-12] 01:25PM ASA-NEG ETHANOL-NEG ACETMNPHN-6.6 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG Brief Hospital Course: 77-yo-woman w/ DM2, CAD, HTN, CRI and ARF, CHF presenting w/ improving tremor, improving acidemia secondary to uremia, also w/ UTI and anemia. . 1. Non-oliguric ARF on CRF, Uremia/Acidemia: ARF with Cr increase from 3 to 6.1 was likely secondary to prerenal azotemia from hypovolemia, given decreased PO intake over past 2 weeks, though FENa of 4% supports intrinsic renal etiology. UTI is another possible exacerbating factor, though unlikely as no signs of pyelonephritis. The pt had evidence of uremia with decreasing appetite, asterixis, and acidosis, no hyperkalemia. The patient was admitted to the MICU on presentation for management of uremia and acidosis. A bicarbonate gtt was initiated [11-12], and discontinued [11-13], after repeat ABG was 7.24/47/133/21. Asterixis/tremor subsequently diminished. The patient was transferred from the MICU to the Medicine floor service on [11-13]. The patient was followed by the nephrology team during the course of her admission. Renal U/S performed [11-13] showed no obstruction or hydronephrosis. Given the pt's diabetes and worsening renal status, the nephrology team recommended initiation of hemodialysis. The pt received a tunneled right IJ catheter placed by IR on [11-14], and started hemodialysis [11-15]. She received daily hemodialysis on [11-15]. During her admission, the patient had weight, fluid status, and electrolytes monitored daily. She also was started on Lisinopril by the nephrology team. She was also seen by transplant surgery, to discuss eventual need for AV fistula placement for hemodialysis. The patient was subsequently set up for outpatient dialysis, and had her first appointment [11-20] at 11:15AM. . 2. UTI: The pt was found to have a UTI on UA on admission, but no fever or other signs of systemic infection. Her acute urinary infection may have contributed to her ARF. UCx >100,000 enterococcus, initially treated empirically w/ levofloxacin; the patient received a full 3 day course which finished [11-14]; however, urine culture/sensitivities subsequently came back as Levo resistant, and the pt's foley was removed, and she was started on Vancomycin [11-16]. The pt was renally dosed, based on trough levels; [11-17] Vanc trough was 6.8, and the patient received an additional dose that day. Trough on [11-18] was 17.7, and no further doses of vancomycin were given. The pt remained afebrile, with no elevation in white count. . 3. CAD: The patient had a h/o CABG, stents, severe 3VD, w/ some partially reversible defects on last PMIBI. No cardiac symptoms or EKG changes on admission. On admssion, troponin was elevated at 0.06, however CK/MB were normal, and tropinin levels remained constant; therefore, elevated troponin therefore most likely due to renal failure. On [11-15] during her first hemodialysis session, the pt developed 5/10 chest pain which lasted 5 minutes, and spontaneously resolved, no associated symptoms. EKG showed new left bundle (previously had IVCD) and peaked T waves. The patient never had any further chest pain, shortness of breath or palpitations. She remained on her home regimen of ASA, Plavix, Metoprolol, Nitropatch, and statin. 4 Hypercarbia: The patient's ABGs showed respiratory acidosis along with metabolic acidosis. The patient is a very obese woman who reportedly snores at night, thus calling into question possibility of pickwickean syndrome vs. sleep apnea. Pulm consult was requested, who stated that the patient has a physiologically abnormal response to hypercarbia, and recommmended obtaining a sleep study as outpatient. During the course of her admission, the team also attempted to limit administration of narcotics, in order to minimize respiratory depression. ABG's were checked daily until [11-15]; post-dialysis ABG was attempted by multiple providers but failed, and pt refused further attempts. Renal team subsequently followed bicarbonate levels on chem-10 during daily dialysis. . 5. DM2: Controlled w/ home regimen of NPH 25units qam, Humalog SS . 5. HTN: Metoprolol, clonidine, nitro patch, lisinopril 2.5 mg qd was started [11-16]. . 6. Anemia: Secondary to chronic renal disease, Hct decreased from 42 [11-12] to 32.8 [11-13]. Guaiac negative. Possibly was hemoconcentrated on admission, then hydrated resulting in dilution. Erythropoietin was given at at each dialysis session. Iron was discontinued, and the pt was started on nephrocaps. . 7. Hypothyroid: Controlled w/ home regimen of Levoxyl. . 8. FEN: cardiac/[Doctor First Name ] diet . 9. Proph: heparin sc, PPI, bowel regimen . 10. Access: Peripheral IV - PICC attempted by RN but failed. . 12. CODE STATUS: Pt was initially DNR/DNI, however, pt subseuqently discussed code status with Dr. [Last Name (STitle) ] on [11-15], when she stated that she wished to be full code, and would accept intubation, shock, pharmacotherapy - however, that she did not wish to have prolonged measures. The patient was discharged on [11-18], after receiving her 3rd in-house course of hemodialysis; she was scheduled for her first outpatient dialysis session for [11-20]. Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 3. Calcium Acetate 667 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:90 Tablet(s) Refills:2 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Chronic renal failure/Acute renal failure, DMTypeII, coronary artery disease, hypertension, urinary tract infection Discharge Condition: Stable Discharge Instructions: Outpatient hemodialysis as instructed. Call your primary care provider with any shortness of breath, chest pain, edema/swelling, fever/chills, confusion, tremor, any other worrisome symptoms Followup Instructions: - You have an appointment for dialysis at [Location (un) ] [Location (un) ], Wednesday [11-20] 11:15AM, then on Tues/Thurs/Saturday - Please call Dr.[Name (NI) 5452] office for follow-up appointment in [2-1] weeks - Please call [Telephone/Fax (1) 6856] to schedule a sleep study to evaluate for sleep apnea Completed by:[2176-11-18] ICD9 Codes: 5849, 2762, 5990, 4280, 2449, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8813 }	Medical Text: Admission Date: [2122-4-1] Discharge Date: [2122-4-10] Date of Birth: [2095-4-9] Sex: F Service: MEDICINE Allergies: Xanax / Lamictal Attending:[First Name3 (LF) 9415] Chief Complaint: Suicide attempt by polypharmacy ingestion Major Surgical or Invasive Procedure: Endotracheal intubation Incision and drainage of left wrist phlebitis PICC placement History of Present Illness: 26 female with history of depression, previous suicide attempts and numerous psychiatric admission who was found down at home. Last seen a couple of days ago. Bowl of pills found near her containing acetaminophen-diphenhydramine, ibuprofen. Other meds she takes include quetiapine and duloxetine. FS in field 190. Brought to ED. Initial vitals 97.8 130 75/60 14 100%NRB. She presented obtunded, tachycardic, dilated pupils and has dry mucous membranes. Withdraws to noxious stimulus. Intubated for airway protection. Got fluids with improvement in blood pressure. Initial ECG reveal tachycardia, QRS 90, QTc 454. NG lavage did not reveal any pill fragments. Tylenol level positive at 178. Trycyclic positive on tox screen likely [2-16] diphenhydramine ingestion. Initial ABG 7.0/43/646/11. Started on NAC and bicarb gtt. Head CT and chest CT negative. Transferred to ICU. In ICU, intial vitals 97.0 114 136/91 21 100% on AC. Pt restless, jerking movements, eyes moving frenetically. Evidence of cutting on arms and abdomen. K 6.5 with EKG changes suggestive of hyperkalemia so gave 1 amp Ca and 10 units insulin plus an amp of D50. Past Medical History: 1) Depression with hx of previous ECT - [2121] x 6-8 months at [Doctor First Name ] at one point 2) Suicide Attempts x4 involving Tylenol Overdose 3) Multiple Psychiatric Hospitalizations 4) Anorexia nervosa 5) Bulimia Social History: per psych inpatient consult Born and raised in [Location (un) 686]. FTT as a baby, not very social and cried a lot. At ten yo, started getting panic attacks. This was treated with therapy, no meds. Pt did well in school, but had social anxiety. No known history of abuse. No known history of romantic relationships. Youngest of 3 (one sister and one brother). Family History: No known or pertinent family medical history. FAMILY PSYCHIATRIC HISTORY: per psych inpatient consult Mat Grandfather committed suicide at [Hospital1 ] in [2074], had been hospitalized for ECT. Maternal aunt with manic depression. Maternal aunt ?borderline - multiple hospitalizations. Brother - became very isolated, living on streets, [Last Name (un) 68185]. Now doing well. Physical Exam: Upon Discharge: VS: T 98.2, BP (105-140)/(70-90), HR (66-85), RR 18, O2sat 99% RA GEN: NAD HEENT: PERRL, EOMI, wears corrective lenses, oral mucosa moist NECK: Supple, no LAD, EJ IV site with minimal tenderness and without erythema CARD: RR, nl S1, nl S2, no M/R/G PULM: Minimal bibasilar decreased breath sounds and dullness to percussion, no crackles ABD: Muliple scars on lower abdomen with one healing superficial laceration of RLQ, BS+, soft, mildy tender RUQ, ND EXT: no C/C/E, left wrist with erythematous pustule and reduced swelling and no residual bleeding s/p I&D NEURO: Oriented x 3, non-focal, ambulatory without assistance PSYCH: Good range of affect Pertinent Results: ECG [2122-4-1]: Sinus tachycardia, rate 129. Vertical axis. Left atrial abnormality. No other diagnostic abnormality. No previous tracing available for comparison. Rate PR QRS QT/QTc P QRS T 129 114 90 334/454 73 95 71 CHEST (PORTABLE AP) [2122-4-1]: IMPRESSION: Appropriate position of ET tube. No acute intrathoracic process. CT HEAD W/O CONTRAST [2122-4-1]: IMPRESSION: No acute intracranial process. ECG [2122-4-2]: Sinus tachycardia. Non-specific T wave flattening throughout the tracing. These diffuse T wave changes may be related to electrolyte abnormalities. Clinical correlation is suggested. Rate PR QRS QT/QTc P QRS T 125 124 80 282/395 68 80 29 ECG [2122-4-4]: Sinus tachycardia. Diffuse non-specific T wave flattening. Compared to the previous tracing of [2122-4-2] there is no significant diagnostic change. Rate PR QRS QT/QTc P QRS T 125 134 70 278/391 56 47 37 CHEST (PA & LAT) [2122-4-5]: IMPRESSION: Probable multilobar aspiration pneumonia. TTE (Complete) [2122-4-7]: CONCLUSIONS: The left atrium is normal in size. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. No vegetations seen (cannot definitively exclude). HEMATOLOGY: [2122-4-1] 08:05PM BLOOD WBC-13.0* RBC-4.53 Hgb-13.3 Hct-41.8 MCV-92 MCH-29.3 MCHC-31.7 RDW-13.9 Plt Ct-395 [2122-4-2] 05:56AM BLOOD WBC-12.6* RBC-3.28# Hgb-10.2# Hct-29.8# MCV-91 MCH-31.0 MCHC-34.1 RDW-14.2 Plt Ct-265 [2122-4-3] 08:31PM BLOOD Hct-24.7 [2122-4-7] 03:45PM BLOOD WBC-6.6# RBC-3.30* Hgb-9.8* Hct-29.4* MCV-89 MCH-29.8 MCHC-33.5 RDW-14.5 Plt Ct-244 COAGS: [2122-4-1] 08:05PM BLOOD PT-15.5* PTT-25.3 INR(PT)-1.4* [2122-4-3] 03:20AM BLOOD PT-17.4* PTT-32.5 INR(PT)-1.6* [2122-4-7] 03:45PM BLOOD PT-13.1 INR(PT)-1.1 CHEMISTRY: [2122-4-1] 08:05PM BLOOD Glucose-156* UreaN-28* Creat-2.8* Na-142 K-5.2* Cl-102 HCO3-11* AnGap-34* [2122-4-1] 08:05PM BLOOD TotProt-7.3 Albumin-4.4 Globuln-2.9 Calcium-9.4 Phos-9.5* Mg-2.1 [2122-4-2] 05:56AM BLOOD Glucose-243* UreaN-21* Creat-2.1* Na-146* K-3.8 Cl-110* HCO3-18* AnGap-22* [2122-4-3] 03:20AM BLOOD Glucose-95 UreaN-17 Creat-1.4* Na-142 K-3.8 Cl-113* HCO3-20* AnGap-13 [2122-4-5] 06:22AM BLOOD Glucose-97 UreaN-5* Creat-0.6 Na-140 K-3.4 Cl-113* HCO3-20* AnGap-10 [2122-4-7] 03:45PM BLOOD Glucose-110* UreaN-5* Creat-0.7 Na-142 K-4.3 Cl-105 HCO3-27 AnGap-14 [2122-4-7] 03:45PM BLOOD Albumin-3.5 Calcium-9.1 Phos-3.8 Mg-1.8 HEPATOLOGY: [2122-4-1] 08:05PM BLOOD ALT-36 AST-57* LD(LDH)-217 CK(CPK)-1056* AlkPhos-58 TotBili-0.2 [2122-4-3] 03:20AM BLOOD ALT-42* AST-80* CK(CPK)-2179* AlkPhos-38* TotBili-0.3 [2122-4-6] 05:05AM BLOOD ALT-47* AST-38 LD(LDH)-270* CK(CPK)-489* AlkPhos-62 TotBili-0.4 [2122-4-7] 03:45PM BLOOD ALT-38 AST-29 TotBili-0.2 IRON STUDIES: [2122-4-3] 08:31PM BLOOD calTIBC-274 Ferritn-32 TRF-211 [2122-4-3] 08:31PM BLOOD Iron-8* TOXICOLOGY: [2122-4-1] 08:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-178.9* Bnzodzp-NEG Barbitr-NEG Tricycl-POS [2122-4-2] 05:56AM BLOOD Acetmnp-92.9* [2122-4-2] 10:02AM BLOOD Acetmnp-73.6* [2122-4-3] 03:20AM BLOOD Acetmnp-16.4 [2122-4-3] 08:31PM BLOOD Acetmnp-NEG LACTATE TREND: [2122-4-1] 11:33PM BLOOD Lactate-4.9* [2122-4-2] 10:23AM BLOOD Lactate-2.2* [2122-4-3] 01:18PM BLOOD Lactate-0.9 MICROBIOLOGY: [2122-4-7] URINE URINE CULTURE-FINAL, NO GROWTH [2122-4-6] BLOOD CULTURE Blood Culture, Routine-PENDING NGTD [2122-4-6] BLOOD CULTURE Blood Culture, Routine-PENDING NGTD [2122-4-5] BLOOD CULTURE Blood Culture, Routine-PENDING NGTD [2122-4-5] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY {STAPH AUREUS COAG +} OXACILLIN SENSITIVE; Anaerobic Bottle Gram Stain-FINAL [2122-4-5] URINE URINE CULTURE-FINAL, CONTAMINATED [2122-4-2] MRSA SCREEN MRSA SCREEN-FINAL, NEGATIVE Brief Hospital Course: MICU COURSE: The patient was extubated successfully. Mental status improved. Per Toxicology recommendations, she was continued on NAC until her Tylenol level was undetectable and her mental status had improved. A Renal consult was obtained and felt that ARF likely multifactorial including ATN, rhabodomyolysis, APAP, Iburprofen. ARF resolved prior to transfer to medical floor and further Renal follow-up was not recommended. Psychiatry was also consulted and recommended minimal medications in her initial overdose and planned for psychiatric admission once medical issues were stable. Additionally, upon admission K was 6.5 on arrival with peaked T waves on EKG. She was given calcium, insulin, and glucose. Potassium stabilized with resolution of ARF. Patient noted to have small amount of bloody secretions on NGL, likely gastritis in setting of Motrin ingestion, GI evaluated and no need for urgent scope. HCT remained stable and this was not pursued further while in the ICU. The patient was transferred to the floor with a 1:1 sitter on night of [2122-4-3]. FLOOR COURSE: #. Fevers / Bacteremia / Pneumonia: Patient initially became febrile overnight on [2122-4-4]. On morning of [2122-4-5] CXR revealed a multilobar pneumonia. Patient was started on vancomycin and Unasyn on [2122-4-5] due to concern for HAP. Patient initially with bibasilar crackles, decreased breath sounds, and dullness to percussion. Plan at that time was to only cover pseudomonas if sputum cultures grew pseudomonas, if patient did not defervesce within two days, or if patient had acute worsening. Had minimal dry cough and never able to provide a sputum sample. On morning of [4-6], single blood culture from [4-5] returned positive for gram positive cocci and later speciated as an MSSA on [4-8]. Given MSSA bacteremia, Vancomycin discontinued on [4-8] and Unasyn planned to be continued for total of 14 days via PICC line placed on [4-8]. Last dose of antibiotics should be given on morning of [2122-4-19]. After that time, the PICC line should be discontinued. Patient's pulmonary exam normalized on [2122-4-9] with no residual abnormal findings. Patient's last fever spike was at 0600 on [2122-4-6]. Given this data, patient is medically stable for discharge to any extended care facility that can manage IV antibiotics via PICC. At time of discharge, a blood culture from [4-5] and two blood cultures from [4-6] were still pending and will need to be followed to finality. The number for the microbiology lab is [Telephone/Fax (1) 4645]. #. Left wrist phlebitis: At former IV site there was an indurated erythematous pustule. I&D on [2122-4-7] with minimal drainage. No culture of exudate was able to be obtained due to insufficient volume. At time of discharge the wound appeared to be resolving and needed no further medical care. #. Tylenol toxicity: Tylenol level returned as negative on [2122-4-4], the morning following transfer to the medical floor and patient's NAC infusion was discontinued. LFTs were trended daily until they completely normalized on [2122-4-7] and no more labs were felt to be needed. Hepatology team following upon transfer; however, signed off of the case once patient's LFTs were reliably trending down. Was felt that patient should have an acetaminophen restriction of < 2 grams daily for 2 weeks from [2122-4-7] as a precaution to prevent further liver injury. Patient is medically stable from this standpoint. #. Anemia: HCT at time of admission ([2122-4-1]) was 41.8 and this dropped precipitously to 29.8 on morning after admission. Patient had question of pinkish aspirate from NG tube prior to transfer to floor on [2122-4-3]; however, NG lavage was negative for UGI bleeding. HCT was measured daily through [2122-4-7] (nadir of 24.7 on [2122-4-3]) and found to be stable (and trending upward slightly) with final measured HCT of 29.4 on afternoon of [2122-4-7]. Iron of 8 and iron sat of 2.9% from [2122-4-3] indicated iron deficiency anemia. GI absorption of iron supplement likely to be reduced in setting of PPI twice daily, thus we decided to replete iron stores with ferric gluconate 125 mg IV daily for 5 total days. Patient will be on ferrous sulfate 325 mg [Hospital1 ] for iron supplement upon discharge. She will need a daily stool softener to combat and constipation related to her iron supplements. She is medically stable from anemia standpoint and any further follow-up can be done as an outpatient. #. Sinus Tachycardia: On presentation from MICU, heart rate was ranging from 100 to 140s when patient ambulatory. Was given fluid boluses, which decreased rate slightly. Some consideration given to benzodiazepine withdrawal; however, heart rate not significantly responsive to low dose benzos. After fever spike on night of [2122-4-4], patient noted to have pneumonia and later bacteremia. Then team felt that tachycardia related to fevers and infectious state. Tachycardia resolved shortly following resolution of fevers and patient had no episodes of tachycardiac in her last 4 days of hospitalization. She is medically stable and ready for discharge from this standpoint. #. Depression/anxiety/suicide attempt: Patient was observed with 1:1 sitter and received safety trays with meals. Patient with good range of affect on daily examinations by medical team. Patient was followed by psychiatry team. Her inpatient psychiatric medications were seroquel 100 mg QHS as well as lorazepam 0.5 mg TID:PRN anxiety. Patient denied feeling anxiety and used only one PRN lorazepam dose. Medical team and psychiatry team agreed that patient should be in care of psychiatry inpatient unit upon discharge. She was deemed medically stable and was discharged with plans for 9 additional days of IV Unasyn via PICC ending on [2122-4-19]. The PICC should be discontinued once antibiotic course is complete on morning of [2122-4-19]. Medications on Admission: Seroquel 400mg QHS Cymbalta 120mg daily Ativan 0.5mg TID Prilosec 20mg daily Tetracycline 500mg daily Discharge Medications: 1. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 4. Ampicillin-Sulbactam 3 gram Recon Soln Sig: Three (3) grams of Recon Soln Injection Q6H (every 6 hours) for 9 days: Final dose on morning of [2122-4-19]. 5. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 8. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Discharge Diagnosis: Primary: Drug overdose Aspiration pneumonia Bacteremia Depression with suicide attempt and suicidal ideation Discharge Condition: Stable, afebrile Discharge Instructions: You were admitted due to an overdose of medications. You briefly required a breathing tube, but were quickly able to breathe on your own. You also have gastritis, or irritated stomach lining, for which you were started on an acid blocker called pantoprazole. You developed a pneumonia, likely from vomiting while you were unconscious, which is being treated with antibiotics. You also developed a blood infection which is being treated with intravenous antibiotics through a special IV called a PICC. Please complete the entire course of your antibiotics. If you develop fevers, chest pain, shortness of breath or any other concerning symptoms please contact your primary care provider or return to the Emergency Department. You are being discharged to a psychiatric facility to help you with your depression. Followup Instructions: Please call your primary care provider [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 32651] [Telephone/Fax (1) ] to schedule a hospital follow-up appointment after you complete your psychiatric treatment. Completed by:[2122-4-10] ICD9 Codes: 5845, 5070, 2930, 7907, 2762, 5990, 4589, 2767
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8814 }	Medical Text: Admission Date: [2181-7-11] Discharge Date: [2181-7-17] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4679] Chief Complaint: Carcinoid arising from distal left main-stem bronchus. Major Surgical or Invasive Procedure: [2181-7-11]: Therapeutic bronchoscopy, Left thoracotomy, Lysis of adhesions. Sleeve left lower lobectomy with bronchial anastomosis between the left main-stem and left upper lobe bronchus. History of Present Illness: The patient is an 83 year-old male who presented with polymyositis. His workup included an x-ray and a subsequent CT scan that disclosed a tumor of the left lower lobe. Endobronchial evaluation confirmed a carcinoid tumor. This tumor arose from the distal left main-stem bronchus and included the left lower lobe. He is being admitted for sleeve lobectomy, resection. Past Medical History: Hypertension BPH Psoriasis Basal cell carcinoma: on nose, excised with skin graft in early [2181-3-17] Social History: Quit smoking 27 years ago. No alcohol or drug use. Retired postal worker. No exposure to asbestos. Used to be in the Navy in the Pacific during WWII. Family History: both parents and a brother had MI Physical Exam: VS: T: 98.2 HR: 62 SR BP: 138/68 Sats: 94% RA General: sitting in chair no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lyphadenopathy Card: RRR normal S1,S2 no murmur/gallop or rub Resp: decreased breath L>R with faint crackles LLL GI: benign Extr: warm no edema Incision: Left thoracotomy site clean, dry intact no erythema Neuro: non-focal Pertinent Results: [2181-7-15] WBC-14.0* RBC-3.58* Hgb-10.5* Hct-30.3* Plt Ct-348 [2181-7-14] WBC-13.4* RBC-2.81* Hgb-8.2* Hct-24.1* Plt Ct-238 [2181-7-11] WBC-17.8* RBC-3.32* Hgb-9.7* Hct-28.0* Plt Ct-243 [2181-7-14] Glucose-119* UreaN-20 Creat-0.9 Na-137 K-4.1 Cl-100 HCO3-29 [2181-7-11] Glucose-167* UreaN-25* Creat-0.9 Na-141 K-4.6 Cl-107 HCO3-22 PORTABLE CHEST, [2181-7-15] The chest tube has been removed. Since the chest tube removal, there appears to have been increased shift of mediastinal structures to the left. No pneumothorax is identified. There is increased volume loss on the left with increased opacification of left lung. Right lung is relatively clear with minimal atelectasis in the right lung base. IMPRESSION: Status post left chest tube removal with mediastinal shift to the left, increased opacification of left lung. [2181-7-16] Portable CXR: persistent opacification of the left hemithorax Brief Hospital Course: [7-11]: The patient underwent the above procedure. He tolerated the procedure well and was transferred to the TSICU for intense monitoring following the procedure. He had an epidural in place for pain relief, diet was advanced slowly, foley catheter in place, two chest tubes in place to suction. [7-12]: The patient was transferred to the floor for continued monitoring. He developed supraventricular tachycardia followed by atrial fibrillation. He remained hemodynamically stable and asymptomatic. He was given Lopressor 5mg IV for a total of five doses, he did not convert. He was given a bolus of Amiodarone 150mg and drip and converted to sinus rhythm. The patient became hypotensive and the amiodarone drip was stopped. He remained in sinus rhythm. The chest tubes were placed to water-seal with no air leak. His pain was relieved with an epidural. [7-13]: He had an episode of rapid atrial fibrillation and the amiodarone drip was restarted and he converted sinus rhythm. He was diuresed. He was seen by physical therapy whom declared him safe for home. [7-14]: Remains in sinus rhythm, on PO amiodarone and atenolol. The apical chest-tube was removed. [7-15]: The remaining chest-tube was removed. His HCT was found to 24 for which he was transfused 2 unit PRBC to a HCT of 30. [7-16]: The epidural was removed and his pain was well controlled with PO pain medication. The foley was removed and he voided without difficulty. He underwent flexible bronchoscopy which showed an adherent fibrin clot. The chest x-ray revealed a collapsed left lower lobe. [7-17]: The patient underwent a rigid bronchoscopy for removal of fibrin clot. He tolerated the procedure well. The follow-up CXR revealed moderates increased aeration of the left lung. He was discharged to home and will follow-up with Dr. [First Name (STitle) ] in 1 week. Medications on Admission: atenolol 50 mg daily, doxazosin 4 mg daily, prednisone 20 mg daily, lisinopril 20 mg daily, omeprazole 20 mg daily, hydrochlorothiazide 12.5 mg dialy, Bactrim Ds daily, MVI daily, alendronate 70mg weekly Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 13. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. Discharge Disposition: Home Discharge Diagnosis: Left lower lobe Carcinoid Tumor Hypertension, BPH Psoriasis Arthritis. Discharge Condition: Stable Discharge Instructions: Call Dr.[Name (NI) 5067] office [Telephone/Fax (1) 170] if experience: -Fever > 101 or chills -Increased cough or shortness of breath -Chest pain -Incision develops drainage or increased redness Chest-tube cover with a bandaid until healed No Driving while taking narcotics: Take stool softners with narcotics You may Shower: No swimming or tub bathing for 6 weeks Continue Regular diet Walk frequently throughout day Followup Instructions: Follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [7-24] at 10:00am on the [Hospital Ward Name 5074] [Hospital Ward Name 23] Clinical Center [Location (un) ]. Report to the [Location (un) ] Radiology Department for a Chest X-Ray 45 minutes before your appointment. Completed by:[2181-7-17] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8815 }	Medical Text: Admission Date: [2111-1-8] Discharge Date: [2111-1-11] Date of Birth: [2082-8-18] Sex: F Service: MEDICINE Allergies: E-Mycin Attending:[First Name3 (LF) 25342] Chief Complaint: Dka Major Surgical or Invasive Procedure: none History of Present Illness: 28F with hx of chronic sinusitis and DM type I who has had several admission for DKA in the past who was sent to ED from [Last Name (un) ] for persistent hyperglycemia. Pt was recently admitted in [State 792]for sinusitis/bronchitis on [2110-12-24] for which she was given Levaquin. Ever since that admission, her sugars have been difficult to control. Recent blood sugars have been critically high on her glucometer (>600). Pt's PCP has been increasing her doses of insulin over past few weeks from 50U [Hospital1 ] to 75U [Hospital1 ] with no effect. Pt tyhen called and made an appointment to see her [Last Name (un) ] physician who then sent her to the ED. Pt currently complains of nausea, fevers (up to 101 at home), abd pain, decreased appetite, cough, rhinorrhea, dysuria, tooth pain. Pt states she has been seeing a dentist in RI for some left sided tooth pain and she is currently scheduled for a root canal in 2 days for possible tooth abscess. . In [Name (NI) ], pt found to have blood sugar of 583 with an elevated gap. She was given 10U of IV insulin followed by initiation of insulin drip. She was also given ceftriaxone and clindamycin for her tooth abscess. Past Medical History: Type I and II diabetes mellitus, c/b previous episodes of DKA chronic sinusitis Irritable bowel syndrome Gerd Depression asthma Social History: works as preschool teacher, lives with her husband, no children at this time, occasional EtOH, denies tob, illicits Family History: type II DM in materanal grandmother, paternal grandmother, and one uncle, also CAD Physical Exam: temp 98.7, BP 135/69. HR 99, R 24, O2 97% RA Gen: NAD, pleasant HEENT: EOMI, MM dry; no visible abscess on left lower jaw but tender to palpation; left maxillary sinus tenderness CV: RRR, no g/m/r Chest: clear Abd: +BS, soft, mildly tender to palpation on left flank Ext: no edema, warm Skin: raised erythematous skin near elbows . Pertinent Results: Brief Hospital Course: Admitted to MICU on Insulin drip until after gap closed, glucose within normal range, and eating. Started on Clindamycin for presumed tooth abscess. [Last Name (un) ] consult obtained to design home insulin regimen. Confirmed dental appointment in upcoming week as outpt to evaluate need for root canal, possibility of abscess. . Transfered to the floor on d2 once her insulin drip was stopped and her glucose well controlled. She was noticed to have not voided since admission. A bladder scan was stopped before completed due to lack of patient cooperation but the limited scan showed 375cc in the superior aspect of the bladder. The patient was informed of the need for straight cath to empty her bladder and the risks of not undergoing this procedure including ARF, hydronephrosis, infection, and need for dialysis but still refused catheterization throughout her stay. . [Last Name (un) ] followed the patient's glucose on the floor and altered her insulin regimen prn. Once her glucose levels were under better control on th 29th she was d/c home w/ close [Last Name (un) ] f/u. Medications on Admission: * Humalin 75U qam, qhs * Humalog 75U qam, qhs * Humalog 20U with meals if BS>300 * Protonix 40mg qd * Nortriptyline 50mg qd * Levaquin 500mg qd since [12-26] Discharge Medications: 1. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 10 days. Disp:80 Capsule(s) Refills:0 4. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain for 5 days. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: DKA Dental Abscess Discharge Condition: Stable Discharge Instructions: Please follow-up with your dentist at the scheduled appointment to address possible lung abscess. Continue new antibiotics and new insulin regimen as designed by [Last Name (un) ]. . Please return to the ER or call your PCP [Name Initial (PRE) ]: 1. fever to 101 2. abdominal pain 3. elevated glucose levels 4. chest pain 5. shortness of breath 6. other concerning symptoms Followup Instructions: 1) Follow up with Dr [Last Name (STitle) 12746] at [Last Name (un) ] next week as planned. The attending physician that saw you in the ICU was Dr. [First Name8 (NamePattern2) 402] [Last Name (NamePattern1) ]. 2) You also have scheduled appointments with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 17181], and your dentist, both within the next week. Discuss the results of your lipid panel and iron studies with Dr. [Last Name (STitle) 17181]. Completed by:[2111-1-14] ICD9 Codes: 5849, 311, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8816 }	Medical Text: Admission Date: [2199-1-10] Discharge Date: [2199-1-19] Date of Birth: [2143-6-21] Sex: F Service: MEDICINE Allergies: Morphine / Betadine / Iodine / Demerol / Lisinopril Attending:[First Name3 (LF) 1928] Chief Complaint: SOB Major Surgical or Invasive Procedure: intubation Central venous Line History of Present Illness: This is a 55 year-old female with a history of tracheobronchomalacia, COPD, HTN, HL who presents with respiratory distress. Unable to obtain history from patient. The patient underwent bronch on [12-24] for removal of her y-stent. They found granulation tissue partially occluding the left main stem. She was to follow-up with Dr. [Last Name (STitle) ] in 1 month. . Per the mother she was at work today and told her co-workers that she was pale and dizzy. They brought her to the [Doctor First Name ] Vineyards ED where she had a "coughing fit" and had difficulty breathing. She was given duonebs, 250mg IV solumedrol and started on BiPAP. She was then transferred to the [Hospital1 18] ED via [Location (un) ] and given another 3 albuterol nebs. . In the ED, 97.0 107 155/85 22 97% on bipap. In the ED they continued BiPAP. A CXR was performed and showed atelectasis, but no other change. She was sent up to the MICU where she was initially comfortable on BiPAP, but then began having increased coughing, work of breathing and stridor. She was emergently intubated shortly after arrive to the ICU. . Past Medical History: - COPD per past notes, though patient nonsmoker and denies history of COPD/emphysema or chronic bronchitis or past asthma; no history of breathing difficulties prior to [2198-4-13] - TBM as above; per patient plan for pulm rehab x months with future stenting - Hypertension - Hyperlipidemia - ?anaphylactic reaction in [2198-4-13] - patient recalls this was onset of respiratory symptoms leading to diagnosis of TBM - Numerous right hand surgeries s/p R hand trauma - Cholecystectomy - Appendectomy - Tonsillectomy - Back surgery (unclear procedure) - Hyperglycemia in setting of steroids Social History: Denies ETOH, Tobacco ever. Lives with mother, father, and brother. Family History: Mother with DM and HTN. Father with HTN. Grandfather had some type of blood clot Physical Exam: Vitals: T: BP: HR: RR: O2Sat: GEN: Pt on BiPAP in respiratory distress Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [2199-1-10] CXR: Subsegmetnal atelectasis is seen in the lingula. Otherwise, no consolidation or edema is evident. The mediastinum is distorted due to low lung volumes. The cardiac silhouette similarly so, but remains likely top normal for size, accounting for patient and technical factors. No effusion or pneumothorax is noted. The osseous structures are unremarkable. [2199-1-16] V/Q scan: Normal perfusion and ventilation scan. Unchanged from [2198-8-28]. [2199-1-16] Bilateral lower extremity veins U/S: No evidence of lower extremity DVT [2199-1-10] 08:44PM BLOOD WBC-7.3 RBC-3.98* Hgb-12.3 Hct-36.3 MCV-91 MCH-31.0 MCHC-34.0 RDW-14.3 Plt Ct-188 [2199-1-14] 04:07AM BLOOD WBC-5.0 RBC-3.54* Hgb-11.0* Hct-32.7* MCV-92 MCH-31.1 MCHC-33.8 RDW-14.1 Plt Ct-213 [2199-1-16] 06:17AM BLOOD WBC-5.2 RBC-3.33* Hgb-9.9* Hct-30.2* MCV-91 MCH-29.9 MCHC-32.9 RDW-14.2 Plt Ct-161 [2199-1-18] 04:30AM BLOOD WBC-5.4 RBC-3.13* Hgb-9.4* Hct-28.6* MCV-91 MCH-30.1 MCHC-33.0 RDW-14.0 Plt Ct-161 [2199-1-19] 02:55PM BLOOD Hct-30.7* [2199-1-10] 08:44PM BLOOD Glucose-231* UreaN-14 Creat-1.0 Na-138 K-4.2 Cl-101 HCO3-20* AnGap-21* [2199-1-18] 04:30AM BLOOD Glucose-98 UreaN-14 Creat-0.7 Na-141 K-3.7 Cl-107 HCO3-26 AnGap-12 [2199-1-12] 04:03AM BLOOD ALT-15 AST-20 AlkPhos-66 Amylase-19 TotBili-0.4 [2199-1-12] 03:35PM BLOOD ALT-19 AST-22 LD(LDH)-166 AlkPhos-74 TotBili-0.6 [2199-1-12] 04:03AM BLOOD Lipase-15 [2199-1-10] 08:44PM BLOOD cTropnT-<0.01 [2199-1-13] 03:39AM BLOOD CK-MB-3 cTropnT-<0.01 [2199-1-11] 03:28AM BLOOD Calcium-8.7 Phos-4.1 Mg-1.8 [2199-1-11] 12:20AM BLOOD Type-ART Temp-38.5 FiO2-70 pO2-93 pCO2-47* pH-7.30* calTCO2-24 Base XS--3 Intubat-INTUBATED [2199-1-12] 10:16PM BLOOD Type-ART Temp-36.7 pO2-93 pCO2-54* pH-7.36 calTCO2-32* Base XS-2 Intubat-NOT INTUBA Comment-NEBULIZER Brief Hospital Course: # Respiratory Failure: Pt with history of tracheobronchomalacia and COPD presents with acute respiratory distress and then failure. She recently had her Y-stent removed due to granulation tissue occluding the stent. Possible worsening of her TBM causing occlusion of her airways. Other possiblities include pneumonia secondary to aspiration given cough/secreations on BiPAP. Additionally, COPD/bronchospasm may be contributing to her respiratory status. Patient was intubated and sedated; treated with broad coverage antibiotics, nebulizers and steroids. She was subsequently seen by IP who felt that placing new stent was not necessary at this time. Patient completed course of vancomycin / Cefepime for 8 days, and with round the clock inhalers. Patient was extubated without difficulty and continued to improve. Sputum cultures, blood cultures remained negative and no clear precipitant was found for this event. At time of discharge, patient was maintaining oxygen saturation of 98% on room air. . #. Hypotension / Blood pressure: Noted on admission, Likely multifactorial in setting of PEEP, possible infection, hypovolemia. Patient improved with above workup and quickly became hypertensive as per her baseline. At time of discharge, patient was initiated on all home medications. . #. Anemia: Pt. had down trending Hct over the course of her admission from 36 down to 30. This was thought multifactorial including critical illness with frequent phlebotomy. Her admission Hct was also likely hemoconcentrated given her subsequent drop in creatinine and Hct after fluid resucitation. She should have B12, folate and iron studies as an outpt. # Dizziness: Prior to discharge, the pt began complaining of dizziness with with lateral head movement. Orthostatics were negative and neuro exam was remarkable for onset of dizziness with R lateral head movement. No nystagmus could be elicited. The pt was started on meclizine PRN for peripheral vertigo and instructed to follow up with her primary care doctor if her symptoms did not resolve. . # Code: FULL . Medications on Admission: 1. Amlodipine 10 mg daily 2. Zocor 20 mg daily 3. Clonidine 0.2 mg daily 4. Albuterol Sulfate Neb 5. Duonebs every 6 hrs. 6. Benzonatate 200 mg TID 7. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H 8. Omeprazole 40 mg 9. Toprol XL 100 mg daily Discharge Medications: 1. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO twice a day. 2. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Nebulizer Inhalation Q2H (every 2 hours) as needed for wheezing. 5. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One (1) Nebulizer Inhalation four times a day. 6. Benzonatate 200 mg Capsule Sig: One (1) Capsule PO three times a day. 7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Guaifenesin 100 mg/5 mL Syrup Sig: [4-22] mL PO four times a day. 10. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. Disp:21 Tablet(s) Refills:0 11. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO every other day. Disp:15 Tablet(s) Refills:0 12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO every other day. Disp:15 Capsule, Sustained Release(s) Refills:0 13. Meclizine 25 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for dizziness. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Tracheobronchial malacia Secondary Critical illness deconditioning Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted to the hospital with hypercarbic respiratory failure. This was most likely secondary to your tracheobronchial malacia. You should continue your albuterol/duonebs. You were also treated for a full course of ventilator associated pneumonia. You should keep your follow up appointment with interventional pulmonary on [2199-1-23]. We started you on baclofen 10mg three times per day for back spasms, you can continue this for 7 more days. We started you on meclezine 25mg every 6 hours as needed for dizziness. If your dizziness continues beyond one week, you should follow-up with your primary care provider. [Name10 (NameIs) ] started you on lasix and potassium supplements which you should take every other day. Followup Instructions: Provider [Name10 (NameIs) ] INTAKE,ONE [Name10 (NameIs) ] ROOMS/BAYS Date/Time:[2199-1-23] 10:30 Provider [First Name8 (NamePattern2) ] [Name9 (PRE) ], MD Phone:[Telephone/Fax (1) 5072] Date/Time:[2199-1-23] 11:00 Provider [Year/Month/Day ] ROOM TWO Phone:[Telephone/Fax (1) 5072] Date/Time:[2199-1-23] 11:00 Please call your primary care doctor for an appointment in the next 1-2 weeks [Telephone/Fax (1) 29822] Completed by:[2199-1-21] ICD9 Codes: 5180, 496, 2768, 4589, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8817 }	Medical Text: Admission Date: [2148-12-7] Discharge Date: [2148-12-16] Date of Birth: [2110-2-12] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 348] Chief Complaint: Infected AICD Major Surgical or Invasive Procedure: AICD removal PICC Central line History of Present Illness: 38 year old male with h/o CAD s/p 2 vessel CABG, biventricular pacemaker placement, dilated cardiomyopathy, and CHF with EF 20-25% who presents with erythema and swelling over AICD site. It was difficult to obtain history as patient was very sleepy, and information is gathered from chart and from limited patient interaction. Patient states that approximately one week ago he noticed swelling around AICD site, and over past week site has become warm and painful. Pain occasionally radiates across chest to the right, but no jaw pain, arm pain, SOB, palps. Does relate fever, but unclear of onset. He presented to [Hospital3 417] today and was found to have a fever to 104, o/w HD stable, with erythema and warmth around AICD site. Given Invanz (Carbapenem) 1G IV, Vanc 1 g IV, and dilaudid and then developed runs of NSVT (monomorphic, 16-20 beats per ED verbal, 10-15 per ED notes, [3-30] per tele sent over from [Hospital3 417]) that broke on its own. Patient was given lidocaine 100 mg IV, amiodarone 150 mg PO x 1 and started on amiodarone gtt. Transferred to [Hospital1 18] for further management. . In ED patient was febrile to 101.9, HR 100, BP 110/70. His site was noted to be erythematous and painful and was given gentamycin loading dose of 430mg x 1 as well as dilaudid, tylenol, and amiodarone gtt. 2 large bore IV's were placed and patient sent to floor. Past Medical History: # 2VD CABG (LIMA --> LAD, SVG --> PDA) in [5-/2146] # Last CATH [2147-9-14] - 3VD, occluded SVG-RPDA, patent LIMA-LAD, no intervention. # Last ECHO [2148-8-12] - Apical LV aneurysm, 1+MR, 1+TR. No EP report on when BiV pacer was placed. # Has had LAD and RCA stents placed in past, but in North [Doctor First Name ] # H/O NSVT # AICD placed [2148-10-13] - leads in RA and RV (old pacer leads abandoned on CXR [10-2]) # Dental extraction [10-17] (7 teeth removed) # CHF/Ischemic cardiomyopathy - EF 20-25%, admissions in past for CHF # Previous wedge P 30s in [8-31] cath # HTN # Hyperlipidemia # H/O Biventricular pacemaker, now removed # MRSA abscess on abdomen Social History: He is divorced and has one daughter. [Name (NI) ] spent two months in prison secondary to domestic abuse charges. He quit smoking after his CABG. He does not use alcohol or illicit drugs. He does not work and is on disability. His mother is very ill and has hospice services. She is his main source of support. Family History: CAD - mother Physical Exam: Vitals: 104.8, 98/60 (MAP 70), 110, 98% on 4L, 26 HEENT: PERRL, EOMI, anicteric sclera, MMM, no teeth Neck: supple, no LAD, no thyromegaly Cardiac: tachycardic, regular, NL S1 and S2, no MRGs Lungs: CTAB, no wheezes, rhonchi, crackles anteriorly Abd: soft, mildly TTP in lower quadrant, NABS, no HSM, no rebound or guarding Ext: cool (on cooling blanket), 2+ DP pulses, no C/C/E Neuro: CN III-XII intact, MAE Skin: psoriatic plaques with silvery scale on abdomen around umbilicus, right knee, left LE Skin: . Pertinent Results: [2148-12-7] 09:30PM WBC-13.9# RBC-4.92 HGB-16.3 HCT-48.3 MCV-98 MCH-33.0 MCHC-33.7 RDW-14.1 [2148-12-7] 09:30PM NEUTS-87* BANDS-1 LYMPHS-9* MONOS-2 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [2148-12-7] 08:42PM LACTATE-1.5 K+-6.6* [2148-12-7] 09:30PM DIGOXIN-<0.2* [2148-12-7] 09:30PM CALCIUM-9.0 PHOSPHATE-3.5 MAGNESIUM-1.7 [2148-12-7] 09:30PM CK-MB-NotDone cTropnT-<0.01 [2148-12-7] 09:30PM CK(CPK)-55 Brief Hospital Course: A/P: 38 year old male with CAD s/p CABG, pacer, AICD, CHF, who presents with infection over AICD site. . # AICD INFECTION: His AICD was placed in [2148-9-27] for non-ischemic cardiomyopathy. He presented from OSH on [12-7] with high grade MRSA bacteremia and infected AICD pocket. ID consult was called and he was put on vancomycin and gentamycin. On [12-9], he had the AICD and all the wires removed. His blood cultures drawn from [12-9] to [12-12] were persistently positive for MRSA. While in the ICU, he remained hemodynamically stable. A temporary subclavian central catheter was placed for access and was later discontinued. A left PICC was placed on [12-12] while still presumably bacteremic but he needed access. Surveillance cultures from [12-13] onward finally became negative. His PICC was left in since he became afebrile and MRSA was no longer growing in his blood. Gentamycin was discontinued after blood cultures remained negative x 72 hours. He had a TTE on admission that was negative for endocarditis or abcess but he needed a TEE for a more definitely rule out. However, he persistently refused to have the TEE despite encouragement from the primary team and the ID consult team. . On [12-16], he left the hospital against medical advice. He was being set up for VNA service and will get long term vancomycin treatment (6 weeks) since he refused the TEE. However, he decided not to stay until the VNA was set up. Eventually VNA was scheduled and they will follow up at home. He still had his PICC when he left. . For followup, he needs to be seen at infectious disease clinic, appointment made for him at discharge. He also needs to follow up at [Hospital ] clinic since his AICD was removed. For the pocket wound, plastics surgery was consulted and they recommended wet to dry dressings x 4 weeks with help from VNA. Then he will need primary closure. Orthopaedic consult was called to assess for possibly bone infection in the pocket area but this was deemed unlikely. . # NSVT: He has had runs of NSVT on telemetry but is asymptomatic. He was started on amiodarone, loaded with 400mg [Hospital1 ] x 1 week and then 100mg daily therafter. PFTs were done to assess lung function pre-amiodarone: FVC 59%, FEV1 56%, FEV1/FVC 94%, suggesting baseline restrictive disease. His TSH and LFTs were normal. He will follow up with Dr. [Last Name (STitle) ] at [Hospital ] clinic. . # CAD: s/p CABG. PMIBI in [Month (only) ] showed no definite areas of ischemia although there is global perfusion abnormalities. EKG did not suggest active ischemia and troponins were negative x 3. He continued asa + metoprolol + lisinopril + plavix + lipitor + ezetimibe. . # CHF: echo on this admission shows EF of 15-20%. He had signs of overload on admission and was diursed in his MICU course. He continued metoprolol and lisinopril but lasix and spirinolactone were held because he seemed euvolemic after adequate diureses and his blood pressure was low-normal. Medications on Admission: Digoxin 125 mcg PO QD Atorvastatin 80 mg PO QD Spironolactone 25 mg PO QD Lasix 80 mg PO QAM ASA 81 mg PO QD Plavix 75 mg PO QD Metoprolol 25 mg PO BID Ezetimibe 10 mg PO QD Gemfibrozil 600 mg PO QD Fluticasone 110 mcg 2 puffs [Hospital1 ] Lisinopril 5 mg PO QD Folic acid Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 5 days: then 400mg (2 tablets) daily thereafter. Disp:120 Tablet(s) Refills:0 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:30 Tablet(s) Refills:0 12. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q 8H (Every 8 Hours) for 6 weeks. Disp:90 Recon Soln(s) Refills:1 Discharge Disposition: Home with Service Discharge Diagnosis: PRIMARY DIAGNOSIS: Infected AICD (defibrillator) Bacteremia SECONDARY DIAGNOSIS: CAD CHF Non-sustained Vtach Htn Hyperlipidemia Discharge Condition: hemodynamically stable, afebrile, ambulating Discharge Instructions: Please take all medication as prescribed. Keep all appointments listed below. If you have fever or chills or worsening pain where your defibrillator site was, please seek medical attention immediately. Also seek attention if you have chest pain or shortness of breath. If you have any general medical questions or concerns, please call your doctor or go to the emergency room. ------------------ You need to do wet-to-dry dressings on your wound twice a day for 4 weeks. After 4 weeks, you need to go back to your cardiologist for futher care of your wound, possibly including primary closure of the wound. ------------------ You will be on vancomycin three times daily x 6 weeks. ------------------ HEART FAILURE INSTRUCTIONS Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500mL Followup Instructions: Please follow up with your PCP in two weeks: [Last Name (LF) ],[First Name3 (LF) ] H. [Telephone/Fax (1) 63353] -------------------- Please follow up with Dr. [Last Name (STitle) 11382] from Infectious Disease: [Telephone/Fax (1) 457]. Appointment is set [1-1] @ 11am. Call for their location. She will monitor you antibiotics level and lab work. -------------------- You need to follow up with Cardiology in four weeks with Dr. [Last Name (STitle) ]. ([Telephone/Fax (1) 5862]. Please call for an appointment. They will check on your wound to see if anything needs to be done. Completed by:[2149-6-11] ICD9 Codes: 4254, 4271, 4280, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8818 }	Medical Text: Admission Date: [2146-7-19] Discharge Date: [2146-7-31] Date of Birth: [2146-7-19] Sex: M Service: NB HISTORY: The infant is a 34 and 2/7 weeks 2445 gram male newborn who was admitted to the NICU for management of prematurity. Prenatal history: The infant was born to a 38-year-old G2, para 1, 2, now mother. Prenatal screens: Mother's blood type is A positive, antibody negative, hepatitis B negative, RPR nonreactive, rubella immune. GBS status unknown. Maternal obstetrical history: Previous full term male newborn delivery with a vacuum assist. The child is doing well. This pregnancy was complicated by PPROM, with initial leakage of fluid noted on [7-13], with further fluid leakage and preterm contractions noted on [7-19]. Labor was allowed to progress, leading to spontaneous vaginal delivery. Apgars were 9 and 9. PHYSICAL EXAMINATION ON DISCHARGE: Weight is 2.450 gm, head circumference is 32 cm, and length is 47 cm. HEAD, EARS, EYES, NOSE AND THROAT: Palate intact. Anterior fontanel open and soft. Ears normal. Positive red reflex bilaterally. CARDIOVASCULAR: No audible murmur on examination. Regular rate and rhythm. Heart rate 140s to 160s with a blood pressure of 73/44 with a mean of 55. Symmetric chest. RESPIRATORY: Breath sounds are equal and clear with no obstruction. GASTROINTESTINAL: Abdomen soft and round. Positive bowel sounds. No hepatosplenomegaly on examination. GENITOURINARY: Normal circumcised male genitalia. Testes descended bilaterally. NEUROLOGIC: Appropriate for age tone. Positive Moro. Positive suck and positive grasp. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: The infant has been in room air since birth with minimal respiratory insufficiency. Occasional desaturations have been noted, consistent with an immature breathing pattern. By the time of discharge, infant has been free of desaturation events for over 5 days. CARDIOVASCULAR: The infant has been hemodynamically stable throughout admission, with no murmur noted. FLUIDS, ELECTROLYTES AND NUTRITION: Infant was initially maintained on IVF with introduction of enteral feeds on first day of life. Enteral feeds were advanced to full volume feeds without difficulty, initial per gavage and then transitioned to oral. By time of discharge, infant has been feeding orally for over 48 hours with adequate intake and weight gain. Infant is discharged on similac 24 cals/oz formula. GASTROINTESTINAL: Maximum bilirubin of 8.5/0.3 on day of life 3. The infant did not require phototherapy for treatment. Last bilirubin obtained on day of life 4 was 7.9/0.3. HEMATOLOGY: Hematocrit and platelet count on admission to NICU: Hematocrit was 51.9 with a platelet count of 349,000. Blood type not obtained. The infant did not require blood transfusion. INFECTIOUS DISEASE: Blood and CBC with differential obtained on admission. Initial white count was 16.6 with 32 poly's and 1 band. The infant received 48 hours of ampicillin and gentamycin and blood culture is negative. NEUROLOGY: Infant maintained a normal neurologic exam throughout admission. Hearing screen was performed and passed bilaterally. PSYCHOSOCIAL: [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] social work involved with the family and can be reached at phone No.: [Telephone/Fax (1) ]. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To home with parents. NAME OF PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. Telephone No.: ([Telephone/Fax (1) 72435]. CARE RECOMMENDATIONS: 1. Feeds at discharge: The infant is eating ad lib feeds of Similac 24 calorie. 2. Car seat position screening: The infant passed. 4. State newborn screens were sent per protocol. Initial results showed elevated 17 OHP. Second state newborn screening sent on [2146-7-28], and results are pending. Electrolytes were normal. 5. Immunizations received: The infant has received Hepatitis B vaccine on [2146-7-24]. 6. Immunizations Recommended: 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. This infant has not received a Rotavirus vaccine. The American Academy of Pediatrics recommend initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable or at least 6 weeks but fever than 12 weeks of age. Follow up appointments scheduled: Follow up with pediatrician, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] 48 hours after discharge from newborn intensive care unit. DISCHARGE DIAGNOSIS: Prematurity. The infant born at 34 and 2/7 weeks. Rule out sepsis and hyperbilirubinemia. [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [MD Number(2) 56682] Dictated By:[Last Name (NamePattern1) 71799] MEDQUIST36 D: [2146-7-30] 18:15:56 T: [2146-7-30] 21:23:42 Job#: [Job Number 73749] ICD9 Codes: 7742, V053, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8819 }	Medical Text: Admission Date: [2199-2-8] Discharge Date: [2199-3-1] Date of Birth: [2126-1-14] Sex: F Service: CARDIOTHORACIC Allergies: Keflex / Statins-Hmg-Coa Reductase Inhibitors / Sulfasalazine Attending:[First Name3 (LF) 165] Chief Complaint: loss of consiousness Major Surgical or Invasive Procedure: left and right heart catheterization, coronary angiogram redo sternotomy, aortic valve replacement (21mm CE Magma pericardial) History of Present Illness: The patient 73 year old white female was admitted to [Hospital1 18] on [2199-2-8] after being found collapsed in her kitchen at home. Her husband reportedly left for work at approximately 6:30 am on [2-8]. He then called his wife at 8:30 am to relay a message, and when she did not answer the phone, he became concerned. He drove home and found her unconscious on the kitchen floor. Per report, he did not notice any abnormal movements, incontinence, or tongue biting. When the paramedics arrived, she had GCS score of 5 and was intubated and transferred to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. There, she had a head CT that was concerning for possible [Last Name (LF) ], [First Name3 (LF) ] she was transferred to [Hospital1 18] for further care. On arrival to [Hospital1 18], she was admitted to the trauma ICU, where she was treated empirically for seizures with phenytoin. She had a CT/CTA head, which was negative, and subsequent MRI showed a small area of [Hospital1 ] but no major bleed. Given the fact that the previous CTA was normal, it was deduced that the subarachnoid hemorrhage was traumatic rather than the cause of her collapse. She was extubated on [2-9] and was then transferred to the neurology service. [2-10] patient without complaints, VS notable for SBP range: 160-197/90-100s, HRs: 90-100s, On [2-11] at approximately 5 am, when she became acutely dyspneic. She was given Lasix 10 mg IV x1 and Morphine, and EKG showed new ST depressions in V4-V6. Cardiology was called, and she was started on a heparin gtt. Since this time, she has received 2 more doses of Lasix IV and was started on albuterol nebulizations for increased dyspnea. . Currently, the patient is short of breath and states that she feels like she is "drowning." Otherwise, she has no new complaints. Cycled enzymes at that time were positive: CK: 1132 MB: 29 MBI: 2.6 Trop-T: 0.90. . . Past Medical History: DM HTN Liver CA CABG x5 (4yrs ago) Social History: She is married, and has two children, a son who lives in [Name (NI) 531] and a daughter who lives locally. She has a three-pack per day x20 year history of smoking, quitting in [2177]. She previously was employed making fuses, but has not worked since about the time when she was 40 years old Family History: Her father died at a young age of a large ulcer and was an alcoholic. Her mother died at the age of 86 of an MI and also had diabetes. She has a brother who also has issues with low blood counts; family is not sure of the diagnosis. Her brother also has diabetes Physical Exam: On Admission to Cardiology Service: VS: T 99.0, BP 152/90, P 87, R 18, O2 97% on 3L GENERAL - Elderly woman, pleasant, using excessory muscles in obvious respiratory discomfort. HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry mucus membranes - clotted blood in mouth, OP clear NECK - supple, no thyromegaly, no carotid bruits, JVD ~10 cm CV: RRR, III/[Doctor First Name 81] holosystolic murmur which radiates to to the carotids and axilla, no peripheral edema LUNGS - Diffuse expiratory wheezes bilaterally in all lung fields, decreased bs at bilateral bases. ABDOMEN - soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - no rashes or lesions NEURO - awake, A&Ox1 (to person only), CNs II-XII grossly intact, muscle strength 5/5 throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady . On Discharge: VS: ; weight: GENERAL - Elderly woman, pleasant, using excessory muscles in obvious respiratory discomfort. HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry mucus membranes - clotted blood in mouth, OP clear NECK - supple, no thyromegaly, no carotid bruits, CV: RRR, III/[Doctor First Name 81] holosystolic murmur which radiates to to the carotids and axilla, no peripheral edema LUNGS - ABDOMEN - soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - no rashes or lesions NEURO - awake, A&Ox1 (to person only), CNs II-XII grossly intact, muscle strength 5/5 throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady Pertinent Results: TTE: The left atrium is mildly dilated. The right atrial pressure is indeterminate. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Trace aortic regurgitation is seen. The mitral valve leaflets and annulus are moderately thickened. There is no mitral stenosis. The high mean gradient is likely due to mitral regurgitation. Moderate to severe (3+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with low normal systolic function. Severe aortic valve stenosis. Moderate to severe mitral regurgitation. Pulmonary artery systolic hypertensio . MRI brain [2199-2-9]: IMPRESSION: No evidence of acute infarct or enhancing brain lesion. Subtle area of hyperintensity in the right posterior frontal sulcus, both on FLAIR and diffusion images likely represents a small area of subarachnoid blood related to recent trauma. No evidence of acute intraparenchymal hemorrhage seen. Brain atrophy noted [2199-2-8]: CT ANGIOGRAPHY HEAD: CT angiography of the head demonstrates exuberant calcification and diffuse atherosclerotic disease involving the left distal vertebral artery in the V4 segment. The basilar artery and the right distal vertebral artery appear patent. In the anterior circulation mild irregularity of the vascular structures are seen in the anterior circulation due to atherosclerotic disease without high-grade stenosis. No vascular occlusion is identified. IMPRESSION: 1. CT angiography of the neck demonstrate diffuse atherosclerotic disease involving the left common carotid artery in the neck with irregularity of the arterial margin. Bilateral widely patent and proximal internal carotid arteries are noted which could be related to previous surgery. Clinical correlation recommended. No evidence of high-grade stenosis in the neck. 2. CT angiography of the head demonstrates exuberant calcification and diffuse atherosclerotic disease involving the distal left vertebral artery. Mild atherosclerotic disease seen in the anterior circulation involving middle cerebral arteries. 3. A small wedge-shaped opacity seen posteriorly in the left upper lung could be due to atelectasis, but clinical correlation recommended. 4. An aberrant right subclavian artery is incidentally noted. CT C-spine: [2199-2-8]: IMPRESSION: 1. No evidence of fracture or malalignment. 2. Multilevel degenerative changes including moderate-to-severe central canal narrowing secondary to disc osteophyte complexes at C4-5 and C5-6. Narrowing of the central spinal canal predisposes to spinal cord injury in the setting of trauma. MR is more sensitive than CT for evaluation of the spinal cord. 3. Sub-cm left thyroid nodule with adjacent calcification. Clinical correlation recommended, and consider non-emergent ultrasound for further evaluation. Labs: [2199-2-8] 01:30PM ALT(SGPT)-62* AST(SGOT)-75* CK(CPK)-178 ALK PHOS-209* TOT BILI-1.0 [2199-2-8] 01:30PM CK-MB-6 cTropnT-0.03* [2199-2-8] 01:30PM WBC-9.5 RBC-3.80* HGB-12.2 HCT-37.2 MCV-98 MCH-32.1* MCHC-32.8 RDW-18.2* [2199-2-8] 01:30PM NEUTS-87.7* LYMPHS-7.2* MONOS-4.8 EOS-0.2 BASOS-0.2 [2199-2-8] 01:30PM PLT SMR-LOW PLT COUNT-83* [2199-2-8] 01:30PM PT-13.2 PTT-29.5 INR(PT)-1.1 [2199-2-8] 01:30PM GLUCOSE-145* UREA N-32* CREAT-1.2* SODIUM-141 POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-22 ANION GAP-16 [2199-2-8] 01:30PM CALCIUM-9.3 PHOSPHATE-2.2* MAGNESIUM-1.9 [2199-2-8] 01:30PM ALT(SGPT)-62* AST(SGOT)-75* CK(CPK)-178 ALK PHOS-209* TOT BILI-1.0 [2199-2-8] 01:30PM CK-MB-6 cTropnT-0.03* [2199-2-8] 06:29PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2199-2-8] 01:30PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG Brief Hospital Course: On arrival to [Hospital1 18], she was admitted to the trauma ICU, where she was treated empirically for seizures with phenytoin. She had a CT/CTA head, which was negative, and subsequent MRI showed a small area of [Hospital1 ] but no major bleed. Given the fact that the previous CTA was normal, it was deduced that the subarachnoid hemorrhage was traumatic rather than the cause of her collapse. She was extubated on [2-9] and was then transferred to the neurology service. [2-10] patient without complaints, VS notable for SBP range: 160-197/90-100s, HRs: 90-100s, On [2-11] at approximately 5 am, she became acutely dyspneic. She was given Lasix 10 mg IV x1 and Morphine, and EKG showed new ST depressions in V4-V6. Cardiology was called, and she was started on a Heparin infusion. Subsequent cardiac work up included catheterization to reveal patent LIMA to LAD and vein grafts to the OM and RCA and right heart pressures were normal. Aortic stenosis was present with valve area of 0.8-1cm squared, moderate MR. She was referred for redo sternotomy and aortic valve replacement. On [2-19] she went to the Operating Room where she underwent redo sternotomy/ Aortic valve replacement with a size 21-mm [Last Name (un) 3843]- [Doctor Last Name ] Magna tissue valve with Dr.[First Name (STitle) ]. Please refer to operative report for further details. Cardiopulmonary Bypass Time= 81 minutes. Cross clamp time=64 minutes. She tolerated the procedure well and was transferred to the CVICU intubated and sedated in critical but stable condition. She weaned and extubated easily,all lines and drains were discontinued in a timely fashion. She had asysytole underneath temporary pacing wires and she was atrially paced. Electrophysiology was consulted and on [2199-2-20] at 06:43:27 where it was evident that there was no intrinsic rhythm present. [2199-2-25] Cardiology placed a dual chamber [Company 1543] PPM. She tolerated the procedure well and epicardial wires were removed. EP interrogated the PPM the following day. Physical Therapy was consulted for evaluation of strength and mobility. The remainder of her hospital course was essentially uneventful. On POD# [9-24] she was cleared for discharge to [Hospital3 ] in [Location (un) ]. All follow up appointments were advised. Medications on Admission: Medications (as per OSH sheet with no doses listed); -lantus -celexa -lisinopril -isosorbide -toprol -aspirin -mvt -iron -humulog -epogen Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day: until lower extremity edema resolved. 3. Combivent 18-103 mcg/Actuation Aerosol Sig: [12-23] Inhalation four times a day as needed for shortness of breath or wheezing. 4. multivitamin Tablet Sig: One (1) Tablet PO once a day. 5. iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 7. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheeze. 14. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 15. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 18. Insulin- regular Insulin per sliding scale finger stick before meals and at bedtime. Discharge Disposition: Extended Care Facility: [Hospital1 ] Pavilion - [Location (un) ] Discharge Diagnosis: Aortic Stenosis s/p AVR Atrial Fibrillation - s/p permanent DDD pacer on [2199-2-25] Hypertension Urinary Tract Infection subarachnoid hemorrhage s/p bilateral carotid endarterectomies s/p bilateral cataract extractions non insulin dependent diabetes mellitus h/o hepatocellular carcinoma s/p chemoembolization of liver tumor chronic thrombocytopenia hypertension hyperlipidemia Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Edema 1+ LE bilaterally Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks for sternal precautions No lifting or pulling anything weighing more than five pounds using left arm due to pacemaker insertion Do NOT raise your left elbow above the height of your shoulder due to pacemaker insertion. Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon:Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 170]on [2199-3-4] 2:00 Please call to schedule appointments with: Primary Care: DrGavin Little in [3-26] weeks ([Telephone/Fax (1) 84226] Cardiologist:Dr.[Last Name (STitle) 77919] in [2-22] weeks([Telephone/Fax (1) 65733]) Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2199-3-1] ICD9 Codes: 5849, 2875, 2760, 4168, 4280, 5990, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8820 }	Medical Text: Admission Date: [2195-10-4] Discharge Date: [2195-10-9] Date of Birth: [2114-12-19] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1835] Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: 80F transferred from OSH s/p mechanical fall in her yard, hit her occiput on vinyl siding. No reported LOC. OSH head CT revealed small SDH, INR 4.3, arrived to [Hospital1 18] receiving 2u ffp. Past Medical History: PMHx: Afib, DM2 neuropathy LLE>RLE, macular degeneration, HTN, pacemaker All: [First Name9 (NamePattern2) ] [Last Name (un) 1724]: coumadin, fe, lasix, incor, glyburide, digoxin, indural Social History: lives alone Physical Exam: On Admission: 98.2 60 170/74 18 98%RA Gen: WD/WN, comfortable, pleasant, NAD. HEENT: Pupils: R pupil 1.5->1mm, L pupil macular degeneration, assymetric, 6mm. EOMI, no nystagmus. Neck: Supple. Lungs: CTAB. Cardiac: RRR. nl S1/S2. Abd: BS+, S, NT/ND Extrem: Warm and well-perfused. Neuro: Mental status: AA+Ox3, cooperative with exam, nl affect. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements or tremors. Strength full power [5-30] throughout except L IP 5-/5. No pronator drift. Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally. Pertinent Results: Radiology Report CT HEAD W/O CONTRAST Study Date of [2195-10-4] 8:26 PM IMPRESSION: Small focus of high-density material tracking along the right lateral aspect of the falx consistent with a small subdural hematoma, with minimal mass-effect. Radiology Report CT HEAD W/O CONTRAST Study Date of [2195-10-5] 4:01 AM IMPRESSION: 1. Stable small subdural hematoma along the falx cerebri. 2. Multiple foci of air seen within the soft tissues, likely within veins, and likely due to venous access. Radiology Report CT HEAD W/O CONTRAST Study Date of [2195-10-6] 11:59 PM IMPRESSION: Stable appearance of small subdural hematoma along the falx cerebri. Brief Hospital Course: Pt was admitted to the neurosurgical service on [2195-10-4] s/p mechanical fall p/w small SDH. In stable condition. Pt was admitted to the SICU for strict blood pressure control and Q1h neuro checks. Repeat head CT on HD 2 and HD 3 showed a stable subdural hematoma with no continued bleeding. Pt's neurological status remained stable with no focal neurological deficits. However, while in the ICU pt would become agitated and confused at night. The evening of HD2/HD3, an emergent psychiatry consult was ordered for agitation and confusion. Anticonvulsant medication was switched from dilantin to keppra to r/o dilantin as exacerbating confusion. Pt was given IV Haldol and agitation improved. A repeat head CT showed no interval change. Pt remained on Haldol PRN until her transfer to the neurosurgical floor. Agitation was resolved and confusion improved after being transferred from the ICU and Haldol was discontinued. At time of discharge pt was ambulatory, tolerating a regular diet and had no focal neurological deficits. Medications on Admission: coumadin, fe, lasix, incor, glyburide, digoxin, indural Discharge Medications: 1. Home medications please continue all home medications unless otherwise instructed 2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Continue medication until your follow-up appointment. Disp:30 Tablet(s) Refills:2 3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Subdural Hematoma Discharge Condition: Good Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR.[Last Name (STitle) ] TO BE SEEN IN 6 WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST ICD9 Codes: 3572, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8821 }	Medical Text: Admission Date: [2113-7-21] Discharge Date: [2113-8-15] Date of Birth: [2044-9-24] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) / Prednisone / Avelox Attending:[First Name3 (LF) 1283] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [7-21] Cardiac Catherization [7-25] Coronary artery bypass graft x 2 (Left internal mammary artery > Left anterior descending, Saphenous vein graft > Posterior descending artery) Aortic Valve replacement (25mm Mosaic porcine) Mitral Valve Repair (28mm annuloplasty band), Ascending Aorta Replacement (26mm gelweave) [8-1] Sternal Debridement [8-2] pectoral & omental flap closure Cardioversion History of Present Illness: 68 yo male with extensive PMH and increasing DOE with fatigue. Serial echos have shown decreasing [Location (un) 109] with current 1.0 cm2. PFTS in [4-24] showed moderate obstructive and mild restrictive lung disease. Chest CT in [6-24] showed asc. aorta 4.7 cm and 3.7 cm at the aortic root. Cath in early [Month (only) 216] revealed RCA 100%, 40% LAD, 40% pCX, and occluded distal CX. Referred for surgery. Past Medical History: Coronary artery disease Aortic Stenosis Mitral Regurgitation Atrial Fibrillation Obesity Hypertension Elevated cholesterol PAF and previous cardioversions and ablation Chronic obstructive pulmonary disease PVD/carotid dz. catheter ablation MVA with 2 prior lumbar surgs. prior bil. carpal tunnel surgs. prior sinus [Doctor First Name ]. left ankle surgs. x2 tonsillectomy facial [Doctor First Name ]. (MVA) quad. tendon rpair hernia repair Social History: never used tobacco retired photographer rare use of ETOH lives with wife Family History: father expired of MI @54; mother died of CAD @67 Physical Exam: Admission Vitals 75, 132/74, 20, 98 O2 Sat JVP no distention, Carotids no bruit Lungs CTA bilaterally Abd Soft, NT, ND Pulses +2 radial, femoral, DP, PT bilat Pertinent Results: [2113-7-21] 02:05PM HGB-11.6* calcHCT-35 O2 SAT-97 [2113-8-14] 06:09AM BLOOD WBC-12.4* RBC-3.53* Hgb-10.6* Hct-31.9* MCV-90 MCH-30.1 MCHC-33.3 RDW-14.9 Plt Ct-631* [2113-8-12] 04:51AM BLOOD WBC-11.6* RBC-3.24* Hgb-10.1* Hct-29.3* MCV-91 MCH-31.1 MCHC-34.3 RDW-15.0 Plt Ct-526* [2113-8-10] 06:00AM BLOOD WBC-12.3* RBC-3.31* Hgb-10.4* Hct-30.9* MCV-93 MCH-31.3 MCHC-33.6 RDW-15.5 Plt Ct-605* [2113-8-14] 06:09AM BLOOD Plt Ct-631* [2113-8-14] 06:09AM BLOOD PT-16.7* PTT-27.2 INR(PT)-1.5* [2113-8-13] 05:35AM BLOOD PT-19.1* INR(PT)-1.8* [2113-8-14] 06:09AM BLOOD Glucose-100 UreaN-33* Creat-1.3* Na-132* K-4.8 Cl-92* HCO3-33* AnGap-12 [2113-8-13] 05:35AM BLOOD UreaN-33* Creat-1.2 K-4.5 [2113-8-12] 04:51AM BLOOD Glucose-96 UreaN-34* Creat-1.2 Na-130* K-4.4 Cl-92* HCO3-31 AnGap-11 [2113-8-10] 06:00AM BLOOD Glucose-109* UreaN-35* Creat-1.4* Na-128* K-4.5 Cl-91* HCO3-28 AnGap-14 [2113-8-9] 03:02AM BLOOD ALT-85* AST-83* AlkPhos-125* Amylase-33 TotBili-4.6* [2113-8-7] 10:02AM BLOOD ALT-62* AST-50* LD(LDH)-324* AlkPhos-76 Amylase-33 TotBili-5.7* Brief Hospital Course: Admitted [7-21] for heparin coverage while off coumadin and cardiac catherization. The catherization revealed RCA 100%, 40% LAD, 40% pCX,and occluded distal CX. Carotid US did not show any significant stenosis. He went to the operating [**] for coronary artery bypass graft, aortic valve replacement, mitral valve repair, and ascending aorta replacement. Please see operative for further details. He was transferred to the CSRU in stable condition on phenylephrine and propofol drips. In the first twenty four hours he awoke neurologically intact, weaned from sedation and was extubated without complications. He received a five day course of azithromycin given by history for chronic sinusitis each time the he has been intubated in the past. Cardiology was consulted due to ST elevations in V2-V6 with pericardial rub, Echo and EKG obtained. Started on NSAID for pericarditis and plavix for poor targets. Transferred to the floor on POD #2 to begin increasing his activity level. He was gently diuresed toward his preoperative weight and beta blockade titrated. Pacing wires removed without incident on POD #3. He went into Atrial fibrillation [7-29], but converted back to sinus rhythm. He again went into rapid atrial fibrillation and was treated with amiodarone and lopressor with no response. He was then bolused and started on cardiazem drip that he converted to sinus rhythm for a few hours and then went into atrial flutter. Electrophysiology was consulted and plan for cardioversion. He developed a sternal click and chest xray revealed sternal dehiscence on POD 6. He returned to the OR POD 7 for sternal debridement and cardioversion. He then went to the OR on POD 8 with Dr. [First Name (STitle) ] (plastics) for debridement and omental flap closure. Transferred to the CSRU and then extubated again on [8-3]. EP re-consulted for continuing A fib management. Diagnosed with a probable TIA on [8-5]. Started on coumadin on [8-6]. Transferred back to the floor on [8-9]. Continued to make good progress and was cleared for discharge to rehab on [8-15]. Pt. is to make all follow-up appts. as per discharge instructions. Medications on Admission: toprol XL 25 mg daily verapamil 120 mg daily lisinopril 5 mg daily coumadin 5 mg daily (last dose 7/27) ASA 81 mg daily zetia 10 mg daily singulair 10 mg daily mucinex 600 mg 2-4 tabs daily aldactazide 25/25 mg 2 tabs daily advair 250/50 one puff [Hospital1 ] nasocort AQ mcg 2 sprays daily NTG 0.4 mg one spray daily albuterol 17 gm 2 puffs QID prn azmacort 20 gms 2 puffs [Hospital1 ] prn Tussi-Organi 2 tsp q 4 hours prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. 4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet 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): one inhalation [Hospital1 ]. 8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours). 12. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days: then 200 mg daily until seen by Dr. [Last Name (STitle) ]. 15. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Coronary artery disease s/p CABG Aortic Stenosis s/p AVR Mitral Regurgitation s/p MV Repair Atrial Fibrillation Atrial Flutter s/p Cardioversion sternal dehiscence/debridement/flap closure Obesity Hypertension Elevated cholesterol PAF and previous cardioversions and ablation Chronic obstructive pulmonary disease PVD/carotid dz. catheter ablation MVA with 2 prior lumbar surgs. prior bil. carpal tunnel surgs. prior sinus [Doctor First Name ]. left ankle surgs. x2 tonsillectomy facial [Doctor First Name ]. (MVA) quad. tendon rpair hernia repair Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Please call to schedule all appointments Dr. [First Name (STitle) ] (Plastic Surgery) in 1 week ([Telephone/Fax (1) 1429] Dr. [Last Name (STitle) 1290] in 4 weeks [Telephone/Fax (1) 170] Dr. [Last Name (STitle) 2161] or Dr. [Last Name (STitle) 60676] (PCP) in [12-20] weeks [Telephone/Fax (1) 60677] Dr. [Last Name (STitle) 60678] (Cardiologist) in [1-21] weeks Dr [Last Name (STitle) 60679] (electrophysiology) in [1-22] weeks [Telephone/Fax (1) 2934] Completed by:[2113-8-15**] ICD9 Codes: 4240, 496, 9971, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8822 }	Medical Text: Admission Date: [2167-11-29] Discharge Date: [2167-12-2] Date of Birth: [2126-11-29] Sex: M Service: ACOVE CHIEF COMPLAINT: Cough. HISTORY OF PRESENT ILLNESS: This is a 41-year-old man with a history of alcoholism, cirrhosis, with ascites, small varices, alcoholic seizures, and hepatitis C, who has been alcohol free for several months prior to admission. The patient then noted a cough several days prior to admission that he notes to be nonproductive. He stated he was out in the rain all day, then came home, and fell asleep. He woke up with high fever and chills, but could not tell me the temperature. Her also has pain in his left upper chest with inspiration and pain in his back. His mother called EMS. The patient was brought to [Hospital3 3834] [Hospital3 ]. Vital signs were 102.3, 100/38, 112, 100%. White blood cells at that time was 16.6 with 27 bands. He was given ceftriaxone 1 gram IV, Zithromax 500 mg IV. The patient soon dropped his blood pressure to 70 systolic, but was asymptomatic. He was admitted to the Intensive Care Unit. He had a Swan Ganz catheter placed. He was then given Dopamine and switched to Levophed and Neo. The patient was then transferred to [Hospital1 1444] for further evaluation. Upon admission, the patient complained of fever, chills, and slight nausea. Had a nonproductive cough as well as mild back and abdominal pain. PAST MEDICAL HISTORY: 1. Chronic hepatitis C with history of hepatic encephalopathy. 2. Cirrhosis with ascites. 3. Anemia. 4. History of alcohol abuse. 5. History of small varices on esophagogastroduodenoscopy in [2167-9-20]. 6. History of alcoholic seizure disorder. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION TO [Hospital1 ]: 1. Ceftriaxone 1 gram q day. 2. Levofloxacin 500 mg IV q day. 3. Lasix 40 mg po q day. 4. Aldactone 100 mg po q day. 5. Protonix 40 mg po q day. 6. Lactulose 30 mg po tid. FAMILY HISTORY: Father died of alcoholism. Mother is alive and living with depression. SOCIAL HISTORY: Patient is currently 1.5 pack per day smoker, and has been so for greater than 20 years. He had a history of heavy alcohol use, but quit three months ago. He lives with his mother and his son. [Name (NI) ] has a history of intravenous cocaine use many years ago. He denies any history of heroin use. PHYSICAL EXAMINATION: Vital signs: 97.8, 103, 107/57, 24, and 98% on room air. In general, this is a pleasant middle-aged man in no acute distress. HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular muscles are intact. Slight icterus. Neck: Right Swan, supple. Lungs are clear to auscultation bilaterally. Cor tachycardia, but regular, rate, and rhythm. No murmurs, rubs, or gallops. Abdomen is soft, moderately distended, decreased bowel sounds, no rebound or guarding, but mild diffuse tenderness. Extremities: 1+ edema. Neurologic is alert and oriented times three. Positive slight asterixis. Many tatoos, mild macular pin-point rash, flushed, spider angiomas. LABORATORIES: White blood cells 30.8, hematocrit 30.3, platelets 173. Chem-7 132, 3.8, 103, 13, 19, 2.6 and 92. Urinalysis negative. Chest x-ray with a question of a left lower lobe infiltrate. Electrocardiogram with normal sinus rhythm at 87, normal axis, intervals, and no ST-T wave changes. HOSPITAL COURSE: 1. Infectious Disease: Patient was admitted to the hospital with sepsis of unclear etiology. Patient was afebrile on admission with stable blood pressure of 107/97, heart rate of 103. His pressors were weaned off. He had a cardiac echocardiogram which demonstrated an ejection fraction of 60%, dilated, [2-18]+ TR, and mild pulmonary hypertension. A right upper quadrant ultrasound demonstrated cholelithiasis, traced perihepatic ascites, hepatosplenomegaly with hepatofugal flow and recanalized umbilical veins consistent with portal hypertension. Paracentesis was attempted, but could not be done secondary to lack of fluid. Chest x-ray with left lower lobe atelectasis versus infiltrate. The patient was given levofloxacin 500 IV and Flagyl 500 IV tid for question of SBP versus pneumonia. After 24 hours in the Intensive Care Unit, the patient was weaned off the pressors. He also remained afebrile on IV antibiotics. Patient was then switched to po antibiotics and transferred to the floor. On the floor, the patient did well with stable blood pressure in the low 100s and he remained afebrile. Repeat chest x-ray demonstrated collapse or consolidation of the left lower lobe as well as patchy infiltrate in the right middle lobe. Linear atelectasis was also visualized consistent with a pneumonia. The patient was discharged on oral antibiotics. 2. GI: The patient was taken off his diuretics for his hypotension. Once the patient's blood pressure stabilized, he was put back on his Lasix 40 po q day and aldactone 100 mg po q day for his portal hypertension. Patient was not started on a beta blocker secondary to his hypotension. This is something that may be considered as an outpatient. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient was discharged home with followup with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 17029] on [12-8] at 2 pm. DISCHARGE DIAGNOSES: 1. Pneumonia complicated by sepsis. 2. Hypotension. 3. Cirrhosis. 4. Alcoholism. 5. Hepatitis C. DISCHARGE MEDICATIONS: 1. Lasix 40 mg po q day. 2. Aldactone 100 mg po q day. 3. Thiamine 100 mg po q day. 4. Folate 1 mg po q day. 5. Multivitamin one tablet po q day. 6. Protonix 40 mg one tablet po q day. 7. Flagyl 500 mg one tablet po tid. 8. Levaquin 500 mg po q day. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735], M.D. [MD Number(1) 736] Dictated By:[Name8 (MD) ] MEDQUIST36 D: [2167-12-2] 14:00 T: [2167-12-5] 09:59 JOB#: [Job Number 45646] ICD9 Codes: 0389, 486, 2761
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8823 }	Medical Text: Admission Date: [2127-10-8] Discharge Date: [2127-10-13] Date of Birth: [2077-8-7] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 832] Chief Complaint: fever, abdominal pain, hypotension Major Surgical or Invasive Procedure: Right internal jugular central venous line placement History of Present Illness: 50 yo F with no significant past medical history who presented to the ED on [10-8] with fevers, chills, lightheadedness and numbness/tingling of her hands and was found to be febrile to 100.4 with BP 67/36. Labs notable for WBC 14 w/ 28% bands, lactate 4, Cr 2.3 from normal baseline. Non-contrast CTAP demonstrated diffuse mesenteric stranding. Blood and urine cultures were sent, patient received vanc, zosyn and dexamethasone and was admitted to the MICU. She initially required levophed but was quickly weaned. UCG was initially positive but serum HCG negative (patient with successful pregnancy via IVF s/p delivery 8 months ago). OB thought this was incidental, and pelvic ultrasound deonstrated no evidence of fetus or retained products. Repeat CT abdomen-pelvis with IV contrast was done, again demonstrating colitis but no abscess, fluid collection, etc. Patient defervesced, BP normalized, ARF resolved, leukocytosis and bandemia downtrended. All culutures remained negative. The source of sepsis is not clear. . Of note, Ms. [Known lastname ] reports that 4 weeks ago on the first day of her period she experienced an episode of fever, nausea, vomiting and diarrhea. She presented [Hospital1 2025] ED and was found to be febrile to 103.7. She was admitted overnight and received fluids; her symptoms resolved and she reports some weaness for the rest of the week. She reports that she recently started using "super ultra" absorbent tampons for her last couple menstrual periods as her menstrual flow has been very heavy since she gave birth in [January 2127]. . On acceptance to the medical service, Ms. [Known lastname ] feels well. Her dizziness has resolved. She is tolerating a regular diet. Review of systems was notable for diarrhea x5 yesterday afternoon. LMP started [10-5]; she reports using super absorbent tampons early this week and her symptoms began on [10-7]. Past Medical History: None. Social History: Patient works as photography director at the [Location (un) 86] Globe. She is unmarried, and has a healthy 8 month old named [Name (NI) 3613]. She has never smoked, drinks occasionally and denies a history of drug use. Family History: No contributory. Physical Exam: VS: 97.8; my manual readings: 114/67(R) & 114/70(L), pulse 60; (86-122/48-80), 55-93; 16, 96-100%RA 8H: not recorded / BRP 24H: 530 (last shift NR) / BRP General: Alert, awake in chair, NAD, pleasant HEENT: NCAT, EOMI, PERRL, MMM, oropharynx clear without erythema or exudate, sclerae anicteric, face symmetric Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, nontender, nondistended, hyperactive bowel sounds, no HSM Ext: warm, well perfused, no C/C/E, 2+ DP/PT pulses b/l Skin: warm, dry and intact with no rashes or lesions Neuro: A+Ox3, CN II-XII intact with no focal deficit. Strength, sensation and movement symmetric. Gait WNL. Pertinent Results: [2127-10-13] 05:50AM BLOOD WBC-11.0 RBC-4.31 Hgb-12.2 Hct-38.0 MCV-88 MCH-28.4 MCHC-32.2 RDW-14.2 Plt Ct-227 [2127-10-13] 05:50AM BLOOD Glucose-87 UreaN-15 Creat-0.5 Na-137 K-4.2 Cl-106 HCO3-23 AnGap-12 [2127-10-13] 05:50AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.0 . GENITAL CULTURE FOR TOXIC SHOCK (Final [2127-10-14]): NO GROWTH Staph aureus Screen (Rectal Swab) (Final [2127-10-13]): NO STAPHYLOCOCCUS AUREUS ISOLATED. . FECAL CULTURE (Final [2127-10-11]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [2127-10-11]): NO CAMPYLOBACTER FOUND. . OVA + PARASITES (Final [2127-10-10]): NO OVA AND PARASITES SEEN. . CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2127-10-10]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . Blood Culture, Routine (Final [2127-10-14]): NO GROWTH. . URINE CULTURE (Final [2127-10-9]): NO GROWTH. . LYME SEROLOGY (Final [2127-10-9]): NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA. . CT ABDOMEN W/CONTRAST Study Date of [2127-10-9] 12:31 PM IMPRESSION: 1. Soft tissue prominence in the region of the cervix, recommend direct visualization. 2. Bibasilar pulmonary atelectasis with small bilateral pleural effusions. This may be infectious or inflammatory. 3. Fold thickening of the sigmoid, recommend clinical correlation for evidence of colitis. . At time of discharge, serum staphylococcal exotoxin antibody is pending. Brief Hospital Course: # Septic shock - The patient was hypotensive with pressures of 60s/40s on presentation, febrile with leukocytosis to 14 and bandemia of 28%, all most consistent with septic shock. The patient was fluid resuscitated with 8L of fluid in the ED and started on vanco/zosyn for broad coverage. In the MICU she received dexamethasone and was on levophed briefly but quickly weaned off. The definitive etiology of her infection is unknown, but given her history of new, super-absorbent tampon use that correlates directly with her symptoms, toxic shock syndrome is our presumptive diagnosis. OB/GYN was consulted due to the patient's recent delivery and positive urine HcG in the ED, but had no new recommendations. An infectious disease consult was obtained, and eventually the patient was weaned off antibiotics. Her pressures returned to baseline and she remained afebrile and hemodynamically stable on the floor. . # Acute Renal Failure: Secondary to pre-renal etiology from dehydration and hypotension. After fluid resuscitation and pressor support, her creatinine returned to [Location 213]. . # Diarrhea: Resolved. Remained guaiac negative. All stool studies were negative. . # Positive HcG: Thought to be a false positive secondary to a bad batch of pregnancy tests. Her serum HcGs were undectable and a repeat urine test that was sent when the patient was on the floor was negative. A pelvic ultrasound that was done in the ED showed no evidence of intrauterine contents. Medications on Admission: None. Discharge Medications: None. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Septic shock Acute renal failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: 1. You were admitted to the hospital for low blood pressure, which was likely due to either a severe infection or from toxic shock syndrome. You were given fluids, antibiotics and medicine to increase your blood pressure, which you responded well to. It is possible that your symptoms were caused by tampon usage. We advise that you do not use tampons in the future. 2. On discharge, you have pending vaginal and rectal culture results as well as pending blood work. Please follow up these results with your PCP. 3. Please resume all of your previous home medications as prescribed. 4. It is important that you keep all of your follow up appointments. Followup Instructions: Please schedule a follow-up appointment with you PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 27322], within 1 week (tel: [Telephone/Fax (1) 7477]). Completed by:[2127-10-14] ICD9 Codes: 5849, 2762, 0389
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8824 }	Medical Text: Admission Date: [2107-6-18] Discharge Date: [2107-6-22] Date of Birth: [2039-3-10] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1990] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 19017] is a 68yo gentleman with h/o HTN and severe COPD on 4L of oxygen presenting with chest pain. . The patient describes substernal chest pain "like pins and needles" over the last two days with minimal exertion, such as getting up out of bed. Last night, he began having chest pain at rest. Pain was associated with diaphoresis and shortness of [Known lastname 1440] (above his baseline). It was not radiating. He took a sublingual NTG with temporary relief of the pain. Although he reports having heart attacks in the past, he is not sure if his current symptoms are similar to his prior events. He felt warm two days ago but did not check his temperature. No cough, myalgias, or congestion. . In the ED, initial VS were: 98.4 90 77/46 16 90%. By the time he arrived in the ED, chest pain had resolved. Guaiac was negative. EKG showed RBBB without significant change from prior; cardiac enzymes were negative. A CTA of the chest was negative for dissection. IV fluids were given with improvement in his blood pressure, although his pressures continued to be somewhat labile. He received a dose of ASA as well as vanc and zosyn for possible pneumonia. Just prior to leaving the ED, he was given stress dose steroids because of hypotension in the setting of chronic prednisone use. He was incidentally found to have a laceration of his hand and a tetanus shot was given. Past Medical History: s/p NSTEMI in [2101] with Troponin of 12; however [2103] cath showed normal coronaries. TTE [8-10] showed mild RV enlargement and preserved BiV function Possible pulmonary HTN per chart but not documented on TTE or cath COPD on baseline 4L NC, nightly BiPAP 12/5 HTN Hyperlipidemia per records, but last cholesterol in [2105] showed HDL 62 and LDL 58 Iron-deficiency anemia with baseline Hct 29-31 GERD Diverticulosis UTIs with VRE and Pseudomonas Chronic low back pain s/p L1-L2 laminectomy s/p b/l cataract surgery BPH s/p TURP h/o pseudomonas and MRSA Social History: Originally from [Country 7936]. Lives with his wife in [Location (un) 686]; her health is good. Has children who live in the area. Retired mechanic. 20 pack year history, quit at age 37. Prior marijuana use. Drinks alcohol occasionally. Family History: Father with [Name2 (NI) 499] cancer diagnosed in his 70s. Mother with [Name (NI) 2481]. Physical Exam: 97.3 111/65 86 25 97% 4L 79.6kg Very pleasant, thin man with labored breathing at rest. Pupils small and equal. EOMI. No scleral icterus. Mucous membranes moist, dentures in place, OP clear. Neck supple. No thyroid enlargement. JVP not elevated. S1, S2, RRR, but very distant heart sounds. Purse-lipped breathing. +barrel-chested with paradoxical movement of abdomen. Lungs with poor air movement and very increased expiratory phase. No crackles or wheeze. Abd soft and not tender. No hepatosplenomegaly. Femoral pulses +2 b/l without bruits. DPs are weakly dopplerable and very high towards ankles. Alert and oriented, fluent speech, moving all extremities equally. No LE edema b/l. ++clubbing. +Skin tear covering most of dorsum of right hand. No fluid collection or fluctuance. Not actively bleeding. Steri strips in place. Pertinent Results: Admission labs: [2107-6-18] 08:02AM WBC-11.0 RBC-4.03* HGB-10.5* HCT-34.0* MCV-84 MCH-26.1* MCHC-31.0 RDW-14.2 [2107-6-18] 08:02AM NEUTS-66.9 LYMPHS-14.7* MONOS-6.9 EOS-11.0* BASOS-0.4 [2107-6-18] 08:02AM PLT COUNT-282 [2107-6-18] 08:02AM GLUCOSE-136* UREA N-12 CREAT-0.7 SODIUM-135 POTASSIUM-5.8* CHLORIDE-89* TOTAL CO2-40* ANION GAP-12 [2107-6-18] 08:02AM ALT(SGPT)-15 AST(SGOT)-41* LD(LDH)-494* CK(CPK)-81 ALK PHOS-66 TOT BILI-0.4 [2107-6-18] 08:02AM LIPASE-25 [2107-6-18] 08:02AM CK-MB-NotDone cTropnT-<0.01 proBNP-99 [2107-6-18] 02:16PM CK(CPK)-31* [2107-6-18] 02:16PM CK-MB-4 cTropnT-0.01 [2107-6-18] 08:46PM CK(CPK)-33* [2107-6-18] 08:46PM CK-MB-4 cTropnT-<0.01 . Imaging: CXR: PORTABLE SEMI-UPRIGHT RADIOGRAPH OF THE CHEST: The hilar and cardiomediastinal contours are stable although prominent main pulmonary arteries bilaterally suggest pulmonary arterial hypertension. Aorta is tortuous. The lungs are clear with no focal consolidation, pleural effusion or pneumothorax. Atelectatic changes of the right lung base has improved. There is hyperinflation of both lungs with flattening of the diaphragm suggesting obstructive pulmonary disease. . CTA: 1. Interval progression in degree of lower lobe bronchiectasis with increased bronchial wall thickening, right lower lobe ground-glass opacity, and fibrotic-type changes involving the right lower lobe which all likely represent sequelae of acute on chronic recurrent aspiration and/or infectious bronchiolitis. No evidence of aortic dissection. 2. Unchanged diffuse emphysema with probable underlying pulmonary arterial hypertension. Brief Hospital Course: A/P: 68yo gentleman with severe COPD on home oxygen and history of MI with clean cath in [2103] presenting with chest pain. . # COPD exacerbation: Ruled out for MI given reported chest pain and CTPA without dissection or PE. Responded to doubling of his steroid and azithromycin for 5 day course. . # Hand laceration: Confirmed with ED staff, there was no indication for stitches. Pt has steri strips in place. These were replaced once during admission for partial dislodgement. There was no erythema or inflammation or pain to suggest hand infection. He was instructed to return to the ED if pain/redness/fever develop. He received tetanus vaccine in ED. . # Chronic low back pain: - continued home percocet, MS contin low dose added with good effect. Medications on Admission: ASA 81mg daily Prednisone 20mg daily Lisinopril 5mg daily--not taking Pravastatin 40mg daily--not taking NTG 0.4mg SL prn Montelukast 10mg daily, taking prn Omeprazole 20mg daily to [Hospital1 ] (recently stopped b/c not having heartburn lately) Percocet 7.5mg/325mg 2 tablets up to five times a day prn pain Lorazepam 0.5mg QHS Bactrim 800/160mg three times a week Alendronate 70mg weekly Calcium/Vitamin D [Hospital1 ] Lactulose 30ml prn constipation Senna prn Albuterol nebs and inhaler Spiriva 18mcg daily Home oxygen at 4L with BIPAP at 12/5 at night Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:0 2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:0 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:90 Capsule, Delayed Release(E.C.)(s) Refills:0 4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:90 Tablet(s) Refills:0 5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). Disp:40 Tablet(s) Refills:0 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: do not drink alcohol or drive while using. Disp:240 Tablet(s) Refills:0 7. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every Monday). Disp:12 Tablet(s) Refills:0 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:0 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed for shortness of [Hospital1 1440], patient request. Disp:60 nebs Refills:0 10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:90 Cap(s) Refills:0 11. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for 5 days: Then resume usual dosing of one tablet daily, ongoing. Disp:95 Tablet(s) Refills:0 12. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:180 Tablet(s) Refills:0 13. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:2 Tablet(s) Refills:0 14. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours): do not drink alcohol or drive while using. Disp:180 Tablet Sustained Release(s) Refills:0 15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:270 Tablet, Chewable(s) Refills:0 16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for Constipation. Disp:1000 ML(s) Refills:0 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:180 Capsule(s) Refills:0 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Disp:180 Tablet(s) Refills:0 19. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for puritis. Disp:1 tube Refills:0 20. commode Sig: One (1) bedside commode once a day. Disp:1 bedside commode Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Severe copd with exacerbation chronic lower back pain Discharge Condition: Stable, VSS, AF, at baseline O2 use of 4 litres via nasal cannula. Discharge Instructions: Return to the [Hospital1 18] for shortness of [Hospital1 1440], chest pain, fevers Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10134], MD Phone:[Telephone/Fax (1) 7976] Date/Time:[2107-7-7] 2:15 Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2107-8-11] 10:10 Provider: [First Name11 (Name Pattern1) 1569] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. Phone:[Telephone/Fax (1) 612] Date/Time:[2107-8-11] 10:30 ICD9 Codes: 4019, 2720, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8825 }	Medical Text: Admission Date: [2112-3-8] Discharge Date: [2112-3-11] Date of Birth: [2048-10-3] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2569] Chief Complaint: Fall Major Surgical or Invasive Procedure: CT/CTA ECHO History of Present Illness: HPI: 63 yo man who denies PMHx (also says he does not see PMD regularly) who presents after being found down this am (~3am). He reports getting up to go to BR when his "R knee give way." He fell and was unable to get up because "my knees kept sliding out from under me" (both knees per patient). He stayed down and was unable to get up to a sitting position or to stand. His neighbor found him on the floor and contact[Name (NI) ] paramedics. He denies LOC, substance use. Presently, he feels he is just as strong as ever, however. Denies sensory or visual symptoms, feeling weak. He does report 1 week of URI sx and cough for which he has been taking nyquil and ASA 325. ROS: Gen: No fevers/chills/sweats, CP, SOB, palpitations, N/V, abd pain, dysuria, melena, BRBPR, rash, travel Neurological: No deficits noted in: memory, personality, vision, hearing, language/speech, swallowing, coordination, writing, walking, bowel/bladder function. No history of stroke, HA, seizures. No weakness, no sensory loss, no neck pain. Past Medical History: Social History: no tob. 7 beers in one sitting Qweek. no illicits. Family History: father with CAD - passed away from heart disease in late 40s. GF with CA, DM Physical Exam: VS: T 99.4 HR 99 BP 170/114 -> 136/94 RR 41 Sat93->96% on RA PE: General NAD HEENT AT/NC, MMM no lesions Neck Supple, no bruits Chest CTA B CVS RRR, no m/r/g ABD soft, NTND, + BS EXT no C/C/E, multiple abrasions over L side. NEUROLOGICAL MS: General: alert, appropriately interactive, normal affect Orientation: oriented to person, place, date, situation. able to related coherent hx Attention: full??????days if week backwards Speech/[Doctor Last Name ]: fluent w/o paraphasic errors; simple and complex command-following w/o L/R confusion. Repetition impaired for abstraction, naming intact. + dysarthria Memory: [3-22] after 5 minutes Praxis: Able to mimic brushing teeth with either hand. Calculations: 7 quarters = $1.75 CN: II,III: VFFTC, pupils 2.5-1 mm bilaterally to light III,IV,V: EOMI, no ptosis. Normal saccades/pursuits. R gaze preference V: sensation intact to LT/temp VII: decreased NLF on L VIII: hears finger rub bilaterally IX,X: voice normal, palate elevates symmetrically [Doctor First Name 81]: SCM/trapezeii [5-24] bilaterally XII: tongue protrudes midline without atrophy or fasciculation Motor: Normal bulk and tone; no tremor, rigidity, or bradykinesia. No pronator drift. Delt [Hospital1 ] Tri WE FE Grip C5 C6 C7 C6 C7 C8/T1 L 3 5 5- 4 4- 5 R 5 5 5 5 5 5 IP Quad Hamst DF [Last Name (un) 938] PF L2 L3 L4-S1 L4 L5 S1/S2 5- 5 4+ 5- 5 5 5 5 5 5 5 5 Reflex: [Hospital1 ] Tri Bra Pat An Plantar C5 C7 C6 L4 S1 CST L 3 2 3 1 0 Extensor R 2 2 2 1 0 Flexor Sensation: LT intact. no extintction to DSS. Coordination: FTN intact on R. unable on L. HTS intact on R, decreased on L but consistent with weakness. [Doctor First Name ] decreased on L consistent with weakness. Pertinent Results: [2112-3-10] 06:00AM BLOOD WBC-14.5* RBC-3.76* Hgb-13.2* Hct-38.4* MCV-102* MCH-35.1* MCHC-34.3 RDW-14.2 Plt Ct-215 [2112-3-9] 04:01AM BLOOD WBC-10.2 RBC-3.87* Hgb-13.5* Hct-39.0* MCV-101* MCH-35.0* MCHC-34.8 RDW-14.3 Plt Ct-218 [2112-3-8] 08:54AM BLOOD WBC-17.3* RBC-4.28* Hgb-15.2 Hct-42.3 MCV-99* MCH-35.5* MCHC-36.0* RDW-13.5 Plt Ct-253 [2112-3-9] 04:01AM BLOOD Neuts-76.3* Lymphs-15.4* Monos-6.1 Eos-1.7 Baso-0.5 [2112-3-10] 06:00AM BLOOD Plt Ct-215 [2112-3-10] 06:00AM BLOOD PT-12.1 PTT-26.5 INR(PT)-1.0 [2112-3-10] 06:00AM BLOOD Glucose-51* UreaN-18 Creat-0.8 Na-142 K-4.0 Cl-106 HCO3-18* AnGap-22* [2112-3-9] 04:01AM BLOOD Glucose-82 UreaN-12 Creat-0.7 Na-139 K-3.5 Cl-107 HCO3-24 AnGap-12 [2112-3-8] 08:54AM BLOOD Glucose-142* UreaN-13 Creat-0.9 Na-143 K-3.7 Cl-108 HCO3-23 AnGap-16 [2112-3-9] 03:18PM BLOOD CK(CPK)-169 [2112-3-9] 10:21AM BLOOD CK(CPK)-308* [2112-3-8] 08:54AM BLOOD ALT-24 AST-43* CK(CPK)-191* AlkPhos-64 TotBili-0.6 [2112-3-9] 10:21AM BLOOD CK-MB-5 [2112-3-8] 08:54AM BLOOD Lipase-22 [2112-3-8] 10:08PM BLOOD CK-MB-7 cTropnT-<0.01 [2112-3-10] 06:00AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.1 [2112-3-9] 04:01AM BLOOD Calcium-8.4 Phos-2.5* Mg-1.5* Cholest-147 [2112-3-8] 08:54AM BLOOD Albumin-4.1 Calcium-9.1 Phos-1.4* Mg-1.5* [2112-3-9] 04:01AM BLOOD %HbA1c-5.2 [2112-3-9] 04:01AM BLOOD Triglyc-108 HDL-53 CHOL/HD-2.8 LDLcalc-72 [2112-3-8] 08:54AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2112-3-8] 08:57AM BLOOD Glucose-125* Lactate-2.1* Na-144 K-3.7 Cl-105 calHCO3-23 [2112-3-8] 08:57AM BLOOD Hgb-16.2 calcHCT-49 CT 2.17: 4.3 cm right basal ganglia hemorrhage with approximately 2 to 3 mm of right to left midline shift. Given the location of the hemorrhage, these findings likely represent a hypertensive hemorrhage. CT C-Spine: 1. No evidence of acute fracture of the cervical spine. 2. Minimal grade 1 retrolisthesis of C3 on C4 which is likely degenerative in nature. 3. 4-mm right apical pulmonary nodule in a region of apical scarring. If indicated, a chest CT is recommended for further evaluation on a nonemergent basis. CT Sinus: Probable inflammatory bilateral mastoid and middle ear opacification. No evidence of fracture is seen. Brief Hospital Course: Pt was admitted to the neuro-ICU for further management and work-up of his basal ganglia bleed. He was monitored with cardiac telemetry and frequent neuro-checks. Risk factor work-up was done and was unremarkable. His BP was closely monitored. ENT was consulted for prior issue of recent hearing difficulty. He was noted to have bilateral middle ear effusions. CT sinus revealed no significant pathology. An audoigram was ordered but was unable to be done during this hospitalization. It will be scheduled as an outpt. ENT feels this is likely conductive loss from his effusions and will resolve over time. His discharge exam is significant for minor left facial droop, weakness of the left hand distal>proximal. He also has some slight dysmetria of that hand as well. He is able to ambulate with assistance. He will have a follow-up MRI in 6 weeks and then follow-up in stroke clinic as arranged. He should have his BP regularly checked and likely will need to go on an anti-hypertensive therapy. Medications on Admission: asa 325 Qday x 1 week nyquil Discharge Medications: 1. FoLIC Acid 1 mg IV Q24H 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 4. Pepcid AC 20 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Right basal ganglia bleed Discharge Condition: Improved Discharge Instructions: You were admitted because of a bleed in your brain. It was likely caused by high blood pressure. If you have any new weakness, numbness or dizziness you should immediately return to the ER. You will return next week for your hearing test as an outpt. You are also scheduled to get an MRI of your [Doctor Last Name ] in 6 weeks Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 640] [Last Name (NamePattern4) 3445], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2112-5-11] 4:30 Audiogram [2112-3-17] at 2:30PM with Dr. [Last Name (STitle) ] [Name (STitle) 6752] 6 floorProvider: RADIOLOGY MRI Phone:[Telephone/Fax (1) 327] Date/Time:[2112-4-29] 11:55 [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575] ICD9 Codes: 431, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8826 }	Medical Text: Admission Date: [2195-6-18] Discharge Date: [2195-6-22] Date of Birth: [2116-5-13] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2782] Chief Complaint: Fever, abdominal pain, jaundice Major Surgical or Invasive Procedure: ERCP History of Present Illness: Mr. [Known lastname 91520] is a 79 year old male with hx of HTN, HL, DM2, and chronic pancytopenia, transferred here from [Hospital3 ] with fever, abdominal pain, and jaundice for further evaluation. He initially presented to [Hospital1 ] on [6-12] with epigastric pain, abdominal distension with mild nausea/vomiting. Labs and CT scan were done and unremarkable and he was sent home. He then re-presented with similar symptoms to an acute care visit in his PCP's office, who noticed he was jaundiced and febrile and sent him to the [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] once again. His pain was [6-7] at its worst and seemed to improve with Gas-X. He was febrile to 102.3 and given a dose of zosyn and vanco. CT abdomen was again unremarkable, but RUQ U/S showed a small echogenic calculus in the GB neck. CXR was unremarkable, per OSH read. Labs were notable for Tbili 5.7, ALT 364, AST 426, AP 155, creat 2.4, wbc 4.7, INR 0.99, and guaiac neg. In the [Hospital1 18] ED, initial vitals were: 96.6, 70, 82/49, 16, 99%. RUQ U/S was repeated, confirming the presence of a 7mm stone in the GB. Foley was placed to monitor UOP and he was given a total of 5L IVF for his hypotension with good response. Surgery was consulted and recommended ERCP, IVF, abx coverage, and admission to the ICU. ERCP was consulted and will see in the AM unless patient worsens overnight. Upon transfer, his vitals were: 75, 101/51, 20, 98% RA. In the ICU, the patient is quite comfortable and explains that he has been pain-free all day. His blood pressure continued to remain stable without pressors. . Review of systems: (+) Per HPI (-) Denies 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 diarrhea, constipation, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes. Past Medical History: Past Medical History: -Waldenstrom's diagnosed by BM biopsy and followed by Dr. [First Name (STitle) 4223] at [Hospital ] Hosp. -HTN -HL -NIDDM -Anemia (on iron supplementation) -Chronic pancytopenia -BPH -Bilateral inguinal hernias, never repaired -CKD Social History: - Tobacco: 1 pk/day for about 15 years - Alcohol: glass of wine per night, denies previous EtOH abuse - Illicits: denies Family History: DM2, HTN, breast CA Physical Exam: ADMISSION PHYSICAL EXAM: General: jaundiced, alert, oriented, no acute distress HEENT: icteric sclera, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema ICU Discharge PE: VS: T 96.7 HR 78 BP 136/80 RR 17 O2Sat 97% on RA General: Patient is laying in bed comfortably, alert and oriented HEENT: Sclera icteric, MMM, oropharynx clear NECK: Supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally with no added sounds CVS: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs or gallops GI: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley removed EXT: Warm, well-perfused with no clubbing, cyanosis or edema; 2+ pulses NEURO: Alert and oriented to person, place and situation; gross neurological exam normal DERM: No lesions appreicated Pertinent Results: ADMISSION LABS: [2195-6-18] 09:17PM LACTATE-1.3 [2195-6-18] 09:15PM URINE COLOR-Yellow APPEAR-Cloudy SP [Last Name (un) 155]-1.018 [2195-6-18] 09:15PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-MOD UROBILNGN-2* PH-5.5 LEUK-NEG [2195-6-18] 09:15PM URINE RBC-1 WBC-10* BACTERIA-FEW YEAST-NONE EPI-0 [2195-6-18] 09:15PM URINE GRANULAR-17* HYALINE-6* [2195-6-18] 07:33PM COMMENTS-GREEN TOP [2195-6-18] 07:33PM GLUCOSE-173* LACTATE-1.2 K+-4.7 [2195-6-18] 07:15PM GLUCOSE-182* UREA N-46* CREAT-2.8* SODIUM-136 POTASSIUM-4.7 CHLORIDE-106 TOTAL CO2-15* ANION GAP-20 [2195-6-18] 07:15PM estGFR-Using this [2195-6-18] 07:15PM ALT(SGPT)-358* AST(SGOT)-379* ALK PHOS-143* TOT BILI-5.5* [2195-6-18] 07:15PM LIPASE-68* [2195-6-18] 07:15PM VIT B12-1292* FOLATE-GREATER TH [2195-6-18] 07:15PM WBC-3.9* RBC-2.51* HGB-8.9* HCT-25.4* MCV-101* MCH-35.4* MCHC-35.0 RDW-14.1 [2195-6-18] 07:15PM NEUTS-81.5* LYMPHS-11.2* MONOS-6.9 EOS-0.2 BASOS-0.1 [2195-6-18] 07:15PM PLT COUNT-100* [2195-6-18] 07:15PM PT-12.7 PTT-26.9 INR(PT)-1.1 [2195-6-20] 03:41AM BLOOD WBC-1.9* RBC-2.46* Hgb-8.5* Hct-24.5* MCV-100* MCH-34.5* MCHC-34.7 RDW-13.1 Plt Ct-69* [2195-6-20] 03:41AM BLOOD PT-12.7 PTT-27.0 INR(PT)-1.1 [2195-6-20] 03:41AM BLOOD Glucose-91 UreaN-23* Creat-1.6* Na-138 K-4.1 Cl-108 HCO3-15* AnGap-19 [2195-6-20] 03:41AM BLOOD ALT-215* AST-157* AlkPhos-148* TotBili-6.3* DirBili-5.6* IndBili-0.7 [2195-6-20] 03:41AM BLOOD Calcium-8.6 Phos-2.3* Mg-1.6 Micro: Urine culture: Negative Blood cultures: Pending Imaging: RUQ U/S: Non-distended benign-appearing gallbladder with a single 7mm stone. Focal wall thickness in the gallbladder fundus is most likely secondary to adenomyomatosis. Focal GB carcinoma cannot be completely excluded. ERCP [2195-6-19]: Impression: Sphinctrotomy performed. Small CBD stone/sludge removed. No pus seen. Cystic duct stone could not be removed. Otherwise normal ercp to third part of the duodenum Brief Hospital Course: 79 year old man with history of HTN, HTL, DM, Waldenstrom's macroglobulinemia, chronic pancytopenia, and CKD presented to [Hospital3 ] with fever, RUQ pain, jaundice and an obstructive pattern to his LFTs consistent with acute cholangitis. # Acute cholangitis -[2195-6-19] - ERCP with sphincterotomy - small CBD stone/sludge was removed, and a cystic duct stone was seen but could not be removed -Was hypotensive in the ED and admitted initially tot he ICU but responded rapidly to IVF and IV unasyn ([Date range (1) 18857]). Blood and urine cultures from [6-18] remain negative. He was changed to PO cipro/flagyl on [6-21] for a 10d course to end on [6-26]. . # Macrocytic anemia: Hct on admission low at 25.4 with an MCV of 101. His baseline is 32 (in [2195-2-27]). He is only on iron supplementation as an outpatient, but his MCV seems to indicate that his anemia may be caused by B12/folate deficiency or MDS. B12 and folate were tested and found to be high. This makes most likely cause of macrocytosis his obstructive jaundice, as phospholipids can be deposited on cell membrane surface. His Hct with aggressive hydration dropped to 22 on [6-21] but he was completely asymptomatic and refused transfusion. He will be monitored closely and restarted on iron. There was no clinical evidence of bleeding. His [Month/Year (2) 9766] 81mg/day (at home) will be held for at least 7 days after the sphincterotomy, until [6-26]. . # Chronic pancytopenia: In addition to the anemia above, patient is also leukopenic and thrombocytopenic. This can be from a variety of different causes including viral infections like HIV, heme conditions such as MDS, and vitamin deficiencies as above. Daily CBCs were drawn to trend WBC and plts showing downward trends of all cell lines which may be dilutional. He is followed by hematology at [Hospital3 ] as an outpatient (Dr. [First Name (STitle) 4223]. On [6-22] his hematocrit was 25, wbc 2.4, and plts 74 . # Acute kidney injury in the setting of CKD: Creatinine elevated at 2.8 on admission. Likely pre-renal in the setting of infection and the patient was bolused 5L in the ED. Serum Cr decreased to 1.6. He continued his [Last Name (un) ] (diovan) # DM II: On admission, his pioglitazone was held. During the admission, he was started on ISS with FSBGs QACHS while NPO. Once he started eating, his home medications were restarted. He had previously been on glipizide, which was stopped in [2195-4-29] after an episode of hypoglycemia. # Hypertension: His home metoprolol and diovan were held for initially given hypotension in ED, then were subsequently restarted. . # Hyperlipidemia: His home statin was held given abnormal LFTs and his niacin 1500mg per day is being held. His statin was resumed. Med changes: ASA held till [6-26] cipro & flagyl to end [6-26] Niaspan held ITEMS for f/u per PCP []anemia workup and management (Patient has outpatient hematologist as well) []f/u of gallstones with GI []followup of glucose and diabetes Medications on Admission: Actos 45mg daily Niaspan 1500mg daily Metoprolol 100mg [Hospital1 *] Diovan 160mg daily Simvastatin 20mg qhs Prandin 1mg prior to evening meal if BS>140 "Iron" 325mg daily MVI daily ASA 81mg Discharge Medications: 1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days. Disp:9 Tablet(s)* Refills:0 2. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 4 days. Disp:12 Tablet(s) Refills:0 3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. 6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. repaglinide 0.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Outpatient Lab Work please have your PCP's office repeat your CBC and LFTs Discharge Disposition: Home Discharge Diagnosis: Cholangitis Choledocholithiasis with obstruction; resolved Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with blocked bile ducts and a procedure called an ERCP with sphincterotomy was performed to remove the gallstones which were causing the obstruction. There was also infection of your bile ducts which was treated with antibiotics. Your blood counts dropped, and you will need to have labs drawn after discharge by your primary care physician. [Name10 (NameIs) 9766] and niancin have not been restarted. Followup Instructions: Name: NP [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 91521] Location: [Hospital3 ] INTERNAL MEDICINE ASSOCIATES Address: [Street Address(2) 4472], [Apartment Address(1) 4473], [Hospital1 ],[Numeric Identifier 9331] Phone: [Telephone/Fax (1) 4475] Appointment: Wednesday [2195-6-24] 11:30am Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4469] [Telephone/Fax (1) 76066] [7-15] 11AM **This is a follow up appointment of your hospitalization. You will be reconnected with your primary care physician after this visit. ICD9 Codes: 5849, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8827 }	Medical Text: Admission Date: [2107-6-15] Discharge Date: [2107-7-4] Date of Birth: [2053-8-15] Sex: M Service: MEDICINE Allergies: Compazine / Unasyn Attending:[First Name3 (LF) 2145] Chief Complaint: EtOH intox / abdominal pain Major Surgical or Invasive Procedure: intubation/extubation RIJ central venous line placement evacuation of R femoral vein hematoma by vascular surgery paracentesis History of Present Illness: 53M w/ h/o IVDA, HCV cirrhosis, current ETOH abuse presents with epigastric pain in the setting of alcohol intoxication. Pt reports epigastric pain. Unable to get more detailed history due to pt's somnolence. Per last d/c note, the patient has a history of chronic pancreatitis and polysubstance abuse and has had multiple admissions in the past for nausea, vomiting, and abdominal pain. During these admissions he has been treated for alcohol withdrawal and possible chronic pancreatitis (though no evidence of such). Past Medical History: -hepatitis C cirrhosis, incompletely tx with IFN (Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], hepatology [Hospital1 2177]) -self-reported chronic pancreatitis (not documented and does not require home narcotics) - Hx hx drug seeking behavior, confirmed with clinic (Health care for the Homeless) - per OSH records, hx IVDU - Hx Grade I esophageal varices per [Hospital1 2025] records - hx bilateral varicoceles by [Hospital1 2025] scrotal U/S [9-27] s/p cholecystectomy s/p splenectomy after MVA -polysubstance abuse (alcohol with history of DTs, tobacco, narcotic seeking behavior, past IVDA) -depression with suicide attempts -asthma -s/p cholecystectomy -s/p splenectomy -s/p spinal fusion surgeries Social History: + history of IVDA, EtOH, and tobacco. He was formerly employed as a painter but per last d/c summary disabled due to back and stomach problems for >5 years. Son, a computer programmer, and daughter, a nurse, live in [Name (NI) 3914]. In the past, has lived in [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) ] and [Location (un) 8072] houses Family History: Mother died of MI age 57. Father, a bar owner, died at 47 of stomach cancer. Parents not alcoholics. Physical Exam: VS: T 97.1, BP 160/108, HR 112, RR 20, SaO2 89%/RA -> 90%/2L, 94%/3L Gen: somnolent, NAD, arousable but falls back asleep HEENT: PERRL, EOMI, dry MM Neck: supple, no LAD, blood posteriorly Chest: diffusely rhonchorous +wheezes CV: RRR, nl S1, S2, no murmurs/rubs/gallops Abd: soft, tender in RUQ, no rebound or guarding, +distension, + decreased BS Ext: no peripheral edema Neuro: unable to assess as pt somnolent, not following commands well Pertinent Results: Labs: . Serum EtOH 225 Serum Benzo Pos Serum ASA, Acetmnphn, Barb, Tricyc Negative . 143 / 105 / 7 gluc 101 AGap=17 -------------------- 3.8 / 25 / 0.8 . Ca: 8.1 Mg: 1.7 P: 2.6 . ALT: 80 AP: Tbili: 1.2 AST: 166 [Doctor First Name ]: 55 Lip: 31 . WBC 8.8 HCT 27.1 PLT 253 N:56 Band:0 L:23 M:17 E:0 Bas:0 Atyps: 2 Metas: 2 Hypochr: 1+ Poiklo: 2+ Target: 2+ . PT: 15.3 PTT: 28.3 INR: 1.4 . Studies: [6-15] Tib Fib & Ankle films: No acute fracture. . [6-16] Abd U/S: Evaluation of the right upper, right lower, left upper and left lower quadrants of the abdomen demonstrated a small amount of ascites in the right upper quadrant. The quantity was not sufficient to mark a spot for paracentesis. . [6-16] CTA Chest: 1. No evidence of pulmonary embolism. No consolidation within the lungs. 2. Old compression deformity of a mid thoracic vertebral body. 3. Nodular liver consistent with a cirrhotic liver, associated small amount of ascites, and likely reactive lymph node at the gastroesophageal junction. 4. Calcification along the right pectoralis major muscle is suggestive of a prior hematoma in this region. . [6-16] CT Head: No evidence of intracranial hemorrhage. Likely old small infarct in the right cerebellar hemisphere. . [6-16] CT Abd/Pelvis: 1. Cirrhosis with small amount of perihepatic ascites tracking into the right paracolic gutter. 2. Extensive wall thickening of the ascending and transverse colon indicating colitis of indeterminant etiology, possibly secondary to liver failure. 3. No evidence of pancreatitis. . [6-17] Femoral Vascular U/S: Findings most consistent with AV fistula at the site of the femoral puncture. . [6-17] CT Abd/Pelvis: 1. Fatty cirrhotic liver without enhancing lesions identified. Perihepatic ascites. 2. Bilateral tiny pleural effusions. . [6-20] CXR: Left basilar opacity since [2107-6-16]. . [6-22] CXR: Left lower lobe collapse, unchanged since [6-20], accompanied by increasing moderate left pleural effusion. No pneumothorax. Tip of the right PIC catheter projects over the superior cavoatrial junction. No mediastinal widening. The right lung clear. Mild cardiomegaly stable. Dilated azygos vein suggests elevated central venous pressure or volume. . [6-23] RUQ U/S: 1. Nodular liver consistent with cirrhosis. 2. Moderate amount of ascites. Brief Hospital Course: # Abdominal pain: According to past records from [Hospital1 18] and from [Hospital1 2025], the patient has a long history of admissions and ED visits for abdominal pain, as well as a history of narcotic-seeking behavior. He has a history of HCV cirrhosis. The differential diagnosis of his pain was broad, and included pancreatitis (although amylase, lipase, and CT findings argue against this), SBP (paracentesis results were negative), colitis (some chronic changes noted on CT, no change from prior), and gastritis. The patient did have an elevated bilirubin, but RUQ ultrasound was unrevealing, other than his known cirrhosis. Chronic mild elevation of LFTs was felt to be secondary to HCV and EtOH. The patient was initially kept NPO and given IV fluids and PPI. Due to his somnolence on admission, narcotics were initially avoided. Later in the hospital course, the patient was given PO opiates only, due to his hypercarbic respiratory failure (see below). The patient was very demanding and constantly requested IV pain medications. He also frequently refused all PO medications. At time of discharge he was on tramadol po only and is eating well without significant abdominal pain. The patient does claim to have a history of chronic pancreatitis as the etiology of his pain, so to make a definitive diagnosis he could be referred for a secretin test. This can be consider as an outpatient. . # Groin hematoma: Following placement of a femoral venous catheter for IV access, the patient developed a hematoma and became hypotensive. He was taken to the OR on [6-18] given concern for an AVM. No AVM was found, but a large hematoma was evacuated. A JP [Month/Year (2) 19843] was left in place, but on [6-23] the patient pulled this out. At that time the [Month/Day (4) 19843] had still been draining 600-700cc/day. Serosanguinous fluid continued to [Month/Day (4) 19843] from the site of the JP [Last Name (LF) 19843], [First Name3 (LF) ] vascular surgery recommended placement of an ostomy bag over the site to collect the fluid and monitor its volume, as well as to protect the patient's skin. The patient's hematocrit remained stable. Lasix was also restarted in the hopes that treating the patient's peripheral edema would help to prevent reaccumulation of fluid in the groin site. (though albumin is quite low so this may not be successful) The patient had apparently been on diuretics as an outpatient as well, but adherence was not certain. Needs follow up with vascular surgery. . #HCV/EtOH Cirrohsis - Now closer to euvolemic. Continue on lasix 40 po bid and spironolactone. Also on lactulose and rifimaxin with improvement of mental status. Will restart bactrium SBP prophylaxis. Paracentesis neg for SBP. . #Scrotal cellulitis - Has prior hx of scrotal edema and bilateral varicoceles per [Hospital1 2025] records from [9-27]. This admission was noted to have scrotal erythema and TTP. Started on treated with levofloxacin and vancomycin when not taking PO. Now will take a 10d course of cipro. . # Hypercarbic respiratory failure: The patient was first noted to be somnolent in the PACU following evacuation of his groin hematoma on [6-18]. ABGs over time were 7.19/69/135 -> 7.23/55/170. He received 2 doses of narcan with some response, but the response waned quickly. He was re-intubated in the PACU and transferred to the MICU for further management. He was extubated on [6-19] and transferred back to the floor. However, overnight he again became somnolent with a decreased RR and ABG 7.15/63/80. He had received morphine 2mg IV ~12 hours earlier. He was again given narcan, after which his RR increased to 24 and he became acutely wheezy and tachycardic to the 140s. He was transferred to the MICU, but did not need to be re-intubated at that time. No further intervention was needed, and he was again transferred to the floor. From that time onward, sedating medications were kept to a minimum, and IV opiates were avoided entirely. As mentioned above, the patient tended to refuse PO medications, so he received relatively small amounts of narcotics. He was noted to have a persistent LLL opacity on serial CXR, but as he was afebrile and it was not felt that he had a pneumonia clinicially, he was not treated with antibiotics. . # altered mental status: On admission this was secondary to EtOH withdrawal/intoxication (see below). There was also concern for a head bleed given a history of possible head trauma, but head CT was negative for bleed. EtOH abuse was treated as below. The patient remained very agitated, combative, and uncooperative throughout his admission. As above, he pulled out a JP [Month/Year (2) 19843] from his groin following hematoma evacuation, and at another time he pulled out a R IJ central venous line. He required a 1:1 sitter for his own safety and that of others, as he threatened to harm staff members and to jump out a window. At the time of discharge mental status has cleared and he had no active suicidal ideation. . # ETOH abuse: The patient was intoxicated on admission, and he does have a history of withdrawal and DTs. He was kept on a CIWA scale with ativan. He was given a banana bag on admission and was also continued on PO thiamine, folate, MVI. There was no evidence for acute alcoholic hepatitis on admission. . # hypoxia: On admission the patient was found to be hypoxic. As mentioned above, it was not felt that he had pneumonia. Given that he was also tachycardia, there was also concern for PE. This was ruled out with CTA of the chest. He was give albuterol and atrovent nebs as well, given his history of asthma/COPD His hypoxia has now resolved. . # leg pain: The patient had this complaint on admissin. X-rays were negative for fracture. Medications on Admission: (on last discharge [4-27]): 1.Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2.Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 3.Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 4.Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 5.Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6.Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 7.Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q 12H (Every 12 Hours) as needed for pain. 10. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 12. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 16. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day). 17. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 19. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. 21. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO once a day. 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Multivitamin Capsule Sig: Three (3) Cap PO DAILY (Daily). Disp:30 caps Refills:2 4. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:180 cap Refills:2 5. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:1 mdi Refills:2 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 7. 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 8. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day). Disp:1 bottle Refills:2 14. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. 18. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: abdominal pain EtOH intoxication hypercarbic respiratory failure secondary to opiates right groin hematoma, secondary to right femoral central venous line . Secondary Diagnoses: HCV cirrhosis polysubstance abuse depression asthma Discharge Condition: good Discharge Instructions: If you experience fever, chills, nausea, vomiting, abdominal pain, or any other new or concerning symptoms, please call your doctor or return to the emergency room for evaluation. . Please take all medications as prescribed. . Please attend all followup appointments. Your PCP should make sure you follwo up with the vascular surgery clinic for your groin hemoatoma (bruise). You also need to follow up with a liver specialist. Followup Instructions: You should follow up with your primary care doctor (Dr. [Name (NI) 5124]) in the next week. You have an appointment with Dr. [Last Name (STitle) 1391], your Vascular Surgeon, on [7-20] at 10:30 AM. His office is on the [Location (un) 6332] of the [Hospital Unit Name ]. Their phone number is [Telephone/Fax (1) 1393]. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2158] Completed by:[2107-7-5] ICD9 Codes: 4019, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8828 }	Medical Text: Admission Date: [2196-5-13] Discharge Date: [2196-5-16] Service: CHIEF COMPLAINT: GI bleed, transfer from [Hospital3 4527]. HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old woman with a history of Sjogren syndrome with sicca syndrome and also CREST with predominant Raynaud's, history of GI bleed in the past thought secondary to gastritis and arteriovenous malformations, status post left gastric and left gastroduodenal artery embolizations in [7-18] and [6-18] respectively. She presented to [Hospital3 4527] in mid-[2196-4-17] with bright red blood per rectum and an hematocrit drop from 34 to 28. Her work-up at that time consisted of an abdominal CT that revealed a pancolitis, increased splenomegaly, and new ascites. She was transfused two units and discharged to rehabilitation on [2196-5-7], and then two to three days prior to admission the patient noted dark stools and on the morning prior to admission the patient had nausea, decreased appetite, and an episode of vomiting bright red blood. She subsequently went to [Hospital3 4527] on [2196-5-12] in the morning. In the emergency room there her systolic was in the 90s, hematocrit was 18, down from 28 on discharge. Her INR was 1.7. She had a left IJ triple-lumen catheter placed, a right EJ peripheral line, and she subsequently underwent EGD which revealed grade 0-1 esophageal varices, portal gastropathy, gastric varices, but no active bleed, although there were multiple blood clots in the stomach. She was treated with IV Protonix and was started an octreotide drip. She was transfused several units, which improved her hematocrit from 18 to 28, and then on the morning of the 27th around 1 AM she had a repeat episode of hematemesis, and nasogastric lavage did not clear after two liters of saline. An emergency EGD was performed that revealed a large varix at the gastroesophageal junction, and there was blood in the fundus. Sclerotherapy was attempted, which resulted in an initial blood spurt, however the bleeding subsequently stabilized and overall during the resuscitative efforts, she was given six units of red cells and four units of fresh frozen plasma, and she was transferred to [Hospital1 346] for evaluation of emerging TIPS. Here in the intensive care unit the patient was comfortable with no nausea or vomiting, no further hematemesis. She denied any abdominal pain. PAST MEDICAL HISTORY: 1. Sjogren's with sicca syndrome. 2. CREST with predominant Raynaud's. 3. History of GI bleed status post left gastric artery embolization in [7-18], and left gastroduodenal artery embolization in [6-18]. 4. History of pancolitis. 5. Recent episode of bleeding points. 6. Irritable bowel syndrome. 7. Hypertension. 8. Hashimoto's hypothyroidism with positive antibody. 9. Diverticulosis. 10. History of left femoral DVT in [6-18]. 11. History of chronic obstructive pulmonary disease/bronchitis. MEDICATIONS: 1. Octreotide drip at 50 mcg per minute. 2. Protonix 40 IV b.i.d. 3. Ativan p.r.n. 4. Atrovent, albuterol nebulizers. 5. Vitamin K subcutaneous x 3. ALLERGIES: The patient is allergic to sulfa and penicillin. SOCIAL HISTORY: The patient lives in [Location (un) 4528] skilled nursing facility. Her son lives locally, daughter is on the west coast. Minimal alcohol history and remote tobacco. The patient has a son with [Name (NI) 4522] disease. PHYSICAL EXAMINATION: On arrival her temperature was 98, blood pressure 160/80, heart rate 80s, respiratory rate 16, saturating 95% on two liters. General: She was a well-appearing, elderly, frail woman. HEENT: She had crusted blood in her oropharynx. Pupils equal, round and reactive to light. Sclerae anicteric. Neck: Supple, with no lymphadenopathy. Chest: Examination revealed decreased breath sounds at the left base and bronchial breath sounds at the right base. Cardiac: There was a [12-24] crescendo/decrescendo systolic murmur at the right upper sternal border without radiation. Abdomen: Benign, positive bowel sounds, nontender. There was no fluid wave. No liver edge was appreciated. Extremities: There was no peripheral edema. Skin: There was no jaundice notable. Neurologic: The patient was alert and oriented x 3, otherwise nonfocal. LABORATORY DATA: On the morning of admission white count was 10.8, hematocrit 31.9, which had been up from 22 earlier in the morning, platelet count 68, which was around her baseline, SMA-7 was unremarkable. BUN and creatinine were normal. INR was 1.3. PT 14.1, PTT 32.8, fibrinogen was 161, albumin 3.2. ALT, AST, and alkaline phosphatase were within normal limits. Total bilirubin was 2.1. Urinalysis on the morning of arrival had been negative. EKG showed sinus tachycardia at [Street Address(2) 4529] depressions in 2, 3, aVF, V4 to V6, but no acute change compared to old. HOSPITAL COURSE: 1. Upper GI bleed/variceal bleed: Patient was thought to have cirrhosis of unclear etiology with new ascites and new splenomegaly on recent abdominal CT, and on endoscopy at the outside hospital, portal gastropathy and esophageal varices were found. The patient was initially transferred to [Hospital1 69] for evaluation for emerging TIPS. The patient had a type and cross with four units of red cells and fresh frozen plasma on hold. She had a central line in her left neck as well as a right EJ. She was continued on octreotide drip at 50 mcg per hour. She was continued on Protonix 40 IV b.i.d. Her coagulopathy, her hematocrit and platelet count were corrected with products as needed. The patient was evaluated by the liver team, who felt that given her comfortable status and high risk of precipitating encephalopathy, TIPS would not be the best strategy; rather the patient was observed on octreotide drip. Her daughter and son were available as well as the patient during this conversation and agreed that conservative management of her varices was the best route. The patient was continued on octreotide drip for the plan of five days, and was continued on Protonix IV b.i.d. She was started on nadolol for further decrease of her portal hypertension, and a work-up was initiated for her etiology of cirrhosis including hepatitis panel, [Doctor First Name ], SPEP, and antimitochondrial antibody. A right upper quadrant ultrasound was performed that revealed no evidence of portal vein thrombus and a cirrhotic liver. The patient had no further episodes of hematemesis during her hospitalization. Her hematocrit remained stable throughout her hospitalization. 2. Mental status change: The patient initially was alert and oriented upon arrival, however became delirious within 24 hours of her hospitalization. Further work-up revealed a positive urinalysis consistent with a urinary tract infection, probably catheter related. The patient also had 4/4 bottles positive for gram-positive cocci in clusters in her blood, which were drawn off a left IJ, consistent with a line infection with sepsis. The patient had already been DNR, however now the patient's code status after discussion with her daughter and son, was changed to DNR/DNI, and made comfort measures. No antibiotics were given for her line infection. The line was not changed due to the morbidity involved in a central line procedure, and unfortunately, the passed away likely due to overwhelming sepsis both from line infection and urinary tract infection. The patient was pronounced at 10:20 PM on [2196-5-16]. Daughter and son were present at the bedside. DISCHARGE DIAGNOSES: 1. Line infection/sepsis. 2. Urinary tract infection. 3. Variceal bleed/hemorrhage. 4. New diagnosis of cirrhosis in addition to her diagnoses on arrival. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 968] Dictated By:[Name8 (MD) 2439] MEDQUIST36 D: [2196-6-21] 11:09 T: [2196-6-27] 07:14 JOB#: [Job Number 4530] ICD9 Codes: 5715, 4280, 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8829 }	Medical Text: Admission Date: [2177-3-23] Discharge Date: [2177-3-27] Date of Birth: [2102-4-5] Sex: M Service: CCU CHIEF COMPLAINT: Acute dyspnea. HISTORY OF PRESENT ILLNESS: This is a 74-year-old male with no prior medical history except his first myocardial infarction in [2177-2-14] in the setting of five days of new onset of substernal chest pressure and was eventually found to have 2-vessel disease by cardiac catheterization and elevated right-sided pressures. On that admission, the patient ruled in for a myocardial infarction with a peak creatine kinase of 1665, a MB of 138, and a troponin of greater than 50. His echocardiogram revealed an ejection fraction of 25% with significant inferoapical akinesis and multiple basolateral hypokinetic segments. The patient was doing well after his myocardial infarction and compliant with his medications (as per his report). However, he was having two to three episodes of early a.m. dyspnea with exertion, and the exertion was basically doing household chores. On the morning of admission, the patient again had an episode of dyspnea while doing some household chores. However, unlike his prior episodes, this one did not resolve with rest and continued to worsen. There was no associated chest pain, and no vagal symptoms. There is no history of paroxysmal nocturnal dyspnea, and the patient has stable three-pillow orthopnea. There is no history of infectious symptoms such as fevers, chills or cough; and the patient reports no dietary indiscretion. In the Emergency Department the patient was observed to be hypertensive to 211/116, with a heart rate of 128, satting 97% on 100% nonrebreather mask. He was tachypneic with paradoxical breathing motions, and speaking in single syllables. The patient was given Lasix, nitroglycerin, morphine, and hydralazine. An initial arterial blood gas revealed a pH of 7.12, a PCO2 of 77, and a PAO2 of 78 on 100% nonrebreather. The patient was subsequently put on noninvasive pressure ventilation. The Coronary Care Unit was then contact[Name (NI) ] for management of presumed acute flash pulmonary edema of unclear etiology. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post myocardial infarction in [2177-2-14]. Cardiac catheterization on [2177-2-21] revealed 100% fresh proximal left circumflex lesion which received percutaneous transluminal coronary angioplasty and stent; 100% proximal right coronary artery chronic occlusion with no action; the wedge was 25; the pulmonary artery pressure was 54/21. His cardiac risk factors include a distant 50-pack-year history of smoking; quit 10 years ago, hypertension, and age. 2. Depressed ejection fraction of 25% with multiple region wall motion abnormalities including inferoapical akinesis by [2177-2-24] echocardiogram. MEDICATIONS ON ADMISSION: (Medications on admission included) 1. Coumadin 5 mg p.o. q.d. 2. Lipitor 10 mg p.o. q.d. 3. Atenolol 25 mg p.o. q.d. 4. Aspirin 325 mg p.o. q.d. 5. Plavix 75 mg p.o. q.d. 6. Trandolapril 1 mg p.o. q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is a widower for the last few years. He lives alone and does his own activities of daily living, and he has a distant 50-pack-year history of tobacco; he quit 10 years ago. The patient did smoke unfiltered cigarettes. PHYSICAL EXAMINATION ON PRESENTATION: Admission physical examination revealed vital signs with a blood pressure of 140/60, temperature of 99.7, heart rate of 108, respiratory rate of 25, oxygen saturation of 97% on BiPAP. In general, alert and oriented times three, with significant respiratory distress. Head, eyes, ears, nose, and throat revealed normocephalic and atraumatic. Pupils were equal, round, and reactive to light. Extraocular movements were intact. The oropharynx was clear. No jugular venous distention. The neck was supple. Pulmonary revealed bilateral expiratory wheezing, high-pitched rales heard one-half of the way up the lung field. Cardiovascular examination revealed distant heart sounds, but no murmurs, rubs or gallops. No abnormal pulsus paradoxus. The abdomen was protuberant, nontender and nondistended, normal active bowel sounds. Paradoxical motions observed with respirations. Extremities revealed no clubbing, cyanosis or edema, cool, and pink. Neurologically intact on cranial nerve and strength examination. PERTINENT LABORATORY DATA ON PRESENTATION: Admission laboratories revealed a white blood cell count of 15.1, hematocrit of 39.5, platelets of 297. Coagulations revealed PT of 21.4, PTT of 37.1, INR of 3.2. SMA-7 revealed sodium of 138, potassium of 4.7, chloride of 103, bicarbonate of 21, blood urea nitrogen of 11, creatinine of 1.3, and glucose of 383. Creatine kinase of 110, MB of 3, troponin of 0.3. RADIOLOGY/IMAGING: Electrocardiogram revealed an old right bundle-branch block, sinus tachycardia, old first heart sound Q3-T3 pattern, and no acute ST-T wave abnormalities. Chest x-ray obtained was notable for significant perihilar edema, moderate-to-severe upper zone redistribution, and bilateral small pleural effusions. The left hemidiaphragm was also obscured. HOSPITAL COURSE: The patient was admitted to the Coronary Care Unit for management of poor respiratory status that was felt to be secondary to flash pulmonary edema. The cause of this was not clear on presentation, but the leading considerations were medication noncompliance leading to hypertension, a hypertensive spike, and ischemic event leading to worsening left ventricular compliance. The patient was on BiPAP for the first several hours of admission with significant improvement in his arterial blood gas, and about 24 hours into his hospitalization he was on nasal cannula oxygen with no ventilatory or oxygenation abnormalities. In terms of the patient's known coronary artery disease, cardiac enzymes were cycled as were electrocardiograms. Electrocardiograms revealed no new changes; however, the patient did rule in for a myocardial infarction with a peak creatine kinase of 186, and a peak MB index of 7.5. The patient's Plavix was discontinued on [2177-3-25] after a 30-day course following his stent placement, and the patient was started on folate. In terms of the patient's depressed ejection fraction, it was unclear why the patient was not placed on Lasix prior to this admission; however, he diuresed well to p.r.n. doses of 60 mg intravenously of Lasix, and at the time of discharge he was on 40 mg of Lasix p.o. q.d. The patient's ACE inhibitor was also titrated up. He was initially started at 12.5 mg of captopril, and eventually we were able to get him to 25 mg p.o. t.i.d. of captopril. He will be discharged on 2 mg of trandolapril per day. The patient's admission blood sugar was 383. A hemoglobin A1c noted in the OMR was 5.8. This was all consistent with worsening glucose intolerance. However, once the patient's acute stressor resolved, his blood sugars came down into the normal range, and he did not need sliding-scale insulin. Finally, the patient's INR was climbing for unclear reasons from an admission INR of 3.2 to a maximum of 4.8 on the day prior to discharge. On the day of discharge, it was 2.5 with no interventions made. The patient's captopril had been held throughout the hospitalization, and it will be restarted at the time of discharge. The patient's hematocrit also mysteriously dropped from 39 to 32; and, so, an anemia workup was initiated. The patient's reticulocyte count was 3, iron was 39, with a TIBC of 260. The mean cell volume was normal at 89. The hematocrit came up of its own [Location (un) ] from 32 to 39, so no further actions were taken. On [2177-3-27], after a Physical Therapy consultation the patient was felt to be stable for discharge home with home physical therapy for medication monitoring and assistance with arrangements of followup. DISCHARGE DIAGNOSES: 1. Non-ST elevation myocardial infarction. 2. Flash pulmonary edema. 3. Congestive heart failure; class I to II. 4. Inferoapical akinesis. 5. Worsening glucose intolerance. MEDICATIONS ON DISCHARGE: 1. Trandolapril 2 mg p.o. q.d. 2. Lasix 40 mg p.o. q.d. 3. Folate 1 mg p.o. q.d. 4. Atenolol 25 mg p.o. q.d. 5. Lipitor 10 mg p.o. q.d. 6. Aspirin 325 mg p.o. q.d. 7. Coumadin 5 mg p.o. q.d. DISCHARGE FOLLOWUP: 1. The patient will follow up with his primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], in one to two weeks. 2. The patient will follow up in the [Hospital 197] Clinic in two to three days for recheck of his INR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 2057] Dictated By:[Name8 (MD) 2653] MEDQUIST36 D: [2177-3-26] 11:23 T: [2177-3-27] 14:35 JOB#: [Job Number 38026] cc:[Name8 (MD) ] ICD9 Codes: 4280, 2859, 2720, 4019, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8830 }	Medical Text: Admission Date: [2118-12-24] Discharge Date: [2119-1-4] Service: CARDIOTHORACIC Allergies: Penicillins / Prilosec Attending:[First Name3 (LF) 1505] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: s/p Coronary Artery Bypass Graft x 1 (SVG to RCA) & Mitral Valve Replacement (tissue) on [2118-12-27] History of Present Illness: Ms. [Known lastname 39533] is a 83 y/o female with multiple admissions to outside hospitals in recent months for CHF. She was discharged from [Location (un) 1110]/[First Name4 (NamePattern1) 3075] [Last Name (NamePattern1) 3549] hospital [12-9] for Pneumonia (+MRSA) and then readmitted on [2118-12-16] to [Hospital 47] [Hospital 1281] Hospital for increased shortness of breath. She also had hypotension requiring pressors in the ICU and received RBC transfussion and improved hemodynamically. Subsequent Echo revealed severe mitral stenosis with mitral regurgitation and normal EF. Cardiac cath revealed 60-70% RCA lesion and severe, calcific rheumatic MS & MR. She was transferred to [Hospital1 18] for surgical management (CABG/MVR). Past Medical History: Coronary Artery Disease Congestive Heart Failure Chronic Obstructive Pulmonary Disease Atrial Fibrillation Degenerative Joint Disease s/p Cholecystectomy s/p Hysterectomy s/p Tonsillectomy s/p Right Hip Replacement Social History: Smoked 2ppd x many years. Quit [10-31]. ETOH: 1 drink/day Lives with husband Family History: unknown Physical Exam: Neuro: Grossly intact HEENT: EOMI, PERRLA, NC/AT, edentulous Pulm: Lungs with rare exp. wheeze, course bilat. Cor: RRR, +S1S2 Abd: Soft NT/ND, +BS Ext: Warm, -edema Pertinent Results: Echo [12-26]: The left atrium is moderately dilated. Left ventricular systolic function is hyperdynamic (EF>75%). The aortic valve leaflets are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. The mitral valve leaflets are moderately thickened. There is moderate mitral stenosis. Moderate to severe (3+) mitral regurgitation is seen. Suspect that the mitral stenosis is a consequence of severe mitral annular calcification and not rheumatic disease. There is mild pulmonary artery systolic hypertension. Carotid U/S [12-26]: Mild bilateral stenosis of the internal carotid arteries of less than 40%. CXR [1-3]: A right internal jugular vein approach central venous line is present seen to terminate in the upper third of the right atrium. There is no evidence of pneumothorax on either side. Comparison with the previous examination shows a local pleural density in the right mid lung field compatible with some pleural effusion accumulating in the minor fissure. The lateral pleural sinuses are free including the diaphragmatic contours and no acute parenchymal infiltrates can be identified. [2119-1-2] 04:27AM BLOOD WBC-7.7 RBC-3.89* Hgb-12.1 Hct-34.3* MCV-88 MCH-31.2 MCHC-35.3* RDW-15.5 Plt Ct-149* [2119-1-4] 06:40AM BLOOD Hct-33.7* [2119-1-4] 06:40AM BLOOD PT-32.3* PTT-34.8 INR(PT)-3.5* [2119-1-2] 04:27AM BLOOD Glucose-97 UreaN-15 Creat-0.8 Na-134 K-3.7 Cl-98 HCO3-27 AnGap-13 [2119-1-4] 06:40AM BLOOD UreaN-13 Creat-1.0 K-4.4 [2119-1-4] 06:40AM BLOOD Mg-2.1 [2118-12-31] 02:29AM BLOOD freeCa-1.04* [2119-1-3] 01:14PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG Brief Hospital Course: As mentioned in the HPI, pt was admitted for surgical management of her CAD and MS/MR. In addition of the appropriate pre-op work-up, she underwent a Carotid U/S and Echo (please see pertinent results). Her PFT's from MWMC were obtained. She eventually consented to surgery and on [2118-12-27] she was brought to the operating room where she underwent a Coronary Artery Bypass Graft x 1 and Mitral Valve Replacement (tissue). Please see op note for surgical details. Pt. tolerated the procedure well and was transferred to the CSRU in stable condition receiving Neo-Synephrine and Propofol. Pt remained intubated overnight and was then weaned from Propofol on post-op day #1 and awoke neurologically intact. She was then weaned from mechanical ventilation and extubated. Post-op day one pt went into Atrial Fibrillation and was started on Amiodarone and Coumadin (already started on Lopressor). Also on this day she was transfused 1 unit of RBCs. She was stable and slowly improving and was transferred to the cardiac step down unit on post op day two. Overnight she had a decrease in both her blood pressure and urine output and was transferred back to the CSRU. Again transfused 1 unit pRBCs on this day. Epicardial pacing wires were removed on post op day 4. She had hemodynamic improvements but required aggressive pulmonary toilet. She was gently diuresed to her pre-op weight. On post-op day five she was then transferred back to the cardiac step down unit. During entire post op course her cardiac rhythm went in and out if AFib. At time of discharge she was in sinus rhythm. She was given Coumadin during her post-op course, but has been held for last 2 days (INR 3.5). Her goal INR is 1.8. Electrolytes were repleted and physical therapy followed pt during entire post op course and treated her accordingly. She was transferred to rehab facility in stable/good condition on post op day #8. Her INR should be checked and Coumadin adjusted for goal INR. Medications on Admission: 1. Protonix 40mg qd 2. MVI 3. Thiamine 100mg qd 4. Colace 100mg [Hospital1 ] 5. Coumadin 4mg qd 6. Seroquel 12.5mg qhs prn 7. Albuterol/Atrovent qid Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. 10. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 5 days. 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Warfarin 1 mg Tablet Sig: MD to order daily dose Tablet PO DAILY (Daily): for Atrial Fibrillation. Goal INR 1.8. 13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): After 2 weeks, take 400mg qd for 2 weeks. Then 200mg qd until stopped by cardiologist. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 1 Mitral Stenosis/Regurgitation s/p Mitral Valve Replacement Chronic Obstructive Pulmonary Disease Atrial Fibrillation Degenerative Joint Disease Discharge Condition: stable Discharge Instructions: Can take shower. Wash incisions with gentle soap and water. Gently pat dry. Do no apply lotions, creams, ointments or powders to incisions. Do not bath. Can no lift more than 10 pounds for 2 months. Can no drive for 1 month. If you notice any redness, drainage from your incisions, or experience fever greater than 101 please contact office immediately. Followup Instructions: Dr. [Last Name (STitle) ] in 4 weeks Dr. [Last Name (STitle) 3659] in [12-30] weeks Dr. [Last Name (STitle) 4427] in [11-28] weeks Completed by:[2119-1-4] ICD9 Codes: 4280, 4240, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8831 }	Medical Text: Admission Date: [2143-11-10] Discharge Date: [2143-12-11] Date of Birth: [2089-2-6] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern4) 290] Chief Complaint: Fevers, Altered Mental status Major Surgical or Invasive Procedure: intubated History of Present Illness: Patient unable to give history himself. Most history is from [Hospital1 1562]. 54M with a history of CABG, remote MI, hip/shoulder surgery, liver failure, hypertension, hyperlipidemia, depression, alcohol and tobacco abuse who is transferred from [Hospital 1562] Hospital after decompensating there. The patient is a 54-year-old man who was brought into [Hospital1 1562] from [Location (un) 3244] detox with significant juandice, lethargy, and an episode of syncope while exiting the bathroom. At [Hospital1 1562], his initial presentation was alert and oriented x 3 and speech clear. Pertinent labs at [Hospital1 1562]: WBC 19.6 Hct 29 Plt 210 INR 2.7 Lipase 20 K 3.2 Cl 88 Ammonia 66 Ca 7.9 CO2 37 K 3.2 Total bili 14.7 Direct bili 10.0 Total protein 6.3 Alb 2.6 AST 213 ALT 23. The patient then became febrile to nearly 102 and lethragic, only oriented to self. He became agitated as well, intermittently. At [Hospital1 1562] before transfer the patient had received 8mg Ativan, 1gm ceftriaxone, 600mg ibuprofen, 40mg K, 2g IV MG. The patient's urine output began to drop despite 3L NS. . In the ED, temp 98 Hr 120 Bp 123/84 RR 18 94% RA. Patient was given 1mg ativan for sedation, placed in wrist restraints. [x] EKG: sinus tachycardia with nonspecific ST-T changes [x] CXR: [x] RUQ ultrasound was performed. [x] Liver consult was called. [x] LFTs: [x] UA, Ucx: [x] Bcx: pending [x] Guaiac: Negative [x] ICU transfer requested [x] Serum, urine tox, tylenol [x] SIRS treatment: vancomycin, cefepime, flagyl . . On the floor, was intermittently agitated. BP was 92/52 HR ws 98 RR was 14 he was 100%on RA. . Review of sytems: could not be obtained as patient is not cooperative Past Medical History: Per OSH history: history of CABG remote MI, hip/shoulder surgery, liver failure, hypertension, hyperlipidemia, depression, alcohol and tobacco abuse Social History: Tunnel worker. Speaking with sister, he drinks close to a quart a day of vodka with gatorade. [Last Name (un) 5487] last drink. Smokes a pack a day. Drugs:[Last Name (un) ], but may have in the past. He lives with his gilfriend Family History: unknown. Physical Exam: VS: T: 97.9, P: 128, BP: 112/53, RR: 26, 91% RA General: Oriented to name only. Intermittently responsive. HEENT: Icteric Sclerae, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: tachycardic, normal S1 + S2, Chest: multiple spider angiomas throughout. Abdomen: tense, +bowel sounds, non-tender, no rebound tenderness or guarding, no organomegaly, without shifting dullness, tympanitic on percussion. GU: foley in place. Ext: mild palmar erythema, warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A&Ox1, Cranial Nerves intact grossly, good strenght in his extremities, profound asterixis. Discharge expired Pertinent Results: [2143-11-10] 09:05PM BLOOD WBC-17.9# RBC-2.74# Hgb-10.0# Hct-29.1# MCV-106# MCH-36.4 MCHC-34.3 RDW-14.0 Plt Ct-171 [2143-11-10] 09:05PM BLOOD Neuts-90* Bands-0 Lymphs-4* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2143-11-10] 09:05PM BLOOD PT-23.9* PTT-39.2* INR(PT)-2.3* [2143-11-10] 09:05PM BLOOD Glucose-89 UreaN-10 Creat-0.7 Na-137 K-3.3 Cl-92* HCO3-36* AnGap-12 [2143-11-10] 09:05PM BLOOD ALT-24 AST-194* CK(CPK)-65 AlkPhos-261* TotBili-14.1* DirBili-9.7* IndBili-4.4 [2143-11-10] 09:05PM BLOOD Albumin-2.4* Calcium-7.5* Phos-1.6* Mg-1.8 Iron-111 [2143-11-10] 09:05PM BLOOD TSH-0.72 [2143-11-11] 04:41AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2143-11-11] 04:41AM BLOOD AMA-NEGATIVE Smooth-POSITIVE * [2143-11-11] 04:41AM BLOOD [Doctor First Name ]-POSITIVE * Titer-1:40 [2143-11-10] 09:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2143-11-11] 04:41AM BLOOD HCV Ab-NEGATIVE discharge expired Brief Hospital Course: 54M with a history of remote MI, hip/shoulder surgery, liver failure, hypertension, hyperlipidemia, depression, alcohol and tobacco abuse who is transferred from [Hospital 1562] Hospital with fevers, leukocytosis and altered mental status, transferred to the ICU for hypoxemic respiratory failure. He expired during this admission. . #Hypoxemic Resp. failure- could have been due to mucous plugging, pontine demylination. Regardless he was intubated and successfully extubated on the [2144-10-1]. He tolerated 40% face mask and 4-5 L NC. He was re-intubated after transfer to the ICU for respiratory distress again later in his course, believed to be related to aspiration. He did not recover, family meeting was held and he was made CMO, and expired. Medications on Admission: n/a Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] ICD9 Codes: 0389, 486, 2760, 5849, 2724, 4240, 2875, 3051, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8832 }	Medical Text: Admission Date: [2143-9-6] Discharge Date: [2143-9-9] Date of Birth: [2103-6-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7651] Chief Complaint: Back/chest pain Major Surgical or Invasive Procedure: Cardiac catheterization Promus Drug eluting stent placed to Left Circumflex artery History of Present Illness: 40 y/o gentleman with type 1 DM, dyslipidemia, presented with back pain radiating to chest. Patient stated feeling unwell yesterday afternoon with ? diffuse myalgia. Last night at around 9 PM he started having back pain radiating to his chest. He has had similar pain in the last two years but not as severe as last night. He felt nauseous, diaphoretic and short of breath. He came to [Hospital1 18] ED. . In the ED, initial vitals were T 96.1 HR 58 BP 133/77 RR 18 100% in RA. He recieved ASA 325 mg, Plavix 300 mg, heparin bolus/gtt, integrillin bolus/gtt. He also recieved nitro SL x 3, morphine/dilaudid, zofran 4 mg IV x1. He was eventually started on nitro gtt. Given his chest pain has not resolved and he had concerning ECG changes he was taken to cardiac catheterization. He recieved 2.5x23 promus to occluded proximal LCX. He had angiosesal in right groin. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, - Hypertension 2. CARDIAC HISTORY: N/A 3. OTHER PAST MEDICAL HISTORY: - Type 1 DM approx 33 years - Concussion some 6 years ago after a mechanical fall, short episode of LOC. - ? Seizures, but patient think they were hypoglycemic episodes Social History: Works as a consultant in financial services. Lives at home with his wife and twins. -Tobacco history: Denies. -ETOH: Denies. -Illicit drugs: Denies. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T=... BP=134/76 HR=86 RR=... O2 sat=... GENERAL: Pleasant gentleman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 6 cm. CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: Labs on Admission: [2143-9-5] 11:00PM BLOOD WBC-9.5 RBC-4.80 Hgb-14.5 Hct-40.9 MCV-85 MCH-30.2 MCHC-35.4* RDW-12.9 Plt Ct-330 [2143-9-5] 11:00PM BLOOD PT-11.7 PTT-24.1 INR(PT)-1.0 [2143-9-5] 11:00PM BLOOD Glucose-173* UreaN-16 Creat-1.1 Na-139 K-3.7 Cl-102 HCO3-25 AnGap-16 [2143-9-5] 11:00PM BLOOD CK(CPK)-104 [2143-9-5] 11:00PM BLOOD CK-MB-3 [2143-9-6] 05:00AM BLOOD Cholest-200* [2143-9-5] 11:00PM BLOOD %HbA1c-7.1* [2143-9-6] 05:00AM BLOOD Triglyc-35 HDL-71 CHOL/HD-2.8 LDLcalc-122 On discharge: [2143-9-7] 04:34AM BLOOD WBC-11.5* RBC-4.52* Hgb-13.6* Hct-38.9* MCV-86 MCH-30.1 MCHC-35.0 RDW-13.4 Plt Ct-308 [2143-9-9] 05:47AM BLOOD Glucose-50* UreaN-14 Creat-1.1 Na-143 K-4.3 Cl-107 HCO3-26 AnGap-14 [2143-9-9] 05:47AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.1 [2143-9-6] 05:00AM BLOOD Triglyc-35 HDL-71 CHOL/HD-2.8 LDLcalc-122 Brief Hospital Course: # CORONARIES: STEMI s/p drug eluting stent (Promus) to prox LCX. Pt was CP free after intervention, no complications. CK peak was 3869 with MBI of 6.2 and Trop of 3.39. Started on Metoprolol, Lisinopril, Aspirin and Plavix. His Atorvastatin was increased to 80 mg. LDL 122, goal will be < 80. Hgb A1C 7.1. His groin was stable with no significant ecchymosis, bruit or hematoma. Angioseal device was used. Pt understands that he needs to take Plavix every day for one year without missing any doses. He should not stop taking Plavix unless Dr.[Name (NI) 3733] tells him to. He received discharge activity instructions and will follow up with Dr.[Doctor Last Name 3733] for a repeat ECHO and stress test. Cardiac rehabilitation was suggested to him and Dr.[Doctor Last Name 3733] will refer. . # Regional left ventricular systolic dysfunction: TTE with inferior/lateral wall hypokinesis with EF 45%. No symptoms of congestive heart failure during hospital stay. Filling pressures in the cath lab were normal. Daily weights were discussed with pt prior to dischage, started on Lisinopril and Metoprolol Succinate at discharge. . # RHYTHM: Currently in NSR. No history of rhythm abnormalities. Few episodes of NSVT seen on telemetry. . # TYPE 1 DM: Patient has an insulin pump. A1C 7.1. Currently followed by endocrinologist at [Hospital1 2025] but requesting new endocrinologist at [Hospital1 18]. Appt made after discharge. # Continuing care: Pt has requested that his care be changed to [Hospital1 18]. He will f/u with Dr.[Name (NI) 3733] for cardiology, Dr. [Last Name (STitle) 2204] for primary care and Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 17033] for endocrinology. Medications on Admission: Insulin pump with humalog Atorvastatin 20 mg daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take every day for one year. Do not stop taking unless Dr.[Name (NI) 3733] tells you to. . Disp:30 Tablet(s) Refills:11 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). Disp:45 Tablet Sustained Release 24 hr(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: ST Elevation myocardial infarction Diabetes Mellitus Type 1 Dyslipidemia Discharge Condition: stable Discharge Instructions: You had a heart attack and a cardiac catheterization showed a blockage in your left circumflex artery. You received a drug eluting stent (Promus) in your left circumflex. No lifting more than 10 pounds for one week, no pools or bathing for one week. You may shower and cover the cath site with a band-aid. You were started on the following new medicines: 1. Plavix: a platelet inhibitor that prevents the stent from clotting off and causing another heart attack. Don't miss [First Name (Titles) 691] [Last Name (Titles) 11014]s or stop taking Plavix for one year unless Dr.[Name (NI) 3733] tells you to. 2. Aspirin: a platelet inhibitor that works with the Plavix to prevent the stent from clotting off. 3. Lisinopril: a blood pressure medicine that helps your heart recover from the heart attack 4. Metoprolol: a medicine that slows your heart rate and helps your heart recover from the heart attack. 5. Increase your Atorvastatin to 80 mg. This help with inflammation and will lower your bad cholesterol further. . You should follow the activity instructions given to you by the physical therapist. Dr.[Name (NI) 3733] will refer you to cardiac rehabilitation after he sees you in one month. Please call Dr. [Doctor Last Name 11723] if you have a reoccurance of your back pain, trouble breathing, sweating, nausea, fevers, bleeding or swelling at the cathterization site or any other concerning symptoms. Followup Instructions: Cardiology: Dr. [First Name4 (NamePattern1) 4648] [Last Name (NamePattern1) ] Phone: [Telephone/Fax (1) 62] Date/time: [9-17] at 1:20pm. [Hospital Ward Name 23] Clinical Center, [Location (un) 436], [Location (un) ], [Location (un) 86]. Endocrinology: Provider: [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 1726] [Last Name (NamePattern1) 19862] Phone: [Telephone/Fax (1) 2384] Date/Time: [9-13] at 8:00 am for registration, you have a opthamology appt scheduled after this appt. Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 17033] Phone: ([Telephone/Fax (1) 75101] Date/time: office will call you with an appt. . Primary Care: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2204] Phone: [Telephone/Fax (1) 2941] Date/time: [State 75102]., [Apartment Address(1) ] [Location (un) ], [Numeric Identifier 822]. Office will call you with an appt. Completed by:[2143-9-11] ICD9 Codes: 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8833 }	Medical Text: Admission Date: [2134-12-26] Discharge Date: [2134-12-28] Date of Birth: [2091-2-27] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2181] Chief Complaint: tx from [Hospital3 26615] Hospital for further management Major Surgical or Invasive Procedure: paracentesis History of Present Illness: Pt is a 43 yo male with history of EtOH who presents as transfer from OSH for further work up. Per history, pt has been a daily drinker since the age of 14. His last drink was five days prior to admission. Three days PTA, family told pt that he looked yellow. Since then, he has had subjective fevers, chills, abdominal pain in the epigastric region, with mild nausea and dry heaves. His family also noted increased abdominal girth over the past few weeks. He has also been progressively lethargic and decreased energy per transfer note. On interview the patient is mildly confused and states that he came to the hospital because of "back pain" but cannot give further details. . Patient presented to OSH 1 day ago. He was found to have a sodium of 106. He was started on hypertonic saline at 100 cc/hr and NS at 70 cc/hr. He was also started on albumin. Pt was afebrile at OSH and VSS with SBPs in the 80s-90s systolic. Labs on admission at OSH: Na: 105; K: 3.8; Cl: 66; Bicarb: 28; BUN/cr 22/1.0. Albumin 1.8. Tbili 18.1. UNa-8 . On transfer he states that he feels well. He denies dyspnea, cough, abdominal pain, diarrhea, constipation. He denies any history of bleeding, any history of jaundice (his family endorses this). He does report noticing increasing abdominal girth and weight gain over several weeks. Past Medical History: Alcholoism with previous DTs and seizures (grand mal 2 months ago) Social History: Not married. No children. Not working; used to be a welder. Endorses EtOH (2 "nips" of sambuca per day); denies any h/o IVDA or any other drug abuse. No tobacco. Family History: no liver disease, no alcoholism. No DM. Physical Exam: VS: 97.7, HR 100, BP 117/68, RR 20, O2sat 95% 4LNC Gen: lying flat in bed, interactive, NAD HEENT: + scleral icterus. Erythematous face w/ scaling, flaking skin. dry mucosa. EOMI CV: RRR, no murmurs, no rubs Lungs: +rhonchi at bases Abd: distended, tense, no guarding, tender to palpation diffusely, hypoactive BS Ext: 2+ pitting edema up to knees, DP pulses palp and symmetric. Multiple tatoos, + jaundice. No spider angioma, no caput medusa, no palmar erythema Neuro: A/OX 3. + asterixis Pertinent Results: WBC 9.4, Hct 35.6, Plt 115, MCV 108 Na 119, K 3.2, Cl 93, Bicarb 25, BUN 29, Cr Alb 2.1, bili 14.1, AST 191, ALT 90 INR 2.5, PTT 56, Fi 75 . CXR AP: No acute cardiopulm process. Low lung volumes . ABDOMINAL US: 1. Diffuse fatty infiltration of the liver. Nodular hepatic contour indicates significant underlying significant fibrosis/cirrhosis. Assessment for hepatic mass is limited. 2. Large amount of perihepatic ascites. 3. Hepatofugal in the main and right anterior portal veins consistent with underlying portal hypertension. Patent right hepatic artery. Limited assessment of the left portal and hepatic veins, and main/left hepatic artery. 4. Mild gallbladder wall thickening likely secondary to third spacing given the significant ascites and cirrhosis. Brief Hospital Course: During his MICU admission, the hepatology service was consulted and the pt was started on Pentoxyfilline (discriminant factor 82). Hepatitis serologies were sent and returned negative. Abdominal US revealed diffuse fatty infiltration of the liver, nodular hepatic contour indicating significant underlying fibrosis/cirrhosis, large amount of perihepatic ascites, and portal hypertension. The patient underwent paracentesis with 3 liters fluid removed, no evidence of SBP. The patient was treated with NS and fluid restriction, and sodium has improved to 125. The patient was also maintained on CIWA scale for possible ETOH withdrawl. . Patient was transferred to the medical floor on the evening of [12-27]. He had stable vital signs and was alert and oriented complaining only of nausea after oral potassium replacement. He was noted to have stable vital signs at midnight and sleeping comfortably at approximately 3:30am. At ~4:20am, he was found by the nurse to be unresponsive. A code blue was called. He was found to be in asystole. He was intubated by Anesthesia and ACLS was performed. Time of death called at 4:45am on [12-28]. Covering attending and next-of-[Doctor First Name ] were notified. Medications on Admission: n/a Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Asystolic cardiac arrest Cirrhosis Hyponatremia Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a Completed by:[2134-12-28] ICD9 Codes: 2761
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8834 }	Medical Text: Admission Date: [2134-7-5] Discharge Date: [2134-7-12] Date of Birth: [2134-7-5] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: This is a quadruplet #2, 34 and [1-11] week gestation male infant born to a 33 year-old G2 para now 5 pregnancy with trichorionic quadramniotic placentas were present (2 boys known to be monozygotic twins). All 4 babies are male. Pregnancy complicated by ovarian torsion, maternal gestational diabetes diet controlled, in preterm labor treated with magnesium sulfate and bed rest. Mom was treated with betamethasone on [2134-5-10]. Pregnancy was monitored very closely and all babies have had appropriate growth in utero. Ultrasound screening was unremarkable. PRENATAL LABS: Mom is O positive, antibody negative, hep B surface antigen negative, RPR nonreactive, Rubella immune, GBS unknown. LABOR AND DELIVERY: Elective repeat C section, no maternal fever, no fetal tachycardia and rupture of membranes was at the time of delivery. Baby 2 emerged with poor respiratory effort, but responded well to stimulation and Apgars were 8 and 9. ADMISSION PHYSICAL EXAM: Vital signs temperature 97.9. Heart rate 158. Respiratory rate 42. Blood pressure 55/31 with a mean of 37 and O2 sats are 95%. The birth weight was 1855 grams, length was 44 cm (30 percentile) and head circumference was 31 cm (50 percentile). General baby is [Name2 (NI) 3584], patent, breathing comfortably on room air. Head and neck AFOF. Palette intact. PERRLA. Positive red reflex in both eyes. Respiratory clear breath sounds bilaterally. Cor S1 S2 are normal. No murmur. Good perfusion. Abdomen soft, nontender, nondistended with good bowel sounds. GU normal male, testes descended bilaterally. Neurologically with good tone and moving all extremities equally bilaterally. HOSPITAL COURSE: Respiratory: The patient was on room air since birth breathing 40 to 60s throughout the entire hospital stay. No apneic episodes were recorded and sats remained over 95% the entirety of his stay. Cardiovascular: The patient had normal heart rates and blood pressure throughout his stay with the most recent blood pressure being 67/37 and a mean of 49. No murmurs. Fluids, electrolytes and nutrition. The baby began since birth po feeding with Premature Enfamil, which was changed on day of life 5 to Enfamil 24 calorie and is taking excellent po every 4 hours ad lib with 120 cc per kilo minimum. He took 150 cc per kilo per day po on the day of discharge. GI: No problems noted. [Name2 (NI) ] been stooling consistently heme negative. Hematology: Patient had a bilirubin max of 8.1 and a direct of 0.3 on day of life 6 and has not progressed. No appreciable jaundice on exam. Infectious disease: No antibiotics were given. Patient had stable temperatures and was weaned from the isolette on day of life 4 and has been cobedding and has been stable otherwise. Neurology: No significant abnormalities. Audiology: Screened with automated auditory brainstem responses. Initially passed the left and was referred on the right, but the exam was repeated on the day of discharge and the patient passed both ears no problems. Ophthalmology: Positive red reflex bilaterally. No formal eye exam was clinically indicated. Social work: [Hospital1 18] social work is involved with the family. The social worker can be reached at [Telephone/Fax (1) 8717]. CONDITION AT DISCHARGE: Stable to home. PRIMARY PEDIATRICIAN: Dr. [First Name4 (NamePattern1) 122] [Last Name (NamePattern1) 63973] in [Hospital1 1474]. FEEDS AT DISCHARGE: Enfamil 24 calorie po ad lib. DISCHARGE MEDICATIONS: None. NEWBORN SCREEN: Sent [2134-7-8] and is pending. IMMUNIZATIONS: Received hep B vaccine on [2134-7-11]. Influenza immunization is recommended annually in the fall for all close care providers. OUTPATIENT APPOINTMENT: Appintment is scheduled for Thursday [7-15] with Dr. [Last Name (STitle) 63973]. DISCHARGE DIAGNOSES: Prematurity. Mild physiologic jaundice. The patient was circumcised on [2134-7-12] with no complications to date. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD Dictated By:[Last Name (NamePattern1) 63976] MEDQUIST36 D: [2134-7-12] 11:23:36 T: [2134-7-12] 11:56:59 Job#: [Job Number 63977] ICD9 Codes: 7742, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8835 }	Medical Text: Admission Date: [2124-2-13] Discharge Date: [2124-2-18] Date of Birth: [2055-12-9] Sex: M Service: Cardiothoracic HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old gentleman with known coronary artery disease, hypertension, and diabetes who presented with exertional chest pain to an outside hospital. The patient had a stress test done at the beginning of [Month (only) 956] which showed anterior apical and inferior hypokinesis with an ejection fraction of 30%, and a partially reversible inferior defect. The patient then had a cardiac catheterization which showed 3-vessel disease. The patient was transferred to [Hospital1 69] for coronary artery bypass grafting by Dr. [First Name (STitle) ] [Last Name (Prefixes) ]. The patient had burning chest pain one week prior to admission which lasted for five hours and was relieved with Maalox. Over the past few months, the patient has complained of occlusion chest pressure on exertion without shortness of breath, nausea, vomiting, or diaphoresis. The patient is currently pain free. PAST MEDICAL HISTORY: (Past medical history is significant for) 1. Type 2 diabetes mellitus. 2. Hypertension. 3. Coronary artery disease. 4. Arthritis. 5. Gastroesophageal reflux disease. ALLERGIES: The patient states an allergy to PENICILLIN. MEDICATIONS ON TRANSFER: 1. Aspirin 81 mg by mouth once per day. 2. Norvasc 10 mg by mouth once per day. 3. Glucotrol 5 mg by mouth once per day. 4. Lopressor 50 mg by mouth twice per day. 5. Nitroglycerin as needed. 6. Glucosamine two tablets by mouth once per day. 7. Vitamin C 250 mg by mouth once per day. SOCIAL HISTORY: The patient denies tobacco. Occlusion ethanol. He is a retired [Location (un) 86] .................... worker. FAMILY HISTORY: Mother had hypertension. Father had coronary artery disease. PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 98.2, his heart rate was 75, his blood pressure was 120/62, his respiratory rate was 18, and his oxygen saturation was 97% on room air. General physical examination revealed the patient was in no acute distress. Alert and oriented. Head, eyes, ears, nose, and throat examination revealed no jugular venous distention. The neck was supple. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sounds and second heart sounds. No murmurs, rubs, or gallops. Respiratory examination revealed the lungs were clear to auscultation bilaterally. The abdomen was soft, nontender, and nondistended. There were positive bowel sounds. The extremities were warm with needed. The skin with no rashes. PERTINENT LABORATORY VALUES ON PRESENTATION: Hematocrit was 38.4 and platelets were 312. Sodium was 143, potassium was 4.7, chloride was 106, bicarbonate was 31, blood urea nitrogen was 17, creatinine was 1, and his blood glucose was 158. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram showed a sinus rhythm with a rate of 73 with inferior Q waves. An echocardiogram at [Hospital3 1280] Hospital on [2-8] showed left ventricular hypertrophy with basal inferolateral hypokinesis with an ejection fraction of 50% to 55%, mild-to-moderate mitral regurgitation, pulmonary artery pressure was 28 to 33. A cardiac catheterization done on [2-11] also a [Hospital3 6454] Hospital revealed a right-dominant system with 80% proximal left anterior descending artery, 60% diagonal, and total occlusion of the left circumflex, with left-to-right collaterals, and 90% mid right coronary artery occlusion. The ejection fraction was 35% with inferoposterior akinesis. Carotid studies done on the day of admission showed no significant lesions in either the right or left carotid arteries. CONCISE SUMMARY OF HOSPITAL COURSE: On the following day, the patient was brought to the operating room where he underwent coronary artery bypass grafting. Please see the Operative Report for full details. In summary, the patient had a coronary artery bypass graft times four with a left internal mammary artery to the left anterior descending artery, saphenous vein graft to the posterior descending artery, saphenous vein graft to the obtuse marginal, and saphenous vein graft to the diagonal. His bypass time was 108 minutes with a cross-clamp time of 84 minutes. The patient tolerated the procedure well and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient was A paced at 87 beats per minute. He had a mean arterial pressure of 70 and a central venous pressure of 12. He had milrinone at 0.25 mcg/kg per minute, Neo-Synephrine at 0.5 mcg/kg per minute, and insulin at 1 unit per hour, and propofol at 10 mcg/kg per minute. The patient did well in the immediate postoperative period. His anesthesia was reversed, and he was successfully extubated. He was weaned from his Neo-Synephrine drip and transitioned to nitroglycerin. It was noted shortly after extubation that the patient had ST changes on the monitor. An electrocardiogram was done, and the patient was brought to the Cardiac Catheterization Laboratory. This revealed that all grafts were widely patent. However, the patient did have a thrombus in the mid right coronary artery vessel. A thrombectomy was performed, and a stent was placed in the native right coronary artery. Following cardiac catheterization, the patient returned to the Cardiothoracic Intensive Care Unit where he remained hemodynamically stable. On postoperative day two, the patient was off all cardiac active intravenous medications. He remained hemodynamically stable. He was begun on beta blockade as well as diuretics, and he was transferred to [Hospital Ward Name 121] Two for continued postoperative and cardiac rehabilitation. On postoperative day three, the patient continued to progress. His chest tubes, pacing wires, and Foley catheter were removed. His activity level was increased with the assistance of Physical Therapy and the nursing staff. On postoperative day four, it was decided that the patient was stable and ready to be discharged to home. At the time of discharge, the patient's physical examination was as follows. Vital signs revealed his temperature was 99, his heart rate was 84 (sinus rhythm), his blood pressure was 102/54, his respiratory rate was 20, and his oxygen saturation was 95% on room air. Weight preoperatively was 79 kilograms. At discharge his weight was 82 kilograms. Laboratory data revealed his white blood cell count was 7.2, his hematocrit was 28.6, and his platelets were 162. Sodium was 137, potassium was 4, chloride was 101, bicarbonate was 29, blood urea nitrogen was 17, creatinine was 0.8, and his blood glucose was 159. Physical examination revealed the patient was alert and oriented times three. He was moving all extremities. He followed commands. Respiratory examination revealed the lungs were clear to auscultation bilaterally. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sounds and second heart sounds. The sternum was stable. The incision with Steri-Strips were opened to air. Clean and dry. The abdomen was soft, nontender, and nondistended. There were positive bowel sounds. The extremities were warm and well perfused with 1+ edema bilaterally. Bilateral saphenous vein graft harvest sites with Steri-Strips were opened to air. Clean and dry. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg by mouth once per day. 2. Plavix 75 mg by mouth once per day (times at least three months). 3. Glucotrol 5 mg by mouth once per day. 4. Metoprolol 50 mg by mouth twice per day. 5. Percocet 5/325-mg tablets one to two tablets by mouth q.4h. as needed. DISCHARGE DIAGNOSES: 1. Coronary artery disease; status post coronary artery bypass grafting times four (with a left internal mammary artery to the left anterior descending artery, saphenous vein graft to the posterior descending artery, saphenous vein graft to first obtuse marginal, and saphenous vein graft to diagonal). 2. Status post percutaneous transluminal coronary angioplasty with a cypher stent to the native right coronary artery. 3. Type 2 diabetes mellitus. 4. Hypertension. 5. Arthritis. 6. Gastroesophageal reflux disease. CONDITION AT DISCHARGE: The patient's condition on discharge was good. DISCHARGE DISPOSITION: The patient was to be discharged to home with [Hospital6 407]. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with Dr. [Last Name (STitle) 1655] and Dr. [First Name (STitle) 1075] in two to three weeks. 2. The patient was instructed to follow up with Dr. [First Name (STitle) ] [Last Name (Prefixes) ] in four weeks. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Name8 (MD) 415] MEDQUIST36 D: [2124-2-18] 09:48 T: [2124-2-18] 09:50 JOB#: [Job Number 53296] ICD9 Codes: 4240, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8836 }	Medical Text: Admission Date: [2201-3-14] Discharge Date: [2201-3-22] Date of Birth: [2139-4-7] Sex: M Service: MEDICINE Allergies: Vancomycin Attending:[First Name3 (LF) 4854] Chief Complaint: Weakness, [First Name3 (LF) 7186] of breath Major Surgical or Invasive Procedure: None History of Present Illness: 61 y/o male with history of Wegener's granulomatosis and autoimmune lymphopenia, on immunosuppression complicated by multiple infections as detailed in HPI below presents with weakness and [First Name3 (LF) 7186] of breath. He has been maintained on long term azathioprine with a recent taper of his immunosuppresion over the past several months. He has complained of dizziness and headaches but this has thought to be related to his antihypertension medications. Most recently he has not had any evidence of active pulmonary vasculitis and stable emphysema. Today he developed lethargy and was brought to the ED by his nephew. [Name (NI) ] was noted to be hypotensive with SBP 78 and tachycardic and was started on an NRB. A CXR demonstrated a LLL PNA. A central line was placed and he was started on levofloxacin and Zosyn. A CT chest/abdomen without contrast was performed that demonstrated multiple anomalies including: 1. Multiple new small nodules, many of which are cavitating, within the right lung, which may be consistent with patient's known Wegener's granulomatosis. However, infectious process, including fungal or septic emboli, cannot be excluded. 2. Extensive consolidation in the left lower lobe, consistent with pneumonia. 3. Limited examination for mesenteric ischemia; however, there is loss of normal haustra and mild bowel wall thickening of the colonic wall starting from the hepatic flexure extending to the proximal descending colon. This could represent an infectious/inflammatory colitis. Ischemia is thought to be less likely due to the distribution of the abnormality, spanning different vascular territories. . He was paralyzed, intubated, and sent to the ICU for further care. Past Medical History: - cANCA+ vasculitis - renal bx [7-5]; pulmonary-renal disease; s/p plasmapheresis x 1 week, IVP steroids; PO Cytoxan x1 month with neutropenia; AZA since [1-6] with slow pred taper. - Prolonged neutropenia in [9-4] and [12-6]. - Aspergillus fumigatus PNA in [7-5] (sputum+, galactomannan+), voriconazole x 6 wks in [8-5]. - Stenotrophomonas PNA while neutropenic in [9-4] (BAL+), completed Bactrim course x 3 wks. - ?Latent TB (right-sided apical pulmonary scar on chest CT + h/o exposure from father; PPD neg, 3x induced sputum neg in [7-5]), INH [Date range (1) 79239] completed. - Parainfluenza in [12-6]. - Pseudomonas PNA in [12-7]. - ACD, Aflutter, emphysema/COPD. - Presumed autoimmune lymphopenia. - Steroid-induced osteoporosis. - Primary hypogonadism. Social History: He lives by himself. He works as a machine operator and currently not working. He does not smoke. He does not drink alcohol. Family History: No family history of osteoporosis. His brother has coronary artery disease and his twin brother has heart disease. Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: LABS ON ADMISSION: [2201-3-14] 06:10PM PT-11.1 PTT-20.7* INR(PT)-0.9 [2201-3-14] 06:10PM PLT COUNT-255 [2201-3-14] 06:10PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-2+ POLYCHROM-2+ OVALOCYT-1+ STIPPLED-OCCASIONAL TEARDROP-1+ PAPPENHEI-1+ BITE-1+ [2201-3-14] 06:10PM NEUTS-18* BANDS-41* LYMPHS-5* MONOS-17* EOS-7* BASOS-1 ATYPS-3* METAS-5* MYELOS-1* YOUNG-2* NUC RBCS-14* [2201-3-14] 06:10PM WBC-4.1 RBC-3.97* HGB-13.5* HCT-39.3* MCV-99* MCH-34.0* MCHC-34.3 RDW-18.6* [2201-3-14] 06:10PM HGB-14.0 calcHCT-42 [2201-3-14] 06:10PM GLUCOSE-239* LACTATE-7.5* K+-5.7* [2201-3-14] 06:10PM ALBUMIN-3.2* [2201-3-14] 06:10PM cTropnT-0.11* [2201-3-14] 06:10PM ALT(SGPT)-27 AST(SGOT)-19 ALK PHOS-82 TOT BILI-0.3 [2201-3-14] 06:10PM GLUCOSE-253* UREA N-140* CREAT-3.8* SODIUM-133 POTASSIUM-6.0* CHLORIDE-95* TOTAL CO2-15* ANION GAP-29* [2201-3-14] 06:35PM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 [2201-3-14] 06:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2201-3-14] 06:35PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.012 [2201-3-14] 07:29PM GLUCOSE-129* LACTATE-4.2* NA+-136 K+-4.3 CL--117* TCO2-12* [2201-3-14] 10:29PM freeCa-1.04* [2201-3-14] 10:29PM O2 SAT-86 [2201-3-14] 10:29PM GLUCOSE-201* LACTATE-3.3* NA+-133* K+-4.9 CL--111 [2201-3-14] 10:29PM TYPE-ART RATES-16/ TIDAL VOL-450 O2-100 PO2-72* PCO2-54* PH-7.06* TOTAL CO2-16* BASE XS--15 AADO2-601 REQ O2-96 -ASSIST/CON INTUBATED-INTUBATED [2201-3-14] 11:34PM O2 SAT-80 [2201-3-14] 11:34PM LACTATE-1.8 [2201-3-14] 11:34PM TYPE-ART TEMP-35.8 RATES-/24 TIDAL VOL-450 PEEP-16 O2-100 PO2-54* PCO2-47* PH-7.08* TOTAL CO2-15* BASE XS--16 AADO2-626 REQ O2-100 -ASSIST/CON INTUBATED-INTUBATED ======== MICROBIOLOGY: - [2201-3-14] Urine culture: no growth - [2201-3-14] Blood culture: no growth - [2201-3-15] Blood culture: no growth - [2201-3-15] Blood culture: no growth - [2201-3-15] MRSA screen: no MRSA isolated - [2201-3-16] Blood culture: PENDING - [2201-3-16] Urine legionella antigen: negative - [2201-3-17] Sputum: Gram stain - <10 PMNs and <10 epithelial cells/100X field, 2+ microorganisms consistent with oropharyngeal flora; culture - sparse growth commensal respiratory flora, moderate growth yeast, rare growth Aspergillus fumigatus. - [2201-3-19] C. difficile toxin: negative - [2201-3-20] CMV viral load: PENDING - [2201-3-20] Cryptococcal antigen: negative - [2201-3-21] Sputum: Gram stain - <10 PMNs and <10 epithelial cells/100X field, 1+ GNR, 1+ budding yeast with pseudohyphae; culture - PENDING ; fungal culture - PENDING ======== IMAGES/STUDIES: [2201-3-14] ECG: Atrial flutter with rapid ventricular response. ST-T wave abnormalities are non-specific. Since the previous tracing of [2200-11-26] ventricular rate is faster and further ST-T wave changes are present. [2201-3-14] CXR: UPRIGHT AP VIEW OF THE CHEST: Dense consolidation within the left lung base is concerning for pneumonia. There is likely a small left effusion. Right internal jugular central venous catheter tip terminates within the SVC. Focal ill-defined patchy and nodular opacities within the right upper lobe appear similar to the prior study. Relative lucency of the lung apices reflects underlying emphysema. Cardiac, mediastinal and hilar contours are unremarkable. There is no pneumothorax. IMPRESSION: New consolidation in left lung base concerning for pneumonia. Followup radiographs after treatment are recommended to ensure resolution. [2201-3-14] CT torso: IMPRESSION: 1. Multiple new small nodules, many of which are cavitating, within the right lung, which may be consistent with patient's known Wegener's granulomatosis. However, infectious process, including fungal or septic emboli, cannot be excluded. 2. Extensive consolidation in the left lower lobe, consistent with pneumonia. 3. Limited examination for mesenteric ischemia; however, there is loss of normal haustra and mild bowel wall thickening of the colonic wall starting from the hepatic flexure extending to the proximal descending colon. This could represent an infectious/inflammatory colitis. Ischemia is thought to be less likely due to the distribution of the abnormality, spanning different vascular territories. 4. Avascular necrosis of the right femoral head. 5. New L2 compression deformity, and unchanged T12 wedge compression fracture. [2201-3-16] Abdominal x-ray: IMPRESSION: A solitary overhead view of the abdomen excludes the lower pelvis. As far as one can tell with the patient in this position, there is no appreciable distention of the GI tract, with the exception of the stomach which is fluid filled, despite a nasogastric tube in place. Upright views would be helpful. [2201-3-16] Head CT: IMPRESSION: 1. No acute intracranial abnormality. 2. Sinus disease as above. [2201-3-17] CXR: Of note the left CP angle was not included on the film, The visualized left lower lobe with ill-defined opacities is unchanged. This is more likely due to hemorrhage. Otherwise there are no changes in the right lobe with pleural parenchyma scarring in the right apex. Lines and tubes remain in place. [2201-3-18] CXR: FINDINGS: In comparison with the study of [3-17], the monitoring and support devices are essentially unchanged. Areas of increased opacification persist in the lower half of the left hemithorax. This could be due to pulmonary hemorrhage or superimposed pneumonia. Apical pleural changes are again seen. Respiratory motion somewhat obscures the sharpness of the image. [2201-3-18] RUQ ultrasound with Doppler: FINDINGS: Extremely limited views of the liver demonstrate no focal or textural abnormality. There is no intra- or extra-hepatic biliary dilatation. The gallbladder is normal without evidence of stones. The common bile duct is not dilated measuring up to 3 mm. There is no evidence of splenomegaly with spleen measuring up to 9.9 cm. DOPPLER EXAMINATION: The main portal vein, right anterior and posterior, and left portal branches are patent with appropriate directions of flow and Doppler waveforms. The right, middle, and left hepatic veins are patent. The IVC is patent. The main hepatic artery is patent with appropriate arterial waveforms. No appreciable ascites. IMPRESSION: 1. Limited study with no gross abnormalities of the liver. 2. Patent hepatic vasculature. [2201-3-19] CXR: FINDINGS: As compared to the previous radiograph, the monitoring and support devices are unchanged. Unchanged extent of the predominantly left basal parenchymal opacities, combined to some degree of retrocardiac atelectasis. Unchanged borderline size of the cardiac silhouette without evidence of pulmonary edema. No newly occurred opacities. The presence of a small left pleural effusion cannot be excluded. [2201-3-19] IVC filter placement: [2201-3-19] CT torso: IMPRESSION: 1. Worsening of pulmonary abnormalities in right lower lobe and left upper lobe but improvement in left lower lobe. 2. Findings consistent with bleeding in the internal adductor muscles of the left hip. 3. Small amount of perihepatic fluid. [2201-3-20] CXR: Bibasilar consolidation, left greater than right, worsened since [3-17], stable since [3-19], consistent with bilateral pneumonia, possibly due to aspiration, alternatively pulmonary hemorrhage. Left lung base is excluded from the examination, probable small persistent left pleural effusion. Heart size normal. ET tube, right internal jugular lines in standard placements, nasogastric tube passes below the diaphragm and out of view. No pneumothorax. [2201-3-21] CXR: FINDINGS: As compared to the previous radiograph, the monitoring and support devices are unchanged. The pre-existing bilateral apical and bilateral basal opacities that are slightly more severe on the left than on the right, have mildly improved. New parenchymal opacities are not seen. Normal size of the cardiac silhouette. Brief Hospital Course: 61 y/o male with a history of Wegener's granulomatosis admitted with respiratory failure thought to be due to pneumonia. He was intubated and admitted to the MICU for further management. The suspicion was highest that he developed respiratory failure due to pneumonia in a patient with emphysema and [Month/Day/Year ] lung damage from repeated infections and Wegener's granulomatosis. Given his history of multiple past pulmonary infections he was started on broad spectrum antibiotic coverage. His hospital course was complicated by sepsis requiring multiple vasopressors, oliguric renal failure with hyperkalemia, acidosis, and volume overload requiring CVVH, lower extremity deep vein thrombosis, atrial tachyarrhythmia, ileus, and anemia with CT scan showing internal adductor muscle bleed. Regarding his DVT, given his bleeding and evidence of coagulopathy he underwent a temporary IVC filter placement by interventional radiology. Multiple services were consulted including the infectious disease team regarding management of his pulmonary infection, the renal service for management of oliguric renal failure, and rheumatology given his Wegener's disease. Despite out combined efforts, his respiratory status declined as he developed an increasing FiO2 requirement with agonal breathing, also with worsening hemodynamic status and acidemia, and deterioration in his neurological status. With the family's urging, the decision was made to transition the patient towards comfort measures. The vasopressors were stopped, CVVH was held, and he was extubated with the family by his side. He expired on [2201-3-22]. The family accepted our offer for post-mortem. Medications on Admission: Medications (per OMR): - Tylenol #3 1 Tab Q8 Hrs - Azathioprine 150 daily - Aransep 60mg every other week - Diltiazem XR 120 daily - Ergocalciverol 50,000U weekly - Furosemide 40 [Hospital1 ] - Combivent 1-2 puffs Q 4 hours - Lisinopril 5 daily -- stopped on [3-13] - Toprol XL 100 daily - Nystatin 100,000 2 tablespoons by mouth QID for thrush - Predinsone 2mg daily - Sertraline 50mg daily - Simvastatin 20mg daily - Sodium Polystyrene Sulfonate 30g as needed for elevated K - Bactrim DS 1 Tab TIW - Androgel 1% gel apply one packet to back daily - Spirival 18mcg Capsule 1 capsule daily - ASA 325 daily - CaCO3 500mg TID - Ferrous Sulfate 324 Tab 1 tab daily - Ranitidine 150 daily - Sodium Bicarbonate 650 1 tab [Hospital1 ] Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Wegener's granulomatosis Pneumonia Sepsis DVT Anemia Acute renal failure Ileus Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased [First Name11 (Name Pattern1) 1877] [Last Name (NamePattern1) 1878] MD, [MD Number(3) 4858] ICD9 Codes: 0389, 486, 5849, 2762, 2851, 2767
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8837 }	Medical Text: Admission Date: [2108-10-26] Discharge Date: [2108-11-2] Date of Birth: [2035-3-26] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 7651] Chief Complaint: Cardiac Arrest Major Surgical or Invasive Procedure: 1. Left ventricle [First Name3 (LF) 33362] 2. Implanted cardiodefibrilator device (ICD) placement History of Present Illness: 71M with hx of MI in [2081] medically managed, AFib on coumadin, and IDDM2 who was headed to the gym when he felt dizzy in his car. He got out and collapsed and was found by bystander. Denies LOC (although family states he is a poor historian) ambulance was called and he was found to be in monomorphic vtach with pulse. Was shocked into polymorphic VT and got amiodarone, went into vfib (although no strip evidence of this) and was shocked again with return to NSR with prolonged PR and STE but was alert and interactive. Was BIBA to our ED. . ED/Cath Lab Course: VS: HR 72, BP 142/84, O2 97%NRB Per report, EKG in ED with RBBB and prolonged PR. Given ASA 325 and Plavix 600mg. Code STEMI and was transferred to cath lab, found to have 60-70% occluded Mid LAD, total occlusion of RCA and circumflex. No intervention taken as occlusions did not appear to be acute. Received 4000 U of Heparin on table. Transferred to CCU. . In unit, he is alert, oriented, interactive and asymptomatic. He corroborates much of the above story. Denies chest pain, SOB, lightheadedness, weakness, numbness, or tingling. He denies recent illness, changes in health, prodromal syndromes, recent syncope, pre-syncope or other symptoms of concern to him. . He additionally denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: MI in [2081], no interventions - CABG: none - PERCUTANEOUS CORONARY INTERVENTIONS: none - PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - Atrial fibrillation, on coumadin, INR 4.6 last week. - IDDM type 2 - 30+ pack-year smoking - BPH s/p TURP - CKD (baseline Cr 1.4) Social History: - Tobacco history: 30+ pack years, quit in [2081] - ETOH: None - Illicit drugs: None Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM VS: T=95.4 BP= 126/70 HR= 70 RR= 14 O2 sat= 994LNC GENERAL: NAD. AOx3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Dry MMM, no xanthalesma. NECK: Supple with JVP of 2 cm above sternal angle at 25 degrees. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2 with physiologic split. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Obese, Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Trace-1+ pitting edema at ankles b/l SKIN: Xerosis, onychomycosis, and chronic stasis changes at shins bilaterally PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP [1-1]+ PT [1-1]+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP [1-1]+ PT [1-1]+ . DISCHARGE EXAM: VS: T=97.8 BP= 134/76 HR= 81 RR= 16 O2 sat= 99RA GENERAL: NAD. AOx3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Dry MMM, no xanthalesma. NECK: Supple with JVP of 1 cm above sternal angle at 25 degrees. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2 with physiologic split. No m/r/g. No thrills, lifts. No S3 or S4. Cannot appreciate MR found on ECHO LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Obese, Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Trace-1+ pitting edema at ankles b/l SKIN: Xerosis, onychomycosis, and chronic stasis changes at shins bilaterally PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP [1-1]+ PT [1-1]+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP [1-1]+ PT [1-1]+ Pertinent Results: ADMISSION LABS: [2108-10-26] 10:58AM WBC-15.0* RBC-5.25 HGB-15.7 HCT-46.0 MCV-88 MCH-29.9 MCHC-34.2 RDW-13.1 [2108-10-26] 10:58AM NEUTS-66.8 LYMPHS-24.7 MONOS-5.1 EOS-3.1 BASOS-0.4 [2108-10-26] 10:58AM PLT COUNT-264 [2108-10-26] 12:44PM GLUCOSE-357* UREA N-20 CREAT-1.5* SODIUM-133 POTASSIUM-6.5* CHLORIDE-97 TOTAL CO2-24 ANION GAP-19 [2108-10-26] 12:44PM CALCIUM-8.8 PHOSPHATE-3.7 MAGNESIUM-1.8 CHOLEST-134 [2108-10-26] 02:21PM ALT(SGPT)-172* AST(SGOT)-181* LD(LDH)-312* ALK PHOS-83 TOT BILI-1.3 [2108-10-26] 12:44PM PT-30.5* PTT-42.8* INR(PT)-3.0* . PERTINENT LABS: [2108-10-26] 02:21PM BLOOD CK-MB-5 cTropnT-0.05* [2108-10-27] 05:45AM BLOOD CK-MB-4 cTropnT-0.03* [2108-10-26] 12:44PM BLOOD %HbA1c-12.6* eAG-315* . DISCHARGE LABS: [2108-11-2] 05:46AM BLOOD WBC-10.6 RBC-4.65 Hgb-13.6* Hct-40.3 MCV-87 MCH-29.1 MCHC-33.6 RDW-12.9 Plt Ct-206 [2108-11-2] 05:46AM BLOOD Glucose-182* UreaN-38* Creat-1.6* Na-135 K-4.5 Cl-99 HCO3-25 AnGap-16 . CARDIAC CATH [2108-10-26] COMMENTS: 1. Selective coronary angiography in this right dominant system demonstrates three vessel coronary artery disease. The left atnerior descending contains a 60-70% lesion in the mid-vessel. The right coronary artery is chronically occluded. The circumflex artery is calcified and stenosedin the second obtuse marginal to 50%. \ FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. . ECHO [2108-10-26] The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is a left ventricular aneurysm involving the basal inferior and posterior walls. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %) secondary to extensive inferior and posterior akinesis. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall thickness is normal. Right ventricular chamber size is normal. with depressed free wall contractility. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The mitral valve leaflets do not fully coapt secondary to posterior displacement of the papillary muscles and consequent mitral leaflet tethering. Moderate to severe (3+) mitral regurgitation is seen. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. . ECHO [2108-10-29] LV systolic function appears depressed. The right ventricle is mildy dilated with normal free wall contractility. An eccentric jet of mld to moderate ([1-1]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. Compared with the prior study (images reviewed) of [2108-10-26], findings are similar. . CXR [2108-11-1] IMPRESSION: Appropriately placed pectoral ICD and leads. Interval improvement of the pulmonary vascular bed. CARDIAC MR 1. Normal left ventricular cavity size with normal regional left ventricular systolic function. The LVEF was moderately depressed at 38%. CMR evidence of prior myocardial scarring/infarction, in a right coronary artery distribution, with late gadolinium contrast-enhanced CMR images demonstrating areas of hyperenhancement as described above. 2. Normal right ventricular cavity size and systolic function. The RVEF was mildly depressed at 47%. 3. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was normal. 4. Mild left atrial enlargement. 5. Mild pulmonic regurgitation. Brief Hospital Course: 71M with hx of MI in [2081] medically managed, AFib on coumadin, and poorly-controlled IDDM2 who collapsed in parking lot found to be in monomorphic VT s/p amiodarone and defibrillator x 2 with significant MVD on cath without evidence of acute ischemia. . ACTIVE ISSUES: # Spontaneous monomorphic VT/Out-of-Hospital Cardiac Arrest: First time event for this patient, requiring defibrillation in the field. Cardiac cath showed three vessel disease but no evidence of active ischemia. Cardiac enzymes were elevated but likely from defib x 2. Likely related to scarring from remote posterior RCA-distribution MI as well as MR. [First Name (Titles) ] [Last Name (Titles) 33362] and ablation was attempted bhowever the focus was not found and no ablation was performed. An ICD was succesfully placed. . #MR/ Systolic CHF: EF 40% with moderate MR. [First Name (Titles) ] [Last Name (Titles) ] overloaded during this admission and was diuresed with IV lasix. His metoprolol, diltiazem, and hctz were stopped and carvedilol, lisinopril, spironolactone and furosemide were started. . # Acute Kidney Injury on CKD: He had a briew creatinine elevation from his baseline ~1.4 to 1.9 likely from diuresis and contrast from catheterization. His creatinine decreased to 1.6 on discharge. His metformin was discontinued to avoid lactic acidosis given his elevated creatinine. . # IDDM2: HbA1c 12.6 on admission which indicates average BSL of ~370. Hi shome regimen included insulin 70/30 and metformin. Sugars under better control in the hospital on same insulin without metformin. This suggest poor medication or diet compliance outside of hospital. . #Atrial fibrilation: CHADS score of 4. His coumadin was held for his ICD placement and then restarted at his home dose. On discharge his INR was 1.4 . #CAD: S/p cardaic cath [10-26]. Chronic-appearing occlusions of RCA, 60-70% mid LAD occlusion, and branch off of circumflex. No intervention done. No evidence of acute ischemia. On carvedilol, lisinopril and aspirin . #HTN: His metoprolol, diltiazem, and hctz were stopped and carvedilol, lisinopril, spironolactone and furosemide were started. . # HLD: Total chol 153, HDL 45, LDL 81 in 8/[2107]. Simvastatin was decreased to 40mg based on recent FDA warning and possibility of requiring amiodarone which would interact with simvastatin. . TRANSITIONAL ISSUES: . #HbA1c: His HbA1c on admission was 12.6 which indicates an average daily blood sugar level in the 300's. There is concern regarding his access to medcations/insulin (he denies significant issues but this is unclear) and his medication compliance. His sugars have been in the mid-100 to mid 200's range in-house on his home insulin regimen. He will need especially close follow-up for this issue. . #ICD Placement: He has a new ICD device placed. He has been set up with follow-up with the [Hospital1 18] device clinic. . #Afib on Coumadin: Pt has been on coumadin as an outpatient. He will need continued close follow-up of his INR levels . #Transaminitis: Pt found to have transaminitis around his cardiac arrest. Believed to be related to poor forward flow during the resuscitative effort. Would continue to trend these in clinic and conduct a workup if they do not normalize. . #Creatinine and Metformin: Pt has an elevated Cr of 1.6 at the time of discharge (it seems his baseline in ~1.4). We would recommend following his Cr and re-starting his metformin when it returns to his baseline Medications on Admission: - Coumadin 5mg PO daily - Metoprolol succinate 100mg PO daily - Diltiazem CD 120mg PO daily - HCTZ 25mg PO daily - Lisinopril 40mg PO daily - Metformin SR 500mg X 2 PO daily - Simvastatin 80mg PO daily - Aspirin 81mg PO daily - Insulin Aspart 70/30 38 units QAM and QDinner - NTG 0.4mg SL PRN (hasn't taken in years) - Elocon 0.1% cream once daily PRN itch Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 3. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 5. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Elocon 0.1 % Cream Sig: One (1) Topical once a day as needed for itching. 7. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual PRN as needed for pain: x3 as needed for chest pain. 8. Insulin 70/30 38 units at breakfast and 38 units at dinner 9. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day. 10. simvastatin 80 mg Tablet Sig: 0.5 Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Ventricular tachycardia Implanted cardiodefibrilator placement Hypertension Systolic congestive heart failure Secondary Diagnoses: Diabetes Coronary artery disease Atrial fibrilation Hyperlipidemia Chronic kidney disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Chest pain free. Discharge Instructions: Dear Mr [Known lastname ], Thank you for coming to the [Hospital1 1170]. It was a pleasure taking care of you. You were in the hospital because you had a dangerous, irregular heart rhythm. The cardiologist placed an ICD device that will prevent your heart from going in to this rhythm. We also made a few changes in your medications. Medication summary: Please stop Diltiazem Please stop metoprolol please stop hydrochlorothiazide please stop metformin Please start carvedilol 25 mg twice a day Please start furosemide 20 mg daily please start spironolactone 25 mg daily please decrease simvastatin to 40 mg daily please continue taking all other medications as you have been It was a pleasure taking part in your medical care. Followup Instructions: Please attend the following appointments: Name: [Last Name (LF) 41433],[First Name3 (LF) ] Location: [University/College ] PRIMARY CARE MEDICINE Address: [Street Address(2) ], [University/College ],[Numeric Identifier 3471] Phone: [Telephone/Fax (1) 41434] Appointment: TUESDAY [11-6] AT 9:40AM Department: CARDIAC SERVICES When: THURSDAY [2108-11-8] at 10:00 AM 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 Name: SHEFTEL,[Name6 (MD) ] L MD Specialty: CARDIOLOGY Address: [2108], STE#562, [Location (un) ],[Numeric Identifier 8934] Phone: [Telephone/Fax (1) 18278] Appointment: MONDAY [12-3] AT 1:20PM Department: CARDIAC SERVICES When: FRIDAY [2108-12-7] at 1 PM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage ICD9 Codes: 4271, 5849, 4275, 5859, 2724, 412, 4280, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8838 }	Medical Text: Admission Date: [2144-11-30] Discharge Date: [2144-12-9] Service: CARDIOTHORACIC Allergies: Codeine / Tetracyclines Attending:[First Name3 (LF) 14964] Chief Complaint: Jaw tightness Major Surgical or Invasive Procedure: CABGx3 (LIMA->LAD, SVG->OM, PDA) [2144-12-3] History of Present Illness: 88 y/o female who reports jaw tightness w/ rest and activity relieved w/ NTG. ETT [2144-11-18] +CP, ant. ischemia, borderline EKG changes. Cath on [2144-11-30] showed 3VD and was referred for CABG. Also reports angina, pre-syncope, mild DOE. Past Medical History: HTN GERD TIAs Hiatal Hernia s/p hysterectomy '[98] Social History: Widow, Lives w/ son in [Name (NI) 7740]. Denies smoking or ETOH intake. Family History: + CAD hx. Mother died of MI at 71. Grandmother died of MI at 74. Physical Exam: Ht: 5'1" Wt: 174 lbs HR: 93 SR BP: 174/70 General: Laying flat in bed in NAD Neuro: A&O x 3, appropriate NecK: Supple, - carotid bruits Resp: CTAB Cardiac: RRR +S1/S2, -c/r/m/g GI: soft, obese, NT/ND +BS Ext: warm, well-perfused - edema/varicosities Pulses: radisl bilat 2+, DP/PT bilat 1+ Pertinent Results: Pre-op CXR: 1) large Hiatal hernia. 2) Spinal degenerative changes. Carotid U/S: Less than 40% right ICA stenosis, 40-59% left ICA stenosis. Cardiac Cath: Coronary angiography of this right dominant circulation demonstrated three vessel coronary artery disease. LMCA had a 30% ostial stenosis. LAD had a proximal, ulcerated, heavily calcified 95% lesion. There were additional heavily calcified 80% lesion in mid LAD and 60% in distal LAD. LCX had 90% lesion in the proximal major OM2. RCA had ostial heavily calcified 90% lesion. EF 63% [2144-11-30] 09:15AM BLOOD WBC-5.1 RBC-3.63* Hgb-11.4* Hct-33.4* MCV-92 MCH-31.5 MCHC-34.2 RDW-14.3 Plt Ct-267 [2144-12-8] 06:20AM BLOOD Hct-28.5* [2144-11-30] 09:15AM BLOOD PT-12.6 PTT-24.0 INR(PT)-1.0 [2144-11-30] 09:15AM BLOOD Plt Ct-267 [2144-12-7] 06:08AM BLOOD PT-12.8 INR(PT)-1.0 [2144-12-7] 06:08AM BLOOD Plt Ct-204 [2144-11-30] 09:15AM BLOOD Glucose-107* UreaN-18 Creat-0.7 Na-141 K-4.1 Cl-107 HCO3-27 AnGap-11 [2144-12-7] 06:08AM BLOOD Glucose-108* UreaN-23* Creat-0.9 Na-139 K-3.9 Cl-100 HCO3-32* AnGap-11 [2144-12-8] 06:20AM BLOOD UreaN-20 Creat-0.9 K-4.1 [2144-11-30] 09:15AM BLOOD ALT-10 AST-17 AlkPhos-63 Amylase-69 TotBili-0.5 [2144-11-30] 09:15AM BLOOD Triglyc-211* HDL-50 CHOL/HD-4.8 LDLcalc-148* [2144-11-30] 11:45AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.005 [2144-11-30] 11:45AM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [2144-11-30] 11:45AM URINE RBC-[3-20]* WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1 Brief Hospital Course: Pt. was seen by CSURG following Cath which revealed 3VD for CABG. Pt. first need a carotid u/s and neuro consult (CVA work-up) secondary to TIA hx. Carotid duplex w/out significant dz. Neuro cleared pt. for surgery stating no increase in CVA risk. Pt was brought to the OR on HD #4. After general anesthesia pt. underwent a CABG x 3 (LIMA->LAD, SVG->OM, PDA). Pt tolerated the procedure well with a CPB time of 82 min. and XCT of 65 minutes. Please see op summary for full surgical details. Pt. was transferred to CSRU in stable position with MAP of 80, CVP 13, PAD 20, [Doctor First Name 1052] 27, HR 76 NSR and being titrated on propofol and neo. Later that day, propofol was weaned and pt. was extubated. She was alert and neurologically intact. Neo was weaned. POD #1 - Pt. extubated yesterday, CVL removed. POD #2 - Chest tubes removed. Pt. hemodynam. stable. Currently on lasix and lopressor per protocol. Transferred to telemetry floor. POD #3 - Pt. improving well. c/o soreness l. armpit after walking. PE unremarkable. POD #4 - Pt. increasing ambulation. Pacing wires and foley removed. POD #[5-21] - Pt. progessed well with uncomplicated post-op course. VS stable and cleared level 5 w/ PT. D/C home today w/ VNA services. D/C PE: VS: 99.4 75SR 131/61 Neuro: alert, oriented, non-focal Pulm: CTAB Cardiac: RRR Chest: Sternum stable, -erythema/drainage Abd: soft, obeses, NT/ND +BS Ext: warm 1+ edema w/ mild erythema/ecchymosis/tenderness over distal L. leg inc c/d Medications on Admission: 1. ECASA 325 mg qd 2. Plavix 75 mg qd 3. Atenolol 50 mg qAM, 25 mg qPM 4. Omeprazole 20 mg qd 5. Nitro spray PRN Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:14 Tablet(s) Refills:0 3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:28 Capsule, Sustained Release(s) Refills:0 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 7. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Oxycodone-Acetaminophen 2.5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed. Disp:30 Tablet(s) Refills:0 9. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) for 1 months. Disp:30 Capsule(s) Refills:0 10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily) for 1 months. Disp:30 Cap(s) Refills:0 11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:60 Tablet(s) Refills:0 12. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Coronary artery disease s/p CABGx3 (LIMA->LAD, SVG->OM, PDA) [2144-12-3] HTN TIAs GERD Hiatal Hernia Discharge Condition: Good Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 3 months. You should shower, let water flow over wounds, pat dry with a towel. Followup Instructions: Make an appointment with Dr. [Last Name (STitle) ] for 1-2 weeks. Make an appointment with Dr. [Last Name (STitle) 70] for 6 weeks. Completed by:[2145-3-11] ICD9 Codes: 4111, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8839 }	Medical Text: Admission Date: [2179-8-24] Discharge Date: [2179-8-29] Date of Birth: [2121-5-16] Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1232] Chief Complaint: 58 yo male with muscle invasive bladder cancer presented for cystoprostatectomy and ileal neobladder creation. Major Surgical or Invasive Procedure: Radical cystoprostatectomy with creation of ileal neobladder History of Present Illness: The patient is a 58 year old male who presented with well-known muscle invasive transitional cell bladder cancer. He has previously underwent multiple transurethral bladder resections and biopsiesby Dr. [Last Name (STitle) ], as well as a bladder sparing protocol using chemotherapy of Gencytobene, Taxol, and Carboplatin. A biopsy from [2179-7-1] demonstrated persistent low grade papillary urothelial carcinoma involving the smooth muscle. After thorough discussions of his options, the patient subsequently decided to undergo a radical cystoprostatectomy with creation of a neobladder by Dr. [Last Name (STitle) ] at [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 1675] [Last Name (NamePattern1) ] Medical Center. Past Medical History: chronic emphysema and bronchtis, bacterial meningitis, bilateral knee surgery Social History: 40 pack year smoker Physical Exam: General: no acute distress, healthy appearing Lungs: bilateral moderate rales Cardiovascular: rrr, no mrg GI: soft, nontender, nondistended. Staples clean/dry/in tact incision; JP site X 2 clean, dry. SPT site clean/dry Neurologic: alert and oriented X3 Ext: no edema GU: mild ecchymosis of scrotum, penis. Foley draining clear urine Pertinent Results: [2179-8-28] 07:20AM BLOOD WBC-6.8 RBC-3.12* Hgb-9.5* Hct-27.4* MCV-88 MCH-30.4 MCHC-34.5 RDW-14.0 Plt Ct-176 [2179-8-28] 07:20AM BLOOD Plt Ct-176 [2179-8-28] 07:20AM BLOOD PT-13.3 PTT-22.7 INR(PT)-1.2 [2179-8-28] 07:20AM BLOOD PT-13.3 PTT-22.7 INR(PT)-1.2 [2179-8-28] 07:20AM BLOOD Glucose-120* UreaN-22* Creat-0.8 Na-144 K-3.9 Cl-110* HCO3-28 AnGap-10 [2179-8-28] 07:20AM BLOOD Mg-2.0 Brief Hospital Course: The patient was admitted on [2178-8-24] for an elective radical cystoprostatectomy and creation of a neobladder by Dr. [Last Name (STitle) ]. The procedure went well and the patient was dischared to the trauma intensive care unit in stable condition with a Foley, a suprapubic tube, and two JP drains. His hematocrit was stable after 1700 cc blood loss and 2 u prbc given intraoperatively. His sp tube and foley catheter had excellent urine output; his bun/cr were normal. He was extubated on POD 1 and transferred from the ICU to the floor on POD 2. He passed flatus on POD 4 and his NGT was removed. He was started on a house diet, which he tolerated. His pain was initially controlled with a PCA, but was then controlled with percocet after his ngt was removed. He did not tolerate percocet so was switched to vicodin which worked well. He also was given iv toradol. He was followed by the pulmonary medicine service in house. Serial chest films demonstrated a small right lower lobe consolidation although he was afebrile and oxygenating well on room air. He was started empirically on a 10 day course of levofloxacin for nosocomial pneumonia. He required 2-4 l o2 nasal cannula until pod 3 when he was weaned to room air with Sao2around 92-93%. He was ambulatory prior to discharge. Medications on Admission: ativan 1''', combivent 103-18 2 puffs QID, compazine 10''' Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:30 Tablet(s) Refills:0 2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days. Disp:8 Tablet(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): while taking vicodin until bowel movement . Disp:30 Capsule(s) Refills:2 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:1 Disk with Device(s) Refills:2 5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 6. combivent 2 puffs q6 hours Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: bladder cancer s/p cystectomy ileal neobladder Discharge Condition: stable Discharge Instructions: See instructions. House diet - take as much or as little as you can tolerate. Foley and sp tube to gravity; VNA to assist with emptying/recording outputs. [Month (only) 116] shower; no tub soaks/swimming X 4 weeks. Activity as tolerated - stairs ok; no heavy lifting > 10 lbs. Resume preoperative medications. Vicodin for pain; colace to soften stools. Tylenol alone is preferred if it can control your pain since it will not constipate you. [Name8 (MD) ] MD IF: fever >101.5, worsening cough, redness/oozing from wound, difficulty with catheters. Complete 10 day course of levofloxacin for pneumonia. Followup Instructions: 1. Dr. [Last Name (STitle) 261], 2 weeks for staple removal, call for appt. 2. Pulmonary NEXT week, call for appt, need follow up chest xray ICD9 Codes: 486, 2762
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8840 }	Medical Text: Admission Date: [2186-5-16] Discharge Date: [2186-5-27] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1556] Chief Complaint: 88 yo female sp fall on her face Major Surgical or Invasive Procedure: Open reduction/internal fixation of C2-C3 fracture dislocation with posterior segmental instrumentation and posterior arthrodesis C2-C3. History of Present Illness: She had suffered a fall resulting in a fracture dislocation of C2-C3. She had suffered some neurologic compromise, predominantly in the right side and had some difficulty breathing prior to surgery and was intubated prior to surgery. She was brought to the operating room in a hard collar. Past Medical History: PMHx: HTN, HOH, TIA x3, inc chol, stenting x 3, multiple falls last one on R shoulder has [Month (only) ] rom R shoulder, MI [2182], PNA, chronic phelgm PSurgHx: stenting, c-section x2 Physical Exam: Lunga coarse b heart rrr abd soft nt nd ext exam: [3-5] R delt. [4-5] RUE, RLE. [5-5] LUE/LLE Pertinent Results: [2186-5-16] 11:22p Mg: 2.2 P: 4.0 [2186-5-16] 10:45p pH 7.33 pCO2 44 pO2 121 HCO3 24 BaseXS -2 Type:Art; Intubated; FiO2%:54; Rate:8/ ; TV:600 Na:142 K:3.3 Cl:110 TCO2:24 Hgb:8.4 CalcHCT:25 Glu:107 freeCa:1.01 Lactate:2.4 Other Blood Gas: Vent: Controlled [2186-5-16] 9:20p pH 7.32 pCO2 47 pO2 133 HCO3 25 BaseXS -2 Type:Art; Intubated; FiO2%:54 Na:142 K:3.6 Hgb:10.2 CalcHCT:31 Glu:105 freeCa:1.03 Lactate:1.9 Other Blood Gas: Vent: Controlled [2186-5-16] 8:03p pH 7.36 pCO2 44 pO2 157 HCO3 26 BaseXS 0 Type:Art; Intubated; FiO2%:98; AADO2:510; Req:84 Na:141 K:3.7 Hgb:8.0 CalcHCT:24 Glu:108 freeCa:1.03 Lactate:1.8 [2186-5-16] 5:00p pH 7.34 pCO2 42 pO2 244 HCO3 24 BaseXS -2 Type:Art Na:140 [2186-5-16] 4:57p SLIGHTLY HEMOLYZED 144 109 39 195 AGap=15 3.4 23 1.3 Comments: Hemolysis Falsely Elevates K Ca: 6.6 Mg: 1.7 P: 3.5 Comments: Hemolysis Falsely Elevates Mg [2186-5-16] 12:35p CK CPIS TNT ADDED [5-16] @ 15:01 139 98 39 360 AGap=25 3.5 20 1.3 CK: 120 MB: 8 Trop-T: <0.01 Comments: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi Ca: 8.3 Mg: 2.0 P: 4.2 89 16.0 9.8 201 29.5 PT: 13.1 PTT: 25.3 INR: 1.1 [2186-5-15] 11:25p Trop-T: 0.01 Comments: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi 135 98 33 337 AGap=16 5.1 26 1.1 CK: 102 MB: 6 88 19.9 D 11.1 218 33.6 N:85 Band:4 L:7 M:3 E:1 Bas:0 Hypochr: 1+ Anisocy: 1+ Microcy: 1+ Ovalocy: OCCASIONAL Comments: MANUALLY COUNTED Plt-Est: Normal PT: 12.3 PTT: 27.2 INR: 1.1 Brief Hospital Course: suffered a fall resulting in a fracture dislocation of C2-C3. She had suffered some neurologic compromise, predominantly in the right side and had some difficulty breathing prior to surgery and was intubated prior to surgery. She was brought to the operating room in a hard collar. Halo ring was attached to patient's head using standard technique with 4 pins, anesthetizing each of the 4 pin placements. But then she was then placed prone on the operating room table with head controlled with the halo attachment to the [Location (un) 8766] head rest. Under fluoroscopic examination, her fracture was reduced to show alignment of the C2-C3 vertebral body. This was confirmed again on the lateral projection as well as AP projection under the fluoroscope, adn the dssition to perform a Open reduction/internal fixation of C2-C3 fracture dislocation with posterior segmental instrumentation and posterior arthrodesis C2-C3; was taken. Afer the or, patient had failute to wean form ventilator, due to age, debilitation, and generalized weakness. Pt had living will which states she would not wish to be dependent and live in n.h. & her children wanted to honor her wishes. In meeting with them and the TICU attending , the desition of extubateing the patien was taken; with a DNR DNI order. Pt deteriorating after extubation and was decided [Last Name (un) ] made Confort esaure only. Pt expired short after. Medications on Admission: glipizide 5mg am, 2.5 pm; metoprolol 50 [Hospital1 ], enalapril 20, lipitor 20 hs, asa 325, alphagen p gtt ou [Hospital1 ], acuvite, MVI Discharge Disposition: Expired Discharge Diagnosis: respiratory failure Fracture dislocation at the C2-C3 level. Discharge Condition: expired Discharge Instructions: none Followup Instructions: none Completed by:[2186-6-9] ICD9 Codes: 5185, 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8841 }	Medical Text: Admission Date: [2111-3-28] Discharge Date: [2111-5-12] Date of Birth: [2049-1-23] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 5569] Chief Complaint: Ischemic R Foot Major Surgical or Invasive Procedure: [2111-5-11] endobronchial ultrasound with biopsies [2111-4-30] Ex lap, lysis of adhesions [2111-4-6] R BKA [2111-3-29] aortobifem History of Present Illness: The patient is a 62-year-old male with history of bilateral avascular hip necrosis, status post bilateral total hip arthroplasty. The patient was at his rehab facility and noted increasing discomfort at his right lower extremity with diminishing sensation at the foot and some limitation of motor function. He was consented, after initial performance of angiogram demonstrating severe aorta occlusive disease Past Medical History: # COPD (unknown PFTs) # Fatty liver (presumed [2-4] alcohol) # Gastritis (never had upper EGD, never had colonoscopy) # H/o NSVT (3-4 beat run while admitted in [3-11]) # H/o tonsillectomy # Left total hip replacement [2-/2110] Social History: Quit smoking and etoh in [3-11]. Frankly denies current ethanol use, but very heavy use in past per records from OSH. History of 160 pack years tobacco ([2-6] ppd over 40-45 years). No IVDU. Currently unemployed, but formerly works as jeweler. Family History: NC Physical Exam: Vitals: 98.3 97.6 100 104/72 14 95%2LNC GEN: NAD, resting comfortably CV: RRR Lungs: CTAB ABD: Soft, slight distension, but non-tender. Incision clean, dry, and intact. Steri strips in place. Staples removed. RLE: Wound clean and dry. No edema. Pertinent Results: ECHO [2111-4-14]: IMPRESSION: Normal global and regional biventricular systolic function. Moderate pulmonary hypertension. Small pericardial effusion. CT [2111-4-19]: IMPRESSION: 1. Findings described above, likely represent resolving small bowel obstruction. 2. Patent aortobifemoral graft with adjacent surgical stranding and fluid. Although this may be post-surgical in nature, infection should be considered in the correct clinical setting. 3. Stable moderate pericardial effusion. 4. New bilateral moderate pleural effusions with adjacent compressive atelectasis, less likely underlying infectious process. 5. Mesenteric edema which may be post-surgical in nature. 6. Focal opacities in the right lateral lower lobe and lingula may represent atelectasis vs infection, however malignancy is not necessarily excluded. KUB [2111-4-22]: Progression of duodenal and proximal jejunal small bowel distention worrisome for evolving proximal small-bowel obstruction. CTA chest [2111-4-10]: IMPRESSION: 1. Bilateral pulmonary emboli without evidence of right heart strain. 2. Patchy peripheral opacities in the right middle and lower lobes, suspicious for infection. Lymphangitic spread of disease may also have this appearance. 3. Marked interval increase in size of pulmonary nodules and bilateral hilar and mediastinal lymphadenopathy with interval development or right pleural and pericardial effusions. Given this constellation of findings is highly concerning for malignancy; lymphoma and metastases should be considered, although the differential includes sarcoidosis, or cryptogenic organizing pneumonitis. Recommend correlation with bronchoscopic biopsy. [2111-4-27] Abd XR: IMPRESSION: 1. Significantly decreased distention of previously noted dilated loop of small bowel suggesting resolution of partial small bowel obstruction or ileus. 2. The nasoenteric tube is seen in appropriate position with the tip within the distal stomach and the sidehole past the gastroesophageal junction. [2111-4-28] Liver USG: IMPRESSION: 1. Dilated proximal CBD up to 9-mm with mildly prominent right hepatic duct, new since the last CT study dated [2111-4-19]. While no cholelithiasis or proximal choledocholithiasis is directly observed, obstruction at the distal CBD cannot be excluded. If clinical concern remains high, recommend MRCP for further evaluation. 2. Slightly echogenic liver compatible with known fatty liver. No focal hepatic lesions. No ascites. [2111-4-30] CT abd: High-grade small-bowel obstruction with transition point in the left mid abdomen given the swirling appearance of the vessels/bowel loops is concerning for internal hernia or volvulus. No evidence of free air. [2111-5-12] On day of discharge 136 101 25 -------------<89 4.5 25 1.0 Ca: 9.5 Mg: 1.8 P: 5.3 ALT: 35 AST: 31 AP: 442 Tbili: 1.7 11.8 > 26.4 < 314 PT: 18.2 PTT: 27.6 INR: 1.6 Brief Hospital Course: The patient was admitted to the vascular service on [2111-3-28] for an ischemic R foot. He underwent aortbifem on [2111-3-29]. The patient tolerated the procedure well. Please see operative report for more details. Post-operatively, patient was doing well. Diet was advance and pain was controlled. The right foot was monitored [Doctor Last Name ] closely for signs of improvement. After several it became very clear, that the right foot was not going to recover. Arterial non-invasives were performed that showed inadequate blood flow in the R foot. Furthermore, the patient's WBC continued to rise, reaching a peak of 31. It was decided that the patient's R foot would not survive and that R BKA was the best solution. The patient agreed and he was consented after all the risks and benefits were discussed. The patient underwent R BKA on [2111-4-6], which again went well without complication. (Please see operative note.) Postoperatively, the patient's heart rate became an issue. Prior to the BKA, he maintained a HR in the low 100s with occasional bursts into the 120s. He was titrated up on po lopressor, which was helpful in maintaining his heartrate. However, on POD2 after the BKA, patient became hypotensive with SBP in the 80-90s. He was otherwise feeling fine. The lopressor was decreased to a very small dose. However, the heartrate continued to have bursts, now with episodes into the 200s, and the patient began to fell lightheaded. As such, cardiology was consulted and they recommended getting an ECHO to rule out heart issues. This showed normal heart function. However, patient's oxygen requirement had increased, although he denied any shortness of breath. A CT chest was performed that showed extensive bilateral PEs, so patient was started on a heparin drip which was titrated to a goal PTT 60-80. The patient was transitioned to coumadin with a goal INR of [2-5]. However, the patient became supratherapeutic initially, and coumadin was held, and then the INR dropped to subtherapeutic levels, likely due to improved nutrition. Heparin drip was restarted. The patient was weaned off the lopressor as heartrate improved due to treatment of PEs. The patient's Chest CT scan also showed enlarging pulmonary nodules with mediastinal/hilar lymphadenopathy. Thoracic surgery was consulted and recommended EBUS, which is to be performed as an outpatient. The patient's appetite was quite limited after his operations. He had distension in his belly initially that improved as he passed more flatus and had bowel movements. He was given supplements to support his nutrition, and he slowly was able to take more food. However, several days after the R BKA, patient began to have more distension in his abdomen with worsening pain. A CT scan was performed that showed evolving pSBO. NGT was placed and patient was started on TPN. The NGT ultimately removed on [2111-4-21], and patient's diet was slowly re-advanced. Repeat CT scan showed improvement in the SBO, but KUB showed persistent dilated loop of small bowel. However, patient felt better clinically. His NGT was removed on [2111-4-24] and he was advanced to sips & clears. On the following day , he became nauseous and had multiple bouts of vomiting. An NGT was placed back in and he was kept NPO for the next few days. A general surgery consultation was sought in view of this persistent ileus. An Abdomina XR was done that showed dilated bowel loops. A liver UWSG was done the following day since the patient was complaining of right upper quadrant pain. It revealed a 9 mm CBD with no e/o stones in the CBD or gall bladder. He had a couple of bowel movements following a suppository. Since, he seemed to be doing better clinically his NGT was removed and he tolerated sips. The following morning his abdomen was distended and he had not passed any flatus. A CT abdomen with PO contrast was done which showed high grade small bowel obstruction. He was taken to the OR for an exploratory laparotomy by the West 1 surgery service, where he underwent an extensive lysis of adhesions on [2111-4-30]. The patient was subsequently transferred to the West 1 service. TPN was continued and the patient continued to be NPO. Diet was advanced slowly. The patient remained on a heparin gtt. Diet was advanced when appropriate first to clears and subsequently to a regular diet. When tolerated the patient was changed over to PO dilaudid. The patient was on a dilaudid PCA. Warfarin 5 was started on [2111-5-5]. The patient continued to remain on warfarin daily with a heparin GTT. On [2111-5-11], the patient's heparin gtt was held and the patient went down to the operating room for an endobronchial ultrasound with biopsies for of the prior nodules found on Chest CT. The heparin gtt was held for several hours after the procedure and it was restarted during the night. The patient also receieved coumadin that evening. On [2111-5-12], the patient obtained a RUQ ultrasound for evaluation of rising alkaline phosphatase levels, which demonstrated gallbladder sludge without notable change in intrahepatic duct size and the same extrahepatic duct size. The patient at this time was eager to leave for a rehabilitation facility. The patient was switched to Lovenox 80 [Hospital1 ] and the heparing gtt was discontinued. A dose of coumadin was given at this time. The patient's fluid status was closely monitored and adjusted as needed. The patient's WBC increased to maximum of 31 during his hospital stay, but promptly came down after his BKA operation. He had low grade fevers initially after his bypass procedure, but these initially resolved after his BKA. The patient on broad spectrum IV atbx and these were discontinued once the WBC began to trend downward. The patient remained stable from a hematologic standpoint. He was transfused two units of blood on [2111-4-8] because his HCT was 25. However, the patient was asymptomatic, and this was done mainly to help improve the healing process. At time of discharge, the patient was comfortable, pain was well-controlled. Pt was in agreement with discharge plan. Medications on Admission: acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H, oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H PRN, 3. enoxaparin 40 Subcutaneous Q 24H, docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID, albuterol sulfate 2.5 mg /3 mL (0.083 %) neb Inhalation Q6H ipratropium bromide 0.02 % Solution neb Q6H, simvastatin 10 mg, calcium carbonate 200 mg PO DAILY, tiotropium bromide 18 mcg Capsule,Inhalation DAILY (Daily), pantoprazole 40 mg Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Coumadin 1 mg Tablet Sig: TO BE DOSED DAILY BASED ON INR VALUE Tablet PO once a day. 8. acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscellaneous Q6H (every 6 hours) as needed for shortness of breath or wheezing. 9. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) SHOT Subcutaneous Q12H (every 12 hours) for 1 weeks: PLEASE GIVE UNTIL PATIENT'S INR IS THERAPEUTIC. 10. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain for 2 weeks. Tablet(s) 11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [Hospital1 ] (2 times a day) as needed for constipation. 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for SBP<100, HR<55. 14. Outpatient Lab Work Daily PT/INR at least until INR is therapeutic to goal of [2-5]. 15. Outpatient Lab Work Please obtain CBC, Chem 10, and LFT's including Alk Phos, AST, ALT, T-Bili daily for the next week. Please fax results to Dr. [Name (NI) 41400] office at ([Telephone/Fax (1) 21178]. 16. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO twice a day. Disp:120 Capsule(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital6 ] hospital- [Location (un) 246] Discharge Diagnosis: Ischemic Right Foot Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: DISCHARGE INSTRUCTIONS FOLLOWING BELOW KNEE AMPUTATION This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. ACTIVITY: There are restrictions on activity. On the side of your amputation you are non weight bearing for 4-6 weeks. You should keep this amputation site elevated when ever possible. No driving until cleared by your Surgeon. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s). New pain, numbness or discoloration of your stump site. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Exercise: Limit strenuous activity for 6 weeks. Do not drive a car unless cleared by your Surgeon. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home. No bathing. A dressing may cover you??????re amputation site and this should be left in place for three (3) days. Remove it after this time and wash your incision(s) gently with soap and water. You will have sutures, which are usually removed in 4 weeks. This will be done by the Surgeon on your follow-up appointment. WOUND CARE: When the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. Avoid taking a tub bath, swimming, or soaking in a hot tub for four weeks after surgery. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new prescription for pain medication, which can be taken every three (3) to four (4) hours only if necessary. Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. CAUTIONS: NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. Avoid pressure to your amputation site. No strenuous activity for 6 weeks after surgery. DIET: There are no special restrictions on your diet postoperatively. Poor appetite is expected for several weeks and small, frequent meals may be preferred. For people with vascular problems we would recommend a cholesterol lowering diet: Follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. Additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. Since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and LDL (Low Density Lipoprotein-the bad cholesterol). Exercise will increase your HDL (High Density Lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. You may be self-referred or get a referral from your doctor. If you are overweight, you need to think about starting a weight management program. Your health and its improvement depend on it. We know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude. If interested you can may be self-referred or can get a referral from your doctor. If you have diabetes and would like additional guidance, you may request a referral from your doctor. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. The key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. Things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. Don't let them go untreated! Please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are 8:30-5:30 Monday through Friday. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE Followup Instructions: Please call Dr.[Name (NI) 1392] office to schedule a follow up appointment in 3 wks. ([Telephone/Fax (1) 4852]. Provider: [First Name11 (Name Pattern1) 674] [Last Name (NamePattern4) 675], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2111-5-22] 1:40 Please follow up with Dr. [Last Name (STitle) ] in one week by calling ([Telephone/Fax (1) 17398] as soon as possible. Completed by:[2111-5-12] ICD9 Codes: 5070, 2760, 496, 4168, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8842 }	Medical Text: Admission Date: [2119-7-14] Discharge Date: [2119-7-20] Date of Birth: [2059-5-24] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2119-7-14] - Cardiac Catheterization and placement of an IABP [2119-7-14] - 1. Emergent coronary bypass grafting x3 on intra-aortic balloon pump with left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from the aorta to the ramus intermedius coronary artery; as well as reverse saphenous vein single graft from aorta to posterior left ventricular coronary artery. 2. Endoscopic left greater saphenous vein harvesting. History of Present Illness: 60 year old gentleman with recent chest pain on exertion. Stress test was abnormal and he was scheduled for cath. Chest pain developed during cath today which revealed left main and multi-vessel coronary artery disease. He is now brought to the operating room urgently for CABG. Past Medical History: osteoarthritis lumbar disc disease hypercholesterolemia Social History: Lives with: wife, works at library Occupation: Tobacco: 1ppd x 30yrs, quit 13yrs ago ETOH: quit years ago Family History: Father died at 62 of heart disease Physical Exam: Pulse: 65 Resp: 18 O2 sat: B/P Right: 121/72 Left: Height: Weight: 74.8kg General: slightly anxious, but NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact x Pulses: Femoral Right: IABP Left: 2+ DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: Left: none Pertinent Results: [2119-7-14] ECHO Pre-bypass: The left atrium and right atrium are normal in cavity size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 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 descending thoracic aorta. 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. IABP seen in the descending aorta with tip 2 cm below the left subclavian artery. Post-bypass: The patient is A paced. IABP remains in good position. Preserved Biventricular function. Aortic contours intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. [2119-7-19] 05:05AM BLOOD WBC-4.9 RBC-2.86* Hgb-8.6* Hct-25.4* MCV-89 MCH-30.3 MCHC-34.1 RDW-12.7 Plt Ct-209# [2119-7-14] 10:40AM BLOOD WBC-5.1 RBC-4.34* Hgb-13.0* Hct-37.7* MCV-87 MCH-30.0 MCHC-34.5 RDW-12.5 Plt Ct-208 [2119-7-15] 07:58AM BLOOD PT-14.0* PTT-33.2 INR(PT)-1.2* [2119-7-14] 10:40AM BLOOD PT-14.5* PTT-150* INR(PT)-1.3* [2119-7-19] 05:05AM BLOOD Na-140 K-4.5 Cl-101 [2119-7-17] 05:10AM BLOOD Glucose-110* UreaN-12 Creat-0.7 Na-136 K-4.2 Cl-101 HCO3-28 AnGap-11 [2119-7-14] 10:40AM BLOOD Glucose-134* UreaN-12 Creat-0.8 Na-138 K-3.6 Cl-106 HCO3-24 AnGap-12 Brief Hospital Course: Mr. [Known lastname 101426] was admitted to the [Hospital1 18] on [2119-7-14] for a cardiac catheterization. This revealed significant left main and three vessel coronary artery disease. As he developed chest pain during his catheterization, an intra-aortic balloon pump was placed. The cardiac surgical service was urgently consulted and surgical revascularization was recommended. Mr. [Known lastname 101426] was taken urgently to the operating room where he underwent coronary artery bypass grafting to three vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. The next morning, his intra-aortic balloon pump was weaned off and removed without incident. He then awoke neurologically intact and was extubated. On postoperative day two, he developed a right pneumothorax following removal of his chest tubes. A right pleural tube was thus placed with resolution of his pneumothorax. Later on postoperative day two, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. After a water seal trial, the right pleural chest tube was removed and he subsequently developed a large right pneumothorax that required a chest tube to be reinserted. Follow up chest X-Ray revealed right lung rexpanded. This chest tube wsa pulled [7-19] without incident after clamping and serial CXR. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Beta blockade, aspirin and a statin were resumed. Mr. [Known lastname 101426] continued to make steady progress and was cleared by Dr.[Last Name (STitle) 914] for discharge to home. He was in normal sinus rhythm and his chest xray showed a small pleural effusion with stable bilateral apical pneumothoraces. He will follow-up with Dr. [Last Name (STitle) 914], his cardiologist and his primary care physician as an outpatient. All follow up appointments were advised. Medications on Admission: Toprol 50 daily SL nitroglycerin simvastatin 20 daily Ascorbic acid 1000mg daily aspirin 325mg daily B complex vitamins Vit. D2 Folic acid MVI Omega 3 FA saw [Location (un) 6485] Vit E Discharge Medications: 1. 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 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:0 6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching . Disp:qs qs Refills:0 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: Centrus Home Care Discharge Diagnosis: Coronary artery disease Hyperlipidemia Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, with ecchymosis at knee and inner aspect of thigh Rash on Buttock, posterior thigh red and raised, resolving on back chest and groin area Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage 2) Please NO lotions, cream, powder, or ointments to incisions 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4) No driving for approximately one month until follow up with surgeon 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Appointment already scheduled [First Name8 (NamePattern2) 177] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2119-8-15] 2:30 Please call to schedule appointments. Please follow-up with Dr. [Last Name (STitle) 33746] in 2 weeks. [Telephone/Fax (1) 56771] Please follow-up with Dr. [Last Name (STitle) 101427] in 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 Completed by:[2119-7-20] ICD9 Codes: 4111, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8843 }	Medical Text: Admission Date: [2154-2-26] Discharge Date: [2154-3-2] Date of Birth: [2095-10-7] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5569] Chief Complaint: Bilateral lower extremity DVTs Major Surgical or Invasive Procedure: [2154-2-27] IVC filter placement History of Present Illness: 58 year old man s/p liver transplant on [2154-1-31] found to have DVT on duplex ultrasound. The patient was recently discharged on [2154-2-14] after a liver transplant complicated by bleeding which required two take-backs to the OR and bilateral occipital stroke with residual left field visual defect. He has been doing very well since his discharge, working with PT with minimal pain, eating well and regaining his strength. His only complaint is his eyesight which has been stable since his discharge. He was seen today for scheduled bilateral lower extremity ultrasounds to evaluate for embolic source for his stroke. These revealed a DVT and the patient was directly admitted to the floor for management. He has no specific complaints at this time. Past Medical History: PMH: cirrhosis, HTN, GI bleeding, GERD, history of basal and squamous cell carcinomas treated topically and surgically PSH: significant for an appendectomy as well as knee and shoulder arthroscopies Social History: Married and lives with his wife, who is in good health. He is employed as a telecommunications technician. He has no children. He reports that he smoked cigarettes for about 10 years but quit approximately 30 years ago. He has no history of use of intravenous or illicit drugs. Family History: significant for colon cancer in his father as well as seizures in his brother Physical Exam: Physical exam: Afebrile, VSS No distress, alert and oriented x 3 PERLA, EOMI, anicteric RRR, no murmurs Lungs clear Abdomen soft, nontender, nondistended, well healed incision Ext: no edema, palpable pulses Pertinent Results: Discharge labs: [2154-3-2] 04:30AM BLOOD WBC-6.5 RBC-3.98* Hgb-11.8* Hct-36.0* MCV-91 MCH-29.7 MCHC-32.8 RDW-16.0* Plt Ct-109* [2154-3-1] 05:35AM BLOOD PT-14.8* PTT-25.5 INR(PT)-1.3* [2154-3-2] 04:30AM BLOOD Glucose-103* UreaN-18 Creat-0.8 Na-141 K-4.1 Cl-106 HCO3-28 AnGap-11 [2154-3-2] 04:30AM BLOOD ALT-32 AST-24 AlkPhos-70 TotBili-0.4 [2154-3-2] 04:30AM BLOOD Albumin-3.0* Calcium-8.4 Phos-4.4 Mg-1.5* [2154-3-2] 04:30AM BLOOD tacroFK-12.4 . CT head [2-26] prior to starting heparin: - 1. Small gyriform foci of hyperdensity in the right occipital lobe at the area of prior infarct may represent areas of hyperperfusion-petechial hemorrhage-laminar necrosis or residual blood from prior hemorrhage, age-indeterminate. No large intracranial hemorrhage is seen. 2. Bilateral occipital lobe hypodensity, right larger than left, unchanged left caudate head hypodensity likely consistent with chronic ischemic changes. . CT head [2-26] after the administration of heparin: - Areas of subacute infarction in the occipital lobes bilaterally, unchanged since [2154-2-26]. Evolving hemorrhage within the infarctions. Close interval followup is suggested. . CT head [2-27]: - Bilateral subacute occipital infarction/hemorrhage. No acute changes. . Duplex: 1. Right superficial femoral and peroneal vein thrombus. 2. Left posterior tibial vein thrombus. Brief Hospital Course: Mr. [Known lastname 71166] was admitted on [2154-2-26] after routine duplex scanning of his legs revealed right superficial and peroneal vein DVT and left posterior tibial DVTs. Due to his recent occipital strokes a CT scan was obtained prior to the administration of heparin. The CT scan showed bilateral occipital lobe hypodensities, right larger than left, unchanged from prior studies. Neurology was consulted and a heparin gtt was started at a low rate. A few hours after the heparin was started he began to complain of new visual hallucinations that he did not have before. Due to concerns for hemorrhagic conversion of his prior CVA he was transferred to the ICU for monitoring and a head CT was obtained that showed areas of subacute infarction in the occipital lobes bilaterally, unchanged since [2154-2-26] with evolving hemorrhage within the infarctions. His heparin gtt was immediately stopped and 2 more follow up head CTs showed no change. An EEG was obtained and this show signs of encephalopathy but no seizure activity. His hallucinations continued and Keppra [Hospital1 ] was started. A 24hour EEG was obtained, an initial interpretation showed no seizure activity, but the final read is still pending as of his discharge. He was transferred back to the floor. His diet was advanced and he is having bowel function. His labarotory work is stable. His visual hallucinations are vastly improving and his main complaints are blurry vision in his left visual fields. He is discharged on Keppra with transplant as well as neurology follow up. A Cardiology consult was obtained to evaluate for closure of his ASD as an appropriate date. His tacro dose was decreased to 1.5mg [Hospital1 ] based on his level. His prednisone was decreased to 15mg daily. Medications on Admission: MMF 1000mg [Hospital1 ], protonix 40mg daily, fluconazole 400mg daily, valcyte 900mg daily, plavix 75mg daily, ASA 325mg daily, Bactrim SS daily, metoprolol 25mg tid, colace 100mg [Hospital1 ], prednisone 17.5mg daily, prograf 2mg [Hospital1 ] Discharge Medications: 1. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 3. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 8. Tacrolimus 1 mg Capsule Sig: 1 and [1-12] Capsule PO Q12H (every 12 hours). 9. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale per scale Subcutaneous ASDIR (AS DIRECTED). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: Bilateral leg DVTs Discharge Condition: Good Alert and oriented x 3 Ambulating independently Discharge Instructions: Please call the [Hospital 1326] Clinic at [Telephone/Fax (1) 673] if you experience any of the following: fever, chills, nausea, vomiting, inability to eat or drink, abdominal pain, diarrhea, chest pain, shortness of breath, a change in your visual symptoms, weakness or numbness on one side of your body, or any other concerns you may have. . Resume all of your medications. Your prednisone dose was decreased to 15mg daily. You were started on Keppra due to concerns for seizures. Your EEG was tentatively read as negative. You should continue the Keppra and follow up with Neurology. Followup Instructions: Provider: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2154-3-4] 9:30 Provider: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2154-3-11] 10:00 Provider: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2154-3-18] 10:00 . Follow up with Dr. [First Name (STitle) ] (Neurology). His office number is ([Telephone/Fax (1) 7394]. You have an appointment on [2154-3-18] but he may want to see you sooner. Call his office on Monday. ICD9 Codes: 431, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8844 }	Medical Text: Admission Date: [2199-12-21] Discharge Date: [2200-1-18] Date of Birth: [2135-3-22] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 17813] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: 64 year old male with Hx of cirrhosis [1-20] NASH, DM, HTN, CHF with EF 40%, CAD, seizure disorder, stage IV decubitus ulcer p/w low grade fever and lethargy. Pt was found to have a temp of 99.6 at nursing home on day of admission. the family also thought that the pt was lethargic and may be w/ AMS. he recd tylenol at NH and his temp came down to 98.6. He was brought to the ER . In the ER VS 98.9 81 116/63 16 96/2L. he had a neg head CT. CXR showed new LLL opacity. he recd 1 dose each of vanc and cefepime. . ROS: ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. . Past Medical History: 1. Seizure disorder with Hx of status epilepticus. Recent admission for recurrent seizures & 2 prior admissions in [2197] & [2199-1-18] for status requiring intubation. Has been on multiple antiepileptic drugs. 2. NASH, cirrhosis, hepatocellular carcinoma, recently removed from transplant list [1-20] chronic illness 3. Diabetes mellitus type II 4. Hypothyroidism 5. Hypertension 6. CHF with EF 40% on ECHO in [7-/2198] 7. Coronary artery disease status post cardiac catheterization in [2187] w/o stenting 8. History of upper GI bleed s/p TIPS in [2197] 9. Stage IV sacral decubitus ulcer Social History: Remote tobacco history. No alcohol or illicit drug use. Currently resides at [Hospital 1820] Nursing Home. Family History: Non-contributory Physical Exam: PHYSICAL EXAMINATION: VS: 98.2 150/75 87 22 93/3l GEN: NAD, awake, alert HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear, OP moist and without lesion NECK: Supple, no JVD CV: Reg rate, normal S1, S2. No m/r/g. CHEST: b/l wheezes and rhonchi. ABD: Soft, NT, ND, no HSM EXT: No c/c/e SKIN: maculopapular rash on back Pertinent Results: CXR: IMPRESSION: Study limited due to low inspiration. Bibasilar likely atelectasis although underlying aspiration or pneumonia cannot be excluded. There may be a small left pleural effusion. Head CT: IMPRESSION: No evidence of hemorrhage seen. Appearance of the brain is unchanged from [2199-6-18]. Opacification of visualized right maxillary sinus unchanged. Abdominal U/S: GRAYSCALE IMAGING: The liver demonstrates a heterogeneous echotexture without focal mass lesion detected on this limited evaluation of the hepatic parenchyma. No intra- or extra-hepatic biliary ductal dilatation with the common duct measuring 3 mm. The gallbladder appears unremarkable, without wall thickening or pericholecystic fluid/intraluminal stone. There is splenomegaly with the spleen measuring 17.6 cm. No intra-abdominal ascites. DOPPLER EXAMINATION: Color and pulsed pulse-wave Doppler images were obtained. The main portal vein is patent with normal hepatopetal flow with a velocity of 22 cm/sec. The TIPS shunt is patent with wall-to-wall flow. Velocities of 27, 90 and 94 cm/sec. The splenic vein and SMV are patent. IVC demonstrates patency with triphasic waveforms. IMPRESSION: Normal TIPS evaluation with wall-to-wall flow. No ascites identified. L/SI Spine plain films and Pelvic plain films: Brief Hospital Course: # Respiratory failure: The patient developed respiratory failure during seziure activity and recent HCAP. He was intubated for airway protection and sent to the MICU. He was able to be extubated days later without difficulty. The patient was treated with lasix for diuresis. Sputum cultures were positive for klebsiella, proteus, sensitive to meropenem, zosyn and tobra however most likely contaminent not infection, and the patient was not started on antibiotics as the patient had received vanc/ceftriaxone/flagyl eariler in his hospital course. He was evaluated by pulmonary who felt his tachypnea was likely due to fluid overload. He was diuresed and his respiratory status later stabilized. No further bronchoscopy was recommended as it was unlikely that he laryngeal/tracheal stenosis given his clinical improvement with diuresis. . #Seizure disorder: The patient has a known seizure disorder and hx of NCSE. He again had continuous seizure activity documented by continous EEG monitoring. His home regimen of keppra, zonegran and topamax was increased and ativan, dilantin were added to the regimen. He required dilantin loading on two occassions. His seizures were eventually well controlled and the ativan was weaned off without seizure recurrence under EEG monitoring. His mental status started to improve signficantly and at discharge, he was answering questions briskly, able to state the place but did not know the date, and was eager to leave the hospital. . # Cirrhosis: Secondary to NASH. During his hospital stay his LFTs/bili and coags remained stable. He underwent an abdominal U/S of liver w/ normal TIPS evaluation with wall-to-wall flow. No ascites identified. He was continued on lactulose and rifaxamin. . #. Stage IV sacral decub: No evidence of osteomyelitis per X-ray. Wound care consulted and recommended daily packing. . #DM: The patient was temporarily taken off home lantus as had episodes of hypoglycemia. He was restarted on his home dose of lantus without problem. . #Hypothyroidism: continued home levothyroxine . # Hypernatremia: The patient became transiently hypernatremic during his MICU course. Free water boluses were increased through his tube feeds. The hypernatremia resolved. . # CAD: stress MIBI in [3-25] w/ Fixed, medium sized, severe perfusion defect involving the PDA territory. Increased left ventricular cavity size. Inferior hypokinesis with preserved systolic function. No recent h/o chest pain. Most recent echo with improved EF. . # Pancytopenia: Chronic issue, likely BM suppression or secondary to seizure medications. Trended, remained stable. . #FEN: tube feeds, repleted electrolytes prn, free H20 boluses through tube feeds. #PPX: PPI, lactulose, pneumoboots (no heparin sq given low platelets), aspiration precautions, contact [Name (NI) 70584] #[Name2 (NI) 7092]: Full Code #Communication: with wife [Name (NI) ] ([Telephone/Fax (1) 70585]-home) and [Telephone/Fax (1) 70586]-cell) Medications on Admission: -Topiramate 100 mg Tablet [Hospital1 ] -Metoprolol Tartrate 25 mg [Hospital1 ] -Levetiracetam 500 mg Tablet [Hospital1 ] -Zonisamide 500 mg Capsule qd -Levothyroxine 400 mcg Tablet -Lactulose 10 gram/15 mL prn -Rifaximin 200 mg TID -Lorazepam 0.5 mg HS -Furosemide 40 mg qd -Heparin 5,000 unit/mL tid -Multivitamin qd -Folic Acid 1 mg qd -Lansoprazole 30 mg Tablet,qd -Thiamine HCl 100 mg qd -Insulin Glargine 100 unit/mL Solution [Hospital1 ]: One (1) 60 units Subcutaneous twice a day: Give 60 units at breakfast, 60 units at dinner. -Ascorbic Acid 500 mg [Hospital1 ] -Ipratropium Bromide 0.02 % Solution q6h -Albuterol Sulfate 2.5 mg /3 mL (0.083 %) qid -Silver Sulfadiazine 1 % Cream -Cephalexin 500 mg Capsule Q6H -Zinc Sulfate 220 mg Capsule [Hospital1 ]: One (1) Capsule PO DAILY (Daily). -Nystatin 100,000 unit/mL three times a day. -Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Ophthalmic PRN -Aspirin 325 mg qd -Lidocaine HCl 2 % Gel [Hospital1 ]: One (1) Appl Mucous membrane PRN -Oxycodone 5 mg Tablet [Hospital1 ]: 0.5 Tablet PO Q4H (every 4 hours) -Clotrimazole 1 % Cream [Hospital1 ]: One (1) application Topical twice a day as needed for facial rash for 3 weeks. Discharge Medications: 1. Levothyroxine 100 mcg Tablet [Hospital1 ]: Four (4) Tablet PO DAILY (Daily). 2. Rifaximin 200 mg Tablet [Hospital1 ]: Two (2) Tablet PO TID (3 times a day). 3. Therapeutic Multivitamin Liquid [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 5. Thiamine HCl 100 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 6. Ascorbic Acid 500 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 7. Zinc Sulfate 220 mg Capsule [Hospital1 ]: One (1) Capsule PO DAILY (Daily). 8. Aspirin 325 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 9. Oxycodone 5 mg Tablet [Hospital1 ]: 0.5 Tablet PO Q6H (every 6 hours) as needed: before sacral ulcer dressing. 10. Nystatin 100,000 unit/mL Suspension [Hospital1 ]: Five (5) ML PO TID (3 times a day). 11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 12. Miconazole Nitrate 2 % Powder [Last Name (STitle) ]: One (1) Appl Topical TID (3 times a day) as needed for tinea cruris. 13. Levetiracetam 1,000 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO BID (2 times a day). 14. Keppra 250 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO twice a day. 15. Zonisamide 100 mg Capsule [Last Name (STitle) ]: Six (6) Capsule PO DAILY (Daily). 16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Last Name (STitle) ]: One (1) neb Inhalation Q4H (every 4 hours) as needed for wheeze. 17. Ipratropium Bromide 0.02 % Solution [Last Name (STitle) ]: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheeze. 18. Erythromycin 5 mg/g Ointment [Last Name (STitle) ]: One (1) application Ophthalmic QID (4 times a day). 19. Lactulose 10 gram/15 mL Syrup [Last Name (STitle) ]: Fifteen (15) ML PO TID (3 times a day): titrate to [1-21] BM per day. 20. Phenytoin 50 mg Tablet, Chewable [Month/Day (3) ]: Four (4) Tablet, Chewable PO DAILY (Daily): Give in AM. 21. Phenytoin 50 mg Tablet, Chewable [Month/Day (3) ]: Six (6) Tablet, Chewable PO DAILY (Daily): Give 8 pm. 22. Topiramate 100 mg Tablet [Month/Day (3) ]: Three (3) Tablet PO BID (2 times a day). 23. Povidone-Iodine 10 % Solution [Month/Day (3) ]: One (1) Appl Topical DAILY (Daily): apply to PEG tube insertion site. 24. Insulin Glargine 100 unit/mL Cartridge [Month/Day (3) ]: Thirty Eight (38) Units Subcutaneous at bedtime. 25. Insulin Regular Human 300 unit/3 mL Insulin Pen [Month/Day (3) ]: 11-32 units Subcutaneous three times a day: Per sliding scale: FS 71-100, 11 Units FS 101-150, 17 Units FS 151-200, 20 Units FS 201-250, 24 Units FS 251-300, 28 Units FS 301-350, 32 Units. Discharge Disposition: Extended Care Facility: [Hospital1 ] Village Discharge Diagnosis: increased seizure frequency in the context of PNA Secondary Dx: NASH DM refractory seizures recurrent hepatic encephalopathy Discharge Condition: stable; baseline MS difficulty with some memory and attention deficits. Distal extremity contractures, and asteryxis. Discharge Instructions: You were admitted with worsening seizures and mental status in the context of acquiring a pneumonia. You required temporary intubation and were treated with antibiotics. Your seizures were controlled with a combination of anti-epileptic medicines, which you should continue. Please return to the ER if you experiece any worsening of your seizure frequency, develop new types of seizures, develop changes in mental status, weakness, changes in sensation, vision, or language, and severe headaches, vertigo, or anything else that concerns you seriously. Followup Instructions: Follow up with neurologist Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]; call ([Telephone/Fax (1) 70587] for appt Completed by:[2200-1-18] ICD9 Codes: 486, 5119, 2760, 4280, 4019, 2449, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8845 }	Medical Text: Admission Date: [2178-9-23] Discharge Date: [2178-9-25] Date of Birth: [2127-4-7] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 13256] Chief Complaint: Anemia Major Surgical or Invasive Procedure: none History of Present Illness: 51yoM with h/o etoh cirrhosis, complicated by diuretic refractory ascites requiring paracentesis and recurrent hepatic hydrothorax requiring thoracentesis, also SBP and HE, who is admitted for s/p thoracentesis and paracentesis today presenting with abnormal labs including hyponatremia, elevated creatinine, and low HCT. He underwent a paracentesis and thoracentesis this afternoon, with approx. 5.4 liters of fluid drained. He subsequently received 50g of albumin. His labs from the AM prior to his paracentesis and albumin showed a creatinine was 1.6 up from 1.3 and patients sodium was 126 down from 133. Dr. [Last Name (STitle) ] was notified, and requested admission for further albumin replacement. Patient did receive dose of Dilaudid 2mg for abdominal pain (patient has standing dose of 2mg every 8 hours for pain) pain was initially a [8-11] now [4-11]. At that time, his vitals were 98.3, 122/70, 84, 18 100%. In the ED, initial VS were 97.8 86 111/62 18 100%. Labs notable for U/A with trace leuks and few bacteria, Na 128, K 5.2, Cl 95, BUN 58, Cr 1.5, HCT 26.6, Plt 37, T bili 4.6, INR 2.3. EKG was unchanged, and CXR to my read showed a decreased R sided pleural effusion. The patient subsequently underwent a CT-non con to assess for bleeding, which showed large volume ascites but no evidence of hemorrhage, as well as fluid containing umbilical and right inguinal hernia. The patient was guiaic negative per the ED, and also received 1 mg Dilaudid, as well as 1 U plt and 1 U plasma. When he was admitted prevoiusly from [8-12] - [8-14], he admitted for [Last Name (un) ] with Cr 2.0 from baseline 1.3 after 4 L paracentesis. For his [Last Name (un) ] at that time, he was given Albumin 1g/kg x 48 hours, and his home diuretics and nadolol were stopped. He was also found to have an Enterococcal UTI from UCx on [2178-8-7] patient was continued on Amoxicillin, which is set to finish on [2178-8-16]. His hyponatremia at the time was treated with a low Na diet, fluid restriction to 2L, Albumin, and tube feeds. On arrival to the MICU, he is AAOx3 without encephalopathy. He does have diffuse abdominal pain [6-11]. (+) Per HPI, endorses weight loss and sore throat after Dobhoff placement. (-) Denies fever, chills, night sweats, recent weight 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: -Alcoholic cirrhosis --diuretic refractory ascites requiring paracentesis --recurrent hepatic hydrothorax requiring thoracentesis --HRS type I ([6-/2178]) following LBP --malnutrition requiring dophoff tube placement -Kidney stones -Esophageal varices -Renal insufficiency -Hypertension Social History: He lives with his girlfriend and is divorced. Patient previously drank eight to 10 beers a night for 10 years up till [Month (only) 359] [2177]. Patient previously smoked cigarettes but quit years ago. He denies any illicit drug use. Family History: Non-contributory Physical Exam: ADMISSION EXAM AAOx3. Caucasian male in NAD. Slight jaundice. Interacting appropriately. HEENT: Sclera mildly icteric CARDIAC: RRR, 2/6 SEM appreciated LUNGS: Unlabored breathing. Speaking in full sentences. Decreased breath sounds on the left lower and mid lung. CHEST: Mild gynecomastia. Striae in axilla b/l. Slight jaundice. L thoracentesis site with mildly bloody bandage ABDOMEN: Striae in suprapubic area. Flank protrusion. Distended, Soft, non-tender. Dullness to percussion diffusely. R para site is C/D/I with new bandage. EXTREMITIES: 1+ B LE edema. 2+ pulses. NEUROLOGY: A+Ox3, no asterixes DISCHARGE EXAM: GENERAL: Well appearing 51yo M/F who appears stated age. Comfortable, appropriate and in good humor. HEENT: Sclera icteric. PERRL, EOMI. NECK: Supple with low JVP CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, S1 S2 clear and of good quality without murmurs, rubs or gallops. No S3 or S4 appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, moving air well and symmetrically. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Mildly distended but Soft. Mild diffuse TTP. Dullness to percussion over dependent areas but tympanic anteriorly. No HSM or tenderness. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+ [Location (un) ] bilaterally to knees. Pertinent Results: ADMISSION LABS [2178-9-23] 12:00PM PT-24.4* INR(PT)-2.3* [2178-9-23] 12:00PM PLT COUNT-62# [2178-9-23] 12:00PM WBC-6.2# RBC-3.29 HGB-11.1* HCT-31.8* MCV-97 MCH-33.9* MCHC-35.1* RDW-16.1* [2178-9-23] 12:00PM ETHANOL-NEG [2178-9-23] 12:00PM ALBUMIN-3.5 [2178-9-23] 12:00PM TOT BILI-4.6* [2178-9-23] 12:00PM estGFR-Using this [2178-9-23] 12:00PM GLUCOSE-105* UREA N-62* CREAT-1.6* SODIUM-126* POTASSIUM-5.7* CHLORIDE-94* TOTAL CO2-25 ANION GAP-13 [2178-9-23] 12:00PM GLUCOSE-105* UREA N-62* CREAT-1.6* SODIUM-126* POTASSIUM-5.7* CHLORIDE-94* TOTAL CO2-25 ANION GAP-13 [2178-9-23] 06:40PM PLT COUNT-37* [2178-9-23] 06:40PM NEUTS-68.4 LYMPHS-11.0* MONOS-16.5* EOS-3.8 BASOS-0.4 [2178-9-23] 06:40PM WBC-4.3 RBC-2.76* HGB-9.0* HCT-26.6* MCV-96 MCH-32.7* MCHC-33.9 RDW-16.2* [2178-9-23] 06:40PM OSMOLAL-283 [2178-9-23] 06:40PM ALBUMIN-3.9 [2178-9-23] 06:40PM ALT(SGPT)-23 AST(SGOT)-59* ALK PHOS-196* DIR BILI-1.3* [2178-9-23] 06:40PM GLUCOSE-99 UREA N-58* CREAT-1.5* SODIUM-128* POTASSIUM-5.2* CHLORIDE-95* TOTAL CO2-24 ANION GAP-14 [2178-9-23] 06:43PM URINE RBC-1 WBC-4 BACTERIA-FEW YEAST-NONE EPI-0 [2178-9-23] 06:43PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-TR [2178-9-23] 06:43PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.010 [2178-9-23] 08:10PM HCT-25.1* [2178-9-23] 08:14PM URINE OSMOLAL-366 [2178-9-23] 08:14PM URINE HOURS-RANDOM UREA N-607 CREAT-43 SODIUM-<10 POTASSIUM-63 CHLORIDE-10 [2178-9-23] 09:10PM HCT-25.2* . Discharge Labs: [2178-9-25] 06:15AM BLOOD WBC-3.4* RBC-2.49* Hgb-8.3* Hct-23.9* MCV-96 MCH-33.3* MCHC-34.6 RDW-16.2* Plt Ct-46* [2178-9-25] 06:15AM BLOOD PT-25.7* PTT-52.7* INR(PT)-2.5* [2178-9-25] 06:15AM BLOOD Glucose-115* UreaN-63* Creat-1.6* Na-131* K-5.0 Cl-98 HCO3-27 AnGap-11 [2178-9-25] 06:15AM BLOOD ALT-20 AST-48* AlkPhos-136* TotBili-3.8* [2178-9-25] 06:15AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.4 [2178-9-25] 06:15AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.4 . Imaging: CT abd/pelvis [2178-9-23]: IMPRESSION: Cirrhosis, splenomegaly, anasarca and mesenteric edema. Large volume ascites without signs of acute hemorrhage. Right fluid-filled inguinal hernia and fluid-filled umbilical hernia. Left pleural effusion with compressive atelectasis. . Micro: [2178-9-24] Blood Culture, Routine-PENDING [2178-9-24] Blood Culture, Routine-PENDING Brief Hospital Course: 51yoM with h/o etoh cirrhosis, complicated by diuretic refractory ascites requiring weekly paracentesis and recurrent hepatic hydrothorax requiring thoracentesis. Also h/o SBP and HE. Admitted s/p thoracentesis and paracentesis [3-5] hyponatremia, elevated creatinine, and low HCT. . Active Issues: # Anemia: Baseline HCT is 25, and patient has had bloody taps as evidenced by prior taps in our system. Information from most recent ascitic fluid was not sent. Hct is 25, which is at his baseline between 23-28; ED values of 31 and 33 are likely spurious. No signs or symptoms of GI bleeding during ED or clinic visit. His Hct were trended and he required no transfusions while in the MICU. His Hct remained unchanged on the floor and was deemed stable at discharge. . # Hyponatremia: Likely was secondary to hyponatremia from hypervolemia, and mild improvement with paracentesis. Urine lytes show FeNa 0.27% and FeUrea 365%. He was given albumin and placed on a fluid restriction. Na improved with 1.5L fluid restricition. No diuretics were given, as these have been held in the past [3-5] kidney and electrolyte abnormalities. . Chronic Issues: # Cirrhosis: EtOH Cirrhosis with history of recurrent ascites, right hydrothorax, esophageal varices, hepatic encephalopathy, and SBP in the past. MELD 26 on admission. Patient does have HCC providing points via [Location (un) 6624] criteria. Rifaximin and lactulose for HE ppx given. Nadolol 10mg qday given for h/o varices. Tube feeds currently in place and were continued. . # Thrombocytopenia: Secondary to underlying liver disease. did not receive platelet transfusion while in MICU. . # CKD: Cr unchanged from prior labs. Likely 2/2 HRS 2. Patient was given albumin and his electrolytes were trended and repleted. . Transitional Issues: #Lytes check in 1 week #COntinue VNA and tube feeds at home #Follow-up blood cultures Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Ciprofloxacin HCl 500 mg PO Q24H 2. FoLIC Acid 1 mg PO DAILY 3. Lactulose 30 mL PO QID 4. Omeprazole 40 mg PO DAILY 5. Rifaximin 550 mg PO BID 6. Thiamine 100 mg PO DAILY 7. Nadolol 10 mg PO DAILY 8. Isosource 1.5 Cal NF (lactose-free food with fiber) 55 ml/hr Oral Daily 55 ml/hr 9. HYDROmorphone (Dilaudid) 2 mg PO Q8H:PRN pain Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q24H 2. FoLIC Acid 1 mg PO DAILY 3. HYDROmorphone (Dilaudid) 1-2 mg PO Q4H:PRN pain hold for sedation, RR < 10 4. Lactulose 30 mL PO TID 5. Nadolol 10 mg PO DAILY 6. Omeprazole 40 mg PO DAILY 7. Rifaximin 550 mg PO BID 8. Thiamine 100 mg PO DAILY 9. Isosource 1.5 Cal NF (lactose-free food with fiber) 55 ml/hr Oral Daily 55 ml/hr Discharge Disposition: Home With Service Facility: [Location (un) 6138] Home Care Services Discharge Diagnosis: Primary diagnosis: hyponatremia acute kidney injury alcoholic cirrhosis Secondary diagnosis: hepatocellular carcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure caring for you at [Hospital1 18]. You were admitted after a procedure where fluid was drained from your abdomen and chest. After the procedure, your kidney function was minimally decreased. We believed that your red blood cells were also decreased. You were admitted to the ICU where you were given fluid through your veins. This helped improve your kidney function. It was determined that your blood cell count had not actually decreased, it was just diluted with fluid. At discharge your kidney function and red blood cell counts were at a normal level for you. You also had a low sodium on admission. Your underlying liver disease predisoposes you to this condition. Please restrict your [Last Name (un) 1534] fluid intke to 1.5L of water per day. This will help keep your sodium normal. If you restrict yourself to less than 1L of water/day, you may worsen your kidney function. You have a follow-up appointment in the liver center on [2178-9-30]. They will check your electrolytes and make sure that your kidney function continues to improve. There were NO medication changes on this admission Followup Instructions: Department: TRANSPLANT When: WEDNESDAY [2178-9-30] at 11:00 AM With: TRANSPLANT [Hospital 1389] CLINIC [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage This appointment replaces the appointment with Dr. [Last Name (STitle) ] for [10-8**] which was cancelled. ICD9 Codes: 2859, 2761, 5849, 5859, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8846 }	Medical Text: Admission Date: [2121-12-10] Discharge Date: [2121-12-15] Date of Birth: [2063-3-22] Sex: M Service: CARDIOTHORACIC SURGERY CHIEF COMPLAINT: Increased dyspnea on exertion. HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old male with a one-year history of increasing dyspnea on exertion and a positive exercise tolerance test with evidence of previous inferior wave myocardial infarction by echocardiogram. He presented to the [Hospital6 256] for elective cardiac catheterization on [2121-12-3]. His cardiac catheterization at that time showed an ejection fraction of 56% with 70-80% occlusion of the right posterior descending artery, 100% occlusion at the right posterior lateral artery, 60% occlusion of the left main coronary artery, 40% occlusion of the lymphadenopathy coronary artery, and 70% occlusion of the obtuse marginal 1 coronary artery. Due to these results, the patient presented to the [Hospital6 1760] for elective coronary artery bypass grafting on [2121-12-10]. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Polio as a child. 4. Remote tobacco use; quit in [2110]. 5. Status post L2-3 spinal fusion in [2118]. 6. Status post deep venous thrombosis. 7. Status post IVC filter placement. 8. Chronic right lower extremity edema. 9. Status post silent inferior wave myocardial infarction. 10. Abnormal PFTs. MEDICATIONS ON ADMISSION: Aspirin 325 mg once per day, Lopressor 25 mg twice per day, Lipitor 15 mg once per day, Multivitamin. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: The patient reported remote tobacco use which he quit in [2110]. PHYSICAL EXAMINATION: General: The patient was a pleasant 58-year-old male in no acute distress. Vitals signs: Heart rate 63 in sinus rhythm, blood pressure 118/64, oxygen saturation in room air at 95%. HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular movements intact. Neck: Supple with 2+ palpable carotid pulses and no bruits. Heart: Regular, rate and rhythm. No murmurs, rubs, or gallops. Lungs: Clear to auscultation bilaterally. No wheezing, rales or rhonchi. Abdomen: Soft, nontender, nondistended. No palpable masses. No hepatosplenomegaly. Extremities: Warm and well perfused with no apparent edema or varicosities. Pulse: He was found to have 2+ palpable femoral, popliteal, dorsalis pedis, posterior tibial and radial pulses bilaterally. Neurological: Cranial nerves II-XII grossly intact. There were no apparent motor or sensory deficits. HOSPITAL COURSE: The patient was admitted to the Operating Room on [2121-12-10], where he underwent a coronary artery bypass graft times five. Please refer to the dictated operative note for full details of this procedure. He tolerate the procedure and without complication and was transferred postoperatively to the Cardiac Surgical Intensive Care Unit. At the time of transfer, the patient was on a Propofol drip at 10 mcg/kg/min. Once in the Intensive Care Unit, he was found to have labile blood pressures and was hypotensive with stimulation. This prompted use intermittently of a Neo-Synephrine drip to maintain his mean arterial pressure greater than 70. He was also volume resuscitated at this time. He was found to have high sanguinous output from his chest tubes later that evening and an activated coagulation time of 123 and was at this time reversed with 50 mg of Protamine and 1 U of platelets. He was found to have a stable hematocrit and platelet count. The patient was weaned from the ventilator and extubated without difficulty. His chest tube output also began to slow down to approximately 20-30 cc/hr of serosanguinous drainage. During postoperative day #1, his blood pressure remained stable, and he was able to be weaned off of Neo-Synephrine drip. On postoperative day #2, the patient was deemed stable and ready for transfer to the regular patient floor. He was transferred subsequently later on postoperative day #2. His chest tubes were discontinued without incident on postoperative day #2 as well. The patient continued to improve over the next couple of days on the floor, and was working with Physical Therapy. He was able to regain a certain degree of strength and mobility. It was felt on postoperative day #3, that when medically stable, he would be ready for discharge home. On postoperative day #5, it was deemed that the patient was stable and ready for discharge home. He was discharged home with VNA services. At the time of discharge, the patient was in no acute distress with a rate in the 70s and in sinus rhythm showing no ectopy. His blood pressure was stable, and his room air oxygen saturation had improved to 96%. His showed a regular, rate and rhythm with no murmurs, rubs, or gallops. His lungs were clear to auscultation bilaterally with slightly decreased breath sounds at his bases bilaterally. His abdomen was soft, nontender, nondistended with no palpable masses and no hepatosplenomegaly. The patient was voiding without difficulty. His extremities were warm, dry and well perfused with no edema. His sternal incision was healing nicely with no drainage and dressing was clean, dry, and intact. DISCHARGE MEDICATIONS: Zantac 150 mg twice per day, Enteric Coated Aspirin 325 mg once per day, Lipitor 15 mg once per day, Lopressor 37.5 mg twice per day, Lasix 20 mg twice per day x 10 days, Potassium Chloride 20 mEq by mouth twice per day for 10 days, Dilaudid 2-4 mg by mouth every 4-6 hours as needed for pain, Colace 100 mg by mouth twice per day. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: 1. Coronary artery disease. 2. Status post coronary artery bypass grafting times five on [2121-12-10]. 3. Hypertension. 4. Hypercholesterolemia. 5. Status post polio as a child. 6. Past tobacco use. 7. L2-3 spinal fusion in [2118]. 8. Deep venous thrombosis. 9. Status post IVC filter placement. 10. Chronic right lower extremity edema. 11. Past silent inferior wave myocardial infarction. FOLLOW-UP: The patient is to follow-up in the [Hospital 409] Clinic in approximately two weeks. Follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1537] was scheduled for four weeks post discharge. It was told to the patient that he should follow-up with his cardiologist in the next 1-2 weeks, and with his primary care physician soon thereafter. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Dictator Info 13817] MEDQUIST36 D: [2122-2-4] 14:50 T: [2122-2-4] 14:50 JOB#: [Job Number 13818] ICD9 Codes: 4019, 2720, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8847 }	Medical Text: Admission Date: [2157-6-11] Discharge Date: [2157-6-18] Service: MEDICINE Allergies: All drug allergies previously recorded have been deleted Attending:[First Name3 (LF) 783] Chief Complaint: hypotension Major Surgical or Invasive Procedure: none History of Present Illness: [Age over 90 ]F diastolic CHF (EF 55%), CAD, CRI, Afib who presented to ED in acute respiratory distress. Most recently hospitalized at [Hospital1 2177] for nausea/vomiting/dehydration, then received IVF putting patient into acute CHF, requiring intubation in [Month (only) 547] this year. <BR> Otherwise, USOH until this week, when she began to complain of some mild difficulty breathing. Was felt by her PCP to have COPD exacerbation and increased baseline prednisone dose of 5QOD to 30mg QD two days prior to admission. Seen by PCP at home who continued to feel this was "bronchitis" - unclear if [Name (NI) ] prescribed at this point. Did well through evening prior to admission (apparently prepared a meal for 5 people), then at 1AM on day of admission, began to have acute shortness of breath. Was given nebs and supplemental O2 by home health aide. <BR> After 1.5 hours, did not improve, and was brought by ambulance to [Hospital1 18] ED, found to have systolic BP in 230s, low grade temp 100.2. Given Lasix, nitroglycerin, found to have ABG of 7.03/89/334 on BiPAP, and consequently was intubated (Etomidate/Rocuronium). Nitro was initially to 333mcg at 0430, then downtitrated as SBP came down to 122-> was found to be agitated while intubated and given Versed 2mg-> subequently SBP down to 40/palp. Started on Dopamine 20mcg/kg with improvement of BP to 97/44. Given total of 5 liter NS. and urine output 930cc over ED stay. Otherwise, given vanco/levo/flagyl, decadron 6. Past Medical History: -CHF- ECHO [12-12] EF 50-55% with mild MR [First Name (Titles) ] [Last Name (Titles) 10225] -Coronary Artery Disease, LAD stent [5-13] -Paroxysmal Atrial Fibrillation -Asthma -s/p thyroid sx -Diverticulitis -Hypercholesterolemia -Right Hip Fracture -History of [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] tears -Chronic Renal Insufficiency Social History: -Lives in apartment with 24 hour home care. Able to walk with walker at home, but uses wheelchair when leaving the house. Daughter is main caregiver in terms of administering medications. Ambulates with a walker. Smoked in her teens but none since. Rare EtOH use. Family History: Non-contributory Physical Exam: GENERAL: Intubated, but awake, NAD. HEENT: PERRL, EOMI, OMMM. NECK: JVP , Supple, no LAD. CARDIOVASCULAR: S1, S2, reg, LUNGS: Anterior exam- clear, but basilar rales. ABDOMEN: Active bowel sounds, Soft, NT, ND EXTREMITIES: Warm, no CCE. NEURO: Awake, and alert, able to mouth words in response to questions. Moving all four. Pertinent Results: [2157-6-11] 04:53AM LACTATE-3.0* [2157-6-11] 05:00AM PT-11.0 PTT-21.6* INR(PT)-0.9 [2157-6-11] 05:00AM WBC-26.3# RBC-4.52# HGB-13.6# HCT-41.3# MCV-91 MCH-30.0 MCHC-32.9 RDW-14.3 [2157-6-11] 05:00AM NEUTS-72 BANDS-18* LYMPHS-6* MONOS-2 EOS-0 BASOS-0 ATYPS-1* METAS-1* MYELOS-0 [2157-6-11] 05:00AM cTropnT-<0.01 [2157-6-11] 05:00AM CK(CPK)-77 [2157-6-12] 04:09AM BLOOD WBC-11.8* RBC-4.09* Hgb-12.2 Hct-38.0 MCV-93 MCH-29.7 MCHC-32.0 RDW-14.9 Plt Ct-315 [2157-6-18] 06:00AM BLOOD WBC-10.1 RBC-4.31 Hgb-12.6 Hct-38.2 MCV-89 MCH-29.2 MCHC-32.9 RDW-15.2 Plt Ct-318 [2157-6-18] 06:00AM BLOOD Glucose-98 UreaN-53* Creat-1.8* Na-143 K-3.9 Cl-104 HCO3-28 AnGap-15 [2157-6-14] 04:11AM BLOOD Glucose-156* UreaN-59* Creat-2.1* Na-142 K-3.6 Cl-110* HCO3-22 AnGap-14 [2157-6-12] 04:09AM BLOOD Glucose-103 UreaN-47* Creat-2.2* Na-141 K-4.4 Cl-106 HCO3-22 AnGap-17 [2157-6-11] 02:44PM BLOOD Cortsol-22.4* [2157-6-17] 04:30AM BLOOD Vanco-14.9* Brief Hospital Course: [Age over 90 ]F diastolic dysfunction, CRI, COPD/Asthma, here w/ respiratory failure and hypotension. * HYPERCARBIC RESP FAILURE: Multifactorial, due to MRSA pneumonia and COPD flare, with likely CHF due to flash pulmonary edema due to hypertensive urgency and large volume resuscitation in the ED given sepsis protocol. Pt was intubated in the ED given her hypercarbia with a pCO2 of 89 on admission. Pt improved her ventilation and oxygenation while intubated after treatment with IV Vanco, steroids and azithromycin. Pt was extubated on HD#3 and did well post-extubation. Her steroids were tapered to fairly quick PO prednisone taper given the findings of her cosyntropin test which showed a brisk adrenal response. Her nebulizer treatments were continued as needed and steroid was tapered off. Pt was discharged to finish 14d-course vancomycin for MRSA pneumonia. However, by a mistake, a VNA arrangement was not confirmed at her time of discharge on [6-18]. Pt was discharged without a VNA arrangement for vanc administration/PICC care and did not receive a dose of vancomycin prior to discharge. The pt returned to the hospital the next day for vancomycin. Vancomycin 1g was given on [6-19] and was discharged home again after receiving vancomycin. . * Hypotension/hypertension: Pt intially hypertensive in the ED to 230s, and was aggressively treated with NTG gtt, and became hypotensive in the ED and with suspected infectious etiology, was placed on sepsis protocol, and had a CVL placed in the ED and received large volume resuscitation. Likely represented aspect of hypovolemia along with element of sepsis along with aggressive iatrogenesis with her IV NTG gtt(her MVo2 remained >70% and cardiogenic shock was thought unlikely). Pt was placed on levophed in the ED to help maintain her MAP >65, which was weaned after HD#2 as her BPs allowed. She became hypertensive after her sepsis had corrected and her antihypertensive regimen was reinitiated with metoprolol 75mg TID, hydralazine and imdur. However, given she only had mild MR, no systolic dysfunction on [Month/Year (2) ], and inconvenient hydralazine dose frequency, hydralazine and imdur were discontinued. . * CRI: At her baseline with good UOP. . #. CAD: s/p stenting in [2153]. Continued asa, lipitor, BB. . #. h/o PAF: Continued BB, not coumadin candidate given h/o falls and diverticular bleeds. . # Hypothyroidism: Continued synthroid 88mc qday. * FEN: NPO while intubated. After extubation, started diet as tolerated to cardiac diet. . * ACCESS: RIJ placed in ED - no checklist. Was removed and L subclavian was placed in the ICU. This was removed once her inital sepsis resolved. . * Prophylaxis: SQH, PPI, bowel regimen. Because pt gets constipated easily, pt wanted mag citrate rx at the time of 2nd discharge. . * CODE: Full . * Comm: Daughter [First Name4 (NamePattern1) ] [Name (NI) ] [Telephone/Fax (1) 10235] H, [Telephone/Fax (1) 10236] C Medications on Admission: Protonix 40 Synthroid 88 Senna Metoprolol 50 TID Albuterol SLNTG 0.3 Lactulose Dulcolax Aspirin EC 325 Nystatin Advair Colchicine 0.6 QOD Prednisone 5 QOD Aranesp 40 Iron 325 Lipitor 20 Colace Lasix 80 QD MVI Discharge Medications: 1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for constipation. 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation every six (6) hours. Disp:qs for 1month Refills:0 11. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO every other day. 12. Ferrous Sulfate 325 (65) mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Multivitamins Tablet, Chewable Sig: One (1) Cap PO DAILY (Daily). 15. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 7 days. Disp:qs 7 days Refills:0 16. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 17. PICC care PICC care per CCS protocol 18. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day) as needed for joint pain. 19. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. Disp:qs 2 weeks Refills:0 20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. Disp:qs 2 weeks Refills:0 21. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO three times a day. Disp:135 Tablet(s) Refills:2 22. Aranesp 40 mcg/0.4 mL Syringe Sig: One (1) syringe Injection every other week. 23. Senna 187 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary diagnoses: Congestive heart failure exacerbation Pneumonia Chronic obstructive pulmonary disease exacerbation Secondary diagnoses: Coronary artery disease Chronic renal insufficiency Discharge Condition: Stable Discharge Instructions: Return to emergency department or call your primary care physician if you develop fevers, chills, worsening cough, chest pain, shortness of breath, or any other worrisome symptoms. Take medications as instructed and Dr. [Last Name (STitle) 10237] will come see you at home. Followup Instructions: Dr. [Last Name (STitle) ] will come to your house and see you next week. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799] ICD9 Codes: 4280, 2760, 2724, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8848 }	Medical Text: Admission Date: [2162-9-27] Discharge Date: [2162-10-6] Date of Birth: [2099-1-30] Sex: M Service:Urology HISTORY OF PRESENT ILLNESS: The patient is a 63 year-old man who was determined to have high grade meso invasive transitional cell carcinoma of the bladder, which was extending superficially into the prostatic urethra. He was admitted for surgery. On [9-27] he underwent a radical ileal loop. There was no operative evidence of metastatic disease. Surgery went well and he was then put in the Intensive Care Unit for monitoring and management. It was noted that he had respiratory insufficiency and remained intubated and also on pressor agents. The respiratory insufficiency was felt to be most likely related to volume overload. He was also hypotensive and this was felt to known to be diabetic and had to be monitored in this respect. He remained intubated in the Intensive Care Unit and his pressor agents were gradually stopped. He did have postoperative fever and was treated with Ampicillin, Gentamycin and Flagyl. He remained intubated until postoperative day four. He appeared to be somewhat encephalopathic following extubation and he remained in the Intensive Care Unit. He had excellent output from his urostomy. His mental status improved and he was transferred to the floor. He did have prolonged ileus and did not start a diet until [10-3]. By [10-6] he was in very stable condition except for some diarrhea. His abdomen seemed distended, but was nontender. His ostomy was healthy and pink. A stool specimen was sent for C-difficile titers and he was discharged to home. DISCHARGE DIAGNOSES: 1. Transitional cell carcinoma of the bladder. 2. Noninsulin dependent diabetes. 3. History of hypothyroidism. 4. Coronary artery disease status post CABV in [2155]. 5. Hypertension. OTHER HOSPITAL DIAGNOSES: 1. Postoperative respiratory insufficiency. 2. Postoperative metabolic encephalopathy. 3. Prolonged postoperative ileus. PROCEDURES: Bilateral pelvic lymphadenectomy, radical cystectomy with en block urethrectomy, creation of ileo conduit [9-27] Dr. [Last Name (STitle) 9125], assistant Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 44278] and Dr. [First Name (STitle) ]. DISCHARGE CONDITION: Satisfactory. DISCHARGE MEDICATIONS: Percocet for pain. Resume preoperative medications. FOLLOW UP: Follow up to be provided through our office and VNA. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], MD [MD Number(1) 13269] Dictated By:[Last Name (NamePattern1) 44279] MEDQUIST36 D: [2163-1-11] 05:31 T: [2163-1-14] 07:19 JOB#: [Job Number 44280] ICD9 Codes: 4019, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8849 }	Medical Text: Admission Date: [2114-5-14] Discharge Date: [2114-5-19] Date of Birth: [2046-1-15] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Angina/Dyspnea on exertion Major Surgical or Invasive Procedure: [2114-5-15] - CABGx1(Left internal mammary artery->Left anterior descending artery), AVR(23mm [Company 1543] Mosaic Porcine Valve) History of Present Illness: 68 y/o gentleman with known CAD/AS with increased DOE over the past several months. Seen originally on [2114-2-27] at the time of his cardiac catheterization and again on [2114-3-15] to discuss surgery. He is admitted today, one day prior to surgery, for intravenous heparin as he stopped coumadin 5 days prior. He takes coumadin for AF however has not had any AF since [3-11]. Past Medical History: AF s/p cardioversions and Pulmonary vein isolation AS CAD Social History: Retired. Never smoked. Lives with wife. 1 alcoholic beverage daily. Family History: None Physical Exam: 64 SR 12 122/68 124/74 70" 200lbs GEN: NAD SKIN: Unremarkable HEENT: PERRL, EOMI, Anicteric sclera, OP Benign NECK: Supple, FROM, No JVD LUNGS: CTA HEART: RRR, III/VI harsh SEM ABD: S/NT/ND/NABS EXT: Warm, well perfused. No edema. No varicosities NEURO: Nonfocal. Pertinent Results: [2114-5-15] ECHO PRE CPB 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. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (area <0.8cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild posterior leaflet (P2) prolapse. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results in the operating room at the time of the study. POST CPB Normal biventricular systolic function. Bioprosthesis in aortic position is well seated. The leaflets are not well seen. There is trace valvular aortic regurgitation. At a cardiac output of 7 liters/min, the peak gradient across the aortic valve is 27 mm Hg with a mean pressure of 20 mm Hg and an effective valve area of 1.2 cm2. There remains mild mitral regurgitation. The thoracic aorta appears intact. RADIOLOGY Final Report CHEST (PORTABLE AP) [2114-5-16] 3:55 PM CHEST (PORTABLE AP) Reason: eval ptx s/p CT d/c [Hospital 93] MEDICAL CONDITION: 68 year old man S/p cabg/avr REASON FOR THIS EXAMINATION: eval ptx s/p CT d/c CHEST RADIOGRAPH INDICATION: Followup. COMPARISON: [2114-5-15]. As compared to the previous examination, the central venous access line, the endotracheal tube, and the drains have been removed. As a consequence, the lung volumes are slightly lower than before. The retrocardiac atelectasis has decreased in extent. There is no evidence of pneumothorax. No newly occurred parenchymal opacities. The remaining radiographic aspect is unchanged. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4130] Approved: WED [2114-5-16] 5:30 PM [2114-5-18] 05:30AM BLOOD WBC-6.3 RBC-3.78* Hgb-11.6* Hct-33.7* MCV-89 MCH-30.8 MCHC-34.5 RDW-12.7 Plt Ct-162 [2114-5-19] 07:15AM BLOOD PT-13.3 INR(PT)-1.1 [2114-5-18] 05:30AM BLOOD Glucose-121* UreaN-20 Creat-1.0 Na-133 K-4.4 Cl-100 HCO3-26 AnGap-11 Brief Hospital Course: Mr. [Known lastname 11753] was admitted to the [Hospital1 18] on [2114-5-15] for surgical management of his aortic valve disease and coronary artery disease. Heparin was started as he had been off coumadin for five days. Mr. [Known lastname 11753] was worked-up in the usual preoperative manner and was ready for surgery. On [2114-5-15], Mr. [Known lastname 11753] was taken to the operating room where he underwent coronary artery bypass grafting to one vessel and an aortic valve replacement using a tissue prosthesis. Please see operative note for details. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. Within 24 hours, Mr. [Known lastname 11753] had awoke neurologically intact and was extubated. A betablocker, statin and aspirin were resumed. Coumadin was not resumed as he had not had atrial fibrillation since [2112-3-5] and a tissue valve was used. Later on postoperative day one, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Beta blockade titrated. Went into rapid A fib on POD #2. Amiodarone started and coumadin restarted. Cleared for discharge to home with services on POD #4 in stable condition. The coumadin clinic at [Hospital3 3583] will continue to follow his coumadin and this was discussed with [Doctor First Name ]. Of note, the pt. states that he cannot take any lipid lowering agents because of severe muscle pain. He will discuss this with his cardiologist at his next appointment. Medications on Admission: Coumadin 5mg Daily Aspirin 81mg daily Amoxicillin 2g PRN dental procedures Discharge Medications: 1. Outpatient Lab Work INR to be drawn on Monday [2114-5-21] with results sent to the coumadin clinic at [Hospital3 3583] ([Telephone/Fax (1) 65418]. INR goal of [1-6].5. Spoke with [Doctor First Name ] on [5-18]. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:60 Tablet(s) Refills:0 6. 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 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:10 Tablet(s) Refills:0 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 5 days. Disp:10 Tab Sust.Rel. Particle/Crystal(s) Refills:0 9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 3 days: Decrease to 400 mg PO daily for 7 days after [Hospital1 ] dose completed, then 200 mg daily after 400 mg dose finished. Disp:50 Tablet(s) Refills:0 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:50 Tablet(s) Refills:0 12. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:60 Tablet(s) Refills:0 13. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 5 days. Disp:20 Capsule(s) Refills:0 14. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime for 2 days: Take as directed by the coumadin clinic for INR goal of [1-6].5. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: CAD AS AF Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [Name2 (NI) 5059] at ([Telephone/Fax (1) 1504]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. 8) Coumadin dosing /INR to be followed by [Hospital 197] clinic at [Hospital3 3583]. Confirmed with [Doctor First Name ] [5-18]. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] in 1 month. ([Telephone/Fax (1) 1504] Please follow-up with Dr. [Last Name (STitle) 5310] in 2 weeks. Please follow-up with Dr. [Last Name (STitle) 61120] in 2 weeks. Please call all providers for appointments. INR to be drawn on Monday [2114-5-21] with results sent to the coumadin clinic at [Hospital3 3583] ([Telephone/Fax (1) 65418]. INR goal of [1-6].5. Spoke with [Doctor First Name ] on [5-18]. Completed by:[2114-5-19] ICD9 Codes: 4241, 9971
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8850 }	Medical Text: Admission Date: [2134-1-31] Discharge Date: [2134-2-13] Date of Birth: [2087-7-27] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 1167] Chief Complaint: Dizziness, weakness Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: The patient is a 46 y/o male with sCHF with EF 20%, DM2, asthma, recently admitted to [Hospital1 1516] from [Date range (1) 68456] for CHF exacerbation, who presents with fatigue and malaise over the last few days. During the patient's prior admission, he was aggressively diuresed, and sent out on a higher lasix (100 mg [Hospital1 ]). After discharge, he followed-up with his PCP and Dr.[Name (NI) 3733], and his dose was ultimately decreased to 60 mg PO BID. He was believed to be dry, based on a low sodium level and low blood pressure. He has held his lasix over the last two days per the instructions of his PCP. [Name10 (NameIs) ] the past few days, he reports URI symptoms, dizziness/weakness, and fatigue. Pt also developed diarrhea x 3-4 days, with about four episodes per day. Pt also notes he felt "cloudy" a couple of days ago but this went away. He denies chest pain and shortness. . In the ED, initial vs were: T 98.7 P 100 BP 102/76 R 16 O2 sat 97% 3L NC. Blood pressure decreased to SBPs 80s when pt stood up to go to the bathroom. He was bolused 1L NS with increase in SBP to the 90s. EKG unchanged with precordial q waves. Guaiac negative. Pt was found to have a lactate 3.5, mild leukocytosis 11.8. . On transfer to the floor, patient's VS were 96.1, 93, 110/74, 22, 99% 2L. He reports fatigue. He states that his legs are significantly less swollen than prior to his last hospital stay. Denies CP, SOB, orthopnea, and PND. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. No dysuria. Denied arthralgias or myalgias. Past Medical History: DM II, controlled gerd sCHF asthma AF on digoxin OSA - severe on sleep study BiPAP 20/10 PSHX: SBO [2-3] ruptured diverticulosis with divertying ostomy. Social History: Lives at home with wife. Supply rep for IV infusion team. -Smoking/Tobacco: Cigars (occasional) -EtOH: Occasional - no recent use -Illicits: None Family History: FH positive for CAD. Cousin with recent stent. Niece with PE on coumadin. No known family histor of bleeding diathesis or coagulopathy. Physical Exam: ADMISSION PHYSICAL: Vitals: T: 96.0 BP: 102/73 P: 95 R: 18 O2: 98%RA General: Alert, oriented, no acute distress HEENT: MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic, 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, trace pitting edema b/l Neuro: CNs2-12 intact, motor function grossly normal . DISCHARGE PHYSICAL: Pertinent Results: ADMISSION LABS: . PERTINENT LABS: Aldosterone: Renin: A1c: . DISCHARGE LABS: . CXR [2134-1-31]: IMPRESSION: Marked globular cardiac enlargement concerning for pericardial effusion. Correlation with echocardiogram is advised. Stable bilateral pleural effusions, right greater than left with right basilar opacity, likely atelectasis though cannot exclude pneumonia. . RUQ U/S [2134-2-2]: IMPRESSION: 1. Normal appearance of the liver and biliary tree. 2. Elevated LFTs in the setting of ascites, pleural fluid, and known CHF, likely reflects congestive hepatopathy. This is also supported by bidirectional pulsatile portal venous flow. . 2D-ECHOCARDIOGRAM: [2134-2-3] The left atrium is markedly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is severe global left ventricular hypokinesis (LVEF = 15 %). The right ventricular cavity is markedly dilated with moderate global free wall hypokinesis. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. 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 no mitral valve prolapse. The mitral valve leaflets do not fully coapt. Moderate to severe (3+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. [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 a very small pericardial effusion. . IMPRESSION: Suboptimal image quality. Severely dilated biventricular cardiomyopathy with global biventricular systolic dysfunction. Moderate to severe mitral and tricuspid regurgitation. . RHC [2134-2-4]: COMMENTS: 1. Resting hemodyanmics revealed markedly elevated right and left heart filling pressures (mean RA 31mmHg and mean PCW 33mmHg). There was moderate pulmonary artery hypertension. The SVR was in the normal range on after load reduction (lisinopril). The PVR was elevated at 229 dynes/sec/cm-5. The cardiac index was markedly reduced (1.2 l/min/m2). There were exagerated V-waves on both the RA and PCW tracings consistent with atrioventricular valve regurgitation. FINAL DIAGNOSIS: 1. Severe systolic left ventricular dysfunction. 2. Moderate pulmonary artery hypertension. 3. Elevtaed left and right heart filling pressures. . TTE [2134-2-6]: Conclusions The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. The estimated cardiac index is depressed (<2.0L/min/m2). A left ventricular mass/thrombus cannot be excluded. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [2134-2-3], the severity of mitral and tricuspid regurgitation is slightly reduced. The left ventricular cavity size is smaller. The heart rate is faster. Brief Hospital Course: HOSPITAL COURSE: The patient is a 46 y/o male with sCHF with EF 20%, DM2, asthma, hypothyroidism, recently admitted to [Hospital1 1516] from [Date range (1) 68456] for CHF exacerbation, who presents with fatigue, malaise; found to have hyponatremia initially attributed to hypovolemia exacerbated by poor forward flow from severe CHF and congestive hepatopathy. . #. Acute on Chronic SCHF exacerbation: Etiology of systolic heart failure is unclear. Echo report from [Hospital1 18] [Location (un) 620] [1-15] showed moderate atrial dilation, mild ventricular dilation, severe left ventricular hypokinesis, moderate-severe mitral regurg, and moderate tricuspid regurg. Repeat Echo [2-3] showed EF 10-15%, severely dilated biventricular cardiomyopathy with global biventricular systolic dysfunction and moderate to severe mitral and tricuspid regurgitation. Given pt's failure to recover Na appropriately with IVF repletion and worsening EF in the setting of volume repletion and congestive hepatopathy (see below) cardiology was consulted. Patient was transferred to the CCU. A right heart cath demonstrated elevated filling pressures and wedge pressure, and moderate to severe MR [First Name (Titles) ] [Last Name (Titles) ]. A PA catheter was placed and he was started on milrinone gtt. His SvO2's were monitored, and improved after milrinone was started. Lasix gtt was added, and pt diuresed over 30 liters. He was continued on metoprolol for beta blockade. Lisinopril was initially held given concern for developing hypotension on milrinone, but was restarted. He was also started on spironolactone and metolazone. Repeat TTE demonstrated mildly improved MR [First Name (Titles) ] [Last Name (Titles) ]. All diuretics were held when the patient experienced an acute drop in his serum sodium, along with an increase in creatinine and urine lytes suggesting hypovolemia. He was given 1 L NS and allowed to self-equilibrate. Once improved, milrinone was discontinued and the patient was started on daily torsemide 100 mg and eplerenone 25 mg for maintenance in anticipation of discharge. Given his low EF (and reported history of atrial fibrillation with CHADS2 = 2) he was started on a heparin gtt and transitioned to Coumadin. Discharge regimen: Torsemide 100 daily, Eplerenone 25 daily, Lisinopril 2.5 daily, Metoprolol Succinate 50 daily, Digoxin 250 mcg daily, ASA 81 daily, Coumadin 5 daily. . #. Hyponatremia: On admission to the medical floors, initially thought to be hypovolemic hyponatremia in setting of increased lasix dosing at home. He was initially given volume repletion with normal saline, but his sodium did not improve. Given severe sCHF, pt was likely intravascularly dry, with third-spacing of fluid (ascites, lower extremity edema), making poor forward flow more likely. Urine lytes were checked and demonstrated low urine sodium, and expected appropriate response with increased ADH. He remained oriented without any confusion. TSH was checked and was 2.2. On transfer to the CCU, given concern for hypervolemic hyponatremia, he was placed on a low sodium diet with fluid restriction to 1L. As discussed above, he was started on a milrinone drip and lasix gtt for diuresis. His serum sodium level improved after diuresis and improvement in his cardiac output. However, after losing approximately 30 liters and being started on metolazone the patient had an acute drop in serum sodium likely secondary to hypovolemia from aggressive diuresis. This was also supported by low blood pressures and an acute increase in creatinine. He was asymptomatic. Diuretics were discontinued and the patient received 1L NS. His serum sodium improved. Diuretics were re-initiated. His serum sodium was 125 at time of discharge, and may likely remain low chronically. . # Congestive Hepatopathy: The patient presented with INR 1.9 and found to have a transaminitis with mild direct hyperbilirubinemia and normal albumin. LFTs continued to trend upward (ALT 386, AST 590), as well as INR. Bilirubin remained stable. Abdominal US showed normal liver echotexture, but bidirectional flow in portal vein as well as mild amount of ascitic fluid in abdomen consistent with congestive hepatopathy. Hepatitis serologies were negative. Vit K administered to help elucidate whether increased INR in setting of normal albumin is related to nutritional deficiency or true liver synthetic dysfunction. After transfer to the CCU, his liver enzymes downtrended. . #. ? Paroxysmal Atrial Fibrillation: Remarked in OMR, but pt was not aware of diagnosis and had never been on anticoagulation previously. He was monitored on telemetry without incidence of atrial fibrillation during the entirety of the admission. Given his CHADS2 score of 2 (CHF and DM) and low EF, the patient was anticoagulated with a heparin gtt, then started on Coumadin. . #. Pleural effusions (R>L): Stable in size compared to prior films, most likely secondary to CHF. Pt had no symptoms of infection to suggest parapneumonic effusion so effusion was not tapped. His lung fields were clear on exam after diuresis. . # Hyperkalemia: Transient. Unclear etiology. Possibly [2-3] decreased effective circulating volume in setting of CHF, resulting in decreased renal tubular secretion of potassium. Given hyponatremia and hyperkalemia in setting of low BP's, aldosterone, renin, and cortisol were checked to evaluate for adrenal insufficiency or hypoaldosteronism, and were found to be within normal range. Unlikely [2-3] beta blockade as on only very low doses of metoprolol and no evidence of hyperglycemia to explain electrolyte shifts and hyperkalemia. Serum potassium improved after initiation of milrinone and lasix gtts. . #. GERD: Patient initially reported active symptoms of reflux. He was continued on his home regimen of Pantoprazole, Zantac, Sucralfate. Maalox-lidocaine-diphenhydramine was added prn. His symptoms resolved. Ranitidine was decreased at discharge and Sucralfate was stopped. He may need testing for H Pylori in the future should his symptoms return. . #. Diarrhea: Etiology unclear, but likely secondary to a mild gastroenteritis. Resolved prior to transfer to CCU. . #. DM II: His HgbA1C was 6.7 at last check. Metformin was held in house, and he was placed on an ISS and diabetic diet. . #. Asthma: No active issues. Pt had mild expiratory wheezes thought to be more likely related to CHF than active asthma. Continued on home regimen of fluticasone and albuterol prn. . #. OSA: Continued on home settings of BiPAP. . #. Hypothyroidism: TSH 2.2 during this admission. Continued home dose of levothyroxine. . #. Hyperlipidemia: Statin was held on admission given elevated LFT's. His LDL was calculated to be 39. It was not restarted at discharge. Gemfibrozil was continued. . TRANSITIONAL CARE: 1. CODE: FULL 2. FOLLOW-UP: Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 437], and PCP 3. MEDICAL MANAGMENT: -Post-discharge labs: chem 7, digoxin level, INR on Monday, [2-15] -INR monitoring for appropriate Coumadin dosing -Statin was discontinued, may need to be re-started in the future -GERD: may need evaluation and treatment for H Pylori -Was given short-course of Trazadone for insomnia, may need refill Medications on Admission: levothyroxine 25 mcg Tablet PO DAILY rosuvastatin 20 mg PO DAILY fluticasone 110 mcg/Actuation 2puffs [Hospital1 ] gemfibrozil 600 mg Tablet PO BID pantoprazole 40 mg Tablet PO Q24H lisinopril 5 mg Tablet PO DAILY metoprolol succinate 25mg daily aspirin 81 mg Tablet PO daily (chewable) furosemide 60mg PO BID (decreased from 100mg [Hospital1 ] on d/c, has not taken the last two days) metformin 1,000 mg Tablet PO BID albuterol sulfate 90 mcg/Inhaler 1-2 puffs q4-6h prn sob/wheezing Flonase 50 mcg/Actuation Spray, 1 spray/nostril daily. Zantac Discharge Medications: 1. Outpatient Lab Work Chem-7, digoxin level and INR/PT on Monday [2-15] at Dr. [Name (NI) 10875] office with results to Dr. [Last Name (STitle) 696] Phone: [Telephone/Fax (1) 3393] Fax: [Telephone/Fax (1) 32573] 2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:30 Tablet Extended Release 24 hr(s) Refills:2 3. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 10. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day. 11. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for sob/wheezing. 13. torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 14. eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 15. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 16. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:30 Tablet(s) Refills:2 17. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia for 7 days. Disp:7 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Acute on chronic systolic congestive heart failure Diabetes Mellitus Non-Ischemic Cardiomyopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], It was a pleasure taking care of you during this hospitalization. You had an exacerbation of your congestive heart failure and needed aggressive diuresis to remove the fluid. You were started on a lasix and milrinone IV drip to help your heart work better and take off fluid. This worked very well and your weight decreased by approximately 50 pounds. Your weight on the day of discharge is 99.7. You will need to monitor yourself very closely to make sure this fluid does not come back. Weigh yourself every morning, call Dr. [First Name (STitle) 437] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Please watch your legs and abdomen for signs of fluid retention. It is very important that you follow a low sodium diet. We made several changes to your medication regimen, as below. . We made the following changes to your medicines: 1. Stop taking Furosemide, take torsemide instead to keep the fluid off. 2. Decrease Lisinopril to 2.5 mg daily 3. Stop taking antacids on a regular basis, take only as needed for heartburn 4. Stop taking sucralfate 5. Decrease the Ranitidine (Zantac) to 150 mg twice daily 6. Change Metoprolol to a long acting version 7. Start Digoxin to slow your heart rate and help your heat pump better 8. Start Epleronone to help your fluid level stay down. 9. Start Warfarin daily You will need your blood levels monitored for PT/INR to ensure that your Warfarin level is at goal. 10. Stop taking Rosuvastatin for now until your liver tests improve. 11. We are giving you a short course of trazadone to help you sleep. Please follow up with your Primary Care Physician to obtain [Name Initial (PRE) ] prescription. Followup Instructions: Department: CARDIAC SERVICES When: Monday [2-15] at 9:30am With: [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 437], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 696] Phone: [Telephone/Fax (1) 3393] Date/time: [3-5**] at 11:30am ICD9 Codes: 2761, 4254, 4280, 4168, 2767, 2449, 2724, 4240, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8851 }	Medical Text: Admission Date: [2160-6-10] Discharge Date: [2160-6-21] Date of Birth: [2097-8-21] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 668] Chief Complaint: Leaking from old G tube site Major Surgical or Invasive Procedure: [2160-6-11] Gastrostomy takedown [2160-6-17] Incision opened and wound vac applied History of Present Illness: Mr. [Known lastname ] is a 62 year old gentleman well known to the transplant surgery service. In brief, he is s/p renal transplant in [2137] for post-streptococcal glomerulonephritis. This failed after several years and he underwent transplant nephrectomy in [2143]. He was recently admitted in [3-/2160] for increased drainage and irritation from his G tube(originally placed in [2156] as part of a re-do ex. lap for mesenteric ischemia following subtotal colectomy for pneumatosis intestinalis). During his latest admission, his G tube was removed and his overlying cellulitis was treated with IV antibiotics and thought to be secondary to gastrocutaneous fistula. He has since had increased output from his former G tube site, and is here today for preoperative anticoagulation management prior to his gastrostomy takedown. Past Medical History: (Per record & patient) ESRD on HD (secondary to post-streptococcal glomerulonephritis, Renal transplant '[37] failed, transplant nephrectomy in [2143]), Hyperparathyroidism, Hypertension, Atrial fibrillation (started on warfarin [Date range (1) 101024]), CAD, Diastolic CHF with remote history of systolic CHF [Date range (1) 8974], Endocarditis w/ Aortic and Mitral valve involvement, Repeated episodes of pneumonia, VRE septic arthritis, L wrist [Date range (1) 8974] infective arthritis, Right hip fracture s/p Right hip hemiarthroplasty, [2157-1-11], Right Prosthetic Hip infection s/p explantation [2-18], Ischemic colitis/ileitis s/p subtotal colectomy and terminal ileal resection, followed by ileocolonic anastomosis with diverting loop ileostomy and gastrostomy tube placement [2156] . PAST SURGICAL HISTORY: (Per record or patient) [2158-11-7]: Aortic valve replacement(21 mm ON-X, Mitral valve replacement 25/33 On-X Conform-X mechanical valve) [2158-10-5]: Right heart catheterization [2158-10-3]: Paracentesis [2158-7-13]: Fistulogram, 6-mm balloon angioplasty of juxta-anastomotic segment [2157-6-16]: Washout and drainage right hip wound infection. [2157-6-14]: Revision left radiocephalic arteriovenous fistula, endarterectomy radial artery. [2157-2-22]: Evacuation drainage of right hip deep hematoma-abscess. [2157-2-18]: Removal right hip hemiarthroplasty. [2157-2-3]: Irrigation, debridement and evacuation of hematoma of right septic hemiarthroplasty. [2157-1-26]: Right hip revision of hemi arthroplasty due to dislocation. [2157-1-15]: Exploratory laparotomy, gastrostomy tube, ileocolonic anastomosis and diverting loop ileostomy. [2157-1-14]: Exploratory laparoscopy, subtotal colectomy. [2157-1-13]: Exploratory laparotomy, Subtotal colectomy, Resection of terminal ileum, Temporary abdominal closure. [2157-1-11]: Right hip hemiarthroplasty. [2156-12-10]: Left wrist incision and drainage. [2156-2-17]: Right ring finger closed reduction percutaneous pinning for mallet finger. Left index and long ring finger PIP joint manipulation under anesthesia. [2155-12-16]: Left carpal tunnel release and left index, long and ring finger trigger releases Social History: SH: H/o ~3 p-y tob, occ etoh. Family History: Father with prostate CA. Physical Exam: Vitals: 100-110/70, R 14-16, afebrile Gen: Elderly male HEENT: pallor present, no icterus, NG tube with biliary drain Neck: Supple, no LAD Chest: CTA b/l CVS: audible mechanical valves, afib, Abd: Soft, wound vac in place Ext: no edema Pertinent Results: [2160-6-10] 01:05PM BLOOD WBC-4.5 RBC-2.99* Hgb-9.3* Hct-30.9* MCV-103* MCH-31.1 MCHC-30.1* RDW-16.7* Plt Ct-134* [2160-6-10] 01:05PM BLOOD PT-20.7* PTT-36.7* INR(PT)-2.0* [2160-6-10] 01:05PM BLOOD Glucose-105* UreaN-13 Creat-5.6* Na-138 K-4.3 Cl-98 HCO3-29 AnGap-15 [2160-6-10] 01:05PM BLOOD ALT-10 AST-22 AlkPhos-155* TotBili-0.3 [2160-6-10] 01:05PM BLOOD Albumin-2.8* Calcium-9.5 Phos-4.8* Mg-1.6 [2160-6-20] 06:20AM BLOOD PT-59.5* INR(PT)-5.9* [2160-6-19] 06:45AM BLOOD WBC-7.3 RBC-3.09* Hgb-9.2* Hct-31.0* MCV-101* MCH-29.9 MCHC-29.7* RDW-16.9* Plt Ct-176 [2160-6-21] 06:05AM BLOOD PT-49.5* INR(PT)-4.9* [2160-6-21] 06:05AM BLOOD Na-133 K-4.2 Cl-95* Brief Hospital Course: 62 y/o male with complicated PMH who is admitted for preoperative anticoagulation management prior to his gastrostomy takedown. The patient is on warfarin for an existing St Jude valve. Patient was taken to the OR with Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] for takedown of the gastrocutaneous fistula. Per the operative report the fistula tract was taken down completely to the stomach. The surgery was without complication and he was transferred to the PACU in stable condition. He had an NG tube in place and was kept strictly NPO through post op Day 3. On POD 2 the patient had fever to 101.1, and on subsequent days he has run a low grade fever. Blood cultures have been sent on [4-12], [6-16] and [6-18] in response to low grade fevers. They are no growth to date but have not yet been finalized. Hemodialysis was continued per routine schedule. On POD 2, the patient had an episode of hypotension into the 80's and desaturation. He was also having a lot of pain at the incision site, and as such was transferred to the SICU, where he was able to receive hemodialysis, and increased monitoring. Blood pressures improved and with fluid removal, the patient had improved respiratory status. He was transfered back out of the ICU the following day, and has maintained adequate blood pressures thereafter. Heparin drip was restarted following surgery, and when appropriate, coumadin was restarted with the heparin bridge. He was therapeutic on POD 7 and the heparin drip was discontinued. On POD 5, the incision was opened due to drainage, and on POD 6 the incision was further opened and a wound VAC was placed for assistance with wound healing. Ostomy output has remained stable from 300 -700 cc daily. He was evaluated by the wound consult service who noted some maceration at the stoma, changed the dressing to better fit stoma. He was see by physical therapy who determined he would need rehab services. His pain was well controlled on PO pain medication. On POD 7, his INR was 5.9 and he received 1 unit of FFP and coumadin was held. His wound vac changed. At this time a 1 cm fascial dehiscence was noted over medial aspect of incision. It appeared amenable to wound vac, so a vac was replaced. On POD8, [2160-6-21], he was discharged to rehab. He was afebrile with stable vital signs, tolerating a regular diet, and pain was controlled. He was discharged to [Hospital ] Healthcare center and will resume his regular [Hospital 2286] schedule. Medications on Admission: warfarin 5.5mg daily, aspirin 81 daily, Digoxin 0.125mg 2x/wk (Tues &Thurs), pantoprazole 40 [Hospital1 ], Sensipar 20mg (3-4 times/week), Renvala 2.4g q day, oxycodone unknown dose but patient states he usually takes 3 tabs per day, lisinopril unknown dose, cipro daily (dose unkmown to patient) Discharge Medications: 1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO QTUTHUR (TU,TH). 6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H (every 4 hours) as needed for spasms. 8. Coumadin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day: Start on [2160-6-22]. 9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare Center - [Location (un) ] Discharge Diagnosis: Gastrocutaneous fistula s/p gastrostomy takedown Non-healing abdominal incision Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You will be transferring to [Hospital ] [Hospital ] Rehab Please call Dr.[Name (NI) 670] office [Telephone/Fax (1) 673] if you have any of the following: temperature of 101 or greater, shaking chills, nausea, vomiting, increased abdominal distension/pain, ostomy output decreases or stops, incision redness/bleeding/drainge, Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Blood draw Monday [6-23] for inr/Coumadin management Hemodialysis to continue every Monday-Wed-Friday Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2160-6-26] 3:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2160-7-3] 2:00 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2160-8-18] 9:00 Completed by:[2160-6-21] ICD9 Codes: 5856, 4280, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8852 }	Medical Text: Admission Date: [2129-4-3] Discharge Date: [2129-4-19] Date of Birth: [2057-10-1] Sex: M Service: MEDICINE Allergies: Penicillins / Tegretol / Spironolactone Attending:[First Name3 (LF) 4765] Chief Complaint: heart failure Major Surgical or Invasive Procedure: Attempted right heart catheterization History of Present Illness: 71 yo M h/o severe dCHF (EF>55%), AS s/p mechanical AVR, AFib on coumadin, pulmonary HTN, CAD s/p CABG, 3rd-degree heart block s/p ppm, and [Hospital 2182] transferred from OSH for further management of chronic diastolic congestion heart failure. . The patient was recently admitted to [Hospital1 18] from [2129-3-7] to [2129-3-17] for altered mental status and failure to thrive. The [Hospital 228] hospital course was complicated by healthcare-associated pneumonia, which was treated with ceftriaxone and vancomycin. The patient was discharged to Life Care Center of [Location (un) 2199]. At the time, his weight was documented as 161 lb. . At rehab, the patient was initially doing well. He was even able to walk with a walker. Beginning around [3-26], however, the patient's family began to notice increasing fatigue along with intermittent confusion, agitation, poor sleep and poor appetite. The family also described [10-18] second periods of tachypnea occurring at 5-minute intervals. The family also describes increased swelling in the patient's face and belly. In the early morning of [3-29], the patient was noted to be more confused, leading him to present to [Hospital 43018] Hospital. . At Wincester, his initial weight was 165 pounds. The patient was started on cefepime and linezolid for HCAP, although there was no evidence of pneumonia. There was no documented fever or leukocytosis. CT chest showed mediastinal adenopathy and bilateral pleural effusions but no infiltrate. The patient was diuresed with Lasix 80 mg IV for presumed CHF in the ambulance on the way to the hospital but did not receive further diuresis in house due to concern for renal failure. There was an episode of desaturation to 80% with confusion. Bronchodilators and IV steroids were given for COPD. The patient was noted to have mildly elevated bilirubin and alk phos. RUQ U/S was negative Coumadin was held and a heparin gtt was started for consideration of thoracentesis, which was not done prior to transfer. . The patient was transferred directly to the CCU at [Hospital1 18]. On arrival, initial vital signs were T 98.6 BP 112/68 HR 65 RR 23 Sat 98% 2L weight 174 pounds. Review of systems was not reliable due to altered mental status. However, patient denied pain, dyspnea, or other symptoms. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, ?Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: 2 vessel CABG -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: PPM placed for 3rd degree AV block 3. OTHER PAST MEDICAL HISTORY: -AS s/p AVR with [First Name8 (NamePattern2) ] [Male First Name (un) 1525] Mechanical Valve s/p AVR in [2116] -Atrial fibrillation, on coumadin -COPD - on spiriva and flovent -HTN -CAD s/p CABG (2 vessel) -s/p CVA with seizure d/o - on lamictal; last sz >1 year ago -Diastolic CHF, EF >70% -Pulmonary HTN -DM: diet controlled -Chronic lethargy and confusion with concern for Dementia -Focal disection of abd aorta - noted CT abdomen [2126-10-16]- unchanged from [2124] -BPH - no difficulty voiding -s/p L ORIF and THR [9-/2128] -S/P pacemaker for 3rd degree AV block -Has had seasonal and H1N1 vaccinations Social History: Lives with wife; son/family lives in same town house; 6 children total. Retired newpaper journalist; He moved to the U.S.A. in [2098], but returned to [Country 11150] to work. He returned here for good in [2120]. -Tobacco history: quit 10 years ago; 80 pack years; chewed tobacco until approximately 5mo ago -ETOH: quit long time ago; unclear how much pt drank in past -Illicit drugs: never Family History: CAD in family with hx of CABG - everyone including all sisters and brothers, who have all died before him, as well as his mother and father. Physical Exam: VS: T 98.6 BP 112/68 HR 65 RR 23 Sat 98% 2L Weight 174# (79.2kg) GENERAL: Frail elderly gentleman in no acute distress, though he does appear uncomfortable when he moves. HEENT: NCAT. Sclera anicteric. NECK: Supple with JVP elevated to ear with patient upright. CARDIAC: RRR, normal S1, mechanical S2. s3 present. No m/r/g. No thrills, lifts. LUNGS: Speaking in [1-8] work sentences but denies dyspnea. Diffusely wheezy and rhonchorous. ABDOMEN: Distended. Non-tender. Exam limited by distention. EXTREMITIES: Poor capillary refill. SKIN: Skin breakdown on lower extremities. NEURO: Sleepy but arousable, oriented to "hospital", "[2128]". Can state his occupation. CN II-XII intact. Asterixis present. No pronator drift. Strength 5/5 throughout. PULSES: Right: Radial 2+ DP doppler PT doppler Left: Radial 2+ DP doppler PT doppler Pertinent Results: Admissions labs: [2129-4-3] 03:07PM BLOOD WBC-6.9 RBC-4.25* Hgb-10.9* Hct-35.8* MCV-84 MCH-25.6* MCHC-30.4* RDW-16.9* Plt Ct-194 [2129-4-3] 06:00PM BLOOD PTT-67.1* [2129-4-3] 03:07PM BLOOD Glucose-105* UreaN-74* Creat-1.8* Na-129* K-4.3 Cl-94* HCO3-26 AnGap-13 [2129-4-3] 03:07PM BLOOD ALT-13 AST-33 LD(LDH)-274* AlkPhos-157* TotBili-1.4 [2129-4-3] 03:07PM BLOOD proBNP-2790* [2129-4-3] 03:07PM BLOOD Albumin-3.5 Calcium-9.6 Phos-3.1 Mg-3.1* [2129-4-3] 06:00PM BLOOD Type-ART pO2-87 pCO2-39 pH-7.43 calTCO2-27 Base XS-1 [2129-4-3] 06:00PM BLOOD Lactate-1.4 . CXR (portable AP) [2129-4-4]: Cardiac silhouette has slightly increased in size, and is accompanied by worsening pulmonary vascular engorgement and increasing predominantly interstitial edema. Additional areas of coalescing opacities in the infrahilar region could reflect progression to alveolar edema. Bilateral pleural effusions have increased in size, right greater than left. Brief Hospital Course: Mr [Known lastname 43019] is a 71-year-old man with a history of dCHF (EF>55%), AS s/p AVR, AF, pulmonary HTN, CAD s/p CABG, 3rd-degree heart block s/p ppm, transferred from [Hospital 43018] Hospital for consideration of vasodilator therapy for pulmonary hypertension in the setting of severe diastolic biventricular heart failure. Acute on chronic diastolic heart failure The patient presented with predominantly right-sided heart failure with peripheral edema, hepatic congestion, poor appetite, weight gain, and elevated JVP. He was diuresed with PO torsemide without effect. The patient was then successfully diuresed with Lasix 100mg IV BID. Metolazone was added however the family warned that this can cause bumps in the creatinine, which we have not noted, however today's creatinine was 1.7. The patient's heart failure was thought to be end-stage, class 4 diastolic and pt has a poor prognosis. Palliative medicine consult was considered however, the family was not interested in this route and was more interested in aggressive medical treatment more than symptom control. Metolazone (2.5 - 5 mg) 30 minuntes prior to Lasix affords improved diuresis, but has in the past resulted in renal failure. This should be done cautiously. When he approaches dry weight of just over 150 lbs, he can be converted to an oral regimen of torsamide. Altered mental status This was thought to be related to CHF encephalopathy or poor forward flow in setting of heart failure. However, asterixis also suggested a toxic-metabolic cause. Hypercarbia was ruled out by ABG. Neurology was consulted and ruled out seizures by negative EEG. Observation has revealed that mental status is improved when pt is not fluid overloaded. It is very helpful his family to be present to assist with orientation, particularly at night. Lateral abdominal hematoma The patient developed a lateral wall abdominal hematoma most likely from trauma by leaning or hitting his flank on the bed rail in the setting of agitation/delerium and supratherapeutic INR. The patient's HCT dropped nearly 10 points from 34 to 24 and CT confirmed an extraperitoneal musculoskeletal hematoma. IR was notified but favored conservative management by correcting coaggulopathy and transfusing. The patient received a total of 4 units of PRBCs and his HCT stabilized once the underlying coaggulopathy corrected. The patient's HCT remained stable for the remainder of the admission in the low 30s. Chronic kidney disease The patient's creatinine remained at his recent baseline of 1.5 to 1.8 even with diuresis. COPD The patient was noted to be rhonchorous and wheezy on exam. He was treated with inhaled fluticasone and nebulized albuterol and ipratropium. Status-post mechanical aortic valve The patient's Coumadin was initially held. The patient was kept on a heparin drip. This was discontinued during the acute bleed, then restarted once patient's HCT stabilized and bridged pt to coumadin. DM The patient was started on an insulin sliding scale. BPH Continued Flomax at home dose. Medications on Admission: Meds on Transfer: Cefepime 1g IV Q24H Linezolid 600mg IV Q12H Methylprednisolone 40mg IV Q8H -- received [4-1] and [4-2] Heparin gtt at 850 Lasix 40mg IV prn -- unclear how many doses he received Lopressor 25mg daily Enalapril 5mg daily -- on hold Flomax 0.4mg QHS Zocor 20mg QHS Lamictal 150mg [Hospital1 ] Calcium carbonate 1000mg [Hospital1 ] MVI daily Coumadin -- on hold Vitamin D 800 IU daily Spiriva inh daily Duoneb QID Fluticasone inhaler 2 puffs [Hospital1 ] Colace 100mg [Hospital1 ] Trusopt 2% [Hospital1 ] Xalatan eye drops 0.005% 1 drop at night both eyes Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheeze. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 3. Lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 7. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 10. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 11. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED): Sliding scale insulin. 12. Dextromethorphan Poly Complex 30 mg/5 mL Suspension, Sust.Release 12 hr Sig: One (1) PO Q12H (every 12 hours) as needed for cough. 13. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 15. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscellaneous Q6H (every 6 hours) as needed for cough, wheeze. 16. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 19. Sildenafil 20 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for diastolic dysfunction. 20. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 21. Furosemide 10 mg/mL Solution Sig: One Hundred (100) MG Injection [Hospital1 ] (2 times a day). 22. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 23. Sodium Chloride 0.9% Flush 10 mL IV Q8H:PRN line flush Midline: Flush with 10 mL Normal Saline every 24 hours and PRN before and after use 24. Heparin Flush (10 units/ml) 2 mL IV PRN use of Midline Daily and after each use 25. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: per sliding scale units Intravenous continuous. Discharge Disposition: Extended Care Facility: [Hospital ] Hospital - [Hospital1 8] Discharge Diagnosis: NYHA Class [3-10], acute on chronic diastolic congestive Heart Failure Secondary: Mechanical AVR Pulmonary Hypertension Chronic Obstructive Pulmonary Disease Diabetes Mellitus, diet controlled. Atrial Fibrillation S/P Pacemaker Seizure Disorder Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: It was a pleasure to take care of you here at [Hospital1 18]. You were admitted for acute on chronic heart failure. We used a water medicine called Lasix to remove the fluid from your lungs and your body. Your heart failure is end-stage and for this reason it is critically important that you follow a low sodium diet, take all your medications as prescribed, and contact your doctor if your weight increases > 3lbs in 1 day or 6 pounds in 3 days. . Medication changes: 1. STOP taking Linezolid, cefepime, methylprednisolone and fluticasone inhaler. 2. START taking Acetylcysteine, Benzonatate, and Dextromethoraphan for your cough 3. Restart coumadin to prevent blood clots 4. Start tylenol for pain as needed 5. STart Aspirin for heart protection 6. Increase lasix to 100mg twice daily 7. Decrease Metoprolol to 12.5 mg twice daily 8. Start Sildenafil to treat your heart failure 9. Start insulin sliding scale to keep your blood sugars under control 10. Start Heparin IV to prevent blood clots until the coumadin level is therapeutic. 11. Start senna to prevent constipation 12. Stop Methylprednisolone and Fluticasone inhaler 13. Start calcium to prevent bone loss. Followup Instructions: Cardiology: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone: [Telephone/Fax (1) 62] Date/time: [2129-5-24] 10:40 . Primary Care; [Last Name (LF) ],[First Name3 (LF) ] B. Phone: [Telephone/Fax (1) 17826] Date/time: please make an appt to be seen after you get out of rehabilitation. Completed by:[2129-4-20] ICD9 Codes: 486, 2851, 4280, 4168, 496, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8853 }	Medical Text: Admission Date: [2128-5-16] Discharge Date: [2128-6-6] Date of Birth: [2128-5-16] Sex: F Service: Neonatology HISTORY OF PRESENT ILLNESS: This is a 33 and [2-1] week baby girl [Name2 (NI) ] to a 20-year-old G-1, P now 1 mother, whose due date was [2128-7-3]. Her prenatal screens were blood type O positive, antibody negative, RPR nonreactive, hepatitis B surface antigen negative, rubella immune on 1 newborn summary, however, nonimmune on another. Her pregnancy was complicated by admission on [5-14], for hypertension and was noted to have proteinuria. She subsequently received betamethasone and, due to persistent headaches and oligohydramnios, the obstetric team elected to deliver the baby. The infant was [Month (only) ] on [5-16], at 8:40 p.m. by C- section with Apgars of 7 and 9. GBS status was unknown and there was no maternal fever. Rupture of membranes was at delivery and there were no intrapartum antibiotics given. Maternal history was significant for polysubstance abuse, status post crack cocaine, last use [2126-11-26], and subsequently she joined a program. She was also diagnosed with bipolar disorder with hallucinations but those have lessened with discontinuation of her cocaine use. Prior to her pregnancy, she used to smoke 1 pack per day but she did not smoke cigarettes during her pregnancy. She also has a history of seizures, her last was in [2126-9-26], which corresponded with cocaine use and she has had no seizures since. The infant emerged vigorous and had an examination which was notable for her prematurity. She had a head circumference of 29 cm which was 10th to 25th percentile, her weight was 1570 grams, 10th to 25th percentile, length was 41 cm which was 10th to 25th percentile. She was admitted with mild respiratory distress. HOSPITAL COURSE: By systems: From a respiratory perspective, she was initially intubated on low ventilatory settings and she got 1 dose of Surfactant. She was subsequently extubated on day of life 1 to room air and has been in room air ever since with occasional apneic and bradycardic events. Her most recent apneic and bradycardic event was on [2128-6-1], and she has subsequently been on apnea and bradycardia countdown. From a cardiovascular perspective, she has had an intermittent soft murmur which is benign in its quality and not heard on subsequent exam. From fluid, electrolytes and nutrition standpoint, initially she was n.p.o. and started on IV fluids and eventually advanced on feeds initially with breast milk and subsequently now is on Neosure 26 calories per ounce taking p.o. ad lib approximately 150 to 170 cc/kg/day. Her NG tube was taken out on [2128-5-30]. She voids and stools with regularity and no complications. here weight at the time of dischsrge is [2066] grams. From a GI perspective, she has had some mild hyperbilirubinemia. She was on phototherapy with a peak bilirubin of 9.7 on [5-19]. She remained somewhat jaundiced and a random bilirubin done on day of life 16, [6-1], was 5.3/0.3. From a hematology standpoint, she has had CBC in her life on day of life zero with a white blood cell count of 9.6, hematocrit was 55.9 and her platelet count was 264,000 with 29 neutrophils and no bands. She has been on iron and is to be on iron. Her physical exam is as follows: Her weight on [6-4], was 1880 grams. She is well appearing. From respiratory perspective, she is in room air breathing comfortably with no retractions, no wheezing and no crackles. Cardiovascular: She has normal S1 and S2, regular rate and rhythm, no murmur. She has 2+ femoral pulses. Abdomen: She has no abdominal distention, positive bowel sounds, no hepatosplenomegaly, and no masses appreciated. GU: She has normal external female genitalia. Musculoskeletal: Her hips are intact. Her clavicles are intact. Neurologically, she has normal tone and moves all extremities easily. She is very well appearing. CONDITION ON DISCHARGE: Stable. DISPOSITION: Home. PRIMARY PEDIATRICIAN: Dr. [Last Name (STitle) 72644] at [Hospital 392] Pediatrics, [Telephone/Fax (1) 42643]. I have tried to call multiple times but the phone is busy. I will continue to try. We will fax the discharge summary. CARE RECOMMENDATIONS: 1. Feeds at discharge are Neosure 26 calories. We recommend continuing Neosure until 6-9 months corrected gestational age and the calories can be weaned as she grows well. 2. Medications: We recommend iron. Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. 3. Car seat position should be in the back facing the back and strapped in. 4. Newborn screening status was normal on [5-19]. She had another one sent on [5-31], which is pending. 5. She received her hepatitis B immunization slightly early on [5-27], before she was 2 kilograms. She will need 3 additional hepatitis B vaccines which can be given when she gets her Pediarix. 6. Furthermore she was recommended routine immunizations in addition: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following 4 criteria: [Month (only) ] at less than 32 weeks, [Month (only) ] between 32 and 35 weeks with 2 of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age sibling, with chronic lung disease or hemodynamically significant cardiac disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age (and for the first 24 months of the child's life), immunization against influenza is recommended for household contacts and out of home caregivers. 7. 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. 8. Follow up appointments are scheduled with the pediatrician at 10 o'clock on [Last Name (LF) 766], [2128-6-7], at 10 a.m. with Dr. [Last Name (STitle) 72644]. Referral to early intervention has been made and a VNA appointment is for Tuesday. DISCHARGE DIAGNOSES: 1. Respiratory distress syndrome. 2. Rule out sepsis with antibiotics. 3. Prematurity. 4. Apnea of prematurity. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Last Name (NamePattern1) 71123] MEDQUIST36 D: [2128-6-4] 13:45:06 T: [2128-6-4] 15:37:49 Job#: [Job Number 72645] ICD9 Codes: 769, 7742, V053, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8854 }	Medical Text: Admission Date: [2113-8-24] Discharge Date: [2113-8-30] Date of Birth: [2044-9-24] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) / Prednisone / Avelox Attending:[First Name3 (LF) 1283] Chief Complaint: Shortness of breath, Bloody JP drainage Major Surgical or Invasive Procedure: [2113-8-24] Re-exploration for Bleeding [2113-8-25] Placement of Bilateral Chest Tubes History of Present Illness: 68 y/o male who is s/p CABG, AVR, MVR, ascending aorta replacement c/p sternal wound dehiscence requiring pectoralis major flap and omental flap on [2113-8-2] presents from rehab with increased sanguinous JP output, tachycardia, and tachypnea. In the ER Hct was found to be 27 down from 32. Taken emergently to OR for exploration. Past Medical History: Coronary artery disease Aortic Stenosis Mitral Regurgitation Atrial Fibrillation Obesity Hypertension Elevated cholesterol PAF and previous cardioversions and ablation Chronic obstructive pulmonary disease PVD/Carotid Disease Social History: never used tobacco retired photographer rare use of ETOH lives with wife Family History: father expired of MI @54; mother died of CAD @67 Physical Exam: Post op: 102 A fib 110/68 36/20 CI 2.0 RR 16 100% NAD Intubated, sedated Coarse rhonchi Irreg irreg heart rate Sternum with Left pectoral fluid collection Abdomen soft/NT Extrem cool, [1-21] + edema Discharge vitals 98.6, 128/74, 80 SR, 20, 94% on 2L NC wt 108.4kg neuro alert and oriented x3 nonfocal pulm clear to ausculation except left base no airation cardiac RRR no M/R/G Abd soft, NT, ND +BS last BM [8-30] Ext warm pulses palpable generalized edema +1 Sternal inc with staples healing no drainage no erythema - JP x2 serosang drainage Bilat old chest sites healing - DSD Pertinent Results: [2113-8-29] 05:50AM BLOOD WBC-12.1* RBC-3.20* Hgb-9.9* Hct-28.6* MCV-89 MCH-30.9 MCHC-34.6 RDW-15.1 Plt Ct-368 [2113-8-24] 12:08PM BLOOD WBC-12.6* RBC-3.41* Hgb-10.2* Hct-31.0* MCV-91 MCH-29.9 MCHC-32.9 RDW-15.2 Plt Ct-561* [2113-8-24] 12:08PM BLOOD Neuts-87.3* Bands-0 Lymphs-8.4* Monos-3.0 Eos-0.8 Baso-0.5 [2113-8-29] 05:50AM BLOOD Plt Ct-368 [2113-8-29] 05:50AM BLOOD PT-14.2* INR(PT)-1.3* [2113-8-24] 12:08PM BLOOD Plt Smr-HIGH Plt Ct-561* [2113-8-24] 12:08PM BLOOD PT-14.9* PTT-24.1 INR(PT)-1.3* [2113-8-24] 02:54PM BLOOD Fibrino-423* [2113-8-29] 05:50AM BLOOD Glucose-98 UreaN-22* Creat-0.8 Na-131* K-3.9 Cl-92* HCO3-32 AnGap-11 [2113-8-24] 10:55AM BLOOD Glucose-156* UreaN-20 Creat-1.0 Na-129* K-4.2 Cl-90* HCO3-30 AnGap-13 [2113-8-24] 10:55AM BLOOD CK(CPK)-424* [2113-8-24] 10:55AM BLOOD CK-MB-6 cTropnT-0.08* [2113-8-29] 05:50AM BLOOD Mg-2.1 RADIOLOGY Preliminary Report CHEST (PA & LAT) [2113-8-29] 11:08 AM CHEST (PA & LAT) Reason: s/p CT removal ? ptx [Hospital 93] MEDICAL CONDITION: 68 year old man with AS,AVR REASON FOR THIS EXAMINATION: s/p CT removal ? ptx HISTORY: 68-year-old male with aortic stenosis and aortic valve replacement, status post chest tube removal, question pneumothorax. COMPARISON: Radiographs [2113-8-28]. TWO VIEWS OF THE CHEST BY PORTABLE TECHNIQUE: There is a small right pleural effusion and a small-to-moderate left pleural effusion. There is a right internal jugular catheter, the tip of which is in the SVC. There is no change in the cardiomediastinal contour. No pneumothorax is identified. IMPRESSION: Small right pleural effusion and small-to-moderate left pleural effusion. No pneumothorax. DR. [First Name (STitle) ] [Doctor Last Name 3900] DR. [First Name (STitle) 3901] [Initials (NamePattern4) ] [Last Name (NamePattern4) 3902] DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4392] RADIOLOGY Final Report UNILAT UP EXT VEINS US LEFT [2113-8-28] 12:58 PM UNILAT UP EXT VEINS US LEFT Reason: r/o dvt - swelling [Hospital 93] MEDICAL CONDITION: 68 year old man s/p CABG, MVR, AVR, ASc Aorta, sternal debridement REASON FOR THIS EXAMINATION: r/o dvt - swelling INDICATION: 68-year-old man with left arm swelling, rule out DVT. COMPARISON: No previous extremity ultrasound for comparison. FINDINGS: [Doctor Last Name ]-scale, color and Doppler son[Name (NI) 1417] of the left jugular, subclavian, axillary, brachial, basilic, and cephalic veins were performed. There is thrombus identified in the left cephalic below the level of the antecubital fossa. At this level, the vein demonstrates no flow and does not compress. There is normal flow, compression, and augmentation in the remainder of the left arm vessels. No deep vein thrombus is identified in any of the deep veins. IMPRESSION: No DVT in the left arm. Thrombus is identified in the left cephalic vein, which is a superficial vein, below the level of the antecubital fossa. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 7832] Approved: TUE [2113-8-29] 4:06 PM Cardiology Report ECG Study Date of [2113-8-25] 12:07:14 AM Probable sinus tachycardia, though atypical atrial flutter cannot be excluded. Right bundle-branch block with left anterior fascicular block. Possible prior inferior wall myocardial infarction. Compared to the previous tracing of [2113-8-24] the ventricular rate is now regular suggesting either sinus tachycardia or atypical atrial flutter. Otherwise, no diagnostic interim change. TRACING #3 Read by: [Last Name (LF) ],[First Name3 (LF) ] V. Intervals Axes Rate PR QRS QT/QTc P QRS T 112 164 184 310/401 36 -21 89 RADIOLOGY Final Report CT CHEST W/O CONTRAST [2113-8-25] 10:59 AM CT CHEST W/O CONTRAST Reason: assess lft effusion/adhesions [Hospital 93] MEDICAL CONDITION: 68 year old man s/p AVR/MVR/CABG/Ao root [Doctor First Name ] reexplored REASON FOR THIS EXAMINATION: assess lft effusion/adhesions CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 68-year-old male status post AVR/MVR/CABG/aortic root, status post surgical re-exploration. Please assess left effusion, and adhesions. COMPARISON: Multiple chest radiographs dating back to [2113-7-25]. TECHNIQUE: MDCT-acquired axial imaging of the chest without intravenous contrast. Multiplanar reformatted images were obtained and reviewed. FINDINGS: There is evidence of previous cardiac surgery, and re-exploration. Mediastinal wires have been removed, along with a portion of the left hemisternum, and there has been closure with a omental/pectoral muscle flap. The flap is relatively large, and appears to displace mediastinal structures posteriorly. Within the soft tissue of the flap, there is a moderate amount of soft tissue stranding, which most likely correlates with post-surgical edema, but could also represent residual of old hemorrhage. There is no large fluid collection or other sign of active bleeding. Two drains are seen within this flap, situated anterior to the sternum bilaterally. A third drain is seen within the flap situated deep, and adjacent to the pericardium. There are small bilateral pleural effusions which contain simple fluid, slightly greater on the left. There is adjacent left basilar atelectasis. There is also a small simple pericardial effusion. There is heavy atherosclerotic calcification of the native coronary arteries. The aortic root graft is unremarkable on this non-contrast enhanced CT. There are bilateral chest tubes. Chest tube on the right is situated within the major fissure. There is a small right pneumothorax. Left chest tube is situated laterally, near the apex. There is a tiny left hydropneumothorax near the chest tube tip. Other than small amount of left basilar atelectasis described above, the lungs are clear. Central bronchi are patent to the subsegmental level. Endotracheal tube and nasogastric tube are in appropriate positions. There is a small amount of soft tissue anasarca. Limited views of the upper abdomen are notable for surgical clips anterior to the stomach. There is a small volume of ascites surrounding the liver. There is mild elevation of the left hemidiaphragm, possibly related to left basilar atelectasis. Osseous structures demonstrate no suspicious abnormalities. As described above, there has been prior median sternotomy, and partial resection of the left hemisternum. There is no sign of periosteal reaction, osseous destruction, or other finding to suggest osteomyelitis. IMPRESSION: 1. Small bilateral pleural effusions, containing simple fluid. 2. Small pericardial effusion. 3. Small right pneumothorax. Right chest tube is situated within the major fissure. Tiny left hydropneumothorax. 4. Large anterior mediastinal flap closure containing pectoralis musculature and omentum with a moderate amount of stranding within, likely related to a combination of edema and residua of prior hemorrhage. No sign to suggest active bleeding. Posterior displacement of mediastinal structures secondary to large flap. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5718] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5785] Approved: SAT [2113-8-26] 4:53 PM Cardiology Report ECHO Study Date of [2113-8-24] PATIENT/TEST INFORMATION: Indication: Shortness of breath; bleeding from two weeks old sternal flap; s/p AVR, MV repair and ascending aorta replacement Status: Inpatient Date/Time: [2113-8-24] at 16:16 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW04-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name11 (Name Pattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] MEASUREMENTS: Left Ventricle - Ejection Fraction: 35% (nl >=55%) INTERPRETATION: Findings: Emergent limited TEE exam to rule major causes of shortness of breath LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Moderate global LV hypokinesis. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. Moderate global RV free wall hypokinesis. AORTA: Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. AORTIC VALVE: AVR well seated, normal leaflet/disc motion and transvalvular gradients. MITRAL VALVE: Mitral valve annuloplasty ring. TRICUSPID VALVE: Moderate [2+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: Effusion is loculated. 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. Resting tachycardia (HR>100bpm). patient. Conclusions: 1) Large sized bilateral pleural effusion. 2) moderate sized loculated anterior pericardial effusion (open pericardium postoperative) 3) Thoracic aortic contour is intact. No evidence of dissection or aneurysms. 4) Aortic valve bioprosthesis is intact and functioning well. 5) Mitral valve ring is intact and mild Mitral regurgitation seen. 6) No evidence of thrombus in the RA, RV or main pulmonary arteries. 7) There is mod RV global systolic dysfunction with moderate TR with bowing of interatrial septum to the left. 8) With epinephrine 0.02mcg/kg/min, there is an improvement of global biventricular systolic function and mild to moderate TR. Electronically signed by [Name6 (MD) 3892] [Name8 (MD) 3893], MD on [2113-8-24] 16:27. [Location (un) ] PHYSICIAN: Brief Hospital Course: He was transfused and a groin line was placed in the ED. He was taken to the operating room on by plastic surgery and cardiac surgery for exploration, hematoma evacuation and was also found to have a component of tamponade. He was transferred to the ICU where he had bilateral chest tubes placed. He underwent bronchoscopy on [8-25] for LLL collapse. He was extubated later on POD #1. He was transferred to the floor on POD #2. His converted to SR and the last episode of Atrial fibrillation was [8-28] short burst. He continued to progress, his chest tubes were removed. He was ready for discharge to rehab on POD 6 with 2 JP drains. Plan for coumadin to be held until all JP drains removed per Dr [Last Name (STitle) 914] and Dr [First Name (STitle) ]. Medications on Admission: Docusate Sodium Aspirin Hydromorphone Montelukast Albuterol-Ipratropium Ezetimibe Fluticasone-Salmeterol 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Ranitidine Potassium Chloride Verapamil Digoxin 14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days: then 200 mg daily until seen by Dr. [Last Name (STitle) ]. 15. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q4H (every 4 hours). 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. 10. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) mL PO BID (2 times a day). 11. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 13. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day. 14. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. 15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-20] Sprays Nasal QID (4 times a day) as needed. 16. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day: while on lasix. 17. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection three times a day. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Cardiac Tamponade Wound Hematoma Pleural Effusions Discharge Condition: Good Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. Wash in incision daily with mild soap and water. Staples to remain intact and will be removed by plastic surgery (Dr [First Name (STitle) ] 2)Avoid creams and lotions to surgical incisions. 3)Call Dr [First Name (STitle) ] for drainage, erythema, or fever 4)No lifting more than 10 lbs unit after seen [9-21] Dr [Last Name (STitle) 1290] 5) Any questions or concerns please call cardiac surgery office [Telephone/Fax (1) 170] Followup Instructions: Dr. [Last Name (STitle) 1290] [Name (STitle) 8784] [2113-9-21] at 1pm [Doctor First Name ] [Hospital Unit Name ] [Telephone/Fax (1) 170] Dr. [Last Name (STitle) 2161] after discharge from rehab [Telephone/Fax (1) 60677] [Name6 (MD) 251] [Last Name (NamePattern4) 677], M.D. Phone:[Telephone/Fax (1) 2934] Date/Time:[2113-10-27] 4:00 Dr. [First Name (STitle) ] (Plastic Surgery) appointment [2113-9-7] at 9am [Apartment Address(1) 1414] [Location (un) ], [Numeric Identifier 1415] Phone: [Telephone/Fax (1) 1416] appointment [2113-9-7] at 9am Completed by:[2113-8-30] ICD9 Codes: 2851, 5119, 496, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8855 }	Medical Text: Admission Date: [2182-7-2] Discharge Date: [2182-7-4] Date of Birth: [2113-2-28] Sex: M Service: MEDICINE Allergies: Doxycycline Attending:[Last Name (NamePattern4) 290] Chief Complaint: Weakness Major Surgical or Invasive Procedure: none History of Present Illness: 69M PMH ESRD on HD, DM, MIx2, CHF, s/p CABG, p/w fall at home [2-4] weakness and lack of strength. Recent admit to [Hospital1 18] early [2-6] with fall, found to be febrile and confused, with pus expressed near the AV fistula. AV graft felt to be infected and thrombosed, blood cultures + for MSSA. Admitted to ICU, vancomycin then oxacillin, with course complicated by decr O2 sat. TEE neg, MRI + cellulitis, - osteo. A MRI of the L shoulder was - for osteo but ? for septic emboli in lungs. AV graft was partially removed. During this time, the pt also experienced a TC seizure. LP, CT EEG were all negative. He was loaded on dilantin and d/c'd per neuro. While septic, he also experienced an NSTEMI, incr INR to 4 with neg DIC panel that was responsive to Vit K, and increased LFT/GGT with neg US. He was d/c'd on 4 weeks of cefazolin. He then returned on [2-/2107] with f/c, cough and SOB. He developed resp distress and was intubated, vanco/ceft-->ox/ceft for PNA. BAL with 2+ poly but cx neg. He had pleural effusion, which when tapped revealed transudate. On this admission, he denied LOC, f/c, cough, CP. Past Medical History: ESRD--HD Kyrle's dz DM CHF, EF 20% CABG [2164] MI x 2--[2173], [2180] Afib Anemia PVD CVA ? protein S def Sz in setting of sepsis septic AV graft Social History: + tobacco for 50 years Family History: NC Physical Exam: V: T 100.4 HR 122 AF BP 119/75 (dop/levo) AC 600x12 1.0 Sat 93% PEEP 5 G: Intubated, sedated HEENT: Intubated, anicteric sclerae, MM dry, PERRL Lungs: CTA BL CV: [Last Name (un) ] S1S2, III/VI SM loudest at apex, no radiation Abd: Soft, NT, ND, No rebound Ext: BL blue toes, chronic vascular changes, BL pulses by doppler, L forearm erythema, AV fistula Neuro: withdraws to pain B, Babinski neg BL Pertinent Results: [2182-7-4] 03:42AM BLOOD WBC-21.4* RBC-4.66 Hgb-15.0 Hct-46.6 MCV-100* MCH-32.1* MCHC-32.1 RDW-15.5 Plt Ct-127* [2182-7-3] 06:07PM BLOOD WBC-19.1* RBC-4.46* Hgb-14.4 Hct-44.0 MCV-99* MCH-32.2* MCHC-32.6 RDW-15.6* Plt Ct-141* [2182-7-3] 08:14AM BLOOD WBC-20.2* RBC-4.66 Hgb-14.9 Hct-45.4 MCV-97 MCH-31.9 MCHC-32.7 RDW-15.7* Plt Ct-121* [2182-7-3] 01:25AM BLOOD WBC-20.5* RBC-4.63 Hgb-14.7 Hct-46.0 MCV-99* MCH-31.7 MCHC-31.9 RDW-15.7* Plt Ct-138* [2182-7-2] 08:00PM BLOOD WBC-18.1* RBC-4.71 Hgb-14.8 Hct-46.4 MCV-99* MCH-31.3 MCHC-31.8 RDW-15.6* Plt Ct-115* [2182-7-2] 02:43PM BLOOD WBC-14.2* RBC-4.10# Hgb-13.3# Hct-40.3# MCV-99* MCH-32.6* MCHC-33.1 RDW-15.8* Plt Ct-90# [2182-7-2] 02:43PM BLOOD Neuts-72 Bands-10* Lymphs-16* Monos-0 Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0 [2182-7-4] 03:42AM BLOOD Plt Ct-127* [2182-7-3] 06:07PM BLOOD Plt Ct-141* [2182-7-3] 08:14AM BLOOD Plt Ct-121* [2182-7-3] 01:25AM BLOOD Plt Ct-138* [2182-7-3] 01:25AM BLOOD PT-14.3* PTT-32.4 INR(PT)-1.4 [2182-7-2] 08:00PM BLOOD Plt Ct-115* [2182-7-2] 08:00PM BLOOD PT-15.5* PTT-31.3 INR(PT)-1.6 [2182-7-2] 02:43PM BLOOD Plt Smr-LOW Plt Ct-90# [2182-7-2] 02:43PM BLOOD PT-26.5 PTT-36.1* INR(PT)-4.6 [2182-7-2] 08:00PM BLOOD Fibrino-378 [2182-7-4] 03:42AM BLOOD Glucose-151* UreaN-64* Creat-8.5* Na-133 K-6.8* Cl-95* HCO3-16* AnGap-29* [2182-7-3] 06:07PM BLOOD Glucose-132* UreaN-55* Creat-8.1* Na-134 K-5.4* Cl-95* HCO3-17* AnGap-27* [2182-7-2] 02:43PM BLOOD Glucose-90 UreaN-35* Creat-7.0# Na-134 K-4.8 Cl-97 HCO3-21 AnGap-21* [2182-7-2] 08:00PM BLOOD ALT-17 AST-27 LD(LDH)-263* AlkPhos-153* TotBili-0.9 [2182-7-4] 03:42AM BLOOD Calcium-6.9* Phos-9.6# Mg-1.6 [2182-7-3] 08:14AM BLOOD Calcium-7.4 Phos-8.0* Mg-1.4* [2182-7-3] 01:25AM BLOOD Calcium-7.0* Phos-6.9* Mg-1.4* [2182-7-2] 08:00PM BLOOD Albumin-3.0* Calcium-7.1* Phos-5.9* Mg-1.3* [2182-7-3] 06:07PM BLOOD Cortsol-24.6* [2182-7-3] 05:42PM BLOOD Cortsol-19.6 [2182-7-3] 01:25AM BLOOD Cortsol-23.1* [2182-7-3] 08:14AM BLOOD Vanco-10.0* [2182-7-4] 03:58AM BLOOD Type-MIX pO2-42* pCO2-51* pH-7.13* calHCO3-18* Base XS--13 [2182-7-3] 07:40PM BLOOD Type-MIX pO2-48* pCO2-44 pH-7.26* calHCO3-21 Base XS--6 [2182-7-3] 06:06PM BLOOD Type-ART pO2-115* pCO2-34* pH-7.34* calHCO3-19* Base XS--6 [2182-7-3] 08:30AM BLOOD Type-MIX Temp-38.0 Rates-[12-13] Tidal V-500 PEEP-5 O2-40 pO2-46* pCO2-46* pH-7.29* calHCO3-23 Base XS--4 -ASSIST/CON Intubat-INTUBATED [2182-7-3] 02:38AM BLOOD Type-ART Temp-37.4 Rates-[12-11] Tidal V-500 PEEP-5 O2-50 pO2-189* pCO2-33* pH-7.36 calHCO3-19* Base XS--5 -ASSIST/CON Intubat-INTUBATED [2182-7-3] 01:34AM BLOOD Type-MIX Temp-37.4 Rates-[12-11] Tidal V-500 PEEP-5 O2-50 pO2-42* pCO2-45 pH-7.29* calHCO3-23 Base XS--4 -ASSIST/CON Intubat-INTUBATED [2182-7-2] 05:33PM BLOOD Type-MIX pO2-37* pCO2-46* pH-7.35 calHCO3-26 Base XS-0 [2182-7-4] 03:58AM BLOOD Glucose-168* Lactate-7.1* Na-133* K-6.8* Cl-97* calHCO3-18* [2182-7-3] 08:30AM BLOOD Lactate-2.1* [2182-7-3] 02:38AM BLOOD Lactate-1.8 [2182-7-3] 01:34AM BLOOD Lactate-1.9 [2182-7-3] 12:20AM BLOOD Lactate-1.8 [2182-7-2] 06:18PM BLOOD Lactate-1.9 [2182-7-2] 02:44PM BLOOD Lactate-2.8* [2182-7-4] 03:58AM BLOOD Hgb-15.6 calcHCT-47 O2 Sat-60 [2182-7-3] 08:30AM BLOOD O2 Sat-72 [2182-7-3] 01:34AM BLOOD O2 Sat-69 [2182-7-2] 05:33PM BLOOD O2 Sat-66 [2182-7-4] 03:58AM BLOOD freeCa-1.05* Brief Hospital Course: Pt admitted to ICU. Intubated. 1. Septic shock: GPC thought to be from line infection vs a pulmonary source. He was started on Vanco CTX, and Gent, with requirement of pressor support for hypotension. Renal was consulted and a decision was made to attempt to treat without pulling the line. The patient was weaned off of pressors. Discussion with the patient's girlfriend revealed that he had been having large volume diarrhea prior to being found on the floor. Further discussion with surgery ensued and pt was slated to go to the OR on [7-4] for evaluation of the infected graft stump. In early AM on [7-4], pt found to be in asystole. Immediately started on pressors and IVF for hypotension. Rhythm changed to Vtach, labs sent and pt found to have hyperkalemia, started on Bicarb, Insulin, glucose. Rhythm returned to asystole, code called, pt pronounced deceased at 4:10AM. Medications on Admission: Plavix, oxycontin, lisinopril, Imdur, Metoprolol, Lipitor, Protonix, Neurontin, Amiodarone Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Sepsis Discharge Condition: deceased [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] ICD9 Codes: 4275, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8856 }	Medical Text: Admission Date: [2193-8-21] Discharge Date: [2193-8-31] Date of Birth: [2112-4-2] Sex: M Service: SURGERY Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending:[First Name3 (LF) 371] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [2193-8-22] Ex-lap, small Bowel Resection History of Present Illness: HPI:81yM with acute onset abdominal pain this morning upon waking up. Did not eat secondary to pain. Denies emesis but does endorse nausea. Pain got progressively worse and he eventually presented to an outside ER. He was in Afib with short-run V-tach x 2. He was bolused with amiodarone and started on a gtt. CT scan demonstrated free air, thickened bowel distal to the ligament of treitz and free leakage of contrast from the bowel. He was transferred to [Hospital1 18] for further care. Past Medical History: CAD, CHF, Afib, CVA, L testicular lymphoma, HTN Social History: lives at home with wife and cousin. Denies EtOH, tob Family History: NC Physical Exam: Physical Exam: upon admission: [2193-8-21] Vitals: T: 97 HR: 110 BP: 130/60 RR: 23 O2Sat: 96% GEN: A&O, appears uncomfortable HEENT: No scleral icterus, mucus membranes moist CV: irregular and tachycardic PULM: clear bilaterally ABD: distended with voluntary guarding throughout. +TTP which is worst in the L abdomen. +Rebound. Ext: No LE edema, LE warm and well perfused Pertinent Results: [2193-8-30] 06:03AM BLOOD WBC-19.9* RBC-3.44* Hgb-10.2* Hct-29.4* MCV-85 MCH-29.6 MCHC-34.6 RDW-14.1 Plt Ct-567* [2193-8-29] 06:00AM BLOOD WBC-19.1* RBC-3.35* Hgb-10.1* Hct-28.5* MCV-85 MCH-30.3 MCHC-35.5* RDW-14.1 Plt Ct-449* [2193-8-27] 05:23AM BLOOD WBC-23.4* RBC-3.19* Hgb-9.9* Hct-26.8* MCV-84 MCH-31.1 MCHC-37.1* RDW-14.4 Plt Ct-412 [2193-8-26] 05:40AM BLOOD WBC-18.3* RBC-3.46* Hgb-10.4* Hct-29.8* MCV-86 MCH-30.2 MCHC-35.1* RDW-14.1 Plt Ct-286 [2193-8-24] 12:15AM BLOOD WBC-27.2* RBC-3.51* Hgb-11.1* Hct-29.5* MCV-84 MCH-31.6 MCHC-37.6* RDW-15.1 Plt Ct-314 [2193-8-22] 05:46PM BLOOD WBC-40.2* RBC-3.81* Hgb-12.3* Hct-32.9* MCV-86 MCH-32.2* MCHC-37.4* RDW-15.7* Plt Ct-390 [2193-8-22] 01:36AM BLOOD WBC-35.5* RBC-4.60 Hgb-14.2 Hct-41.4 MCV-90 MCH-31.0 MCHC-34.4 RDW-14.9 Plt Ct-397 [2193-8-21] 07:10PM BLOOD WBC-44.4* RBC-4.76 Hgb-14.9 Hct-41.7 MCV-88 MCH-31.2 MCHC-35.6* RDW-14.8 Plt Ct-451* [2193-8-22] 01:36AM BLOOD Neuts-86* Bands-5 Lymphs-5* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2193-8-21] 07:10PM BLOOD Neuts-79* Bands-14* Lymphs-4* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2193-8-22] 01:36AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Burr-1+ Tear Dr[Last Name (STitle) ]1+ [2193-8-30] 06:03AM BLOOD Plt Ct-567* [2193-8-30] 06:03AM BLOOD PT-14.3* INR(PT)-1.2* [2193-8-29] 06:00AM BLOOD Plt Ct-449* [2193-8-29] 06:00AM BLOOD PT-64.6* INR(PT)-7.2* [2193-8-28] 06:10AM BLOOD PT-49.4* INR(PT)-5.2* [2193-8-30] 06:03AM BLOOD Glucose-106* UreaN-19 Creat-1.2 Na-136 K-4.0 Cl-106 HCO3-25 AnGap-9 [2193-8-29] 06:00AM BLOOD Glucose-91 UreaN-21* Creat-1.3* Na-138 K-3.9 Cl-109* HCO3-22 AnGap-11 [2193-8-28] 06:10AM BLOOD Glucose-120* UreaN-21* Creat-1.2 Na-137 K-3.8 Cl-107 HCO3-22 AnGap-12 [2193-8-27] 05:23AM BLOOD Glucose-123* UreaN-23* Creat-1.6* Na-138 K-3.7 Cl-106 HCO3-25 AnGap-11 [2193-8-22] 01:36AM BLOOD Glucose-156* UreaN-26* Creat-2.0* Na-134 K-6.5* Cl-104 HCO3-22 AnGap-15 [2193-8-21] 07:10PM BLOOD Glucose-124* UreaN-26* Creat-2.2* Na-138 K-4.1 Cl-99 HCO3-25 AnGap-18 [2193-8-23] 02:32PM BLOOD LD(LDH)-231 [2193-8-30] 06:03AM BLOOD Calcium-8.5 Phos-2.2* Mg-1.7 [2193-8-29] 06:00AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.6 [2193-8-24] 06:14PM BLOOD Type-ART pO2-88 pCO2-38 pH-7.35 calTCO2-22 Base XS--3 [2193-8-24] 06:14PM BLOOD Lactate-1.2 [2193-8-24] 12:40AM BLOOD freeCa-1.14 [2193-8-23] 02:45PM BLOOD freeCa-1.13 [2193-8-21]: EKG: Atrial fibrillation with rapid ventricular response. Left axis deviation. Possible prior anteroseptal myocardial infarction of indeterminate age. Non-specific ST-T wave changes. No previous tracing available for comparison. [2193-8-22]: Echo: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([12-9]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild to moderate mitral regurgitation with moderate to severe pulmonary artery hypertension. Dilated left atrium. [2193-8-24]: chest x-ray: Evidence of failure with pulmonary plethora and a left effusion again seen, essentially unaltered since the prior chest x-ray. The position of the endotracheal tube and left subclavian is also unchanged. IMPRESSION: Persistent failure [2193-8-26]: EKG: Atrial fibrillation. Demand ventricular pacing. Intraventricular conduction delay of left bundle-branch block type. Since the previous tracing there is no significant change. TRACING #3 [2193-8-28]: chest x-ray: FINDINGS: The pacerwire is again seen projecting into the right ventricle. A subclavian catheter is seen in correct position terminating in the SVC. Overall, the lungs appear clearer than they did on [2193-8-24], with a substantial decrease in the amount of pulmonary edema present. There was, however, a residual opacity in the left mid lung, which represents atelectasis. There are bilateral pleural effusions, left greater than right. The cardiomediastinal silhouette is unchanged. Brief Hospital Course: 81 year old gentleman admitted to the acute care service with abdominal pain. Upon admission, he was made NPO and given intravenous fluids. Radiographic images from the OSH demonstrated free air and leakage of contrast from the bowel. He was also reported to be in atrial fibrillation and started on an amiodarone drip. He received fluid resuscitation and was taken to the operating room where he had an exploratory laparotomy and resection of the small bowel. His operative course was stable with a 100cc blood loss. After his surgey he was transported to the intensive care unit where he was closely monitored. On POD #1, he was tachycardic, febrile and hypotensive and there was a concern for septic shock. During this time, he required fluid resusitation and pressor suppport. Blood cultures were sent. An echocardoigram was done to evaluate his cardiac status. He was febrile and started on a 7 day course of zosyn. Because of his labile status, EP was consulted to evaluate his pacemaker status; their final conclusions at the time were a tachy-brady syndrome related to SIRS. Recommendations included ECHO 1 month after discharge, bridging from heparin to coumadin, and rate-control with beta-blockade. His pulmonary status improved and he was extubated on POD #2. His tachycardia was controlled with digoxin and lopressor and he was weaned off his amiodarone. His fever persisted with a rising white blood cell count and he was started on vancomycin and fluconazole. His blood and urine cultures showed no growth. He remained NPO with [Initials (NamePattern4) ] [Last Name (NamePattern4) ]-gastric tube to suction. After his gastric output decreased, the [Last Name (un) ]-gastric tube was removed on POD #3. He was transferred to the surgical floor on POD # 4. He was reported to have an isolated episode of elevated heart rate and his lopressor was increased to control the rate. He also had an isolated episode of emesis and was made NPO. After his nausea subsided, he was introduced to clear liquids with advancement to a regular diet. He tolerated his diet but began having episodes of diarrhea. A stool culture was sent and it was negative for c.diff. On POD #7, he began having periods of oxygen desaturation. A chest x-ray was done which showed left lobe residual opacity suggestive of ateletasis. He was encouraged to use the incentive spirometer and he was started on nebulizers. His oxygen saturation improved and he has been maintained on room air with an oxygen saturation of 100%. He has completed his course of antibiotics on [8-28] but continues to have an elevated white blood cell count of 18,000-20,000. He resumed his coumadin on [8-27], but after one dose was found to have an INR of 7.2. He received Vit. K and his coumadin was held. His current INR is 1.0 and he will receive 5 mg on [8-31] with careful monitoring of his PT/INR. He was evaluated by physical therapy and because of his hospital course and deconditioning, they recommended a rehabilitation facility upon discharge. He has been instructed to follow up with the acute care service and with his primary care provider who will need to schedule a follow-up ECHO in 1 month. Medications on Admission: [Last Name (un) 1724]: digoxin 0.125', coumadin 5', HCTZ 12.5', metoprolol 50'', omeprazole 20', FeSO4 325', Betaxolol 15 0.5, Fluorometholone 15 0.1, Brimondine 15 0.2 Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. betaxolol 0.25 % Drops, Suspension Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day): both eyes. 3. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours): both eyes. 4. digoxin 125 mcg Tablet Sig: One [Age over 90 ]y Five (125) mcg PO DAILY (Daily). 5. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for puritis: pruritis. 6. fluorometholone 0.1 % Drops, Suspension Sig: One (1) Drop Ophthalmic Q24H (every 24 hours): both eyes. 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): as needed for pain. 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stools. 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for loose stools. 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for hr <60, systolic blood pressure <100. 12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 13. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 14. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: please montor INR/PT. 15. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO once a day: please monitor electrolytes. Discharge Disposition: Extended Care Facility: Life Care Center of [Location (un) 8545] Discharge Diagnosis: Bowel perforation atrial fibrillation septic shock Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with abdominal pain. You had an irregular heart beat when you were admitted and you required intravenous medicine to control it. You had a cat scan of the abdomen done which showed a small bowel perforation. You were taken to the operating room where an exploratory laparotomy was performed and a small section of your bowel resected. You went to the intensive care unit after the surgery. Once your vital signs stabilized, you transferred to the surgical floor. Your antibiotics have been discontinued and you are slowly recovering from your surgery. You have been seen by physical therapy who recommended discharge to a rehabilitation facility. Followup Instructions: Please follow-up with the acute care service in 2 weeks. You can schedule your appointment by callling # [Telephone/Fax (1) 600] You will also need to follow-up with your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 29247], or Dr. [Last Name (STitle) 31573] who can arrange a repeat Echocardiogram in 1 month. You will also need to follow up with your Oncologist, Dr. [Last Name (STitle) 91341], in [12-9] weeks. Your pathology results are still pending. These results will be forwarded to your your PCP and your oncologist when they are made available. They will be available during your [Hospital 2536] clinic visit in [1-10] weeks. Completed by:[2193-8-31] ICD9 Codes: 0389, 5180
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8857 }	Medical Text: Admission Date: [2131-8-14] Discharge Date: [2131-8-19] Date of Birth: [2062-9-12] Sex: M Service: Cardiothoracic Surgery CHIEF COMPLAINT: Increased shortness of breath and dyspnea on exertion. HISTORY OF PRESENT ILLNESS: The patient complained of increased dyspnea on exertion and shortness of breath. He had an electrocardiogram which showed increased ST segments and had a thallium scan which showed irreversible defect. PAST MEDICAL HISTORY: Significant for hypercholesterolemia, hypertension. PAST SURGICAL HISTORY: Significant for left herniorrhaphy. MEDICATIONS: Diltiazem, Atenolol, Dilacor, Celebrex, Glucosamine, Acetaminophen, Vitamin E and C and Isosorbide. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Initial physical examination revealed pulse 82, respirations 20. General: No acute distress. Head, eyes, ears, nose and throat was negative for lymphadenopathy, negative jugulovenous distension. Chest was clear to auscultation bilaterally. Heart was regular rate and rhythm. Abdomen was soft, nontender. Extremities: She had varicosities on the right side. Neurological was grossly intact. Pulses revealed femoral and dorsalis pedis +2 bilaterally, posterior tibial +1 bilaterally. HOSPITAL COURSE: The patient was admitted on [2131-8-14] and transferred to the Operating Room with an initial diagnosis of coronary artery disease. The patient's operation included a three vessel coronary artery bypass graft with left internal mammary artery to the coronary artery disease, saphenous vein graft to obtuse marginal and V1. The patient tolerated the procedure well and was transported to the Post Anesthesia Care Unit in stable condition. On postoperative day #1 the patient was extubated and transferred to the floor. On postoperative day #2, the patient continued to do well with increased ambulation and incentive spirometry. On postoperative day #2 the chest tube was also removed and on postoperative day #3 the patient had several bouts of atrial fibrillation with a ventricular response of 100 to 110. The patient was started on Amiodarone 400 mg t.i.d., Lopressor 50 mg b.i.d. and was given 20 mg of Lopressor through an intravenous push. On postoperative day #4 the patient was doing well and was converted back to sinus rhythm. The patient continued on Lopressor and Amiodarone. The patient continued to do well and is scheduled for discharge on [2131-8-19] to home with [Hospital6 407]. DISCHARGE PHYSICAL EXAMINATION: Temperature 97.5, pulse 68, respiratory rate 20, blood pressure 120/90, oxygen 98% on 2 liters, positive 3 kg. Cardiovascular: Regular rate and rhythm. Respiratory is clear to auscultation bilaterally. Abdomen was soft, nontender, nondistended. Extremities: She had no peripheral edema and incision was dry, clean and intact for both chest and lower extremity incision. COMPLICATIONS: Atrial fibrillation which was treated with Lopressor and Amiodarone. DISCHARGE MEDICATIONS: 1. Lopressor 75 mg p.o. b.i.d. 2. Lipitor 10 mg p.o. q.d. 3. Amiodarone 400 mg t.i.d. times four days followed by 400 mg b.i.d. times seven days, followed by 400 mg q.d. times seven days, followed by 200 mg q.d. 4. Lasix 20 mg p.o. q.d. times seven days 5. Potassium chloride 20 mEq p.o. b.i.d. times seven days 6. Hydrochlorothiazide 10 mg p.o. q.i.d. 7. Aspirin 81 mg p.o. q.d. 8. Percocet 1 to 2 tabs p.o. q. 4 to 6 hours The patient will be discharged home with [Hospital6 1587]. PRIMARY DISCHARGE DIAGNOSIS: 1. Status post coronary artery bypass graft times three SECONDARY DIAGNOSIS: 1. Hypercholesterolemia 2. Hypertension FOLLOW UP: The patient will follow up in Dr.[Doctor Last Name ] office in three to four weeks. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 35548] MEDQUIST36 D: [2131-8-18] 14:18 T: [2131-8-18] 15:32 JOB#: [Job Number ] ICD9 Codes: 4111, 9971, 4240, 4019, 2720, 2762
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8858 }	Medical Text: Admission Date: [2176-7-8] Discharge Date: [2176-7-30] Date of Birth: [2129-11-15] Sex: M Service: HISTORY OF PRESENT ILLNESS: Patient is a 46-year-old male status post a motorcycle crash, positive loss of consciousness found down with [Initials (NamePattern4) ] [Last Name (NamePattern4) 2611] coma score of 8, sats of 90%. He had a large amount of crepitus in the right chest, needed compressions x2 with rush of air and sats up to 100%. [Location (un) 2611] coma score of 12. Hemodynamically stable and brought to the Emergency Room. Airway was patent with right chest tube placed. Patient was later intubated. Pupils were 4 down to 2 mm and briskly reactive. EOMs full. Blood pressure was 100/palp. Respiratory rate was 15. Sats were 92%. He had left facial abrasion. His face is stable. Tympanic membranes are clear. Neck was crepitus bilaterally, right chest crepitus. Bilateral breath sounds were equal. Regular, rate, and rhythm. Abdomen negative. Rectal tone was normal. Back with no stepoffs or tenderness. No deformities in the extremities. Chest x-ray shows a large amount of subcutaneous emphysema with right clavicular fracture. Pelvis: No fractures. Head CT showed no bleed, some facial bone screws from an old fracture. CT of the C spine showed C7 left vertebral artery foramen fracture. Chest showed multiple rib fractures, right scapula fracture, no solid organ injury. The patient was monitored in the ICU with mainly respiratory issues. Had a bronchoscopy done in [7-8] that showed no injury, clot which was aspirated, an irregular distal airways without ............. On [7-9], the patient was awake and alert, although intubated, following commands, moving all extremities. EOMs full. He was neurologically stable, remained in hard collar. Patient had an arteriogram to rule out vertebral and carotid artery dissection which was ruled out. He remained neurologically stable. Patient was followed by the Ortho service for the right clavicular and scapula fractures and rib fractures. Ortho recommended a sling and swath for right scapular and clavicular fractures. They were nonoperative. He spiked a temperature. Sputum culture showed gram-negative rods. The patient was started on Levaquin and finished a 10 day course. He remained neurologically stable. Continued to have the C7 fracture. He was transferred to the Neurosurgery Service on [2176-7-24]. Patient was taken to the OR and underwent C6-T1 posterior fusion without intraoperative complications. Vital signs are stable. Postoperative, he was monitored in the ICU. Vital signs were stable. He was transferred to the regular floor on [2176-7-28], evaluated by Physical Therapy and Occupational Therapy, and found to be safe for discharge to home. PCA pump was discontinued on [2176-7-29]. His drain was removed and he was ready for discharge home on [2176-7-30]. DISCHARGE MEDICATIONS: 1. Oxycodone 40 mg p.o. q.12h. 2. Hydromorphone 2-6 mg p.o. q.3-4h. prn. 3. Trazodone 50 mg p.o. q.h.s. 4. Zantac 150 mg p.o. b.i.d. 5. Nicotine patch 21 mg topically q.d. 6. Peroxetine hydrochloride 20 mg p.o. q.d. 7. Bacitracin ointment application to abrasions b.i.d. CONDITION ON DISCHARGE: Stable. FOLLOW-UP INSTRUCTIONS: He will follow up with Dr. [Last Name (STitle) 1327] in one week for staple removal. [Name6 (MD) 1339] [Last Name (NamePattern4) 1340], M.D. [MD Number(1) 1341] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2176-7-29] 08:36 T: [2176-7-29] 08:40 JOB#: [Job Number 52123] ICD9 Codes: 5185
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8859 }	Medical Text: Admission Date: [2157-8-2] Discharge Date: [2157-8-8] Date of Birth: [2102-1-21] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2969] Chief Complaint: new onset cough and chest pain w/ fever Major Surgical or Invasive Procedure: none History of Present Illness: He presents now with a one day history of productive cough that has steadily increased in frequency and is associated with mild dyspnea. Patient states that he does not believe that he has had a fever during this time and as recently as two days ago, claims that his PCP did not find anything amiss with his oxygen sats. or on physical exam. However, upon his condition worsening this morning, he went again to his PCP and chest xrays were performed that showed evidence of a multifocal pneumonia. Admitted for w/u. Past Medical History: Esophageal ca, history of aspiration pneumonia, COPD, OSA (CPAP), GERD, lipids, s/p back fusion, h/o diverticuli, pain, diabetes Social History: lives w/ wife and children 40 pk year smoker- quit 8 mos ago. No ETOH Family History: non contributory Physical Exam: general: Obese male in NAD VS: 98.4, 92, 132/54, 18, 94% on room air HEENT: unrenarkable Chest: course breath sounds bilat. COR: RRR S1, S2 abd: obese, soft, round, NT, +BS extrem: no LE edema neuro: intact Pertinent Results: cxr [8-2] Cardiomediastinal contours are unchanged. There are bilateral perihilar consolidations, left greater than right, with air bronchograms. Scattered airspace opacities are also seen at the right apex, and left base. There is no definite pleural effusion. Pulmonary vascularity is normal. There is no pneumothorax. IMPRESSION: Bilateral perihilar consolidations, and scattered additional airspace opacities, most consistent with multifocal pneumonia vs other etiologies. Video swallow [8-4] VIDEOFLUOROSCOPIC SWALLOWING EVALUATION: In collaboration with speech and pathology department, a speech and swallow evaluation was performed. Barium of various consistencies was administered to the patient during continuous videofluoroscopic imaging. ORAL PHASE: Bolus formation and AP tongue movements are within normal limits. There is a mild amount of premature spillover seen before the swallow. PHARYNGEAL PHASE: A mild delay in pharyngeal swallow initiation is seen. Palatal elevation, laryngeal elevation, and epiglottic deflection are within functional limits. However, laryngeal valve closure was mildly reduced. A trace amount of residue is seen within the vallecula and piriform sinuses. 13- mm barium tablet passes freely to the stomach. ASPIRATION/PENETRATION: Penetration was seen with thin and nectar-thick liquids, secondary to premature spillover and swallow delay. Aspiration of thin liquids was also seen, and was noted to be silent. IMPRESSION: Mild oropharyngeal dysphagia, with penetration and an episode of aspiration seen. For further details, please refer to speech and pathology report from the same day. Brief Hospital Course: Pt was admitted and taken to the SICU for hypoxia requiring continuous O2 sat monitioring and 100% non-rebreather. Kept NPO for suspetced aspiration PNA. Hydrated and placed on broad spectrum IVAB unasyn and vanco pending sputum culture. Speech and swallow pathology was re- consulted and a video swallow was perform - see results section- essentially-exam unchnaged from previous intermittent,trace aspiration and aspiration was eliminated with thickened liquids and the chin tuck. He is admittedly not 100% compliant at home w/ his swallowing precautions. With aggressive pul tiolet and IVAB, his oxygenation improved and was transferred from the ICU to the general floor. IVAB were changed to augmentin and bactrim per ID recommendations- sputum cultures were contaminated and therefore unrevealing. ON HD# 5 pt developed abd discomfort and distention. A KUB was done and showed large amounts of stool. After bowel regimen was increased, pt passed stool and symptoms improved and was [Last Name (un) 1815] reg diet. On HD#7 developed left sided back pain w/ coughing which was reproduceable w/ palpation. Appears to be muscle strain from coughing. Given toradol and placed on motrin regimen w/ some relief. Medications on Admission: Lipitor 80mg QD Celebrex 200mg QD Relpax 20mg prn Tricor 48mg QD Fioricet prn Ativan 1mg QD Diazepam 2mg prn Albuterol Prilosec Roxicet Zoloft 100mg QD Oxycontin 40mg [Hospital1 ] Metformin 1000mg QD. Discharge Medications: 1. Sertraline 50 mg Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 2. Oxycodone 40 mg Tablet Sustained Release 12 hr [Hospital1 ]: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 3. Hydrocodone-Acetaminophen 5-500 mg Tablet [Hospital1 ]: One (1) Tablet PO Q6H (every 6 hours) as needed for breakthrough pain. 4. Guaifenesin 100 mg/5 mL Syrup [Hospital1 ]: 5-10 MLs PO Q6H (every 6 hours) as needed. 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 6. Lipitor 80 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 7. Celebrex 200 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO once a day. 8. Ativan 1 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day as needed. 9. Diazepam 2 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day as needed. 10. Amoxicillin-Pot Clavulanate 500-125 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day) for 14 days. Disp:42 Tablet(s) Refills:0 11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO BID (2 times a day) for 14 days. Disp:56 Tablet(s) Refills:0 12. Ranitidine HCl 150 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO HS (at bedtime). Disp:60 Tablet(s) Refills:2 13. Ibuprofen 600 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q8H (every 8 hours). Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Esophageal ca, history of aspiration pneumonia, COPD, OSA (CPAP), GERD, lipids, s/p back fusion, h/o diverticuli, pain, diabetes PSH: transhiatal esophagectomy, pyloroplasty, hiatal herniorrhaphy and feeding jejunostomy in [9-18] Discharge Condition: good Discharge Instructions: Call Dr.[Doctor Last Name 4738] office [Telephone/Fax (1) 170] if experience: -Fever > 101 or chills -Difficulty swallowing Complete all the antibiotics. Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] as needed [Telephone/Fax (1) 170] Follow-up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 10740] [Telephone/Fax (1) 40144]- call for an appointment to be seen in 2 weeks. Completed by:[2157-8-8] ICD9 Codes: 5070, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8860 }	Medical Text: Admission Date: [2141-6-19] Discharge Date: [2141-6-25] Date of Birth: [2062-6-11] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4963] Chief Complaint: weakness and lethargy Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Known lastname ] is a 79F with h/o dementia who comes in with anorexia, fatigue for 1-2 weeks. Patient without any localized complaints, felt that "something was not right" and that she "wasn't herself." She had generalized weakness. Review of systems negative in detail for fevers, nausea, vomiting, abdominal or back discomfort, dysuria, urinary frequency, chest discomfort, dyspnea, cough, diarrhea. In the ED, vitals were T 96.6 P 75 BP 95/57 O2 95% RA. Her admission labs were remarkable for WBC of 28.3, and urinalysis showing >50 WBC. Her pessary was reportedly removed, and she received vancomycin and ceftriaxone empirically. Past Medical History: Dementia Stroke HTN Hyperlipidemia s/p TAHBSO h/o vaginal prolapse and vaginal pessary h/o R central retinal vein occlusion Social History: Retired, lives with her husband and son. [Name (NI) ] smoking, EtoH, ilicits Family History: NC Physical Exam: Physical Exam T 96.8 P 76 Bp 100/70 RR 20 O2 94% RA General Breathing comfortably on room air in no acute distress Pulm Lungs with few crackles at L base, no egophony Back no CVA tenderness CV Regular rate S1 S1 no m/r/g Abd Soft, nontender Extrem warm, well perfused 1+ bilateral lower extremity edema Pertinent Results: RENAL ULTRASOUND: The right kidney measures 11.3 cm. The left kidney measures 9.7 cm. There are no stones or hydronephrosis. Mild lobulation of the right renal cortex is unchanged compared to the prior study. IMPRESSION: 1. No stones or hydronephrosis . CT HEAD W/O CONTRAST: IMPRESSION: 1. No hemorrhage or mass effect. 2. Chronic microvascular ischemia. . CHEST (PA & LAT): IMPRESSION: 1) Mild cardiomegaly without congestive heart failure. [2141-6-19] 01:45PM WBC-28.8# RBC-3.63 HGB-11.4* HCT-33.3* MCV-92 MCH-31.5 MCHC-34.3 RDW-13.2 [2141-6-19] 01:45PM NEUTS-86* BANDS-0 LYMPHS-1* MONOS-13* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2141-6-19] 01:45PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ [2141-6-19] 01:45PM PLT SMR-NORMAL PLT COUNT-264 [2141-6-19] 09:26AM URINE HOURS-RANDOM CREAT-182 SODIUM-51 [2141-6-19] 09:26AM URINE OSMOLAL-302 [2141-6-19] 01:45PM GLUCOSE-133* UREA N-92* CREAT-5.5# SODIUM-132 POTASSIUM-3.0* CHLORIDE-87* TOTAL CO2-26 ANION GAP-22* [2141-6-19] 03:05PM LACTATE-1.9 [2141-6-19] 04:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2141-6-19] 04:00PM URINE RBC-21-50* WBC->50 BACTERIA-MANY YEAST-NONE EPI-[1-30] [6-19] blood cultures: URINE CULTURE (Final [2141-6-22]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. LACTOBACILLUS SPECIES. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- 1 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R [6-19] blood cultures E. coli, as above [Date range (1) 73636] blood cultures negative [6-22] stool cultures negative, C. diff negative x1 Brief Hospital Course: 1. UTI, urosepsis - The patient was treated empirically with vancomycin and ceftriaxone in the emergency department. Upon arrival to the floor, she was hypotensive to the 80's systolic. She was subsequently transferred to the medical intensive care unit for close monitoring and did well hemodynamically with fluid support, without any pressor requirement. Her antibiotics were changed to Zosyn, and she showed a good clinical response and improvement in her leukocytosis. On the floor, she was transistioned to PO ciprofloxacin which she will complete for a 14d course, to end on [7-2]. . 2. Acute renal failure - The patient's creatinine improved follow IVF rehydration. Her renal failure was thought to be pre-renal in etiology. She will hold off on Avapro until her follow-up appointment with her PCP, [Name10 (NameIs) ] repeat Bun/Cr will be measured the week following discharge. . 2. CAD - The patient continued aspirin and her statin. . 4. Dementia - She continued aricept for her dementia. . 5. Hypertension - Her anti-hypertensives were initially held in the setting of hypotension. She will resume her home anti-hypertensive regimen excepting Avapro, for further adjustment by her PCP at her next appointment. . The patient was full code. Medications on Admission: Donepezil 10mg daily Simvastatin 40mg daily nifedipine 90mg daily aspirin 325 daily omeprazole 20mg daily terazosin 2mg daily irbesartan 300mg daily bumetanide 2mg daily nadolol 40mg TID Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: primary 1. urinary tract infection secondary 1. acute renal failure 2. hypertension 3. dementia Discharge Condition: good Discharge Instructions: Please seek medical attention if you develop fevers, chills, sweats, shortness of breath, abdominal or back pain, worsened discomfort with urination, or other symptoms that worry you. Please take all of your antibiotics (ciprofloxacin) as directed, even if you are feeling entirely well. Please have the following blood work done on Tuesday [6-27]: complete blood count, BUN, and Creatinine. Please do NOT take your Avapro until Dr. [Last Name (STitle) 172] says to resume it. Followup Instructions: Please follow up with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 172] [Telephone/Fax (1) 133] on [7-3] 1:45 ICD9 Codes: 5849, 5990, 4280, 4019, 2720, 2449, 2768
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8861 }	Medical Text: Admission Date: [2103-7-5] Discharge Date: [2103-7-26] Date of Birth: [2037-2-24] Sex: M Service: SURGERY Allergies: Precedex Attending:[First Name3 (LF) 4748] Chief Complaint: chronic mesenteric ischemia Major Surgical or Invasive Procedure: Mesenteric Angio [7-9] R heart cath [7-11] Open Antegrade Superior Mesenteric Artery bypass with graft [2103-7-12] History of Present Illness: 66M with PVD and left fem to PT bypass with RGSV four months ago for claudication who presented to an outside hospital several days ago with one month of intermittent abdominal pain and 100 pound weight loss over the past three years and 20 pounds over the last month. Imaging was concerning for celiac and SMA stenosis with infra-renal aortic aneurysm and bilateral renal artery infarcts. Catheterization was attempted but aborted given SMA occlusion. Given multiple comorbid conditions and the complexity of his disease, he was transferred to [Hospital1 18] for further management. At [Hospital1 18] he reports chronic abdominal pain which is rather diffuse. He states that it has been worse over the past week, is exacerbated by eating and is associated with diarrhea. He reports that his claudication resolved after his lower extremity bypass. Past Medical History: CAD w severe MI ten years ago, CHF, Grave's disease treated with PTU, SBO, history of [Last Name (un) ] now resolved, COPD, afib (hx of coum), parastomal hernia, renal infarct, SMA stenosis, active smoker (75 pack yr; cut down to 4-5/day), cirrhosis, Pulm htn, right heart strain, ischemic left leg Social History: 100 pack year smoking history. heavy history of etoh with over 24 beverages consumed daily but has not had an alcoholic beverage in several years Family History: sister with lung cancer at 37 yeras of age and another sister with stomach cancer in 70's. Brother with CAD. Physical Exam: At time of admission: Vital Signs: 98.1 80 133/85 20 98 RA General: awake, alert, NAD HEENT: NCAT, EOMI, anicteric Heart: RRR, NMRG Lungs: wheezes bilaterally Abdomen: soft, mildly tender to palpation in epigastrium Extremities: right foot is warm, left foot is slightly cooler. well-healed bypass incision along LLE. cap refill < 2 seconds. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RLE Femoral: P. Popiteal: P. DP: N. PT: D. LLE Femoral: P. Popiteal: N. DP: N. PT: D. Pertinent Results: PFTS: SPIROMETRY 8:37 AM Pre drug Post drug Actual Pred %Pred Actual %Pred %chg FVC 2.27 4.18 54 FEV1 1.74 2.88 61 MMF 1.66 2.74 61 FEV1/FVC 77 69 111 LUNG VOLUMES 8:37 AM Pre drug Post drug Actual Pred %Pred Actual %Pred TLC 4.74 6.52 73 FRC 3.84 3.68 104 RV 2.51 2.34 107 VC 2.25 4.18 54 IC 0.90 2.83 32 ERV 1.33 1.34 99 RV/TLC 53 36 148 He Mix Time 2.50 DLCO 8:37 AM Actual Pred %Pred DSB 11.35 25.24 45 VA(sb) 4.49 6.52 69 HB 14.00 DSB(HB) 11.55 25.24 46 DL/VA 2.57 3.87 66 NOTES: Dx: SOB, Pre-operatory Assessment Medication: Unidentified inhaler not taken prior to testing BMI: 21 Hgb: 14.0 ([2103-7-10]) Good test quality and reproducibility for spirometry and lung volumes. FVC may be underestimated due to early termination of exhalation in all efforts. Effort reported is a composite. SVC is likely underestimated due to early termination of exhalation in all efforts. Good/fair test quality with poor reproducibility for diffusion capacity. only one effort reported due to unreportable test quality in all other efforts. Mechanics: The FVC and FEV1 are moderately reduced. The FEV1/FVC ratio is elevated. Flow-Volume Loop: Moderate restrictive pattern with an abrupt and early termination of exhalation. Lung Volumes: The TLC is mildly reduced. The FRC and RV are normal. The RV/TLC ratio is elevated. DLCO: The Diffusing Capacity corrected for hemoglobin is moderately reduced. Impression: Mild restrictive ventilatory defect with a moderate gas exchange defect. The FVC is likely underestimated due to an early termination of exhalation and for this reason a coexisting obstructive component cannot be excluded. There are no prior studies available for comparison. Right heart cath [6-/2103]: HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.73 m2 HEMOGLOBIN: 14 gms % FICK 100% FIO2 NITRIC OXIDE *PRESSURES RIGHT ATRIUM {a/v/m} /[8-30] RIGHT VENTRICLE {s/ed} 48/12 PULMONARY ARTERY {s/d/m} 48/24/34 47/20/34 42/19/30 PULMONARY WEDGE {a/v/m} /18/14 /30/24 /17/15 CARDIAC OUTPUT CARD. OP/IND FICK {l/mn/m2} 2.08 2.43 2.31 RESISTANCES PULMONARY VASC. RESISTANCE 444 301 FICK 100% FIO2 NITRIC OXIDE % SATURATION DATA (NL) SVC LOW 63 PA MAIN 64 76 75 AO 96 99 100 ARTERIAL BLOOD GAS INSPIRED O2 CONCENTR'N 100 100 pO2 49 47 OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed. TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 2 hours 18 minutes. Arterial time = Fluoro time = 36 minutes. Effective Equivalent Dose Index (mGy) = 208 mGy. Contrast injected: None Premedications: Midazolam 0.5 mg IV Fentanyl 25 mcg IV Anesthesia: 1% Lidocaine subq. Cardiac Cath Supplies Used: - [Company ], MAGIC TORQUE 180CM - ALLEGIANCE, CUSTOM STERILE PACK - MERIT, RIGHT HEART KIT 4FR TERUMO, GLIDESHEATH 7FR [Company ], PULMONARY WEDGE PRESSURE CATHETER 5FR ARROW, BALLOON WEDGE PRESSURE CATHETER 110CM COMMENTS: 1. Resting hemodynamics had marked variation due to atrial fibrillation and respiration. Resting measurements revealed a maximal PASP 58 mmHg with an average of 48 mmHg, a mean PA pressure of 34 mmHg, and a mean PCWP of 14 mmHg. 2. Measurements on 100% FiO2 were obtained after over 50 minutes due to difficulties with arterial access and ability to record a wedge pressure with the PA catheter. The average PASP was 47 mmHg with a maximal value of 60 mmHg with a mean PA pressure of 34 mmHg. The PCWP was measured to be 24 mmHg but this was most likely a damped PA [Location (un) 1131] and not a true wedge pressure given subsequent PCWP after 100% inhaled NO. 3. With 100% inhaled NO, the PCWP was 15 mm Hg. There was a mild improvement in PASP with an average of 42 mmHg, 52 mmHg maximal, and mean PA 30 mmHg. PVR improved from a baseline of 5.55 [Doctor Last Name ] to 3.76 [Doctor Last Name ]. FINAL DIAGNOSIS: 1. Mild to moderate pulmonary arterial hypertension with mild elevation of PCW at baseline (consistent with mild left ventricular diastolic dysfunction) and severely elevated PVR (using assumed oxygen consumption). 2. Technically challenging RHC and vasodilator study due to extreme difficulty delivering catheters into the PCW position, requiring >30 minutes of effort and 3 different catheters. 3. No improvement in PA pressure with 100% O2. 4. Mild improvement in PA systolic pressure, mean PA pressure and PVR with addition of inhaled nitric oxide 40 ppm to 100% O2. 5. No evidence of right-to-left or left-to-right shunts. 6. Additional plans per Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) 1391]. Echo: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 4.6 cm <= 4.0 cm Left Atrium - Four Chamber Length: 6.3 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.7 m/s Right Atrium - Four Chamber Length: 6.7 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.5 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 6.0 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 4.7 cm Left Ventricle - Fractional Shortening: 0.22 >= 0.29 Left Ventricle - Ejection Fraction: 45% >= 55% Left Ventricle - Stroke Volume: 45 ml/beat Left Ventricle - Cardiac Output: 3.69 L/min Left Ventricle - Cardiac Index: 2.03 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.09 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.07 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 13 < 15 Aorta - Sinus Level: 3.1 cm <= 3.6 cm Aorta - Ascending: 3.6 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 13 Aortic Valve - LVOT diam: 2.1 cm Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - E Wave deceleration time: 151 ms 140-250 ms TR Gradient (+ RA = PASP): 40 to 42 mm Hg <= 25 mm Hg Pulmonic Valve - Peak Velocity: 0.9 m/sec <= 1.5 m/sec Findings pt intubated on vent. LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Mild regional LV systolic dysfunction. No LV mass/thrombus. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV systolic function. AORTA: Mildly dilated ascending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No MS. Mild (1+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild [1+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: No PS. PERICARDIUM: No pericardial effusion. Conclusions The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is mild regional left ventricular systolic dysfunction with infero-lateral akinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with borderline normal free wall function. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. NAIS: Doppler waveform analysis reveals monophasic waveforms at the common femoral, superficial femoral and popliteal arteries bilaterally. The right DP and PT are monophasic. The left DP and PT are absent. The right ABI is 0.7, the left ABI is 0. Pulse volume recordings show dampening in the thigh bilaterally, worse on the left than the right. There is appropriate calf augmentation and only mild additional dampening at the right metatarsal. On the left, there is substantially dampened waveform in the thigh with further dampening at the calf and nearly flat trace at the ankle and a flat trace at the metatarsal. IMPRESSION: Bilateral aortoiliac disease and severe left SFA and tibial disease. [2103-7-26] 04:52AM BLOOD WBC-6.7 RBC-2.83 Hgb-8.8* Hct-27.9* MCV-99* MCH-31.1 MCHC-31.5 RDW-16.8* Plt Ct-370 [2103-7-26] 04:52AM BLOOD Plt Ct-370 [2103-7-26] 04:52AM BLOOD PT-17.2* INR(PT)-1.6* [2103-7-25] 05:04AM BLOOD Plt Ct-334 [2103-7-25] 05:04AM BLOOD PT-17.5* PTT-33.1 INR(PT)-1.6* [2103-7-24] 03:31AM BLOOD Plt Ct-268 [2103-7-24] 03:31AM BLOOD PT-19.9* PTT-32.8 INR(PT)-1.9* [2103-7-25] 05:04AM BLOOD Glucose-112* UreaN-57* Creat-0.8 Na-140 K-4.8 Cl-109* HCO3-23 AnGap-13 [2103-7-20] 03:47AM BLOOD ALT-46* AST-74* LD(LDH)-221 AlkPhos-174* Amylase-52 TotBili-2.0* Brief Hospital Course: Patient was admitted to the vascular surgery service after being transferred from OSH for further managment of Mesenteric ischemia on [7-6]. He was made NPO and TPn started as well as a heparin drip given a fib and thrombectomy of recent LLE bypass. Angiography was perfromed on [7-9] with evidence for severe celiac and SMA disease that was not ammendable to percutaneous intervention. Decision was made at that time to persue open bypass. Due to the patient's multiple comorbidities a cardiac and pulmonary workup was pursued preoperativley. He was noted to be of high operative risk by cadiology and right heart cath was performed on [2103-7-11] with results showing severe pulmonary htn. He was medically optimized and on [7-12] he underwent a single vessel antegrade SMA bypass. He failed extubation and was admitted to the CVICU where he had labile pressures requiring multiple pressure support. On [7-13] he demonstrated post-op transaminitis. On [7-15] he went into sepsis with respiratory decopensation with hypotension requiring 3 pressors. This was suspected to be from volume overload and severe pulmonary hypertension. A CXR showed a multifocal PNA, urine and sputum grew E Coli. Antibiotic coverage was changed. On [7-17] he had a cold foot, demonstrating that he had thrombosed a prior bypass graft in his leg despite the fact that he was on sub q heparin prophylaxis. He was restarted on his heparin drip. He continued to improve and on [7-20] had weaned down to one pressor though he continued to fail spontaneous breathing trials. He developed thrombocytopenia on the 27th and Hem-onc was consulted. The recommendations from the consulting team were that his thrombocytopenia was likely secondary to his septic shock and that he ought to continue his heparin drip therapy. He was extubated on the 30th. A speech and wallow consult was retained and they recommended that it was ok for him to take PO. On the 31st he was at his baseline mental status and getting out of bed to chair. On [7-25] he was admitted to the floor, worked with PT and expressed a desire to go home. He tolerated PO medication, was normotensive, returned to his baseline activity level, tolerated food and was ready to be discharged. He was discharged on [2103-7-26] in good/stable condition. Medications on Admission: coumadin 2 daily, coreg 6.25 daily, lisinopril 2.5 daily, ASA 81 daily, vicodin 5/500 prn, PTU 50 daily, lasix 20 prn, symbicort 160/80 [Hospital1 ], xopenex neb prn, ipratropium neb prn Discharge Medications: 1. Albuterol Inhaler 4 PUFF IH Q4H:PRN SOB 2. Artificial Tear Ointment 1 Appl BOTH EYES TID:PRN dry eyes 3. Aspirin 81 mg PO DAILY 4. Carvedilol 3.125 mg PO BID Hold for HR<60,SBP<90 5. Enoxaparin Sodium 60 mg SC BID RX enoxaparin 60 mg/0.6 mL ingect 60 mg twice daily Disp #30 Each Refills:0 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [Hospital1 ] 7. Furosemide 20 mg PO DAILY 8. Ipratropium Bromide MDI 6 PUFF IH QID:PRN SOB 9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX oxycodone 5 mg [12-25] tablet(s) by mouth q 4hr Disp #60 Tablet Refills:0 10. Propylthiouracil 50 mg PO Q 24H 11. traZODONE 25 mg PO HS:PRN insomnia 12. Warfarin 3 mg PO DAILY16 RX Jantoven 1 mg 3 tablet(s) by mouth daily Disp #50 Tablet Refills:0 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: Chronic mesenteric ischemia Ischemia of Left lower extremity secondary to failure of previous bypass graft Severe Pulmonary hyptertension Right heart dysfunction Respiratory failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: What to expect when you go home: It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs Increase your activities as you can tolerate- do not do too much right away! It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (81mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal Call if yur develope discoloration, pain or signs of infection of the left lower leg Followup Instructions: Please follow up with Dr. [Last Name (STitle) 1391] in 2 weeks, please call ([Telephone/Fax (1) 29063] to schedule Please follow up with your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ] for 10 am appt. Completed by:[2103-8-1*] ICD9 Codes: 4168, 5990, 4271, 2762, 2875, 4280, 496, 3051, 4019, 2859, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8862 }	Medical Text: Admission Date: [2130-10-3] Discharge Date: [2130-10-4] Date of Birth: [2074-8-30] Sex: M Service: MEDICINE Allergies: IV Dye, Iodine Containing / Codeine / Levofloxacin / Bactrim / Nafcillin Attending:[First Name3 (LF) 99] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Endotracheal Intubation History of Present Illness: 56YOM with h/o ESLD caused by Hep C and ETOH cirrhosis who lives at [Last Name (un) 4367] [Hospital3 ] who was found down, being transferred to the MICU for hypotension. The patient was reportedly in his normal state without complaints 30 minutes prior to being found down in the bathroom by his caretaker. The patient was reportedly very somnolent and was not verbally responsive or following commands. He was subsequently brought to the ED. Of note, the patient was on the transplant list until recently, with a previous MELD of 18 in [2129]. However, he was taken off the active transplant list due to poor compliance and missing followups in addition to inadequate social support, poor housing, and inadequate period of sobriety. Upon presentation to the [Hospital1 18] ED, the patient was found to be somnolent and was given Narcan with improved mental status. He was noted to have global aphasia, profound agitation, roving eye movements, and was not blinking to threat in either visual fields. His face was symmetric and he was moving all extremities. A code stroke was called. The patient was intubated with etomidate/succ for CT head and CT torso which was negative for acute hemorrhage or infarct but limited due to motion artifact. There was a concern for possible cerebral edema, and neurology recommended MRI head for further evaluation, however then the patient spiked to 104.0 and became hypotensives to SBP 65 s/p CT scan. He was given vanc, ceftriaxone, flagyl. Initially responded to boluses, but then was persistently hypotensive, so R-IJ placed and neo/levophed ggt started. He was overbreathing the vent so he was paralyzed with vecuronium. He had difficulty maintaining BP on pressors and 5 liters of NS boluses and therefore was given stress dose decadron. Foley placed for low UOP. He went into A fib w RVR, and was found to have elevated troponins. Cardiology said demand ischemia and hypotension contributing, and recommended trending enzymes. He was given calcium gluconate and kayexalate for hyperkalemia with widening of QRS complex. NG placed, given lactulose. There was also concern for trauma because of brusing on the abdominal wall. An OG tube was placed which put out yellow/green which progressed to dark brown concerning for GI bleed. Protonix/octreotide ggt ordered but not hung. . On arrival to MICU, he was maxed out on levofed. A left femoral arterial line was placed and was given fluids wide open (3-4L in MICU). Initial ABG in the MICU was 7.13/69/40/24. K was 7.4, and he was given kayexalate, bicarb, calcium gluconate. Started stooling w kayexalate, looked maroon. He was subsequently found to have large, unreactive pupils. Neuro was consulted and recommended CT head once more stable to evaluate cerebral edema and possible herniation. . Review of systems: Not able to be obtained as patient is intubated. Past Medical History: GERD Hep C genotype 3A, cirrhosis([2119]) c/b EGD Grade I varices, portal HTN with gastropathy depression,[2119] hiatal hernia, [2121] TIPS for variceal bleed from alcohol abuse gun shot wound to LE carpal tunnel syndrome arthritis polysubstance abuse: heroin abuse, alcohol abuse, and cocaine abuse, hepatic encephalopathy x 3, neuropathy/chronic abd pain, DM II,Acute interstitial nephritis [3-1] Nafcillin ([2129-1-28]) Social History: Unable to obtain due to mental status. Family History: Unable to obtain due to mental status. Physical Exam: On Admission to MICU General: intubated and sedated HEENT: Bilateral 5 mm, unreactive pupils. dry MM Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, S3 present. no murmurs, rubs, gallops Abdomen: soft, obese, distended, small ascities Skin: multiple areas of ecchymoses across chest Ext: cool and cyanotic Pertinent Results: [2130-10-2] 11:20PM BLOOD WBC-9.7# RBC-5.85 Hgb-19.4# Hct-56.7 MCV-97 MCH-33.2* MCHC-34.3 RDW-17.1* Plt Ct-73* [2130-10-3] 07:35AM BLOOD WBC-13.3* RBC-3.85* Hgb-13.0* Hct-38.6* MCV-100* MCH-33.8* MCHC-33.8 RDW-17.8* Plt Ct-32* [2130-10-3] 07:55PM BLOOD WBC-13.6* RBC-3.69* Hgb-12.7* Hct-37.5* MCV-102* MCH-34.3* MCHC-33.8 RDW-19.6* Plt Ct-36* [2130-10-4] 04:00AM BLOOD WBC-16.1* RBC-3.47* Hgb-11.9* Hct-35.9* MCV-103* MCH-34.3* MCHC-33.3 RDW-19.6* Plt Ct-56* [2130-10-2] 11:20PM BLOOD Neuts-88.2* Bands-0 Lymphs-7.8* Monos-3.2 Eos-0.4 Baso-0.5 [2130-10-3] 06:10AM BLOOD Neuts-79.6* Lymphs-10.6* Monos-8.4 Eos-0.7 Baso-0.7 [2130-10-3] 07:35AM BLOOD Neuts-83.0* Lymphs-10.3* Monos-5.6 Eos-0.6 Baso-0.4 [2130-10-4] 04:00AM BLOOD Neuts-65 Bands-10* Lymphs-9* Monos-9 Eos-0 Baso-0 Atyps-0 Metas-7* Myelos-0 NRBC-5* [2130-10-3] 06:10AM BLOOD PT-28.4* PTT-85.5* INR(PT)-2.7* [2130-10-3] 08:18AM BLOOD PT-44.2* PTT-136.5* INR(PT)-4.6* [2130-10-4] 12:50AM BLOOD PT-27.5* PTT-60.4* INR(PT)-2.6* [2130-10-4] 10:55AM BLOOD PT-38.3* PTT-50.8* INR(PT)-3.9* [2130-10-3] 07:35AM BLOOD Fibrino-67# [2130-10-3] 08:18AM BLOOD Fibrino-71 [2130-10-3] 08:18AM BLOOD FDP-320-640* [2130-10-3] 10:44AM BLOOD Fibrino-93* [2130-10-4] 10:55AM BLOOD Fibrino-126* [2130-10-3] 07:55PM BLOOD ESR-2 [2130-10-2] 11:20PM BLOOD Glucose-116* UreaN-29* Creat-1.9* Na-146* K-5.8* Cl-106 HCO3-13* AnGap-33* [2130-10-3] 07:35AM BLOOD Glucose-175* UreaN-34* Creat-3.0* Na-147* K-5.7* Cl-115* HCO3-17* AnGap-21* [2130-10-3] 10:44AM BLOOD Glucose-60* UreaN-35* Creat-2.8* Na-149* K-4.9 Cl-118* HCO3-14* AnGap-22* [2130-10-3] 07:55PM BLOOD Glucose-255* UreaN-41* Creat-3.3* Na-144 K-5.7* Cl-106 HCO3-7* AnGap-37* [2130-10-4] 10:55AM BLOOD Glucose-199* UreaN-40* Creat-4.0* Na-145 K-5.4* Cl-102 HCO3-12* AnGap-36* [2130-10-2] 11:20PM BLOOD ALT-259* AST-918* LD(LDH)-1400* CK(CPK)-[Numeric Identifier 32171]* AlkPhos-185* TotBili-4.3* [2130-10-3] 06:10AM BLOOD ALT-203* AST-862* LD(LDH)-1335* CK(CPK)-[Numeric Identifier 32172]* AlkPhos-110 TotBili-3.0* [2130-10-3] 10:44AM BLOOD CK(CPK)-[Numeric Identifier 32173]* [2130-10-4] 04:00AM BLOOD ALT-1571* AST-6577* LD(LDH)-6440* CK(CPK)-[Numeric Identifier 32174]* AlkPhos-106 TotBili-6.9* [2130-10-2] 11:20PM BLOOD cTropnT-0.33* [2130-10-3] 06:10AM BLOOD CK-MB-70* MB Indx-0.3 cTropnT-1.19* [2130-10-3] 10:44AM BLOOD CK-MB-86* MB Indx-0.4 cTropnT-1.89* [2130-10-3] 07:55PM BLOOD CK-MB-248* MB Indx-0.7 cTropnT-1.93* [2130-10-4] 12:50AM BLOOD CK-MB-293* cTropnT-2.11* [2130-10-4] 04:00AM BLOOD CK-MB-310* MB Indx-0.7 cTropnT-1.86* [2130-10-2] 11:20PM BLOOD Albumin-3.2* Calcium-10.0 Phos-2.2* Mg-1.8 [2130-10-3] 06:10AM BLOOD Calcium-7.7* Phos-6.9# Mg-1.9 [2130-10-3] 07:35AM BLOOD Calcium-7.4 Phos-5.9* Mg-1.7 [2130-10-4] 12:50AM BLOOD Calcium-6.6* Phos-9.9# Mg-2.1 [2130-10-4] 10:55AM BLOOD Calcium-6.6 Phos-9.5* Mg-1.9 [2130-10-3] 07:35AM BLOOD Hapto-<5* [2130-10-3] 08:18AM BLOOD D-Dimer-GREARTER T [2130-10-3] 04:29AM BLOOD Ammonia-326* [2130-10-3] 02:17PM BLOOD TSH-1.7 [2130-10-3] 10:44AM BLOOD Vanco-8.0* [2130-10-2] 11:57PM BLOOD Type-ART Temp-38.8 Tidal V-550 PEEP-10 FiO2-100 pO2-416* pCO2-34* pH-7.39 calTCO2-21 Base XS--3 AADO2-263 REQ O2-51 -ASSIST/CON Intubat-INTUBATED [2130-10-3] 01:54AM BLOOD pO2-422* pCO2-30* pH-7.36 calTCO2-18* Base XS--6 [2130-10-3] 06:23AM BLOOD Type-MIX pO2-82* pCO2-62* pH-7.14* calTCO2-22 Base XS--8 [2130-10-3] 07:01AM BLOOD Type-ART pO2-40* pCO2-69* pH-7.13* calTCO2-24 Base XS--8 [2130-10-3] 07:41AM BLOOD Type-ART Rates-22/15 Tidal V-500 PEEP-10 FiO2-100 pO2-320* pCO2-47* pH-7.20* calTCO2-19* Base XS--9 AADO2-350 REQ O2-63 Intubat-INTUBATED [2130-10-3] 08:38AM BLOOD Type-ART Rates-22/16 Tidal V-500 PEEP-10 pO2-73* pCO2-47* pH-7.18* calTCO2-18* Base XS--10 Intubat-INTUBATED Vent-CONTROLLED [2130-10-3] 10:59AM BLOOD Type-MIX pO2-42* pCO2-33* pH-7.31* calTCO2-17* Base XS--8 [2130-10-3] 11:06AM BLOOD Type-ART Temp-38.7 Rates-22/11 PEEP-10 FiO2-80 pO2-200* pCO2-26* pH-7.35 calTCO2-15* Base XS--9 AADO2-348 REQ O2-62 Intubat-INTUBATED Vent-CONTROLLED [2130-10-3] 02:56PM BLOOD Type-ART Rates-22/13 PEEP-10 FiO2-50 pO2-145* pCO2-22* pH-7.19* calTCO2-9* Base XS--17 Intubat-INTUBATED [2130-10-3] 04:00PM BLOOD Type-[Last Name (un) ] [2130-10-3] 06:19PM BLOOD Type-ART Temp-36.3 Rates-22/12 PEEP-8 O2 Flow-50 pO2-154* pCO2-20* pH-7.11* calTCO2-7* Base XS--21 Intubat-INTUBATED [2130-10-3] 07:03PM BLOOD Type-[Last Name (un) ] Temp-36.3 [2130-10-3] 08:13PM BLOOD Type-ART Temp-36.3 PEEP-8 FiO2-50 pO2-146* pCO2-21* pH-7.13* calTCO2-7* Base XS--20 Intubat-INTUBATED [2130-10-4] 01:11AM BLOOD Type-ART Temp-37.0 PEEP-8 FiO2-50 pO2-104 pCO2-27* pH-7.06* calTCO2-8* Base XS--21 Intubat-INTUBATED [2130-10-4] 02:17AM BLOOD Type-ART Temp-38.3 PEEP-8 FiO2-50 pO2-106* pCO2-28* pH-7.10* calTCO2-9* Base XS--19 Intubat-INTUBATED Comment-AXILLARY [2130-10-4] 04:35AM BLOOD Type-ART pO2-91 pCO2-28* pH-7.13* calTCO2-10* Base XS--18 [2130-10-4] 06:28AM BLOOD Type-ART Temp-37.7 PEEP-8 FiO2-50 pO2-90 pCO2-25* pH-7.18* calTCO2-10* Base XS--17 Intubat-INTUBATED [2130-10-4] 11:07AM BLOOD Type-ART Rates-22/36 PEEP-8 FiO2-50 pO2-PND pCO2-PND pH-PND calTCO2-PND Base XS-PND -ASSIST/CON Intubat-INTUBATED [2130-10-2] 11:39PM BLOOD Glucose-103 Lactate-5.5* Na-144 K-5.8* Cl-109* calHCO3-19* [2130-10-3] 04:05AM BLOOD Lactate-4.5* K-6.9* [2130-10-3] 06:23AM BLOOD Lactate-6.0* K-7.4* [2130-10-3] 07:01AM BLOOD Lactate-6.1* K-6.5* [2130-10-3] 07:41AM BLOOD Lactate-7.0* [2130-10-3] 10:59AM BLOOD Lactate-7.5* [2130-10-3] 11:06AM BLOOD Lactate-7.8* [2130-10-3] 02:56PM BLOOD Lactate-11.2* [2130-10-3] 06:19PM BLOOD Lactate-14.8* K-5.7* [2130-10-3] 08:13PM BLOOD Lactate-14.9* [2130-10-4] 01:11AM BLOOD Lactate-15.9* [2130-10-4] 02:17AM BLOOD Lactate-16.0* [2130-10-4] 04:35AM BLOOD Glucose-230* Lactate-15.7* Na-142 K-5.0 Cl-109* [2130-10-3] 07:01AM BLOOD freeCa-0.95* [2130-10-4] 04:35AM BLOOD freeCa-0.75* [2130-10-4] 06:28AM BLOOD freeCa-0.77* [2130-10-3] 01:30AM URINE Color-DkAmb Appear-Hazy Sp [Last Name (un) ]-1.025 [2130-10-3] 01:30AM URINE Blood-LG Nitrite-NEG Protein-600 Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-6.0 Leuks-TR [2130-10-3] 01:30AM URINE RBC-76* WBC-7* Bacteri-FEW Yeast-NONE Epi-0 [2130-10-3] 01:30AM URINE CastGr-28* CastHy-39* [2130-10-3] 01:30AM URINE AmorphX-RARE [2130-10-3] 01:30AM URINE Mucous-OCC [2130-10-3] 04:50AM URINE Hours-RANDOM UreaN-661 Creat-289 Na-20 K-88 Cl-32 [2130-10-3] 01:30AM URINE Hours-RANDOM [2130-10-3] 04:50AM URINE Osmolal-566 Myoglob-PRESUMPTIV [2130-10-3] 01:30AM URINE Gr Hold-HOLD [2130-10-3] 04:50AM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-POS mthdone-NEG Brief Hospital Course: [Known firstname ] [Known lastname ] is a 56-year-old male with history of chronic hepatitis C as well as alcohol-induced liver cirrhosis complicated by hepatic encephalopathy, previous variceal bleeds, status post TIPS procedure, who was admitted to the MICU for AMS, hypotension, and fevers and who passed away on hospital day 2. . # Shock: Etiology was uncertain even at the time of death although looked most likely to be septic shock given high fevers and white count. However no clear infectious source was identified. He received broad empiric coverage with Vanc, cefepime, and azithromycin. Toxic ingestion such as amphetamine overdose or serotonin syndrome was also on the differential because he had fever, AMS, and rhabdo, however it was unclear why he would have had hypotension if that was the explanation. Amphetamine overdose and seratonin syndrome were considered because he was prescribed adderall and multiple seratonergic medications. However according to his ALF he was actively abusing drugs in addition to adderall and therefore he could have had almost any toxidrome. A cardiac component to his shock was initially considered as he had elevated troponins and CK-MB however cardiac output was [9-6] as measured by NICOM. ScV02 was high. PE was considered as a possibility as TTE showed RV dysfunction and worsened pulm HTN, but he had RV dysfunction in the past. Bilateral LENIs were negative for DVT. He was not stable enough for CTA or V/Q scan and was unlikely to be able to tolerate anticoagulation given he was also in DIC with active bleeding. . The patient was severely ill on arrival to the MICU and continued to rapidly deteriorate despite aggressive resuscitation efforts. His blood pressure was not able to be maintained despite fluids and multiple pressors. Lactic acid was high on presentation and continued to rise up to 16. He had respiratory failure requiring intubation. His laboratory findings were suggestive of DIC and he required cryo, FFP, and blood transfusion. During the hospitalization he developed bleeding from the rectum, bladder, and mucous membranes. He had severe acute kidney injury and associated electrolyte derangements. He also had evidence of shock liver. Rhabdomyolysis was presents as well which could be explained by toxidrome but unusual for septic shock. . Despite aggressive resuscitation efforts the patient continued to decline. After discussion with the patient's son [Name (NI) 382] and also his brothers it was determined that the patient would not want prolonged intubation or resuscitation if he had a small chance of returning to his previous level of functioning. A decision was made to make the patient CMO and take the patient off of the ventilator. He passed away shortly thereafter. . # Respiratory failure/Hypoxia: Most likely this was ARDS from shock. CT chest showed some small peripheral wedge-shaped infiltrates, which could have been infarcts. He was not stable enough for VQ scan or CTA. . #Altered Mental Status: infection (CNS vs. pulmonary) vs. encephalopathy vs. toxic ingestion. Has tox screen positive for amphetamines/opioids, however he was on adderall and opioids at home. NCHCT did not show any acute process. Neurology was consulted and recommended MRI although patient was never clinically stable enough to be taken for MRI. . # GI bleed: maroon stool, was thought to be possibly from a watershed infarct of colon in setting of profound hypotension. The patient also had known varices but there was only minimal blood-tinged fluid in NG tube. Medications on Admission: ([First Name8 (NamePattern2) ] [Last Name (un) ] ALF) acetaminophen 750mg PO BID albuterol 90mcg 1puff Q6h PRN adderall 15mg PO BID PRN clotrimazole 1% cream [Hospital1 ] to feat vit d 50,000 u Wweek fluticasone 110mcg inh 2 puffs [Hospital1 ] folate 1mg Once daily thiamine 100mg PO Daily Tums 500mg PO BID humalog 75/25 45 units in AM 30 units in evening Klor-con 20meq PO Daily MVI PO Daily omeprazole 20mg PO daily lactulose 30ml PO QID sertraline 50mg PO Daily tramadol 50mg PO TID ibuprofen 400mg PO q6h PRN rifaximin 550mg PO BID Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired ICD9 Codes: 0389, 2762, 5845
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8863 }	Medical Text: Admission Date: [2117-4-21] Discharge Date: [2117-4-26] Date of Birth: [2036-7-19] Sex: M Service: MEDICINE Allergies: lovastatin Attending:[First Name3 (LF) 7299] Chief Complaint: Melena Major Surgical or Invasive Procedure: EGD [2117-4-22] History of Present Illness: Mr. [Known lastname ] is an 80M with hx of atrial fibrillation on coumadin, etoh cirrhosis, prostate cancer, . TIA, HTN, HLD who initially called his PCP today to report an episode of black stools that started last night. He said that when he had a bowel movement it was black and sticky, he then had another black bowel movement this morning so he called his PCP who recommended that he come into clinic. He denies seeing any bright red blood, denies any chest pain, shortness of breath, dizziness or lightheadedness. He does say that since his recent hospitalization when his PPI was discontinued he has had some heart burn symptoms that previously had been well controlled on [Hospital1 ] omeprazole. At his PCP's office he had melanotic stool in the vault, so he was referred into the [Hospital1 18] ER. He denies ever having an episode similar to this in the past, he has had episodes of BRBPR with clots due to his history of radiation proctitis/colitis which were very different from this episode. In regards to his liver disease, he says that he was told in the past to cut down on his alcohol intake and he quit drinking for a period of time. Currently he drinks about [1-4] black russians per week, and says that his primary care doctor has not mentioned any liver problems to him recently. . In the ED, initial VS were: 98.0, 60, 148/54, 16, 99% on RA. His labs were notable for an INR of 2.5, HCT of 26.1 from recent baseline 29-30 in the beginning of [Month (only) 547]. His exam was notable for guaiac positive black stool in the rectal vault, and an NG lavage cleared with 800cc's of saline. Hepatology was consulted and recommended reversal of his INR with 2 units of FFP. He was started on octreotide and pantoprazole drips, given 1 unit of blood and was admitted to the MICU for further management. VS on transfer: 97.9, 82, 133/52, 18, 98% on RA. . On arrival to the MICU, he denied any pain, says that he has not had any further dark bowel movements and denies any current acid reflux symptoms. His only current concern is that he would like to know when he will be getting his procedure. VS on arrival to the MICU: 98.5, 83, 120/53, 26, 92% on RA. . 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. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: prostate cancer s/p XRT approx [2108] atrial fibrillation/flutter TIA alcoholic cirrhosis GERD peripheral neuropathy OSA on CPAP spinal stenosis HTN HLD h/o shoulder surgery gout diverticulosis osteoporosis Social History: Lives with wife. Past cigar user. No tobacco use. Etoh a couple of drinks weekly, not daily. Past [Hospital3 ] working. No other drug use. Family History: No history of kidney disease Physical Exam: \ADMISSION EXAM: . General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: irregularly irregular, no murmurs/rubs/gallops Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: decreased at the bases L>R Abdomen: +BS, soft, palpable liver edge Extremities: Right lower extremity edema: Trace, Left lower extremity edema: Trace Skin: Warm Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): person, place, time , Movement: Purposeful, . DISCHARGE EXAM: T 97-98 BP 111-140/60-80 HR 60-80 RR 18 O2 Sat 98% RA GEN: Elederly male in NAD, comfortable HEENT: Sclera anicteric, conjunctiva pale, MMM, oropharynx clear, EOMI, PERRL CV: Irregular, normal S1 + S2, no murmurs, rubs, gallops PULM: CTAB, no wheezes, rales, ronchi, no increased WOB Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, trace pedal edema Neuro: A/Ox3, no asterexis, CNII-XII intact, non focal Pertinent Results: Admission Las: [2117-4-21] 04:20PM BLOOD WBC-8.3 RBC-2.90* Hgb-8.0* Hct-26.1* MCV-90 MCH-27.5 MCHC-30.5* RDW-13.8 Plt Ct-360 [2117-4-21] 04:20PM BLOOD PT-26.1* PTT-46.3* INR(PT)-2.5* [2117-4-21] 04:20PM BLOOD Glucose-100 UreaN-33* Creat-1.0 Na-143 K-4.5 Cl-110* HCO3-24 AnGap-14 [2117-4-21] 04:20PM BLOOD ALT-18 AST-38 CK(CPK)-53 AlkPhos-173* TotBili-0.4 [2117-4-21] 04:20PM BLOOD Albumin-3.1* [2117-4-22] 03:33AM BLOOD AFP-4.1 . Discharge Labs [2117-4-26] 07:35AM BLOOD WBC-5.7 RBC-2.63* Hgb-7.4* Hct-24.3* MCV-93 MCH-28.0 MCHC-30.3* RDW-14.7 Plt Ct-331 [2117-4-26] 07:35AM BLOOD PT-22.0* INR(PT)-2.1* [2117-4-26] 07:35AM BLOOD Plt Ct-331 [2117-4-26] 07:35AM BLOOD Glucose-92 UreaN-12 Creat-1.1 Na-143 K-3.5 Cl-113* HCO3-22 AnGap-12 [2117-4-26] 07:35AM BLOOD Calcium-8.0* Phos-3.3 Mg-2.1 [2117-4-22] 03:33AM BLOOD AFP-4.1 . LIVER U/S [4-21]: 1. Hypoechoic lesion measuring 0.9 x 0.8 cm within the left lobe of the liver. Given patient's history of cirrhosis, an MRI is recommended for further characterization of this lesion and to exclude malignancy. 2. Right pleural effusion. 3. Splenomegaly. 4. Patent main portal vein. 5. No ascites. . CXR [2117-4-22]: Interval development of mild pulmonary edema with stable small bilateral pleural effusions. . EGD [2117-4-22]: Ulcer in the lower third of the esophagus No evidence of esophageal varices or active bleeding Blood in the antrum No evidence of gastric varices, portal gastropathy, ulcers or active bleeding Ulcers in the duodenum Blood in the first part of the duodenum and second part of the duodenum No evidence of duodenal varices Polyps in the fundus Otherwise normal EGD to third part of the duodenum . CT Abdomen ([2117-4-25]): 1. New small bilateral pleural effusions when compared to chest CT from [2117-3-17]. 2. Cirrhotic liver with sequelae of portal hypertension including splenomegaly and trace of perihepatic ascites with no evidence for intra-abdominal varices. 3. Hypoenhancing lesion adjacent and posterior to the intrahepatic IVC at the dome of the liver with imaging characteristics consistent with w hemangioma. No lesion identified to correlate to that seen within the left lobe of the liver on prior ultrasound of [2117-4-21], but most likely represents a regenerative nodule. No liver lesion seen concerning for HCC. Brief Hospital Course: Primary Reason for Admission: Mr. [Known lastname ] is an 80 y/o M with a history of alcoholic cirrhosis, GERD with recent discontinuation of his PPI, atrial fibrillation on coumadin who presents with melanotic stools and a three point HCT drop over the past two weeks. . Active Problems: . # GI Bleed: Melanotic stool and positive NG lavage both consistent with upper source of bleeding. Hct was 26.1 on admission and remained stable 25-26 after 1U PRBC. He also received 2 U FFP and IV vitamin K to reverse his coagulopathy. RUQ U/S with dopplers was done which ruled out portal vein thrombosis. He was started on octreotide and pantoprazole drips. GI was consulted and he underwent EGD on [4-22] which showed ulcer in the lower third of the esophagus, as well as ulcers in the deuodenum. There was no evidence of varicies. Aspirin was held throughout his course [2-4] ulcers. His coumadin was initially held, but was restarted prior to discharge given history of CVA off anticoagulation. There was no evidence of recurrent bleeding and on the day of d/c, INR was 2.1 and his HCT had remained stable. BM the day of discharge was brown without BRB or melena. Pt was educated to monitor for any signs of rebleeding and is scheduled to get follow up labs in 2-3days. . # Alcoholic Cirrhosis: Per patient his PCP has not mentioned any liver dysfunction concerns recently, liver architecture on RUQ U/S was consistent with cirrhosis, no evidence of synthetic dysfunction, and no varcies on EGD. He declined referral to the liver center and would prefer to follow up with his PCP. . # Hypoechoic liver lesion: Noted on RUQ u/s. Was 0.9 x 0.8 cm within the left lobe of the liver. Given patient's history of cirrhosis, an MRI was recommended for further characterization to exclude malignancy. However, MRI could not be performed due to penile implant, and CT Abdomen was performed instead. CT findings showed likely hemangioma, but lesion noted on ultrasound was not seen on CT, thought possibly due to a regenerative nodule. His AFP was reassuring at 4.1 and there was nothing concerning for HCC seen on CT. . # Atrial fibrillation: Patient with a CHADS2 score of 4, on coumadin for anticoagulation at home. INR was reversed as above. At the time of d/c his INR was 2.1; he was sent home on 1mg Warfarin daiily with instructions to have his INR checked [4-29] during his PCP f/u appointment. His home metoprolol was initially held in the setting of GI bleed and restarted prior to discharge. . # DOE/Pleural Effusions: Pt complained of mild DOE, most recent CXR with moderate effusions, echo on last admission with normal systolic function and no evidence of diastolic dysfunction. Repeat CXR on this admission showed some increased pulmonary edema and was given lasix with improvement in his symptoms . # Hypertension: Initially held home antihypertensive regimen of losartan 50mg daily, nifedipine 30mg daily and metoprolol tartrate 25mg [Hospital1 ] in the setting of his GI bleed. Medications were restarted prior to d/c, though his Nifedipine was held as his BP was well controlled without it. PCP notified of medication changes. . Chronic Problems: . # Hyperlipidemia: - Cont simvastatin 20mg daily . # Lower Extremity Edema: Since his recent hospitalization he has been started on low dose lasix which was initially held given his bleed. This was restarted prior to discahrgve. . # Peripheral neuropathy: - Cont home gabapentin . # OSA on CPAP: - Used autoset CPAP while in house . Transitional issues: -Pt needs close follow up of INR and Hct to ensure stability given recent bleed and known ulcers. Medications on Admission: - betamethasone valerate 0.1 % Cream [Hospital1 ] - Vitamin D2 50,000 unit once a week. - gabapentin 300 mg TID and at bedtime - warfarin 2 mg Daily at 4 PM - metoprolol tartrate 25 mg [Hospital1 ] - nifedipine extended release 30 mg once a day. - losartan 50 mg DAILY - aspirin 81 mg DAILY - Calcium 1000mg once a day. - multivitamin One Tablet once a day. - flaxseed oil 1,000 mg once a day. - lasix 20mg prn lower extremity edema - simvastatin 20mg daily Discharge Medications: 1. Vitamin D2 50,000 unit Capsule Sig: One (1) Capsule PO once a week for 6 weeks. 2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID and at bedtime. 3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. losartan 50 mg Tablet Sig: One (1) Tablet PO once a day. 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 6. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: Two (2) Tablet PO once a day. 7. multivitamin Tablet Sig: One (1) Tablet PO once a day. 8. flaxseed oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day. 9. furosemide 20 mg Tablet Sig: One (1) Tablet PO PRN as needed for leg swelling for 1 doses. 10. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Peptic Ulcer Disease Secondary Diagnosis: Cirrhosis HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [Known lastname ], It was a pleasure taking care of you at [Hospital1 18]. You were admitted for a gastrointestinal bleed. You had an endoscopy, which showed ulcers in your esophagus and duodenum. For this, you were treated with medications. We feel you are now safe to return home. You also were found to have a mass in your liver. For this, you had a CT scan, which showed no evidence of cancer. However, you should see a specialist for ongoing management of your liver disease. At your next appointment with Dr. [Last Name (STitle) 30186], you can arrange for Hepatology follow up. The following changes were made to your medications STOP Aspirin START Pantoprazole DECREASED Warfarin to 1mg by mouth once a day STOP Nifedipine; your primary care phyician can restart this medication if your blood pressure is high Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) ] M. Location: [Hospital1 641] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 2260] Phone: [Telephone/Fax (1) 3530] Appt: Thursday, [4-29] at 10:45am ICD9 Codes: 2851, 5119, 2724, 4019, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8864 }	Medical Text: Admission Date: [2102-9-15] Discharge Date: [2102-9-23] Date of Birth: [2047-11-23] Sex: F Service: MEDICINE Allergies: Clindamycin / Ceftazidime Attending:[First Name3 (LF) 4219] Chief Complaint: Increased secretions and SOB Major Surgical or Invasive Procedure: Rigid bronchoscopy History of Present Illness: 54 y/o female with PMH sig for tracheal stenosis s/p multiple dilations, recent [Hospital1 18] admission [2102-6-16] during which a T-Tube was placed. She had a flexible bronchoscopy in [Month (only) 216] [2101] showing a significant amount of granulation tissue build-up. On advancing to the distal limb of the T-tube, it was noted that the patient had a significant amount of granulation tissue build-up but leaving an approximately 6-mm airway. It was noted that distal to this build-up of granulation tissue, the patient had patent distal airways. . Pt presented on this admission with increased tracheal secretions and DOE over prior 2 days. Denies PND/orthopnea/f/c/night sweats/Chest pain. No SOB @ rest. Pt admitted to MICU where flex bronch revealed severe tracheal narrowing (4mm) at the distal end of the T-tube. No hemoptysis. Pt underwent rigid bronch with placement of tracheal stent and was started on Levaquin for tracheitis. Pt now with no complaints and states that she feels much better. Still has productive cough which is near baseline. Past Medical History: 1. tracheal stenosis - pt is s/p multiple dilatations 2. tracheal bronchitis 3. depression - no meds currently 4. h/o anxiety 5. Type 2 DM - diagnosed 3-5 years ago, reports glucose usually 130s 6. hypertension - diagnosed 3-5 years ago 7. hypothyroidism - on Synthroid 8. anemia 9. GERD 10. hypercholesterolemia Social History: Lives with care provider and her family, since [2101-7-17]. Pt reports she is happy there. Denies tobacco, alcohol, or recreational drug use of any kind. Has not worked outside the home. Has a legal guardian. Family History: pt not aware of any illnesses in the family, including diabetes, cancer, or any tracheal difficulties Physical Exam: VS: T 99.0 HR 84 BP 130/82 O2 94% trach mask Gen: laying in bed, occ productive cough. No dyspnea. Very pleasant and able to talk with trach plugged. HEENT: MMM, pupils equal. Neck JVP flat; white secrections coming from trach tube, minimal erythema around trach. Chest: CTAB, no stridor. very good insp effort and strong cough. CVS: tachycardic, regular without mrg Abd: soft, NABS, NT/ND Extrem: No edema, ecchymosis on RLE. Moves all ext. Pertinent Results: Labs on admission: WBC-4.5 RBC-3.26* Hgb-9.5* Hct-27.9* MCV-86 MCH-29.1 MCHC-34.0 RDW-14.6 Plt Ct-193 Glucose-116* UreaN-8 Creat-0.8 Na-140 K-4.1 Cl-104 HCO3-29 Calcium-9.2 Phos-4.0 Mg-1.8 UA negative PT-13.2 PTT-25.4 INR(PT)-1.2 CXR: Tracheal stents in similar position to the recent CT of the trachea. No evidence of acute cardiopulmonary process. CT trachea/chest: High-grade narrowing of the airway lumen just below the inferior aspect of the tracheostomy tube, with subsequent patency below this level. It is uncertain whether this is due to granulation tissue and/or retained secretions. Disruption of the posterior wall of the tracheal stent in its inferior portion. Patchy ground-glass opacities within the right apex and superior segment of the left lower lobe, most likely due to infection or aspiration. Attention to these areas on followup CT scan may be helpful to ensure resolution. Although the observed findings are most likely due to granulation tissue, tumor involvement cannot be fully excluded and direct correlation with findings at bronchoscopy is therefore suggested. Bronchoscopy: High grade fibrosis beneath the inferior part of tracheostomy tube. Bx: Lung, endobronchial biopsy: 1. Squamous metaplasia with regenerative epithelial change. 2. Acute and chronic inflammation with ulceration. Brief Hospital Course: Ms. [Known lastname 26280] is a 54 y/o female with h/o tracheal stenosis s/p T-tube placement, Type 2 DM, HTN, hypercholesterolemia, who presented with increasing stridor and bronchoscopy showing 4 mm luminal narrowing distal to T-tube. . 1. Tracheal Narrowing: Shortness of breath was likely due to granulation tissue and inflammation seen at old tracheal stent site, as well as increased secretions. The pt was initially stabilized with rigid bronchoscopy and stent placement. Two days PTA the pt went to the OR for more permanent T tube placement without event. 2. Increased tracheal secretions: This was believed to be secondary to tracheitis, given the elevated white count and left shift on admission. Sputum culture revealed strep pneumonia. The pt was treated with Levaquin 500 mg po qd for 7 days. The pt was continued on her inhaled steroids and nebulizers with good effect and dyspnea resolved. 3. Anemia: The pt has a history of anemia per records, but no clear work up. There is an unclear etiology. Iron studies ewre drawn and are likely consistent with anemia of chronic disease. 4. DM2: The pt was continued on a humalog insulin slide scale only during her stay, as her PO status was questionable until her final two days in house. At discharged she was restarted on her oral hypoglycemics. Her finger sticks were generally well controlled. . 5. Nausea: Throughout her stay nausea was a recurrent problem for Ms. [Known lastname 26280], especially after receiving anesthesia for her T tube placement. This was eventually controlled with prn Anzemet, Ativan, Zofran, and Phenergan in different combinations. 6. HTN: We continued the patient's home dose of Lisinopril throughout her stay. . 7. Dyslipidemia: We continued the patient's home statin throughout her stay as well. . 8. Hypothyroidism- We continued the patient's home dose of synthroid throughout her stay. Her TSH was normal. 9. Dispo- Ms. [Known lastname 26280] was discharged to her home with her new Ttube in place and all of her previous home services reinstated. She will follow up with interventional pulmonology in [2-17] weeks for re-scoping. Medications on Admission: albuterol atrovent advair 250/50 1 puff [Hospital1 ] Lipitor 10mg QD Protonix Glipizide 5mg [Hospital1 ] ASA 81mg QD Pepcid 20 mg QD Synthroid 50mcg QD Alprazolam 0.25mg TID PRN Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [Hospital1 ] (2 times a day). 6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 9. atrovent inhaled use atrovent inhaler as previously directed 10. Compazine 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for nausea. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: tracheal stenosis tracheobronchitis Discharge Condition: stable Discharge Instructions: Please take all of your usual medications. Call Dr.[Name (NI) 14680] office for fever, shortness of breath, chest pain or questions. [Telephone/Fax (1) 3020] They will be in touch with you regarding returning for a follow up bronchoscopy in [2-17] weeks. Followup Instructions: Dr.[Name (NI) 14680] office will be in touch with you to schedule for a follow up bronchoscopy in [2-17] weeks. Call Interventional Pulmonology if problems arise. [Telephone/Fax (1) 3020] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 4231] Completed by:[2102-9-24] ICD9 Codes: 2720, 2449, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8865 }	Medical Text: Admission Date: [2148-9-4] Discharge Date: [2148-9-12] Date of Birth: [2106-1-28] Sex: M Service: MEDICINE Allergies: Amoxicillin / Adhesive Bandage / Dicloxacillin / Linezolid Attending:[Male First Name (un) 5282] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: This is 41 yo m w/ hx cirrhosis secondary to EtOH + HCV, OSA, PAH and hypothyroidism, w/ recurrent episodes of severe enceophalopathy and ascites well-known to the MICU who was transferred from the Liver service for encephalopathy. . Mr. [Known lastname 19420] has been at rehab since discharge from [Hospital1 18] on [2148-8-21]. Per his mother he has been having more frequent encephalopathic episodes this month. Over the past few days she reports that [Known firstname ] has been in good health without fevers, night sweats, n/v, or abdominal pain. Over the last few days he has been having ~6BMs/day. Notably, she reports the rehab would not increase the lactulose frequency from Q4hr which [Known firstname ] often requires when he is becoming encephalopathic. . Notably, patient's most recent admission [Date range (1) 77611] was also for changes in mental status. He was found to have a Klebsiella bacteremia and UTI treated with 3 weeks of ceftriaxone ([2148-8-5], to complete on [2148-8-26]). Neurologic work-up demonstrated that he has a comunicating hydrocephalus, etiology of which remains unclear. . In the ED Vitals: 78 98/63 18 99% RA. He received 30mL of PO lactulose as well as Vanc/Cipro/Flagyl for question of infection.He received 2L NS. CXR with mild atelectasis. Duplex U/S showed flow in L portal vein, pt combative and this could not be completed. . In the ICU, patient able to follow directions though continued to have agitated outbursts. Denied any pain or discomfort. Past Medical History: - End Stage Liver Disease [1-22] alcohol and hepatitis C. Currently on the [Month/Day (2) ] list. Course complicated by recurrent ascites, SBP, pulmonary hypertension. Currently on the [Month/Day (2) ] list (s/p aborted liver [Month/Day (2) ] given elevated pulmonary pressures in OR [2148-2-28]) - Sepsis w/ Enterococcus Avium and Group B Step, recent discharge on [2148-7-5] - Spontaneous bacterial peritonitis early [7-27] on Cipro prophylaxis - Grade II esophageal varices - Recurrent hepatic encephalopathy on vegetarian diet - Pulmonary hypertension - Hypothyroidism - Anxiety disorder - History of alcohol and IVDU - Osteoporosis of hip and spine per pt - Anemia with history of guaiac positive stool Social History: He lives with his mother. Remote history of smoking [12-23] ppd. Quit drinking 11 years ago. Prior history of IVDU as a teenager. Family History: Mother with diabetes and hypertension. Father with rheumatic heart disease. Physical Exam: In MICU: Gen: Awake, alert, agitated intermittently HEENT: dry MM, + scleral icterus Pulm: lungs clear bilaterally, no wheezes or rhonchi CV: S1 & S2 regular without murmur Abd: +BS, soft, non-tender, mildly-distended Ext: no lower extremity edema Neuro: Alert, unable to comply with neuro exam Pertinent Results: [2148-9-4] 11:07PM GLUCOSE-100 UREA N-39* CREAT-1.2 SODIUM-154* POTASSIUM-3.7 CHLORIDE-122* TOTAL CO2-25 ANION GAP-11 [2148-9-4] 11:07PM ALT(SGPT)-20 AST(SGOT)-47* LD(LDH)-208 ALK PHOS-120* TOT BILI-7.8* [2148-9-4] 11:07PM ALBUMIN-3.3* CALCIUM-9.8 PHOSPHATE-2.8 MAGNESIUM-1.7 [2148-9-4] 11:07PM WBC-3.7* RBC-2.17* HGB-6.7* HCT-22.7* MCV-104* MCH-31.0 MCHC-29.7* RDW-21.5* [2148-9-4] 11:07PM NEUTS-76.5* LYMPHS-13.9* MONOS-6.7 EOS-2.7 BASOS-0.2 [2148-9-4] 11:07PM PLT COUNT-32* [2148-9-4] 11:07PM PT-28.4* PTT-53.0* INR(PT)-2.8* [2148-9-4] 05:09PM LACTATE-1.3 [2148-9-4] 05:05PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2148-9-4] 05:05PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 Imaging/Studies: CXR: Left and right mid lung subsegmental atelectasis. No focal consolidation or pulmonary edema. . ABD U/S: 1. Cirrhosis, ascites, splenomegaly. 2. Limited doppler exam without evaluation of the main portal vein. If there is high clinical concern for vascular thrombosis, a CT is suggested. 3. Cholelithiasis. . ABD US [8-13] 1. Flow within the main portal vein, now demonstrates a hepatofugal (reversed) directionality (as demonstrated on a prior study from [2148-1-21]) although patent. Flow within the left portal vein could not be obtained no doppler evaluation either secondary to occlusion or very slow flow in this uncooperative patient. 2. Shrunken cirrhotic liver consistent with known cirrhosis. Cholelithiasis with gallbladder wall edema/thickening unchanged over multiple comparisons likely secondary to third spacing from decompensated liver disease rather than acute cholecystitis. 3. Large amount of intra-abdominal ascites. . Head CT [8-15]: No interval change in moderate ventriculomegaly. No evidence of intracranial hemorrhage. . MRI Head [7-23]: 1. Prominent lateral ventricles with evidence for transependymal CSF flow suggestive of communicating hydrocephalus; also prominence of the sulci suggestive of atrophy. 2. No acute intracranial process. Unchanged diffuse hydrocephalus since [2148-7-15] (new since [2148-1-21]) with mild transependymal CSF flow. . CSF Fluid: neg cryptococcal, fungal WBC 0-2, Polys 0, Lymphs 0-56 Brief Hospital Course: 41 year old man with cirrhosis secondary to EtOH and HCV, complicated by recurrent ascites, history of SBP and esophageal varices, who has been hospital w/ recurrent episodes of encephalopathy presents with an episode of encephalopathy. . # Recurrent encephalopathy: Presentation secondary to inadequate bowel regimen while at rehab facility. Work up negative for infection (stool, blood, urine), GI bleed, and U/S failed to show significant ascites. A CT of abdomen was done to evaluate questionable poor flow through the portal vein seen on US. The CT was sig for patent portal vein. Patient was treated with rifaximin and Q2hr lactulose and produced ~4L of stools per day. Mental status improved to baseline on discharge. Cipro was continued for SBP prophylaxis. He was also continued on his vegetarian diet. A decision was made to discharge patient home w/ services as mother felt that she could provide better care at home. Physical therapy was consulted who agreed that the patient could be discharged home. . # Hypernatremia: Secondary to reduced access to free water in the setting of encephalopathy and high stool output. Resolved with free water replacement. . # ESLD. Secondary EtOH and HCV. Patient initially presented with improved ascites and edema. An ultrasound of the abdomen showed poor flow through the portal vein, and CT of the abdomen was done for further assessment. The CT demonstrated patent portal vein. Patient was continued on his lactulose and rifaximin as above. He was also continued on cipro for SBP ppx, his home diuretics and ppi. Octreotide and midodrine were discontinued while in the ICU. The patient's creatine remained stable off treatments. Patient was ultimately disharged to home (see above). . # H/o HRS: Octreotide and midodrine discontinued while in the ICU and were held throughout his hospital course. Creatinine stable off octreotide and midodrine. . # Anemia: Initial hct of 23 lower than baseline of 25-28. Patient hcts were followed throughout hospitalization and were stable. . # Thrombocytopenia: Stable and secondary to liver disease. . # Hypothyroidism: Stable, patient was continued on home levothyroxine. . # Pulmonary HTN: There were no active issues during his hospitalization and the patient was continued iloprost. . # Osteoporosis: Patient was continued on his home regimen of Vit D and Calcium Medications on Admission: Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane 5X/DAY (5 Times a Day). Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO DAILY Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for candidiasis. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig:PO DAILY Lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO QID Octreotide Acetate 100 mcg/mL Solution Sig:Q8H Iloprost 10 mcg/mL Solution for Nebulization Sig:Inhalation 6x/day Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY Midodrine 10 mg Tablet Sig: TID Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet, Discharge Medications: 1. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day): No script given. Disp:0 Troche(s) Refills:0 2. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)): No script given. Disp:0 Capsule(s) Refills:0 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day): No script given. Disp:0 bottle Refills:0 4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): No script given. Disp:0 Tablet(s) Refills:0 5. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): No script given. Disp:0 Tablet(s) Refills:0 6. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily): No script given. Disp:0 Capsule(s) Refills:0 7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for bloating: No script given. Disp:0 Tablet, Chewable(s) Refills:0 8. Iloprost 10 mcg/mL Solution for Nebulization Sig: One (1) ML Inhalation q4hr (): No script given. Disp:0 ML(s) Refills:0 9. Lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO Q2H (every 2 hours) as needed for encephalopathy: For [2-22] Bowel Movements per day. Disp:0 ML(s) Refills:0 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): No script given. Disp:0 Tablet(s) Refills:0 11. Zinc Sulfate 220 mg Tablet Sig: One (1) Tablet PO once a day: No script given. Disp:0 Tablet(s) Refills:0 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day: No script given. Disp:0 Capsule, Delayed Release(E.C.)(s) Refills:0 13. Calcium Carbonate-Vitamin D3 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 14. Tubefeeding Tubefeeding: Nutren 2.0 Full strength Rate: 35 ml/hr; Do not advance rate Goal rate: 35 ml/hr Flush w/ 250 ml water q2H 15. Outpatient Physical Therapy To continue with home physical therapy Discharge Disposition: Home With Service Facility: vna of southeastern mass Discharge Diagnosis: Primary: Hepatic Encephalopathy Secondary: history of SBP, Grade II esophageal varices, Pulmonary hypertension, Hypothyroidism, Osteoporosis, Anemia Discharge Condition: Stable Discharge Instructions: You were seen in the hospital for your confusion. This was because of your liver disease and we treated you with lactulose. We did an ultrasound of your abdomen that did not show worsening ascites but showed poor flow through the portal vein. CT of your abdomen however showed a patent portal vein. While you were in the hospital, we replaced your feeding tube. Your mental status improved to baseline on discharge. We have made the changes to your home medications: 1. You do not need to take lasix, midodrine and octreotide 2. Please continue the rest of your home medications. Please return to the emergency room if you should experience further confusion, severe abdominal pain, fevers > 101, or any concerning symptoms. Followup Instructions: Please follow up with Gastroenterology: Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2148-9-16] 9:00 Completed by:[2148-9-13] ICD9 Codes: 2760, 5180, 2449, 4168, 2875, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8866 }	Medical Text: Admission Date: [2158-6-14] Discharge Date: [2158-7-18] Date of Birth: [2099-6-9] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1556] Chief Complaint: morbid obesity Major Surgical or Invasive Procedure: [2158-6-14] 1. Open laparoscopic adjustable gastric band placement. 2. Repair of incisional hernia with mesh. 3. Liver biopsy using Tru-Cut needle. 4. Biopsy of celiac lymph node. [2158-6-20] 1. Exploratory laparotomy. 2. Partial gastrectomy. 3. Removal of Lap-Band and port. 4. Removal of hernia mesh. [2158-6-21] 1. Reopening of abdomen. 2. Abdominal closure with mesh. [2158-7-4] Wound vacuum-assisted closure change [2158-7-10] Split-thickness skin graft to the abdomen 28 x 18 inches. History of Present Illness: Mr. [Known lastname 4781] is a 58-year-old gentleman with longstanding morbid obesity refractory to attempts at weight loss by nonoperative means. Preoperative weight was 321.6 pounds. Given his height, this translated to a body mass index of 53.8 kg per meter squared. Co-morbidities included diabetes mellitus type 2, history of autoimmune hemolytic anemia, ITP, question of cirrhosis with nonalcoholic fatty liver disease, hypertension, diabetic neuropathy, hyperlipidemia, hypertriglyceridemia, venous stasis. He also suffered from incisional hernia from an open splenectomy. Also by CAT scan he was noted to have mesenteric lymphadenopathy and there was long concern of a potential hematologic anomaly and, therefore, a biopsy was necessary. Past Medical History: 1. Autoimmune hemolytic anemia [2-1] (tx w/ prednisone taper x2 months) 2. ITP after viral syndrome [10-2], refractory to IVIG and prednisone, s/p open splenectomy, fascial repair 3. DM II 4. Atrial fibrillation 5. Morbid obesity 6. s/p appendectomy at age 3 7. s/p left thoracotomy for ?empyema Social History: He denied tobacco or recreational drug usage, has occasional glass of wine maybe two to 3 times a week, drinks one half pot of coffee twice daily and diet soda 12-ounce can 3 times a day. He works in administration and planning for 35+ years at the [Company 2676] Company. He is married living with his wife age 59 and they have no children. Family History: His family history is noted for both parents deceased father with cerebral hemorrhage, diabetes and obesity; mother with lung CA, heart failure, diabetes and obesity; sister living with ITP. Physical Exam: Blood pressure was 135/85, pulse 82, respirations 16 and O2 saturation 96% on room air. On physical examination [Known firstname ] was casually dressed, pleasant and in no distress. His skin was warm, dry with no rashes. Sclerae were anicteric, conjunctiva clear, pupils were equal round and reactive to light, fundi did not demonstrate retinopathy, mucous membranes were moist, tongue was pink, there was a [Doctor First Name ]-like lesion left side lower buccal mucosa and the oropharynx was essentially clear of exudates or hyperemia. Trachea is in the midline and the neck was supple with full range of motion, no adenopathy, thyromegaly or carotid bruits, no JVD. Chest was symmetric and there was a well healed left thoracotomy and sub-costal incision scars, lungs were clear to auscultation bilaterally with good air movement. Cardiac exam was regular rate and rhythm, normal S1 and S2, no murmurs, rubs or gallops. The abdomen was obese but soft and non-tender, non-distended with positive bowel sounds with large ventral hernia and likely second lower hernia more laterally. There was no spinal tenderness or flank pain. Lower extremities were noted for bilateral venous stasis dermatitis left greater than right with no ulcerations and tense 1+ edema. There was no evidence of joint swelling or inflammation of the joints. There were no focal neurological deficits except for decreased sensation in the lower legs/feet/toes, gait appeared normal. Pertinent Results: [2158-6-14] 06:10PM WBC-26.0# RBC-5.40 HGB-14.9 HCT-45.8 MCV-85 MCH-27.5 MCHC-32.4 RDW-14.6 [2158-6-14] 06:10PM HCV Ab-NEGATIVE [2158-6-14] 06:10PM HBc Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [2158-6-14] 06:10PM GLUCOSE-100 UREA N-16 CREAT-1.2 SODIUM-140 POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-32 ANION GAP-13 [2158-6-14] 06:10PM CALCIUM-8.8 PHOSPHATE-4.4 MAGNESIUM-1.7 [2158-6-14] SPECIMEN #1: LIVER, NEEDLE CORE BIOPSY (A). DIAGNOSIS: 1. Moderate portal/septal and mild periportal and lobular mononuclear inflammation. 2. Multiple lobular and single portal non-necrotizing granulomas. 3. Minimal steatosis without ballooning or hyalin. 4. No bile duct injury or loss is identified. 5. Trichrome stain shows increased portal fibrosis with established septa formation, bridging, and focal complete nodule formation (Stage 4 fibrosis). 6. GMS, PAS-D, and AFB stains are negative for organisms. Note: The finding of lobular and portal non-necrotizing granulomas raises the possibility of an infectious process versus an idiopathic systemic granulomatous disease such as sarcoidosis SPECIMEN #2: LYMPH NODE, MESENTERIC (B-C). DIAGNOSIS NONCASEATING GRANULOMATOUS LYMPHADENITIS. SEE NOTE [2158-6-19] CT Abd/pelvis : 1. Moderate amount of free fluid and free gas in the abdomen. The patient is day five post-repair of incisional hernia and gastric band placement. The amount of free fluid and gas within the abdomen is not expected at this stage of the postoperative course. A site of perforation cannot be identified on this suboptimal examination. [2158-6-24] Liver US : Limited study without evidence of cholelithiasis or secondary findings to suggest acute cholecystitis. Microbiology reports: [2158-7-10] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2158-7-3] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2158-7-1] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT [2158-7-1] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST, ESCHERICHIA COLI} INPATIENT [2158-7-1] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2158-7-1] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {ESCHERICHIA COLI, YEAST} INPATIENT [2158-6-28] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2158-6-28] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY INPATIENT [2158-6-28] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2158-6-27] FLUID,OTHER GRAM STAIN-FINAL; FLUID CULTURE-FINAL {[Female First Name (un) ] ALBICANS, PRESUMPTIVE IDENTIFICATION}; ANAEROBIC CULTURE-FINAL INPATIENT [2158-6-27] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT [2158-6-26] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT [2158-6-25] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2158-6-25] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2158-6-25] URINE URINE CULTURE-FINAL INPATIENT [2158-6-24] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST} INPATIENT [2158-6-24] URINE URINE CULTURE-FINAL INPATIENT [2158-6-24] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2158-6-22] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2158-6-22] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2158-6-21] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2158-6-21] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST} INPATIENT [2158-6-21] URINE URINE CULTURE-FINAL INPATIENT [2158-6-20] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL {PSEUDOMONAS AERUGINOSA}; ANAEROBIC CULTURE-FINAL INPATIENT [2158-6-20] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2158-6-20] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2158-6-19] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2158-6-16] URINE URINE CULTURE-FINAL INPATIENT [2158-7-18] 14.0 3.62* 10.2* 32.3* 89 28.0 31.5 16.1* 839* Source: Line-picc BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [2158-7-18] 10:39 PND Source: Line-PICC; heparin dose: [2148] [2158-7-18] 03:39 839* Source: Line-picc [2158-7-18] 03:39 14.9* 74.1* 1.3* Source: Line-picc LAB USE ONLY [2158-7-18] 03:39 Source: Line-picc Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2158-7-18] 03:39 901 9 0.6 134 3.8 98 26 14 Source: Line-picc IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES ESTIMATED GFR (MDRD CALCULATION) estGFR [2158-7-16] 04:33 Using this1 Source: Line-picc Using this patient's age, gender, and serum creatinine value of 0.8, Estimated GFR = >75 if non African-American (mL/min/1.73 m2) Estimated GFR = >75 if African-American (mL/min/1.73 m2) For comparison, mean GFR for age group 50-59 is 93 (mL/min/1.73 m2) GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [2158-7-18] 03:39 8.8 3.7 1.9 Brief Hospital Course: Mr. [Known lastname 4781] was admitted to the hospital and taken to the Operating Room for open gastric band, hernia repair and liver biopsy. he tolerated the procedure well and returned to the PACU in stable condition. He maintained stable hemodynamics with adequate fluid resuscitation and his pain was controlled with an epidural and PCA. He was transferred to the ICU for further monitoring and continues fluid resuscitation. His creatinine rose to 1.5 without any other abnormalities and began to trend down to a baseline of 1.0. His Bariatric diet started while in the ICU and he was able to get out of bed to a chair with assistance. After 48 hours he improved and was able to be transferred to the Surgical floor for further monitoring. He gradually was advanced to a stage 3 diet and tolerated it well without abdominal pain or fullness. Due to his size, he was evaluated by the Physical Therapy service to help increase his ambulation. Following removal of his epidural catheter he tolerated Roxicet for pain and was doing well and planning to go home soon. Unfortunately on [2158-6-20] he developed tachycardia, acute respiratory failure requiring intubation and then was taken emergently to the Operating for an exploratory laparotomy as he had free air in the abdomen on CT scan. He had a good portion of necrosis of the anterior stomach and therefore his lap band was removed and he had a partial gastrectomy. His mesh was also removed. His abdomen was left open and he was brought to the ICU on multiple pressors, intubated and sedated. He returned to the Operating Room the following day for a washout and placement of Vicryl mesh to repair his hernia and this was tolerated well. His WBC was elevated in the 30K range and he was on broad spectrum antibiotics as well as antifungal. His multiple blood cultures were negative but he had pseudomonas in his abdominal wound as well as some [Female First Name (un) ]. He eventually developed pseudomonas in his sputum and treatment continued with Zosyn, Ciprofloxacin, Vancomycin and Micafungin. He remained negative for MRSA. His antibiotics finished on [2158-7-8] and his current WBC is 14K. He has been afebrile. His septic shock was gradually resolving as his pressor needs diminished daily. From a pulmonary status he required vigorous pulmonary toilet including bronchoscopy as he developed a left lower lobe collapse and pseudomonas pneumonia. He was eventually weaned from the respirator and successfully extubated. He continues to wear his own CPAP mask at night and he uses his incentive spirometer as well. His nutritional needs during this period were taken care of with TPN and following extubation his diet was gradually advanced after multiple swallow studies. He remains on a Bariatric diet at stage 5 now and is tolerating that well with close observation by the nutritionist. His surgical wound was eventually managed with a VAC dressing and after good granulation he was taken to the Operating Room on [2158-7-10] for a skin graft. The donor site is his right thigh which is covered with a Xeroform dressing which will eventually dry up. It appears crusty around the edges with some old blood underneath and occasionally oozes if touched with movement. It still needs to dry out some more in the mid portion. His abdominal skin graft is healing well and this is also covered with Zero form dressing and changed daily. He also has a 2 cm wide port site wound in his right lower abdomen which is clean and granulating. Saline damp to dry gauze is loosely packed [Hospital1 ]. From a cardiac standpoint he has a history of rapid atrial fibrillation which was persistent when he was in septic shock. He was treated with beta blockers which he remains on. He also is being anticoagulated with IV heparin and Coumadin started [2158-7-17]. His INR today is 1.3 and he received 5 mg of Coumadin last night with plans for another 5 mg tonight. His goal INR is 2.5. His current dose of Heparin is [2148] units/hr and his PTT on that dose was 64.9 with a goal of 60-80 His rhythm currently is NSR at a rate of 80 on 25 mg of Lopressor [Hospital1 ]. His renal status is back to baseline with a creatinine of 0.6. He had been mobilizing fluid on his own but remains very edematous and will resume Lasix daily at 40 mg. His pre op dose was 40 mg TID and he may eventually need to have it increased based on his creatinine and fluid balance. Due to his extreme weakness and size he remains with a foley catheter in place as he needs to stand to void and at this time he is too weak to do so. He has not had a UTI. Mr. [Known lastname 4781] is a diabetic and prior to his initial surgery was on NPH insulin 6o units qAM ,26 units qPM and metformin however over the last 2 weeks his blood sugars have been in the 90 to 110 range off all insulin and a Bariatric diet. He is currently being checked pre meal and HS. See sliding scale enclosed. He is extremely anxious to get back home and desperate for a disciplined Physical Therapy program to help him attain his goals of independence. Hopefully after this protracted course he will benefit from your program with the hopes of getting him home soon. He will need to have a wound check with Dr. [Last Name (STitle) ] next week. Medications on Admission: AMIODARONE - 200 mg Tablet - 200mg Tablet(s) by mouth twice a day - No Substitution FUROSEMIDE - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 40 mg Tablet - 1 Tablet(s) by mouth three times a day HYDROCODONE-ACETAMINOPHEN - 7.5 mg-750 mg Tablet - [1-28] Tablet(s) by mouth every 4-6 hours as needed for as needed for pain LEVOTHYROXINE - (Prescribed by Other Provider) - 50 mcg Tablet - 1 Tablet(s) by mouth once a day METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - 1 Tablet(s) by mouth three times a day NYSTATIN - (Prescribed by Other Provider) - 100,000 unit/gram Powder - apply to affected areas twice a day as needed Medications - OTC ASCORBIC ACID [VITAMIN C] - (Prescribed by Other Provider) - 500 mg Tablet - 1 Tablet(s) by mouth once a day ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet - 1 Tablet(s) by mouth once a day LORATADINE [CLARITIN] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once daily as needed for allergies NOVOLIN R INNOLET - (Prescribed by Other Provider) - 300 unit/3 mL Insulin Pen - as directed Insulin(s) four times a day per sliding scale NPH INSULIN HUMAN RECOMB [HUMULIN N PEN] - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 300 unit/3 mL Insulin Pen - as directed Insulin(s) twice a day 60 units q am 26 units q HS Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Month/Day (2) ]: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheeze/sob. 2. Metoprolol Tartrate 25 mg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day). 3. Atorvastatin 10 mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily): please crush. 4. Docusate Sodium 50 mg/5 mL Liquid [Month/Day (2) ]: Ten (10) ml PO BID (2 times a day). 5. Duloxetine 20 mg Capsule, Delayed Release(E.C.) [Month/Day (2) ]: Three (3) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Senna 8.6 mg Tablet [Month/Day (2) ]: Two (2) Tablet PO at bedtime as needed for constipation . 7. Multivitamin Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily): please crush. 8. Ascorbic Acid 500 mg/5 mL Syrup [Month/Day (2) ]: 1000 (1000) PO DAILY (Daily). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet [Month/Day (2) ]: 2.5 Tablets PO DAILY (Daily): please crush. 10. Zinc Sulfate 220 mg Capsule [Month/Day (2) ]: One (1) Capsule PO DAILY (Daily): please crush. 11. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] once a day. 12. Dilaudid 2 mg Tablet [Last Name (STitle) ]: 1-2 Tablets PO every four (4) hours as needed for pain: please crush. 13. Acetaminophen 325 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever/pain: please crush. 14. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution [Last Name (STitle) ]: per sliding scale Intravenous ASDIR (AS DIRECTED): Keep PTT 60-80. 15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 16. Coumadin 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day: as directed, adjust to keep INR 2.5. 17. Levothyroxine 50 mcg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 18. Lasix 40 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day: please crush. 19. Insulin Regular Human 100 unit/mL Solution [Last Name (STitle) ]: 4-12 units Injection four times a day: per sliding scale. Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: 1. Diabetes mellitus type 2. 2. Morbid obese 3. Incisional hernia. 4. Nonalcoholic steatohepatitis. 5. Sepsis with suspected intra-abdominal source. 6. Gastric necrosis with perforation 7. Atrial fibrillation 8. Hypothyroidism 9. Left lower lobe collapse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: * You were admitted to the hospital for gastric band placement and hernia repair Discharge Instructions: Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, chest pain, shortness of breath, severe abdominal pain, pain unrelieved by your pain medication, severe nausea or vomiting, severe abdominal bloating, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness or swelling around your incisions, or any other symptoms which are concerning to you. Diet: Bariatric Stage 5 diet diet, do not drink out of a straw or chew gum. Medication Instructions: Resume your home medications, CRUSH ALL PILLS. You will be starting some new medications: 1. You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. 2. You should begin taking a chewable complete multivitamin with minerals. No gummy vitamins. 3. You should take a stool softener, Colace, twice daily for constipation as needed, or until you resume a normal bowel pattern. 4. You must not use NSAIDS (non-steroidal anti-inflammatory drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and Naproxen. These agents will cause bleeding and ulcers in your digestive system. Activity: Work hard with Physical Therapy and Occupational Therapy to increase your strength and endurance. Stage 5 diet Follow your blood sugars closely after discharge from rehab. you may need insulin again Followup Instructions: Call Dr. [Last Name (STitle) 32668] at [Telephone/Fax (1) 12551] for a follow up appointment when you are discharged from rehab. He will need to monitor your blood work and dose your coumadin. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 9325], MD Phone:[Telephone/Fax (1) 305] Date/Time:[2158-7-27] 9:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 647], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2158-8-29] 3:30 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3014], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2158-8-29] 3:30 Completed by:[2158-7-18] ICD9 Codes: 5849, 5185, 5180, 2851, 3572, 2724, 2749, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8867 }	Medical Text: Admission Date: [2201-5-3] Discharge Date: [2201-5-7] Date of Birth: [2138-5-18] Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3190] Chief Complaint: Neck pain with right arm and leg weakness Major Surgical or Invasive Procedure: Anterior/Posterior cervical fusion with instrumentation C4-5 History of Present Illness: 62M transfer from OSH after C4-5 injury. He was participating in a "mud run" on [5-3], when he dove/fell head-first into a mud hole. He complained only of left shoulder pain and a "twinge" of spinal pain. He was moving his upper/low left extremities, but had weakness of upper and lower right extremities. Past Medical History: hyperlipidemia Social History: Lawyer; lives with wife; denies tobacco Family History: N/C Physical Exam: A&O X 3; NAD RRR CTA B Abd soft NT/ND LUE- good strength at deltoid, biceps, triceps, wrist flexion/extension, finger flexion/extension and intrinics; sensation intact C5-T1 dermatomes; - [Doctor Last Name 937], reflexes symmetric at biceps, triceps and brachioradialis RUE- weakness at biceps, triceps and wrist extension LLE- good strength at hip flexion/extension, knee flexion/extension, ankle dorsiflexion and plantar flexion, [Last Name (un) 938]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes symmetric at quads and Achilles RLE- weakness at quads and anterior tibialis Pertinent Results: [2201-5-6] 06:10AM BLOOD WBC-11.3* RBC-4.05* Hgb-12.5* Hct-37.8* MCV-93 MCH-30.9 MCHC-33.1 RDW-13.1 Plt Ct-158 [2201-5-4] 04:00AM BLOOD WBC-9.2 RBC-4.24* Hgb-12.8* Hct-38.8* MCV-92 MCH-30.3 MCHC-33.1 RDW-13.1 Plt Ct-184 [2201-5-3] 04:05PM BLOOD WBC-14.8* RBC-4.66 Hgb-13.8* Hct-42.2 MCV-91 MCH-29.6 MCHC-32.7 RDW-12.8 Plt Ct-218 [2201-5-4] 04:00AM BLOOD Glucose-176* UreaN-24* Creat-0.9 Na-138 K-4.5 Cl-103 HCO3-23 AnGap-17 [2201-5-3] 04:05PM BLOOD Glucose-112* UreaN-28* Creat-1.0 Na-142 K-4.3 Cl-105 HCO3-22 AnGap-19 [2201-5-4] 04:00AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.0 [2201-5-3] 10:30PM BLOOD Calcium-8.5 Phos-4.5 Mg-2.0 Brief Hospital Course: Mr. [Known lastname ] was admitted to the [Hospital1 18] Spine Surgery Service and emergently taken to the Operating Room for C4-5 anterior fusion. Please refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the T/ICU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were given per standard protocol. Initial postop pain was controlled with a PCA. Function of his right upper and lower extremities improved. On HD#3 he returned to the operating room for a scheduled C4-5 decompression with PSIF as part of a staged 2-part procedure. Please refer to the dictated operative note for further details. The second surgery was also without complication and the patient was transferred to the PACU in a stable condition. Postoperative HCT was stable. He was kept NPO until bowel function returned then diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#2 from the second procedure. He was fitted with a cervical collar when out of bed. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet Medications on Admission: simvastatin 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. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:100 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Fracture/dislocation C4-5 Discharge Condition: Good Discharge Instructions: You have undergone the following operation: ANTERIOR/POSTERIOR Cervical Decompression With Fusion Immediately after the operation: -Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. oLimit any kind of lifting. -Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. -Brace: You have been given a collar. This is to be worn for comfort when you are walking. You may take it off when sitting in a chair or while lying in bed. -Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. -You should resume taking your normal home medications. No NSAIDs. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [Hospital Ward Name 23] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Followup Instructions: With Dr. [Last Name (STitle) 363] in 10 days Completed by:[2201-5-7] ICD9 Codes: 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8868 }	Medical Text: Admission Date: [2150-5-22] Discharge Date: [2150-6-5] Date of Birth: [2102-12-1] Sex: F Service: MED HISTORY OF PRESENT ILLNESS: Patient is a 47-year-old female with history of polysubstance abuse and asthma as well as question of a seizure disorder secondary to head injury greater than 10 years ago, history of depression and anxiety admitted to the Medical Intensive Care Unit from the outside hospital on [2150-5-22] for a Klonopin/Dilaudid overdose complicated by rhabdomyolysis and transaminitis, change in mental status, and intubated for airway protection and hypercarbic respiratory failure who was transferred to the floor on [2150-5-24] after extubation for further management. Patient apparently had a suicide pact with her husband two days prior to admission on [2150-5-20] and overdosed on Dilaudid 300 mg (150, 2 mg tabs) and Klonopin 200 mg (50, 4 mg tabs). Patient was found unresponsive by the patient's sister-in-law who found both her husband and the patient lying on the floor. Patient was brought to the emergency department at the outside hospital and received Narcan with good effect. Patient did not receive charcoal and was given intravenous N- acetyl cysteine for question of Tylenol overdose (although unlikely) and Ceftriaxone 2 mg intravenous times one. Per the outside hospital records head CT and chest x-ray were normal and urine toxicology screen was positive for benzodiazepines and opiates. Labs at the outside hospital showed an increased creatinine of 15, AST of 4600, ALT of [2146], CPK of [2146], CPK of 25,000. In the Emergency Department at [Hospital1 188] patient was arousable, satting 100 percent on nonrebreather with an ABG of 7.36/67/167. The patient, however, was intubated later on [2150-5-22] for hypercarbia with an ABG of 7.15, PCO2 of 108, and PAO2 of 96. Patient was seen by the Liver service, as well, and it was agreed that patient should continue with N-acetyl cysteine for five more days for hepato protective effects and a question of ischemic liver injury. Patient was extubated on [2150-5-23] and was satting well on 2 liters nasal cannula and had slightly improved mental status upon transfer to the Medicine floor on [2150-5-24]. Patient was also seen by Toxicology while in the Medical Intensive Care Unit and it was agreed to continue with anacetylcysteine since patient had increased liver function tests and an increased total bilirubin. On transfer to the Medicine floor patient complained of some lower back pain which is chronic and bilateral knee pain but otherwise was breathing comfortably. PAST MEDICAL HISTORY: 1. Asthma. 2. Polysubstance abuse with questionable history of heroin use in the past. Patient has been on Methadone in the past but unclear when last taken. 3. Status post GYN surgery. 4. Lower back pain. 5. Depression and anxiety. 6. Question of seizure disorder secondary to head injury greater than 10 years ago. Per the patient's sister the patient was apparently on Dilantin which had since been discontinued for unknown reasons. 7. Endometriosis status post hysterectomy at age 21. 8. Questionable history of lupus with a positive [Doctor First Name ] but no therapy. This history was also given by the patient's sister. MEDICATIONS PRIOR TO HOSPITALIZATION: 1. Klonopin. 2. Dilaudid. 3. Asthma inhalers. MEDICATIONS ON TRANSFER TO THE FLOOR: 1. IV fluids, normal saline at 250 cc an hour. 2. Humalog insulin sliding scale. 3. Heparin 5000 units subq b.i.d. 4. Famotidine 20 mg IV b.i.d. 5. Thiamine 100 mg IV q.d. 6. Folic acid 1 mg IV q.d. 7. Salmeterol Diskus b.i.d. 8. Flovent inhaler b.i.d. 9. Albuterol nebulizers q. 4 hours. 10. Atrovent nebulizers q. 4 hours. 11. Clindamycin 600 mg p.o. t.i.d. day number one (patient had previously been on Flagyl and Ceftriaxone for the last two days prior to transfer). 12. N-acetyl cysteine times eight doses intravenous. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Patient is married. Her husband's name is [Name (NI) 122] [Name (NI) 55404] and his phone number is [Telephone/Fax (1) 55405]. She also has a sister, [Name (NI) ] [Name (NI) 55406], phone number [Telephone/Fax (1) 55407]. Per the patient's sister patient had recently lost her pet dog and from the trauma of this loss, the patient's husband and her made this suicide pact. [Name (NI) ] husband at the time of this dictation is currently discharged from the hospital but had been hospitalized at [Hospital 5503] [Hospital 7637] Hospital with question of transfer to the CCU for management of cardiac issues. He is currently doing well. Also of note, patient's new primary care physician is [Last Name (NamePattern4) ]. [Last Name (STitle) 55408], phone number [Telephone/Fax (1) 55409]. Previous primary care physician was Dr. [Last Name (STitle) 4610]. PHYSICAL EXAMINATION ON TRANSFER: Temperature 98.1, BP 134/73, pulse 86, respirations 17, satting 96 percent on 2 liters nasal cannula. ABG checked the morning of [2150-5-24], was 7.54, PCO2 of 38, and PAO2 of 109. In general, patient is alert and oriented times two to person and year although did not know the month, and patient knew that she was in a "hospital" but did not know the name of the hospital. HEENT: Pupils equal, round, and reactive to light. Extraocular movements intact. Oropharynx is clear with moist mucous membranes but poor dentition. Neck: Cool and supple; nontender; no jugular venous distention. Pulmonary: Clear to auscultation bilaterally with poor inspiratory effort. Cardiovascular: Regular rate and rhythm with no murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended, with good bowel sounds. Femoral line was in place, clean, dry, and intact. Extremities: No edema, no calf tenderness, with 2 plus dorsalis pedis pulses present bilaterally. LABS ON TRANSFER: White blood cell count 8.5, hematocrit 34.1, platelets 120. Chem-7: Sodium of 146, potassium of 2.3, chloride 108, bicarbonate 32, BUN 7, creatinine 0.3, glucose 84, magnesium 1.4, calcium 7.5, phosphorus 1.4, ALT 649, AST 640, CK 16,278, alkaline phosphatase 44, total bilirubin 2.3 mostly, indirect at 1.4, direct bilirubin 0.9, PTT 38, INR 2.0, troponin less than 0.01, CK-MB of 20, lipase 37, HCV antibody negative, Dilantin level less than 0.06, D- Dimer at 3258. Chest x-ray on [2150-5-22] showed persistent small peripheral opacity in the right lower lobe, small right pleural effusion versus pleural thickening. Abdominal ultrasound showed patent pleural vein with no lesions, no obstruction, positive echogenic kidneys with appropriate flow, normal liver. Gallbladder showed thickening but no signs of cholecystitis,. No ascites. CT of the head showed no hemorrhage, normal ventricles and sulci. There was a focal region of encephalomalacia in the right frontal lobe, but otherwise unremarkable. ASSESSMENT: 47-year-old female with history of substance abuse and question of seizure disorder in the past, asthma status post Dilaudid and Klonopin overdose who was admitted to the Medical Intensive Care Unit with mental status change, rhabdomyolysis, transaminitis, and hypercarbic respiratory failure now transferred to the Medicine floor after extubation, improved, for further management. HOSPITAL COURSE: 1. Medication overdose/Psychiatry: On transfer to the Medicine floor patient was maintained on a one-to-one sitter and was followed by Psychiatry throughout her hospitalization. Given her mental status change she was not restarted on her antidepressants. Psych and Toxicology both were following the patient. As far as from a Toxicology standpoint, patient shortly had her N-acetyl cysteine discontinued on transfer to the Medicine floor since her liver function tests began to trend downward. It was unlikely that patient overdosed on Tylenol, but the N-acetyl cysteine was kept on per Toxicology recommendations for hepato protective effects. Patient showed no signs of benzodiazepine withdrawal and was maintained on a Clinical Institute Withdrawal Assessment scale for several days and required no Ativan per CIWA scale. The CIWA scale was subsequently discontinued after events on [2150-3-27], which will be discussed below. The patient showed no signs of narcotics withdrawal with no nausea, vomiting, or any other associated symptoms. Currently at time of this dictation patient is awaiting inpatient psychiatric treatment either at a rehab facility or at [Hospital1 1444]. 1. Mental status change: Initially on transfer to the Medicine floor patient's mental status seemed slightly improved, although patient still was disoriented and somewhat confused. It was thought initially that patient most likely had a toxic metabolic encephalopathy from her overdose. Initial EEG, which was checked on [2150-5-24], was consistent with a diffuse encephalopathy. Given patient's very high liver function tests, decision was made to hold off on Dilantin loading on transfer on [2150-5-24] given possible hepatotoxic effects on Dilantin and a questionable history of seizure disorder in the past but no evidence of seizures at the time of transfer. Over the next several days from [2150-5-25] to [2150-5-26] patient began to appear more lethargic and her mental status declined. She received no Valium to explain her mental status change, and the Valium per CIWA scale was discontinued. A head CT was checked on [2150-5-25] to rule out anoxic brain injury and results showed bilateral hypodense zones in the main inferior orbital portion of both frontal lobes as well as a 2 cm triangular area of decreased absorption in the right frontal lobe suggesting chronic malasic change in frontal lobes. Dictation suggested a questionable history of prior trauma, and thus it was thought that her head CT was stable. It was most likely chronic change from previous head injury. It was thought that patient still may likely have a toxic metabolic encephalopathy. However, during the course on [2150-5-26] patient began to manifest a worsening mental status and stopped following commands and was not responding even to sternal rub. At the same time patient spiked fevers to 102 and 103. At 5 p.m. on [2150-5-26] patient became tachycardiac in the 100s. Systolic blood pressure rose to the 160s when they had previously been in the low 100s and temperature rose to 102 with a respiratory rate of 40. HEENT exam showed dilated pupils that were minimally active, scleral icterus with bulging sclerae. Funduscopic exam was performed which showed no papilledema. Neuro exam: As mentioned above, patient was not responding to sternal rub and no withdrawal to pain. She was not opening her eyes or following commands. Her deep tendon reflexes were still 2 plus throughout with downgoing Babinski's. With the mental status change and fever, it was concerning that patient was either suffering from a seizure, benzodiazepine withdrawal, or some other neurologic process. Patient was given 1 mg of Ativan times one for question of seizure and benzodiazepine withdrawal but with no effect. Stat chest x-ray showed a question of an aspiration pneumonia in the right lower lobe, but this was most likely secondary to mental status change and not the cause of recurrent fever and mental status. Blood cultures were drawn which showed no growth. Urinalysis was negative. At this point it was attempted to perform an lumbar puncture. Head CT had just been performed the night before and there was no papilledema on funduscopic exam. It was felt comfortable to perform the lumbar puncture. Several attempts were made by two differential physicians and lumbar puncture was unsuccessful on the evening of [2150-5-26] with no fluid retrieval. There were no complications at the attempts. ABG was also checked at that time and it was 7.54, PCO2 of 29, and PAO2 of 99, suggesting a respiratory alkylosis. Of note, patient was also given two units of fresh frozen plasma for an elevated INR of 1.7 prior to lumbar puncture. Since patient was and the lumbar puncture was unsuccessful on the evening of [2150-5-26] patient was empirically placed on Ceftriaxone 2 grams q.d., Vancomycin, and Flagyl for coverage of aspiration pneumonia. The patient continued to spike fevers throughout the night of [2150-5-27] and on [2150-5-28] patient was not responding to sternal rub, following commands, or responding to any pain. Her white count was elevated at 15,000. A tox screen was checked which was negative. At 9 a.m. on [2150-5-27] patient had a grand mal seizure with tonic-clonic movements that were generalized and witnessed by the nursing staff. The seizure resolved after a few seconds. Patient was given Ativan 2 mg times one, but the seizure had already resolved. Her temperature was 103 at that time and her saturations were initially at 95 percent on 2 liters, but they decreased to 70 percent 4 liters. Patient was put on 100 percent nonrebreather with only an O2 saturation at 94 percent on nonrebreather. Anesthesia was called to intubate the patient for airway protection. They performed a nasotracheal intubation most probably secondary to mouth rigidity. Patient was emergently transferred to the Medical Intensive Care Unit after intubation. Repeat head CT at the MICU showed extensive cerebral edema primarily in the white matter in a pattern consistent with reversible leukoencephalopathy syndrome. There were open ventricles and the basal cisternal spaces remain visualized. Neurosurgery was consulted and it was felt that patient would most likely benefit from some type of intracranial monitoring device. Patient was given Mannitol q. 6 hours to keep serum osms less than 320, four units of fresh frozen plasma, and had an intracerebral pressure monitor placed as well as an external ventriculostomy drain. Patient had cerebrospinal fluid sample sent from this drain which showed no signs of infection. CSF showed only 1 white blood cell and normal glucose and total protein. Patient had the drain placed for one day and intracerebral pressures remained stable and the drain was discontinued on [2150-5-29] by Neurosurgery. Repeat EEG still showed just diffuse encephalopathy. MRI of the head was unrevealing. Patient was initially started on Dilantin and then transitioned to Keppra for ease of usage and no monitoring. Patient was also treated with meningitis doses of Ceftriaxone 2 grams q. day for a total of a seven-day course completed on [2150-6-2] for empiric coverage of meningitis since LP could not be performed in the acute setting, and patient had received 24 hours of antibiotics prior to shunt placement and retrieval of CSF. Even at the time of this dictation it is still unclear why patient had this diffuse cerebral edema, and there have been no clear hypotheses as to why this may have occurred. Patient was transferred from the ICU back to the Medicine floor after improvement of her mental status and discontinuation of the intracerebral pressure monitoring and patient has been alert, lucid, and her mental status has been stable. She is alert enough to give a thorough history and is aware of her surroundings as well as her caretakers, which is quite different from her initial presentation. As far as her seizure disorder, she will continue with the Keppra and has not manifested any further seizures. Fevers: It is unclear whether patient may have had an aspiration pneumonia so she was treated briefly with a course of Clindamycin which was subsequently discontinued after her second transfer to the Medicine floor since her chest x-ray from [2150-5-28] was entirely clear. The patient did complete a full course of seven days for a treatment of meningitis with Ceftriaxone 2 grams per day since it was unclear what precipitated her event. Patient had a mild low-grade fever on [2150-6-4], but this has resolved and she has had no further infectious issues at the time of this dictation. She is currently on no antibiotics. Transaminitis: Patient's liver function tests continued to decline and it was thought likely that patient's transaminitis and increased INR were secondary to ischemic liver injury from her initial event. These AST and ALT are almost at normal levels at the time of this dictation. Rhabdomyolysis: Patient's rhabdomyolysis also continued to improve throughout the course of her hospitalization. At the time of this dictation her CK level is now down to 500 from a peak of 26,000, and it is felt there is no need to follow these since they have continued to trend downwards. Patient was maintained on aggressive intravenous hydration at first and now is continuing on maintenance fluids since she continues to have poor p.o. intake. Nutrition goal: Patient initially presented with decreased mental status and was not able to take nutrition, but since her mental status has improved patient has passed a speech and swallow evaluation and is tolerating good Pos. Would continue to encourage fluid intake. Access: Patient had a right femoral groin line placed initially when she was in the Unit and this was subsequently discontinued on her first transfer to the Medicine floor. However, when she decompensated with a grand mal seizure and was intubated, she had a left IJ placed in the MICU. This left IJ remained in place until [2150-6-4] when it was discontinued. The catheter check has been sent for culture since the line site was somewhat erythematous. The culture data is still pending at the time of this dictation. DISPOSITION: Patient has been working with Physical Therapy and has been regaining her strength daily. She still requires some assistance with moving around, but this is felt that it would likely improve with further strengthening. The decision is currently being made at the time of this dictation whether to transfer the patient to the inpatient psychiatric unit or to discharge the patient to psychiatric unit at [Hospital1 69]. It has been confirmed that patient does indeed have insurance, Medicare. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Still unknown at the time of this dictation but likely to an inpatient psychiatric facility with a rehab potential. A discharge addendum will be added to cover the medications and follow-up plans. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], MD [MD Number(2) 27875] Dictated By:[Name8 (MD) 5706] MEDQUIST36 D: [2150-6-4] 20:14:55 T: [2150-6-4] 22:39:26 Job#: [Job Number 55410] ICD9 Codes: 5070
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8869 }	Medical Text: Admission Date: [2170-8-7] Discharge Date: [2170-9-5] Date of Birth: [2123-1-23] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor Last Name 1350] Chief Complaint: neck pain and quadriparesis Major Surgical or Invasive Procedure: [2170-8-7]: C3-C6 laminectomies for C2-C7 epidural abscess. [2170-8-14]: percutaneous tracheostomy at bedside in SICU. [2170-8-17]: C2-T1 posterior instrumented spine fusion with ICBG. History of Present Illness: Neurology Consult Note: CC: fever, neck pain, resp distress, weakness HPI: 47 M w/ hx IVDA, Hep C, alcoholism, COPD, presented to [Hospital ] Hosp with fever, cough, and neck pain. Symptoms began on Sat 2 days prior when he developed neck stiffness. Nonetheless, he traveled with his wife to [Name (NI) 6408]to gamble. On Sun he felt worse, but was mostly fatigued and slept in the car ride back to MA as his wife drove. [Name2 (NI) ] morning, he began c/o B/L hand tingling and electric shock pains going down his body. He developed a fever, and began vomiting and shaking. He thought that he was withdrawing from EtOH. His last drink had been Sat. His wife notes that he became diffusely weak and was unable to walk straight when he tried to walk. His wife brought him in a wheelchair to [Hospital ] Hosp, where his temp was noted to be 103 F. CXR was purportedly suggestive of a mild LLL PNA. NCHCT at midnight was normal. At 2:15 am, [Hospital1 ] ER reports that he was c/o B/L UE weakness and ongoing neck stiffness and intact MS. At 2:45, neck pain is reported as [9-22]. He had apparently been dropping his sat and was placed on a NRB. At 2:50 am, O2 sat noted to be 88% on NRB and though still awake, he was becoming lethargic. He was felt to require intubation, and was intubated at 3 am. Post intubation, though pt appeared to be able to answer yes/ no and move eyes, he had no withdrawal to noxious stim in any ext. He was transferred to [Hospital1 18] and obtained an emergent MRI pan-spine showing significant epidural fluid collection, likely blood, possibly infected. There were also bone marrow changes of unclear etiology, but possibly c/w malignancy. Prior to MRI, pt received ceftriaxone, levaquin, and decadron. Notably, pt comes with CT head and CT-spine reports from [5-22] with an indication for "L arm numbness." Of note, his wife reports an unintentional weight loss of 100 lbs over about 3 years. She also notes that he had an HIV test 1 month ago that was negative. PMH: COPD Hep C 2 brain aneurysms, 2 mm in the R cavernous carotid artery and 4 mm at the origin of the L ophthalmic artery IVDA both heroin and cocaine, last use 6 months ongoing alcoholism L temp lobe arachnoid cyst MEDS: Suboxone 8mg/2mg, 1 tab [Hospital1 ] ALL: NKDA FH: sister and grandparents with alcoholism. Also generically CAD and cancer SH: (+) tobacco, 1 ppd x 30 years, 6 beers per day, prior IV heroin and cocaine use, last 6 months ago. Formerly worked as a furniture mover Exam: T- 104.4 (Tm = [Age over 90 ] F) BP- 115/68 HR- 104 RR- 14 O2Sat 100%intubated Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: in c-collar, but appears supple and he spont moves it side to side. CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no c/c/e; equal radial and pedal pulses B/L. Apparent track marks R antecubital fossa Neurologic examination: Mental status: off propofol for 10 min, opens/closes eyes to command and inconsistently follows command to look left/right. Cranial Nerves: Pupils pinpoint and min reactive to light bilaterally. Appeared to have BTT B/L. Extraocular movements intact bilaterally, no nystagmus. Of note, there did appear to be some disconjugate mvmts and initially felt R eye did not elevate as well as the L, later they seemed equally full. Acknowledges sensation to LT in V1-V3. Facial movement symmetric on grimace. (+) corneals. Motor: Normal bulk bilaterally. flaccid tone throughout. There is no spont mvmt and no mvmt to noxious stim thoughout. Later he appears very agitated, grimacing hard and coughing hard, yet still no mvmt of any limb Sensation: No withdrawl of any limb to noxious; also no apparent grimacing to noxious. Reflexes: 0 and symmetric throughout. Toes downgoing on L, mute on R Labs: pH 7.25 pCO2 63 pO2 284 HCO3 29 BaseXS 0 Comments: pH: Verified pH: Provider Notified [Name9 (PRE) ] [Name9 (PRE) ] Lab Policy Type:Art; Intubated; FiO2%:100; AADO2:383; Req:66; Rate:14/; TV:500; Mode:Assist/Control Urine Opiates Pos Urine Benzos, Barbs, Cocaine, Amphet, Mthdne Negative Lactate:1.3 129 97 13 136 AGap=12 3.2 23 0.6 estGFR: >75 (click for details) ALT: 56 AP: 73 Tbili: 2.4 Alb: AST: 96 LDH: 289 Dbili: TProt: [Doctor First Name ]: Lip: 22 Serum Acetmnphn 11.7 Serum ASA, EtOH, [Last Name (LF) 2238], [First Name3 (LF) ], Tricyc Negative Comments: Positive Tricyclic Results Represent Potentially Toxic Levels;Therapeutic Tricyclic Levels Will Typically Have Negative 101 4.6 12.1 34 36.5 N:92.2 L:3.5 M:3.6 E:0.5 Bas:0.2 Comments: Plt-Ct: Verified By Smear Plt-Ct: Notified [Initials (NamePattern4) ] [Last Name (NamePattern4) ]-Ed 5:20 A.M. [2170-8-7] SED-Rate: 34 Plt-Est: Very Low PT: 15.3 PTT: 37.4 INR: 1.3 UA: large blood, 30 prot, 12 urobilinogen, mod bili, tr ketones, [2-15] RBC, 0-2 WBC, few bact Imaging: CXR (my read): R lung base cut off, but otherwise no clear I/E. MRI pan-spine: Predominantly posterior epidural collection from craniocervical junction through T2, with some signal features that suggest the presence of blood, i.e. this could be an infected epidural hematoma rather than just an epidural phlegmon. Extensive edema/enhancement in the interspinous ligaments from C1-2 through C4-5, and in the posterior paravertebral soft tissues of the cervical spine, which could indicate traumatic injury or spread of infection. Not clear if the epidural collection extends into the skull base - suggest head MRI. Cervical spine CT would also be useful to assess for posterior element fractures. Cervical spondylosis, worst at C5-6 and C6-7, with spinal cord deformity and abnormal cord signal, could be edema or myelomalacia. Diffusely abnormal bone marrow signal, could be due to anemia, chronic systemic illness, or infiltrative disorder including infiltrative malignancy. No focal thoracic spine abnormalities below T2. Chronic mild L1 compression deformity. Mild lumbar spondylosis. Mild epidural edema/enhancement surrounding a disc bulge at L1-2, likely reactive inflammation as there is no evidence of diskitis/osteomyelitis at this level. A/P: 47 M w/ hx IVDA, Hep C, alcoholism, COPD, with significant throbmocytopenia, presented from [Hospital ] Hosp with 3 days neck pain and 1 day of fever to Tmax 105 F, vomiting, malaise, B/L hand parasthesiae and shooting electric pains down his body, found with significant epidural fluid collection from craniocervical junction to T2, thought to be blood, possibly infected (which seems likely given raging fever). Exam now seems c/w quadraplegia, and the acuity of his change can certainly be seen with epidural abscess. MS at least minimally intact and CN's appear intact, though he had some dyscongugate eye movements. He is being taken emergently to the OR for emergent eploration and evacuation. RECS: Agree with emergent surgical evacuation F/U cultures (including BCx at [Hospital1 ]) and broad coverage Abx Brain MRI w/ and w/o Gad 100 lb weight loss and abnormal bone marrow signal probably warrant cancer screen Will follow on consult service Note: Contact = wife [Name (NI) ] at [Telephone/Fax (1) 84595] Case discussed with [Name6 (MD) ] [Name8 (MD) ], MD, Neurology Attendning [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD/PhD, PGY-3 Resident in Neurology Past Medical History: see above Social History: see above Family History: see above Physical Exam: see above for exam on admission. now with approx 4/5 strength in BLE. regaining strength in BUE. c-collar. trach with PMV. Pertinent Results: [2170-8-7] 05:15PM TYPE-ART PO2-101 PCO2-38 PH-7.37 TOTAL CO2-23 BASE XS--2 [2170-8-7] 04:44AM LACTATE-1.3 Brief Hospital Course: MICRO: [2170-8-7]: BCx: MRSA [2170-8-7]: OR (C-spine) Cx: MRSA [2170-8-7]: MRSA Screen: Negative [2170-8-8]: BCx: MRSA [2170-8-9]: BAL: yeast [2170-8-14]: BAL: yeast [2170-8-14]: BCx NG [2170-8-15]: BCx NG [2170-8-17]: TissueCx NG [2170-8-24]: UrineCx NG [2170-8-27]: MRSA neg . IMAGING: [2170-8-7]: skull films (screen for MRI): negative [2170-8-7]: MRI spine: epidural abscess (? infected hematoma) from craniocervical junction to T2 [2170-8-8]: ECHO: Normal left ventricular global and regional systolic function. LVEF > 55%. Right ventricular dilation, [Last Name (un) ] sign, and evidence of right ventricular pressure/volume overload raises the concern for significant pulmonary emboli. No vegetations identified [2170-8-9]: CTA Chest: No pulmonary embolism, aortic dissection or aneurysm. Severe interlobar and left lower lobe segmental and subsegmental bronchial mucoid impaction with left lower lobe atelectasis. Small multifocal peri-bronchovascular ground-glass opacities are most likely infectious or inflammatory in origin [2170-8-13]: DVT ultrasound neg [2170-8-14]: CXR cont opacification at L base, most likely related to atelectasis and possible effusion. [2170-8-17]: nL TTE [2170-8-18]: CT New cervical and upper thoracic spinal fusion hardware, unremarkable. Partially visualized left lung nodule, likely a partially visualized focus of ground-glass opacity similar on CT [2170-8-8]. [2170-8-22]: CXR minimal blunting of L costophrenic sinus could suggest small pleural effusion, unchanged retrocardiac atelectasis, NGT unremarkable [2170-8-23]: CXR hazy opacification at L base w obscured hemi-diaphgragm consistent with small pleural effusion and atelectasis [2170-8-23]: CXR 5pm stable appearance to small left pleural effusion and atlectesis at L base. [2170-8-24]: CXR small amount of left lower lobe volume loss . EVENTS: [2170-8-7]: OR: cervical laminectomy, drainage epidural abscess [2170-8-14]: Perc Trach at bedside. Neuro exam c/w quad. Bronch w/extensive secretions B/L [2170-8-15]: Moving all extremities. BUE [2170-8-16]: Vanc level 15.1. No preop DHT. Weaned to TC. Methadone 20 [Hospital1 ]. TFs back to goal. NPO for 2pm OR time. Wife to visit [8-17] and reconsent. [2170-8-17]: OR for ORIF/Fusion C2-T2 iliac bone graft [2170-8-18]: CT [2170-8-19]: Repeat CT w/ nL hardware. Still lg amounts secretions. Alert/moving all extremities. [2170-8-21] Dobhoff placed, TF re-started. Right Picc line placed. Retaining CO2, methadone held and placed on a rate to blow off CO2. [2170-8-22]: Bronchoscopy. [2170-8-23]: Atelectasis on CXR in AM, incr to PS/CPAP [11-24]. Evening CXR unchanged, ++increased secretions. Afeb. Kept settings same ON. ?Bronch in AM if continued secretion difficulties. [8-25]: Started on soft solid diet after bedside swallow. [8-26]: awaiting rehab. Copious secretions. [8-27]: Speech/swallow->PMV, Nectar thick puree diet. OK to d/c staples per orthospine. Awaiting placement w/Masshealth insurance. outline of hospital stay as above. briefly, was intubated at OSH and transferred to [Hospital1 18] for emergent evaluation and treatment of paralysis requiring intubation prior to transfer. taken to OR for decompression emergently. remained in ICU being treated for epidural abscess, respiratory failure and PNA. had trach placed on [8-14]. had posterior spine fusion on [8-17]. weaned from vent to PMV and mobilized with PT/OT. has started regaining strength in BUE/BLE. ID continued to follow for abx regimen. speech and swallow has consulted for diet. is ready for transfer to [Hospital ] rehab. Medications on Admission: see above Discharge Disposition: Extended Care Facility: [Hospital6 56223] Discharge Diagnosis: cervical spine epidural abscess with spinal cord injury. Discharge Condition: stable Discharge Instructions: You have undergone the following operation: Posterior Cervical Decompression and Fusion C2-T1 for epidural abscess. Immediately after the operation: - Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit in a car or chair for more than ~45 minutes without getting up and walking around. - Rehabilitation/ Physical Therapy: o 2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. o Isometric Extension Exercise in the collar: 2x/day x 10 times perform extension exercises as instructed. - Cervical Collar / Neck Brace: You need to wear the brace at all times until your follow-up appointment. You may remove the collar to take a shower. Limit your motion of your neck while the collar is off. Place the collar back on your neck immediately after the shower. - Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Call the office at that time. If you have an incision on your hip please follow the same instructions in terms of wound care. - You should resume taking your normal home medications. - You have also been given Additional Medications to control your pain. . Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [Hospital Ward Name 23] 2. We are not allowed to call in narcotic prescriptions (oxycontin, oxycodone, percocet) to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Follow up: o Please Call the office and make an appointment for 2 weeks after discharge. Please call the office if you have a fever>101.5 degrees Fahrenheit, drainage from your wound, or have any questions. Physical Therapy: OOB as tolerated with PT. WBAT BLE. no heavy lifting. Treatments Frequency: daily DSD until fully healed. Followup Instructions: call [Telephone/Fax (1) 3736] to schedule follow-up appointment with dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in about 2 weeks. Completed by:[2170-9-5] ICD9 Codes: 486, 5119, 2875, 496, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8870 }	Medical Text: Admission Date: [2137-7-8] Discharge Date: [2137-7-12] Date of Birth: [2060-4-14] Sex: M Service: MEDICINE Allergies: Ibuprofen Attending:[First Name3 (LF) 134] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 77y/o M with DM2, CAD s/p 3v CABG, HTN, Hypercholesterolemia, CHF, developed chest pain at around 7pm while watching the begining of the red sox game. His pain was across his chest, [1-3], non radiating, no shortness of breath, did have some associated lightheadedness/dizziness and weakness, no diaphoresis, no n/v. He took 1 old [Month/Year (2) 9181] without relief then went to his neighbors house who then gave him two [Name (NI) 9181] from hers but did not help with the chest pain either. There he was having visual blurriness/double vision. She took his blood pressure which was 112/66, his pain at that time had increased to [8-3]. His friend then convinced him to let her call 911, EMS arrived by 9pm. They transported him to [Hospital 1474] hospital, upon arrival his cp was [3-3] ECG was read at STEMI by ED, he was given 3 additional [Month/Year (2) 9181] with min relief, decreasing his pain to [1-31]. They then gave him lopressor 5mg iv x one, heparin 4000U x one, placed him on oxygen and then med flighted him to [Hospital1 18] for emergent cath. Here he was started on heparin iv, integrellin iv and was taken up to cardiac cath. Cath showed: HD: Ao 150/66, right dominant system LMCA: mod disease LAD: diffusely diseased w/ serial 60% and 70% stenosis, D1 is a large vessel w/ 90% stenosis. Lcx: TO px, a large OM fills via L-L collaterals RCA: TO px, the PDA and PL fill via L-R collaterals SVG-RCA: atritic and occluded SVG-OM: TO px LIMA-LAD: atritic w/o flow into LAD. Past Medical History: 1. DM2 for 6 years 2. CAD s/p 3v CABG 3. HTN 4. Hypercholesterolemia 5. CHF Social History: TOB: 2 packs for 40yrs, quit in [2123] ETOH: quit in 80's. Lives by self, does ADLS by self, drives. Walks with cane. Family History: Father died 66 from heart failure Mother died 59 from cervical cancer. Diabetes in fathers family as well as heart disease. Physical Exam: T: 93.1 axillary, BP: 131/63, HR: 59, 98% 2L NC GEN: AxOx3, NAD, pleasant male with family in room HEENT: EOMI, PERRL, mmdry, o/p clear NECK: no JVP appreciated, no bruits appreciated CV: RRR, no m/r/g, normal s1/s2 PULM: CTA b/l, no w/r/r ABD: large, bowel sounds present, obese, NT/ND EXT: no c/c, edema present to mid legs 1+ b/l. DP/PT palpated 1+ b/l Neuro: CN II-XII grossly intact. Groin: right groin w/o hematoma, non tender, no bruit appreciated, gauze and dressing in place with minimal blood staining. Pertinent Results: ECG: sinus 68, inferior q waves, 1mm ST depression I, AVL. ***************** CATH 1. Severe three vessel native coronary artery disease. 2. All three bypass grafts occluded. Carotid Series + Venous Duplex 1. Findings consistent with 40%-59% stenosis of the right internal carotid artery secondary to atherosclerotic plaque. 2. Occlusion of the left internal carotid artery. 3. Nonvisualization and query occlusion of the right vertebral artery. 4. Patent left greater saphenous vein with dimensions provided above. *************** ECHO The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is very mildly depressed with focal basal inferior and infero-lateral thinning and akinesis The remaining LV segments appear hyperdynamic. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. *************** P-MIBI Moderate inferior and inferolateral partially reversible perfusion defect. Mild global hypokinesis that is worse in the region of the patient's perfusion defects. EF 45% **************** Stress No angina and no EKG changes suggestive of ischemia. Nuclear report sent separately. **************** [2137-7-9*] 01:25PM BLOOD CK-MB-13 MB Indx-10.2* cTropnT-0.13* [2137-7-8] 11:30PM BLOOD CK-MB-4 cTropnT-0.01 [2137-7-9] 01:25PM BLOOD CK(CPK)-128 [2137-7-8] 11:30PM BLOOD CK(CPK)-87 Brief Hospital Course: A/P: 77y/o M with DM2, CAD s/p 3v CABG, HTN, Hypercholesterolemia, [Hospital 27810] transferred from [Hospital 1474] hospital for STEMI and found to have severe 3VD w/ occluded grafts on cath, no STEMI. Had cardiac cath w/ no intervenable lesions but with severe 3vd and occluded grafts. ECG reread and no evidence of STEMI though sent over for emergent intervention. Start metoprolol 25mg [Hospital1 ], aspirin 325mg once a day, atorvastatin 80mg once a day, no lisinopril given ARF, c/w integrellin, heparin o/n. Patient did not want to undergo any further surgical intervention and so patient was managed medically. Medications on Admission: 1. Lisinopril 2. Amaryl 3. Bumetanide 4. Avandia 5. Simvastatin 6. Atenolol 7. ASA Discharge Medications: 1. Nitroglycerin 2.5 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO twice a day. Disp:60 Capsule, Sustained Release(s) Refills:5 2. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual PRN as needed for pain. Disp:60 Refills:5 3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 7. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:90 Tablet(s) Refills:2 8. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 9. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:270 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: CAD HTN DM type 2 CHF Hypercholesterolemia CAD HTN DM type 2 CHF Hypercholesterolemia CAD HTN DM type 2 CHF Hypercholesterolemia Discharge Condition: Pt is chest pain free, with stable vital signs Discharge Instructions: If you experience any chest pain, lightheadedness, passing out, shortness of breath, palpitations you should seek medical attention immediately. You have appointments set up for you to see a kidney doctor and heart doctor. You should also follow up with your PCP at the VA in the next 1-2 weeks. Followup Instructions: Provider: [Name10 (NameIs) 900] [Name8 (MD) 901], M.D. Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 902] Date/Time:[2137-7-18] 11:00 Provider: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 720], M.D. Where: [Hospital6 29] MEDICAL SPECIALTIES Phone:[Telephone/Fax (1) 435] Date/Time:[2137-9-12] 11:00 Completed by:[2137-9-3] ICD9 Codes: 4280, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8871 }	Medical Text: Admission Date: [2175-1-20] Discharge Date: [2175-1-27] Date of Birth: [2122-7-22] Sex: F Service: CARDIOTHORACIC Allergies: Amoxicillin Attending:[First Name3 (LF) 5790] Chief Complaint: Tracheobronchomalacia. Major Surgical or Invasive Procedure: [2175-1-20] Flexible bronchoscopy with bronchoalveolar lavage, right thoracotomy and tracheoplasty with mesh, left main stem bronchoplasty with mesh, right main stem bronchus/bronchus intermedius bronchoplasty with mesh. History of Present Illness: Ms. [Known lastname ] is a 52-year-old woman who was found to have severe, diffuse tracheobronchomalacia. Her main symptom was dyspnea; but she also had a chronic productive cough. She has also had orthopnea and recurrent respiratory infections. She responded well in terms of her dyspnea to the stent placement therefore is admitted for right thoracotomy, trachaelplasty with mesh placement. Past Medical History: COPD (on 2L home O2) Asthma Allergic rhinitis Atopic dermatitis HTN AoRegurgitation Major Depressive Disorder with Psychotic Features History of Polysubstance Abuse, primarily Cocaine Anxiety Disorder NOS with Situationally Bound Panic Attacks with Agoraphobia Polysubstance abuse hx Ulcerative colitis menorrhagia GERD OSA Narcolepsy Right humerus fx Social History: Pt lives with family. No alcohol or IVDU. Patient has hx of cocaine abuse. On disability. Previous smoker but quit in [2154], smoked [12-24] PPD from 15 to 25 yo (5pk-yr) and 2 PPD from 25 to 32 yo (14 pk-yr) for total of 19 pk-yr. Family History: No family hx of cancer or CAD or DVT/PE. Physical Exam: VS: T 98.1 HR: 87 SR BP: 138/80 96% 2L General: no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple Card: RRR Resp: faint bibasilar crackles otherwise clear GI: obese, abdomen soft non-tender/non-distended Extr: warm no edema Incision: R thoracotomy site clean dry intact, no erythema. CT site clean intact Skin: Right lower extremity with scattered psorasis areas with some skin breakdown Neuro: non-focal Pertinent Results: [2175-1-24] WBC-10.7 RBC-3.57* Hgb-9.0* Hct-28.9 Plt Ct-302 [2175-1-23] WBC-14.0* RBC-3.62* Hgb-9.4* Hct-29.0 Plt Ct-309 [2175-1-20] WBC-20.2# RBC-4.67 Hgb-11.7 Hct-38.5 Plt Ct-357 [2175-1-26] UreaN-12 Creat-0.6 Na-144 K-3.8 Cl-105 HCO3-30 [2175-1-25] Glucose-120* UreaN-14 Creat-0.5 Na-142 K-3.8 Cl-103 HCO3-30 [2175-1-20] Glucose-160* UreaN-13 Creat-0.8 Na-137 K-4.9 Cl-101 HCO3-24 [2175-1-26] Mg-1.9 [2175-1-23] 12:11 pm SPUTUM GRAM STAIN (Final [2175-1-23]): 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [2175-1-25]): MODERATE GROWTH Commensal Respiratory Flora. Chest X-Ray: [2175-1-25] The right internal jugular line has been removed. The right upper lobe opacity has improved in the interim and might be consistent with resolution of post-surgical hematoma. [2175-1-22] Chest tube remains and there is no evidence of pneumothorax or substantial effusion, though pleural thickening persists on the right. Mild vascular congestion is again seen and there are some streaks of atelectasis at the left base. [2175-1-21] Atelectasis has cleared from the right middle lobe, but consolidation persists in the upper lobe could be asymmetric re-expansion edema, contusion or less likely this early in the postoperative period, aspiration pneumonia. Borderline cardiomegaly and mild pulmonary vascular congestion persists and there is subsegmental atelectasis in the left lung, unchanged. Right pneumothorax is minimal, at the apex, if any, and right pleural collection is also very small, if any, one basal and one apical pleural tube is still in place. With the chin down, the tip of the endotracheal tube 2.45 cm above the carina is acceptable. Right jugular line ends at the junction of brachiocephalic veins. Mediastinal drains noted. Brief Hospital Course: Mrs. [Known lastname ] was admtitted on [2175-1-20] for Flexible bronchoscopy with bronchoalveolar lavage, right thoracotomy and tracheoplasty with mesh, left main stem bronchoplasty with mesh, right main stem bronchus/bronchus intermedius bronchoplasty with mesh. She was extubated in the operating room transferred to the SICU for airway monitoring and management. Respiratory: aggressive pulmonary toilet with mucolytic nebs and chest PT were administered. She titrated to her home O2 of 2L with oxygen saturations in the high 96%. Chest-tube: Posterior chest tube was removed on POD2. She was followed by serial chest films which showed atelectasis and stable tiny right apical pneumothorax. Cardiac: She remained hemodynamically stable. Her afterload medications were restarted. GI: Her colitis medications were restarted. Her bowel function returned to [Location 213]. Nutrition: She tolerated a diabetic diet. Renal: On POD 1 she went into acute renal failure with a peak CRE 1.8. With hydration her renal function returned to her baseline of 0.8 on POD 2. Her diuretics were restarted and she was gentley diuresed. Maintained good urine output. Endocrine: her Blood sugars were 130-150's and covered by insulin sliding scale. Her home diabetic medications were restarted once she started a regular/diabetic diet. Pain: Epidural in place was managed by the acute pain service. It came out on POD4 and she was converted to PO pain medications. Neuro: history of bipolar, depression for which her home medications were restarted on POD1. Disposition: She was seen by physical therapy who deemed her safe for home. She continued to make steady progress and was discharged to home on POD7 Medications on Admission: Mucomyst nebs tid Aripiprazole 10 mg PO Daily Benzonatate 200 mg PO TID prn couch Clobetasol 0.05% ointment [Hospital1 ] 2 weeks per month Fluoxetine 60mg PO Daily Fluticasone 50 mcg spray INH [Hospital1 ] Fluticasone 220 mcg Aerosol - 2 puffs INH [Hospital1 ] Advair diskus 500 mcg-50 mcg 1 puff INH [Hospital1 ] Lasix 20 mg Q8AM & 2PM Xopenex 0.63 mg/3 mL nebs TID prn SOB Xopenef HFA 45 mcg INH Q4hrs prn SOB Lisinopril 20 mg PO Daily Mesalamine delayed release 400 - 4 tablets PO TID Metformin 850 mg PO BID Montelukast 10 mg PO Daily Omeprazole delayed release 20 mg PO Daily Tiotropium Brominde 18 mcg, 1 cap INH QAM (10minutes after Advair) Guaifenisen - 1,200 mg Tab, 1 PO BID Loratidine - 10 mg Tablet - 1 PO QAM Discharge Medications: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 5. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four (4) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: [12-24] Tab Sust.Rel. Particle/Crystals PO DAILY (Daily). 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 13. Metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day. 14. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:70 Tablet(s) Refills:0 16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/headache. 17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) mL Inhalation every 4-6 hours as needed for wheezing. 18. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 19. Calcium Carbonate-Vitamin D3 500 mg(1,250mg) -400 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Tracheobronchomalacia. Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Call Dr.[Name (NI) 2347] office [Telephone/Fax (1) 2348] if experience: -Fevers > 101 or chills -Increased cough, shortness of breath or sputum production -Incision develops drainage -Daily weights: keep a log -Continue inhalers and nebulizers -Continue incentive spirometer 10x every hour while awake -You may shower. No tub bathing or swimming for 6 weeks -Take narcotics with stool softners. Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] Date/Time:[2175-2-7] 11:00 in the [Hospital Ward Name 121] Building Chest Disease Center [Hospital1 ] I Chest X-Ray 10:30 in the [Hospital Ward Name 517] Clinical Center [Location (un) ] Radiology Department Follow-up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 13959] [Telephone/Fax (1) 250] Completed by:[2175-1-27] ICD9 Codes: 5849, 4241, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8872 }	Medical Text: Admission Date: [2156-5-29] Discharge Date: [2156-6-4] Date of Birth: [2079-5-15] Sex: F Service: SURGERY Allergies: Lipitor / Fruit Flavor Attending:[First Name3 (LF) 301] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: 1. Exploratory laparotomy 2. Left colectomy. 3. End colostomy. 4. Hartmann procedure. 5. Appendectomy. History of Present Illness: 74 yo with acute onset lower abdominal pain and nausea, 12 hrs in duration. No nausea and vomiting, with loose brown stools, but no gross blood. No history of abdominal pain. Pain began in lower abdomen and became more severe. Past Medical History: vasculitis, on prednisone uveitis CRI (creatinine 1.7) HTN glaucoma history of colitis brocheoalveolar CA T1, NO PSH tonsillectomy D and C X2 appy breast mass resection s/p VATS R upper lobe Social History: 30 pack year smoker Family History: nc Physical Exam: On discharge: 97.5 97.6 64 126/78 16 96 RA NAD RRR, S1,S2 Lungs clear, no respiratory distress Abd soft, non-distended, gas in osteomy, stoma is more pink, sloughing of necrotic tissue. no leg cords Pertinent Results: URINE CULTURE (Final [2156-5-30]): NO GROWTH. Blood Culture, Routine (Final [2156-6-4]): NO GROWTH. [2156-5-29] 6:00 am SWAB Site: PERITONEAL Fluid should not be sent in swab transport media. Submit fluids in a capped syringe (no needle), red top tube, or sterile cup. GRAM STAIN (Final [2156-5-29]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). REPORTED BY PHONE TO [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 44075] [2156-5-29] 08:30AM. FLUID CULTURE (Final [2156-6-1]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. PSEUDOMONAS AERUGINOSA. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 2 S CEFTAZIDIME----------- 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- 8 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S ANAEROBIC CULTURE (Preliminary): Mixed bacterial flora-culture screened for B. fragilis, C. perfringens, and C. septicum. MRSA SCREEN (Final [2156-5-31]): No MRSA isolated. Brief Hospital Course: Following surgery, the patient was admitted to the surgical service on [2156-5-29]. The patient was admitted to the ICU for observation for acidosis of 7.2 Acidosis resolve with fluid repletion. Pressors were needed initially post-op and also weaned off. Extubation was achieved on POD 1. The patient was weaned to 3L NC. Flatus was noted in the osteomy bag on POD2. The patient stabilized and was transferred tp the floor. Presnisone dose was tapered from stress dose levels. Pain was controlled with a dilautid PCA. Osteomy nursing visited with the patient and initiated osteomy teaching. Also, the stoma was assessed. The stoma was thought to be viable with some pink and necrotic tissue. Foley was removed on POD4. Clear liquid were started and advanced to full liquid prior to discharge. GYN was consulted for pessary changing. The pessary was removed and the plan was for replacement as an outpatient. Physical therapy recommended rehabilitation placement. At the time of discharge, the stoma had some sloughing necrotic tissue, improving over the time of hospitalization. She was tolerating a regular diet, and was afebrile. Medications on Admission: fosamax, atenolol 25', prilosec 20', dicyclomine, prednisone 15' Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 2. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 3. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic QID (4 times a day). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection three times a day. 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day). 7. Alendronate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 9. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Vagifem 25 mcg Tablet Sig: One (1) Vaginal 2X/WEEK (2 times a week). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 12 days. 14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 12 days. 15. Ampicillin Sodium 1 gram Recon Soln Sig: Twelve (12) Recon Soln Injection Q6H (every 6 hours) for 12 days. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: 1. Perforated sigmoid colon secondary to probable diverticulitis with possible malignancy. 2. Scarring at the appendix. Discharge Condition: stable Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [6-20] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Monitor for signs of osteomy breakdown. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] in 2 weeks. Call to schedule your appointment. Call ([Telephone/Fax (1) 9000] to schedule to appointment. Follow-up with Dr. [First Name (STitle) ] as an outpatient for pessary replacement. [Telephone/Fax (1) 44076] Completed by:[2156-6-4*] ICD9 Codes: 2762, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8873 }	Medical Text: Admission Date: [2166-1-29] Discharge Date: [2166-2-15] Date of Birth: [2166-1-29] Sex:M Service: DISCHARGE DIAGNOSES: 1. Premature male infant, 34 and 2/7 weeks gestation. 2. Status post feeding immaturity. HISTORY OF PRESENT ILLNESS: Jaden is a former 2.33 kilogram male infant, born at 32 and 4/7 weeks gestation to a 35 year old, Gravida VII, Para III now IV 0 negative female whose remaining prenatal screens were noncontributory. Group B strep culture was unknown. Mother presented to [Hospital3 ] Hospital on the day of delivery with premature rupture of membranes. She had an uncomplicated pregnancy with known gestational diabetes. Mother did not receive her obstetrical care through [Hospital1 ]. Of note, mother was admitted to [Hospital1 188] at the end of [Month (only) 404] with a motor vehicle accident. Mother had no major issues. Mother presented in preterm labor with prolonged rupture of membranes and was treated with antibiotics approximately three hours prior to delivery. Mother delivered vaginally with [Name (NI) ] of nine and nine and infant was admitted to the newborn Intensive Care Unit at [Hospital3 ] Hospital because of prematurity. HOSPITAL COURSE: 1. Respiratory: Infant was placed in oxygen for several hours and then weaned to room air and remained in room air thereafter. Infant did not have episodes of apnea of bradycardia or prematurity. 2. Cardiovascular: There were no cardiovascular issues. 3. Jaden was placed on Ampicillin and Gentamycin and with benign CBC and negative blood cultures. Antibiotics were discontinued at 48 hours. 4. Feeding and nutrition: Two days prior to discharge, the infant weighed 2,385 kilograms. The baby was feeding ad lib demand of [Name (NI) 37112] 20 calories per ounce. 5. Immunizations: Hepatitis B vaccine was given on [2166-2-12]. 6. Circumcision performed on [2-14]. 7. Hematologic: Mother 0 negative; baby 0 positive. The infant had a peak bilirubin of 11.5 for which he underwent several days of phototherapy. His initial hematocrit was 53. 8. Hearing screen on [2-13] was normal. The patient is being discharged home on [2-15] and will have a follow-up appointment at [Hospital1 ] [Location 1268] Center within several days of discharge with Dr.[Last Name (STitle) 55285]. DR.[Last Name (STitle) ],[First Name3 (LF) ] 50-393 Dictated By:[Last Name (NamePattern1) 55286] MEDQUIST36 D: [2166-2-15] 03:43 T: [2166-2-15] 16:41 JOB#: [Job Number 55287] ICD9 Codes: 7742, V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8874 }	Medical Text: Admission Date: [2118-7-9] Discharge Date: [2118-7-19] Date of Birth: [2042-11-7] Sex: F Service: C-MED CHIEF COMPLAINT: Shortness of breath times three days. HISTORY OF PRESENT ILLNESS: This is a 75-year-old woman with a history of congestive heart failure, acute renal failure, diabetes mellitus, hypertension, and peripheral vascular disease who presents with shortness of breath and dyspnea on exertion for three days. The patient was in her usual state of health until approximately three days prior to admission when she reports running out of her Lasix pills. Over the next few days she became progressively more short of breath. She denies increased pedal edema but noticed significant worsening orthopnea and episodes of paroxysmal nocturnal dyspnea. She denies any episodes of chest pain, diaphoresis, palpitations, nausea, and vomiting over the last several days. She does report decreased urine output. She denies intractable nausea, vomiting, confusion, neurologic symptoms, or pruritus. She complains of pain in her right upper quadrant for the past two days, worse with inspiration. Otherwise, she denies any fevers, chills, dysuria, diarrhea, constipation, rash, sore throat, or flu-like symptoms. She was hospital day in [Month (only) 547] at [Hospital6 2561] with congestive heart failure and acute renal failure. Since then, her creatinine has been elevated; her last being 3.9. An echocardiogram at the outside hospital had a normal ejection fraction of 55%. PAST MEDICAL HISTORY: 1. Congestive heart failure; recent admission to [Hospital6 18075] for congestive heart failure led to evaluation with echocardiogram with an ejection fraction of 55%, dobutamine. 2. Acute renal failure, renal ultrasound at [Hospital6 ] negative. Last creatinine was 3.9 in [2117-5-9]. 3. Insulin-dependent diabetes mellitus times 30 years. 4. Hypertension; poorly controlled recently. 5. Hypercholesterolemia. 6. Peripheral vascular disease, status post femoral-femoral bypass. 7. History of Lyme's disease; treated with ceftriaxone. 8. Status post appendectomy. 9. Status post cholecystectomy. 10. Hypothyroidism. 11. Question of temporal arteritis. ALLERGIES: PENICILLIN causes hives; ASPIRIN cause stomach burning. MEDICATIONS ON ADMISSION: Lasix 80 mg p.o. b.i.d., atenolol 25 mg p.o. q.d., Pravachol 20 mg p.o. q.d., Levoxyl 0.375 mg p.o. q.d., Cardia-XT 420 mg p.o. q.d., Flonase 50 mcg 2 puffs b.i.d., prednisone 5 mg p.o. q.d., insulin NPH 32 units q.a.m. and 10 units q.p.m. SOCIAL HISTORY: A 20-pack-year history of smoking; quit 20 years ago. No alcohol use. She is a retired illustrator. FAMILY HISTORY: She has three children with diabetes mellitus. PHYSICAL EXAMINATION ON PRESENTATION: On admission vital signs revealed a temperature of 98.6, heart rate of 84, respiratory rate of 24, blood pressure of 190/70, oxygen saturation of 94% on room air and 96% on 4 liters. In general, tachypneic, speaking without difficulty. Head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light. Extraocular muscles were intact. The oropharynx was unremarkable. Neck was supple. No lymphadenopathy. Jugular venous pressure about 10 cm to 12 cm. Heart revealed a regular rate and rhythm. No murmurs, gallops or rubs. Lungs revealed crackles in lower half of both lung fields. Decreased breath sounds at the bases. The abdomen was soft, nondistended, normal active bowel sounds. Mild tenderness in the right upper quadrant. No [Doctor Last Name ]. Extremities revealed no clubbing, cyanosis or edema. Pedal pulses were 2+. Neurologic examination revealed no wrist or ankle drop. Strength was [6-12] in the extremities. No asterixis. No myoclonus. PERTINENT LABORATORY DATA ON PRESENTATION: On admission white blood cell count was 15.1, hematocrit of 33.6, platelets of 231. Differential revealed 77.4% neutrophils, 17.2% lymphocytes, and 4.7% monocytes. Sodium of 140, potassium of 4.6, chloride of 100, bicarbonate of 24, blood urea nitrogen of 106, creatinine of 4.8, blood glucose of 82. Urinalysis revealed 0 red blood cells, 0 to 2 white blood cells, rare bacteria. RADIOLOGY/IMAGING: Electrocardiogram revealed a normal sinus rhythm with a heart rate of 68, normal axis, no Q waves, 2-mm ST depressions in V6 and 1 mm in V5, a nonspecific conduction delay. Chest x-ray revealed pulmonary edema, blunted angles. IMPRESSION: This is a 75-year-old woman with a history of congestive heart failure, acute renal failure (now chronic), insulin-dependent diabetes mellitus, and hypertension who presented with shortness of breath after running out of her Lasix three days prior to admission. HOSPITAL COURSE: 1. CARDIOVASCULAR: Initially, the patient was thought to be volume overloaded given her chest x-ray. There was no clear evidence of any cardiac event causing her congestive heart failure. A normal ejection fraction on recent echocardiogram suggesting diastolic heart failure possibly secondary to longstanding hypertension and decreased renal function. This situation was thought to be exacerbated by her acute-on-chronic renal failure with a decreased response to diuretics. In the Emergency Department she only put out 100 cc of urine to 80 mg of intravenous Lasix in two hours. The patient's cardiac enzymes were cycled, and she ruled out for a myocardial infarction. Her beta blocker was held initially and then restarted after two days. She was initially on a nitroglycerin drip, and she was given Lasix 160 mg times one. For coronaries, she was continued on her statin and atenolol. The patient was initially placed on Lasix 80 mg intravenous b.i.d. and Zaroxolyn. She was also continued on her calcium channel blocker initially for hypertension control. An echocardiogram showed moderate 2+ mitral regurgitation, moderate symmetric left ventricular hypertrophy, an ejection fraction of greater than 60%, mild left atrial enlargement, left ventricle with a restrictive filling pattern, mild pulmonary hypertension, a small pericardial effusion. Because the patient's creatinine was continuing to rise, her Lasix and Zaroxolyn were both decreased, and clonidine was added for blood pressure control. The patient had some episodes of bradycardia which led to an unstable blood pressure at the beginning of her stay. Eventually, the patient was switched back to Lasix 80 mg b.i.d. (which is her home dose). Her blood pressure control remained poor. On [7-14], because her creatinine continued to worsen, her Lasix was discontinued altogether. Her hypertension improved, but her clonidine was titrated further to have better control. On [7-15], the patient went for her Perm-A-Cath and arteriovenous fistula for hemodialysis initiation, and while she was in the operating room was bradycardic to the 20s and received atropine. She also had a pause in her electrocardiogram. Postoperatively, her heart rate continued to be in the 30s and 40s, and she was hypothermic, but her blood pressure was preserved. She was transferred to the Coronary Care Unit for one night for observation overnight. Her beta blocker was held, as was her calcium channel blocker. The source of the bradycardia was unclear. The pacer pads were in place but were not used. The following day, her heart rate improved and she was transferred back out to the floor. Given the fact that hemodialysis was inevitable, and ACE inhibitor was added to her regimen for hypertension. On [7-17], a low-dose beta blocker was restarted. The patient tolerated this well. A lipid panel was checked and was found to be within normal limits. Her statin was then discontinued given her elevated ALT and AST. While she was in the Coronary Care Unit, she was also ruled out for a myocardial infarction; although, her troponin was slightly elevated at 0.7 (probably due to renal failure). 2. RENAL: The patient presented with acute-on-chronic renal insufficiency. This was thought to be progression of her intrinsic renal disease which may be secondary to her diabetes or hypertension, or maybe secondary to prerenal decreased flow. A Renal consultation was requested. Initially, she was diuresed aggressively as above. A renal ultrasound done at [Hospital6 2561] in [2118-4-8] showed bilateral small kidneys, each measuring approximately 8 cm. Creatinine continued to worsen, reaching in the high 4s on [2118-7-12]. Magnetic resonance angiography of her kidneys was done to rule out renal artery stenosis, and this was inconclusive. Magnetic resonance angiography showed the left kidney of 8.1 cm, right kidney of 8.6 cm. No hydronephrosis. Delayed nephrogram and perfusion of left kidney. Full evaluation of renal artery not performed due to the patient's inability to hold her breath. On [7-14], the patient's creatinine was up to 5.8. She began to have uremic symptoms prompting surgical evaluation for arteriovenous fistula placement and Perm-A-Cath placement for dialysis. On [7-15], the patient went to the operating room to have Perm-A-Cath placed and arteriovenous fistula placed. This was complicated by bradycardia, and she was admitted to the Coronary Care Unit for obstetrician overnight. Hemodialysis was initiated on [7-16]. She was started on calcium carbonate t.i.d. with meals and Nephrocaps. The patient received a second session of hemodialysis on [7-18]. On [7-19], arrangements were made for her to have outpatient dialysis three days per week in [Hospital1 3494], near where she lived. 3. INFECTIOUS DISEASE: The patient's white blood cell count was elevated on admission, but there was no obvious infectious source. She was afebrile. She remained afebrile throughout her hospitalization; although, three days prior to discharge, she did complain of mouth and throat pain. On the day of discharge she was found to have moderate oral thrush, and she was started on clotrimazole troches q.i.d. for this. 4. GASTROINTESTINAL: The patient presented with right upper quadrant tenderness. This was thought to be secondary to right-sided cardiac congestion. Liver function tests and alkaline phosphatase were checked and were within normal limits with only a mild elevation of her ALT at 50. The patient was on Protonix. On [7-17], the patient was found to have an elevated ALT and AST at 74 and 71. Hepatitis serologies were sent off. Because of this elevation, her statin was discontinued; especially since her lipid panel was within normal limits. Her alkaline phosphatase was also slightly elevated at 277. She can be re-evaluated as an outpatient for hypercholesterolemia. 5. ENDOCRINE: The patient was continued on her home dose of insulin. However, she had early morning hypoglycemia. She was also continued on her home Synthroid dose. Because she continued to have early morning hypoglycemia despite a decrease in her nighttime NPH, [Initials (NamePattern4) ] [Last Name (NamePattern4) ] consultation was requested who felt that her low a.m. blood glucoses may be secondary to her high a.m. NPH dose which had not been decreased and which may had stayed longer in her system secondary to her renal insufficiency, as insulin is cleared renally. Thus, their recommendations were followed, and her nighttime NPH was discontinued and her morning NPH was decreased. Her blood sugars became more stable after that point. Prednisone was continued for a question of a past history of temporal arteritis. She was also on a regular insulin sliding-scale. 6. HEMATOLOGY: The patient's hematocrit was noted to drop from 33 to 28 between [7-9] and [7-10] despite aggressive diuresis. Her hematocrit was rechecked that afternoon, and she did not require a transfusion. Iron studies revealed anemia of chronic disease. The Renal Team felt that at this time she did not need to be started on Epogen. Her B12 level was also low normal. She may need supplementation as an outpatient. When the patient was admitted to the Coronary Care Unit on [7-15], she was noted to have a drop in her hematocrit from 30 to 24 which was confirmed on recheck. Estimated blood loss during surgery was only 250 cc, and she received only 500 cc of intravenous fluids. She was transfused, and her blood pressure remained stable after that point. Her hematocrit bumped appropriately to 27.4. She was transfused a second unit at hemodialysis the following day with no evidence of active bleeding. 7. FLUIDS/ELECTROLYTES/NUTRITION: The patient's phosphorous began to become elevated on [7-12] to 5.6. She also became progressively hypocalcemic, and this was repleted in the Coronary Care Unit on [7-15]. She was started on calcium carbonate t.i.d. and Nephrocaps once hemodialysis was initiated and encouraged to eat. 8. PSYCHIATRY: On [7-14], the patient expressed suicidal ideation with potential plans; although, she did not seem serious about executing them, but had some plans in mind. A Psychiatry consultation was called and evaluated the patient. They did not recommend a one-to-one sitter at this time and recommended starting a trial of Ritalin for antidepressant effect starting at 2.5 mg p.o. q.a.m. and eventually titrating to b.i.d. q.a.m. and q. noon without being taken after noon as it can have a very stimulating effect and cause insomnia. A thyroid-stimulating hormone was recommended and was normal. They also recommended psychotherapy; however, the patient was not able to follow up here given the distance from her house. Thus, Ritalin was started at 2.5 mg p.o. q.a.m. and eventually increased to 5 mg p.o. q.a.m. In the Coronary Care Unit, her Ritalin was held given her bradycardia. 9. CODE STATUS: Full. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Home with [Hospital6 407] and home safety evaluation. MEDICATIONS ON DISCHARGE: 1. Synthroid 37.5 mcg p.o. q.d. 2. Prednisone 5 mg p.o. q.d. 3. NPH 15 units subcutaneous q.a.m. 4. Cepacol one lozenge p.o. q.6h. p.r.n. 5. Metoprolol 12.5 mg p.o. q.d. 6. Lisinopril 5 mg p.o. q.d. 7. Calcium carbonate 500 mg p.o. t.i.d. with meals. 8. Nephrocaps 1 capsule p.o. q.d. 9. Methylphenidate HCL 5 mg p.o. q.a.m. and q. noon (not past noon). 10. Clonidine 0.2 mg p.o. t.i.d. 11. Clotrimazole one troche p.o. q.i.d. DISCHARGE DIAGNOSES: 1. Diastolic heart failure. 2. End-stage renal disease, on hemodialysis. 3. Diabetes mellitus. 4. Hypertension. 5. Hypercholesterolemia. 6. Peripheral vascular disease. 7. Depression. 8. History of Lyme's disease. 9. Status post appendectomy. 10. Status post cholecystectomy. 11. Hypothyroidism. 12. Question of history of temporal arteritis. [Name6 (MD) ] [Last Name (NamePattern4) 19519], M.D. [MD Number(1) 19520] Dictated By:[Last Name (NamePattern1) 7069] MEDQUIST36 D: [2118-7-19] 18:54 T: [2118-7-23] 03:29 JOB#: [Job Number 31416] ICD9 Codes: 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8875 }	Medical Text: Admission Date: [2138-5-26] Discharge Date: [2138-6-5] Date of Birth: [2075-3-15] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 552] Chief Complaint: FUO, altered MS Major Surgical or Invasive Procedure: intubation History of Present Illness: Ms. [Known lastname 13304] is a 63 yo F with a h/o EtOH abuse, hemochromatosis, and recent hospitalization for ETOH pancreatitis, who was transferred to the ED from rehab with acute altered mental status. According to her husband she was in her usual state of health when he last spoke to her at 9pm on the evening of admission. He was called by the rehab 2 hours later and informed that she was not making sense and that she was being sent to ED for further evaluation. He reported that when he saw her in the ED she was speaking non-sensically; he had never seen her like this before. On [2138-5-22] she was discharged from [Hospital1 18] to rehab after a month-long hospitalization, including intubation, for severe alcoholic pancreatitis. In the ED, VS were T 97.6, HR 104, BP 156/88, RR 20, 100% on NC. She was initially evaluated for stroke, noted to have B/L mydriasis, sluggishly reactive to light; but no evidence of herniation/hemorrhage or other acute process on head CT. Negative tox screen except for benzos which were given in the ED. She spiked a fever to 102.4 in ED and had an LP performed, which was normal. She was treated with vanco 1g IV x1, levofloxacin 750mg IV x1, flagyl 500mg IV x1. She was also given NS IV x2L, Bannana bag, mag 2g IV x1, 1mg Ativan x2, tylenol 1g PR, ASA 325. Past Medical History: #. Pancreatitis-- hospitalization [4-29] - [2138-5-22], on levo/flagyl; MICU stay w/intubation #. EtOH abuse-- heavy drinking of [1-21] to whole bottle of wine per day every day for 4-5 years; unclear if she has been drinking since recent discharge from hospital #. Peptic ulcer disease #. Hemochromatosis-- requiring therapeutic phlebotomy (no h/o organ dysfunction) #. OSA-- per sleep study on [2138-4-2], patient should be started on auto CPAP with a pressure ranging from 6-10 cm of water; however she hasn't started using CPAP at home yet #. Cognitive impairment-- per husbands report she has been reporting short term memory impairment x3 years; h/o abnormal neuropsych testing Social History: Up until the past month she had been drinking 1 whole bottle of wine per day +/- scotch every day for 4-5 years. Last drink was [2138-4-26], husband denies any access to alcohol since. No h/o tobacco or drug use. Prior to her recent pancreatitis she had been working part time as a therapist, previously as a professor. Lives with husband who does not drink. Family History: non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: VS in the [Hospital Unit Name 153]: T 103.2, HR 121, BP 155/67, RR 30, 99% NC Gen: appears agitated, non purposeful movements, muttering, moans in response to questions/exam Skin: warm, flushed, no rashes or lesions noted HEENT: pupils 3mm, equal, sluggisly reactive, roving eye movements, will not open mouth, dried blood on tongue/[Last Name (LF) ], [First Name3 (LF) ] not open mouth for examination Neck: supple, no LAD, no thyromegaly or thyroid nodules CV: tachycardic, regular rhythm, no appreciable murmur Lungs: unable to cooperate with exam, CTAB Abd: soft, appears to be tender to deep palpation primarily in RLQ, +Bowel sounds, no guarding Ext: no pedal edema Pertinent Results: ADMISSION LABS: Na 132 K 3 CL 102 HCO 26 BUN AST 22 ALT 12 AP 155 Lip 13 CK 36 MB - Trop 0.02 WBC 7.7 HCT 28.1 PLT 390 Serum Tox negative Lactate 1 [5-26] CSF 3WBC 7RBC 29protein 76glucose CSF HSV PCR: pending CSF gram stain: no PMN's or microorganisms CSF bacterial/viral cultures: pending Urine Tox positive for benzos (which were given in the ED), otherwise negative UA: trace blood, occ bacteria otherwise neg [2138-5-26] BCx: Coag negative staph in [11-22] vials [2138-5-27] BCx: [2138-5-28] BCx: [2138-5-26] PICC catheter tip: NGTD C. Diff Toxin A: negative on three samples C. Diff Toxin B: pending [2138-5-26] Stool Cx: negative Imaging: [2138-5-26] CXR: No acute intrathoracic process. PICC tip in standard location. Limited evaluation fue to low lung volumes. [2138-5-25] Head CT: No acute intracranial process. [2138-5-28] TTE: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation may be present (clip [Clip Number (Radiology) ]). The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2138-5-19], the findings are similar. [2138-5-28] Bilateral LE US: [2138-5-28] Torso CT with Contrast: Brief Hospital Course: 63 yo WF w/ ETOH abuse, hemachromatosis, PUD w recent admission for severe pancreatitis/ARDS/intubation/MICU transfer was re-admitted on [5-26] with acute mental status change. Pt underwent CT head (neg), and LP in ED and was transferred to MICU. LP revealed only 3 WBC w/ lymphocytic predominance, 7 RBCs, 29 pro and 76 gluc. CSF Cx were NGTD. Pt was empirically given one dose of Vanc, levaquin, flagyl. Pt had fever and workup revealed pancreatic pseudocyst w >30% necrosis and levaquin/flagyl were continued. Pt also had resp distress/inability to protect airway and was intubated but quickly extubated within 48 hrs. Due to persistent MS change, pt underwent EEG which showed NCSE and she was loaded on Keppra. Pt's MS improved. MRI showed changes consistent with PRES. Pt was transferred to floor: . 1. Acute mental status change - LP neg for infection. EEG did show seizure activity, therefore loaded on keppra. Recent MRI shows changes of Posterior Reversible Leukoencephalopathy (PRES). Per Neuro, pt will need repeat MRI in 8 weeks and outpt FU w/ Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 724] at the same time. Of note, per pt's husband and notes, even prior to admission for pancreatitis, pt did have some issues with short term memory and word finding. On the day of discharge pt was alert and oriented X3 and not showing signs of obvious confusion. Given the HTN may have been the underlying etiology behind PRES, pt started on Norvasc and Metoprolol and BP under reasonable range after that. Neurology also wanted Keppra continued. 2. Pancreatic pseudocyst w/ necrosis - CT guided aspirate shows no growth so far. Per GI, pt will be given total 10 d course of Levaquin/Flagyl. Also, [Name (NI) 653], Resident on Surgery, and given that Cx is sterile, they do not recommend further interventions for the pseudocyst. 4. Diarrhea - Stool C&S, campy, O&P, and Cdiff X 3 NGTD. [Month (only) 116] be related to pancreatitis. Is on pancreatic enzyme replacement. Since infectious workup was neg, and pt was afebrile w nl WBC, pt was started on imodium and improvement in diarrhea was noted. 5. Anemia - Pt had stable anemia noted and had no active signs of bleeding. Pt's stool guaiac was neg X1. Pt has had a colonoscopy in [2135] which was neg. 6. Hx depression - Initially pts psych meds were held as diagnosis was unclear and given fever, seretonin syndrome was on differential but these were later restarted. 7. Renal insufficiency - Before admission in [Month (only) ] cr 0.8-0.9. Cr worsened initially during ICU stay likely [12-21] hypotension and improved and stabilized around 1.1-1.2 8. Abnormal thyroid function - Pt had high tSH (19) and low ft2 (0.73). In the setting of recent criticall illness, this likely represents sick euthyroid and therefore, will not start synthroid. Will need recheck in a few weeks by PCP. [Name10 (NameIs) ] was sent home w/ home services and follow up appt w/ PCP, [Name10 (NameIs) ] and Neuro Medications on Admission: -Acetaminophen 1000 mg Capsule Sig: [11-20] Capsules PO every [2-23] hours as needed for pain. -Heparin 5000 SQ TID -Quetiapine 50 mg Tablet PO at bedtime -Oxycodone 5 mg Tablet PO Q4H prn for pain. -Folic Acid 1 mg Tablet PO DAILY -Thiamine HCl 100 mg PO DAILY -Loperamide 2 mg PO QID prn for diarrhea. -Fentanyl 25 mcg/hr Patch Q72 hr -Aspirin 81 mg PO once a day -Omeprazole 20 mg po daily -Venlafaxine 75 mg PO daily -Amlodipine 7.5mg po qhs -psyllium powder 3.7gm [Hospital1 ] prn Discharge Medications: 1. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: [11-20] Caps PO TID W/MEALS (3 TIMES A DAY WITH MEALS): This medication is to help with diarrhea, which pt with pancreatitis can have. Disp:120 Cap(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): This is for history of Acid Reflux. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): For blood pressure. Disp:60 Tablet(s) Refills:2 4. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for loose stools. Disp:60 Capsule(s) Refills:0 5. Psyllium Packet Sig: One (1) Packet PO TID (3 times a day) as needed: for loose stools. Disp:30 Packet(s) Refills:0 6. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): For Blood Pressure. Disp:60 Tablet(s) Refills:2 7. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:60 Tablet(s) Refills:2 9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed. Disp:15 Tablet(s) Refills:0 10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Antibiotic. finish course. Disp:9 Tablet(s) Refills:0 11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): Antibiotic. Finish course. Disp:3 Tablet(s) Refills:0 12. Levetiracetam 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): For Seizures. Disp:120 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: RPLS. Reversible Posterior Leukoencephalopathy Syndrome Pancreatic pseudocyst Alcohol abuse Hemachromatosis hx of PUD Discharge Condition: Good Discharge Instructions: You were admitted to the hospital with mental status change. You were admitted to the ICU and briefly needed to be put on mechanical ventilation. You were found to have findings on MRI consistent with RPLS, reversible posterior leukoencephalopathy syndrome, which can sometimes be associated with high blood pressure. the EEG also revealed that you were having seizures, so you were started on an anti-epileptic. Neurology wants the MRI to be repeated in ~8 weeks and would like to see you after the MRI. These appointments have been made. You are doing much better from mental status point but should there be any changes, please return to ED You were found to have a pseudocyst around your pancreas. This is a complication from your recent attack of pancreatitis. This was aspirated and it did not show any infection. Gasteroenterology and Surgery were consulted and they recommended 10d antibiotic course but no interventions. You have been made appointment with your GI doctor to follow up on this. You also developed some diarrhea in the hospital but workup did not show any signs of infection. Your diarrhea appears to be slowing down, you may take imodium to help but if your diarrhea worsens or you notice blood in stool or abdominal pain or fevers, please return to ED We checked thyroid function in you. It was mildly abnormal but likely does not represent true thyroid disease. Please have your PCP recheck them in [4-27] weeks. Followup Instructions: Please follow up w/ your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 2472] on Tuesday [2140-6-9]:45am at [Hospital3 ]. Please also follow up w/ appts below Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6970], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2138-6-24] 1:00 Provider: [Name10 (NameIs) 706] MRI Phone:[Telephone/Fax (1) 327] Date/Time:[2138-7-24] 10:35 Provider: [Name10 (NameIs) 640] [Name11 (NameIs) 747] [Name12 (NameIs) ], M.D. Phone:[Telephone/Fax (1) 1844] Date/Time:[2138-7-24] 1:00 ICD9 Codes: 2859, 311, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8876 }	Medical Text: Admission Date: [2202-9-1] Discharge Date: [2202-9-15] Date of Birth: [2121-5-26] Sex: F Service: MEDICINE Allergies: Codeine / Ace Inhibitors Attending:[First Name3 (LF) 5810] Chief Complaint: Unresponsive/weakness Major Surgical or Invasive Procedure: GJ tube insertion History of Present Illness: This is an 81 year old female with past medical history notable for right sided MCA stroke with residual left hemiparesis, COPD, Atrial flutter, and partial gastrectomy for gastric cancer who presented to the ED today with altered mental status as well as weakness this morning. The patient's daughter reports she had been in her normal state of health two days ago but yesterday seemed more confused and was coughing with an increased O2 requirement. At that time the patient's daughter spoke to the patient's PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 8499], who recommended presentation to the ED for evaluation, the patient refused this however and thus stayed at home. This morning the patient was found in bed unresponsive and not speaking to her daughter. extremely altered and not responding in her normal way to her daughter. In fact she was barely responding at all and was unable to stand. The patient was brought to the the ED where she was obtunded with nonmoving left arm and hypertonic left leg. Initial vitals were T 97.9, BP 138/83, P 69, RR 24, 99% on NRB (dropping to 99% on 6L by NC). Neurology consulted and was concerned this could be a new ischemic stroke but the patient also had findings consistent for pneumonia and some concerning ECG changes with elevated troponins. Given multiple issues this was considered possible CVA versus return of previous deficits in the context of other acute illness. Neuro recommended no acute management, case was briefly discussed with cards, who recommended aspirin, and the patient received levofloxacin and cefepime as well as nebs. She was admitted to floor. . ROS: Unobtainable as patient is unresponsive. Past Medical History: -History of right sided MCA ischemic stroke (residual mild left hemiparesis) -Severe aortic stenosis: TTE [2-1] showed severe AS and diastolic heart failure. -Gastric adenocarcinoma s/p partial gastrectomy in [2202-2-2] -Hypertension. -Hyperlipidemia. -COPD (on 2L supplementary O2 by nasal cannula PRN) -Borderline glucose intolerance -Osteoporosis. -Depression. -History of alcohol abuse -History of pyloric stenosis. Social History: She smoked 1ppd for 50 years. Has a history of alcohol abuse but none in five years per previous notes. Lives with her daughter and ambulates with a cane since her stroke. Family History: Parents died in their 70s of unknown causes. Physical Exam: Vitals: T: 97.5, HR: 85, BP: 118/64, RR: 15, O2 sat: 98% on 6L General Appearance: Thin, cachectic, African American female in mild respiratory distress Eyes / Conjunctiva: eyes tightly closed and difficult to open, couldn't test pupils Head, Ears, Nose, Throat: Normocephalic Lymphatic: Cervical WNL Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), systolic murmur throughout the precordium Peripheral Vascular: (Right radial pulse: Diminished), (Left radial pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse: Diminished) Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ), (Breath Sounds: Crackles : , Wheezes : occasional, Diminished: ), pursed lip breathing Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Musculoskeletal: Muscle wasting Skin: Cool Neurologic: Responds to: Verbal stimuli, Oriented (to): person, ? place, Movement: Purposeful, Tone: Decreased, decreased tone in LUE, increased tone in left lower extremity, which is internally rotated and plantar flexed Pertinent Results: Admission laboratories: [2202-9-1] 11:03AM BLOOD WBC-9.2 RBC-4.33 Hgb-10.4* Hct-33.7* MCV-78* MCH-23.9* MCHC-30.8* RDW-18.9* Plt Ct-327 [2202-9-1] 11:03AM BLOOD Neuts-96* Bands-0 Lymphs-1* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1* [2202-9-1] 11:03AM BLOOD PT-14.5* PTT-32.6 INR(PT)-1.3* [2202-9-1] 11:03AM BLOOD ALT-16 AST-48* CK(CPK)-92 AlkPhos-151* TotBili-0.7 [2202-9-1] 11:03AM BLOOD Glucose-141* UreaN-23* Creat-0.9 Na-139 K-2.9* Cl-91* HCO3-32 AnGap-19 [2202-9-1] 11:03AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.1 [2202-9-4] 07:53AM BLOOD calTIBC-238* VitB12-1072* Folate-8.6 Ferritn-29 TRF-183* Cardiac enzymes: [2202-9-1] 11:03AM BLOOD CK-MB-NotDone cTropnT-0.47* [2202-9-1] 07:20PM BLOOD CK-MB-NotDone cTropnT-0.50* [2202-9-2] 03:28AM BLOOD CK-MB-NotDone cTropnT-0.50* Imaging: EEG [8-3]: Abnormal portable EEG due primarily to the disorganization and slowing of the background. This indicates a widespread encephalopathy. Metabolic disturbances, infection, and medications are among the most common causes. There were no prominent focal abnormalities, but encephalopathies may obscure focal findings. There were frequent sharp waves, usually symmetric, indicating areas of cortical hypersynchrony. This does not necessarily indicate the presence of seizures at other times. . ECHO [8-3] - Overall left ventricular systolic function is low normal (LVEF 50%). There is no ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with severe global free wall hypokinesis. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen (which may be underestimated). The left ventricular inflow pattern suggests impaired relaxation. . CXR [8-3]: There is a small right pleural effusion with adjacent atelectasis is very similar. Allowing for rotation, the appearance of the lung parenchyma is unchanged, with degree of emphysema. The cardiac silhouette is borderline in size. There is no pulmonary edema or pneumothorax. . MRI Head/Brain/Neck [8-3]: 1. Multiple small acute infarcts, diffusely scattered in the cerebral and cerebellar hemispheres, on both sides, in the ACA, MCA and the PCA territories, likely related to an embolic source. To correlate clinically. . 2. Patent major intracranial arteries without focal flow-limiting stenosis, occlusion or aneurysm more than 3 mm within the resolution of MR angiogram with bilateral fetal PCA variant and hypoplastic A1 segment of the right anterior cerebral artery. . 3. Suboptimal quality of the contrast-enhanced MR angiogram of the neck, which makes assessment inaccurate. . ekg: sinus tachycardia at rate of 117, normal axis, normal intervals, pseudonormalization of t waves in V2 and V3. Brief Hospital Course: Summary: 81 year old female with multiple medical problems including diastolic heart failure, atrial flutter, severe AS, COPD, and a previous right sided MCA stroke presenting with altered mental status and left sided deficits. #Obtundation/Confusion: There was concern that the patient had AMS from seizures due to her recent embolic strokes. Neurology evaluated the patient and did an EEG which showed encephalopathy likely due to metabolic causes. Her underlying urinary tract infection and hypernatremia were treated and the patient slowly became more responsive, alert and oriented. On discharge, the patient was awake for the majority of the day and answered questions appropriately. #Multiple embolic strokes: The patient has a history of a left sided middle cerebral artery stroke and presents with increased weakness bilaterally and altered mental status. Her new strokes likely come from a cardiac source since they are bilateral. The patient has a history of paroxysmal atrial flutter, so her embolisms are a likely resultant from this pathology. Her strength is globally decreased (L>R) and she had sensory deficits on L>R. She has clonus for the Achilles tendon on the left, but not the right. The patient was started on aspirin and lovenox to help prvent further strokes. #Diastolic heart function: The patient has a history of diastolic dysfunction and had episodes of flash pulmonary edema for unclear reasons. An Echo showed worsening aortic insufficiency, RV hypokinesis a worsening of LVEF (50%). The patient's blood pressure was well controlled with a systolic blood pressure goal of less tahn 130. She should continue to take Metoprolol and losartan for BP control. Severe aortic stenosis: The patient has a history of severe aortic stenosis with a value area of 0.8-1.0. The patient is a poor surgical candidate, so she will be medically managed. #Paroxysmal atrial flutter: The patient is currently in sinus rhythm, though was noted to have periods of tachycardia. Her paroxysmal atrial flutter likely explains her embolic strokes. She was started on Lovenox for anticoagulation and should continue metoprolol for rate control. #Nutrition: The patient failed multiple speech and swallow exams while in the ICU. On the floors, the patient required a [Last Name (un) ]-gastric tube for medicatons and tubefeedings. With clearing of her mental status, the patient was able to tolerate thick liquids, though had low PO intake. The daugther wished to have a feeding tube inserted, so a GJ tube was inserted on [9-15]. #Hypertension: The patient had well controlled blood pressure with most SBP<140 during this hospitalization. Her BP medications on discharge include metoprolol and losartan. She was on lisinopril, however, did not tolerate it due to cough. She had one episode of hypotension, which responeded well to a gentle normal saline bolus of 250 cc. #Non ST elevation myocardial infarction: The patient was noted to have troponin leakage to ~0.87 in the absence of chest pain and EKG changes. An echocardiogram showed increased aortic regurgitation, increased hypokinesis in the right ventricle and a worse left ventricular ejection fraction (50%). Cardiology was consulted and recommended medical management with aspirin, metoprolol, atorvastatin, and losartan. #Community Acquired Bacterial Pneumonia: On presentation, the patient's daughter reported increased cough and respiratory distress at home and a new infiltrate appeared on CXR. She was given a 5 day course of Levaquin and azithromycin and her symptoms improved. She no longer had a productive cough or oxygen requirement. #Leukocytosis: The patient had a persistent leukocytosis since admission. On discharge, she had no signs of any infection, though still had a leukocytosis to 11.8. The leukocytosis could be explained by her cerebral infarctions, though it remains unclear. #COPD exacerbation: The patient presented with respiratory distress. She was diagnosed with pneumonia, but also had a possible component of COPD exacerbation. She was started on IV steroids and eventually switched to a PO taper. She finished her steroid taper by the end of her hospitalization. She was taking ipratropium as needed and did not require supplemental oxygen on discharge. #Hypernatremia: The patient developed hypernatremia during her stay in the ICU. The patient was not intaking many fluids, so it was likely hypernatremia secondary to low PO intake. She was infused with D5W and her hypernatremia returned to [Location 213]. It might have been contributing her to altered mental status state. # Palliative Care: The palliative care service was consulted as an inpatient and spoke at length with her daughter [Name (NI) ] and evaluated the patient. Ultimately she decided that she would like her daughter to go to a rehab and that she would like to pursue palliative care in that setting. The patient was DNR/DNI while an inpatient. Medications on Admission: ALBUTEROL 2 puffs po three times a day PRN BUPROPION HCL 100 mg PO daily FLUOXETINE 40 mg PO daily HYDROCHLOROTHIAZIDE 25 mg PO daily IPRATROPIUM BROMIDE MDI 4 /daily LISINOPRIL 5 mg daily OMEPRAZOLE 20 mg PO daily OXYCODONE-ACETAMINOPHEN 5 mg-325 mg 4/day PRN ACETAMINOPHEN 325-650 mg TID PRN DOCUSATE SODIUM 100 mg PO BID MULTIVITAMIN daily Discharge Medications: 1. Fluoxetine 20 mg Capsule [Name (NI) ]: One (1) Capsule PO DAILY (Daily). 2. Multivitamin Tablet [Name (NI) ]: One (1) Tablet PO DAILY (Daily). 3. Ipratropium Bromide 0.02 % Solution [Name (NI) ]: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 4. Enoxaparin 40 mg/0.4 mL Syringe [Name (NI) ]: Forty (40) mg Subcutaneous [Hospital1 ] (2 times a day). 5. Atorvastatin 80 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 6. Aspirin 325 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day): Hold for HR<60 or SBP<110. 8. Nicotine 14 mg/24 hr Patch 24 hr [Hospital1 ]: One (1) Patch 24 hr Transdermal DAILY (Daily). 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 11. Losartan 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 12. Morphine 10 mg/mL Solution [Last Name (STitle) ]: 2-4 mg Intravenous Q2H (every 2 hours) as needed for dyspnea: Hold for sedation or RR<12. Discharge Disposition: Extended Care Facility: [Hospital6 1643] Center Discharge Diagnosis: Primary -multiple embolic strokes -altered mental status -Non ST elevation myocardial infarction -severe aortic stenosis . Secondary -hypertension Discharge Condition: hemodynamically stable. patient on room air. unable to ambulate without assistance. Discharge Instructions: You came to the hospital because you were confused. You were found to have multiple strokes in your brain. Your blood was thinned to prevent further strokes. You also had a heart attack. You went to the ICU because you had difficulty breathing due to water in your lungs. You became better and went to the general medicine floors. A feeding tube was placed to help increase your intake of food. . Your medications were changed. You should take them as directed. . You should come back to the hospital if you have difficulty breathing, chest pain, or develop increased confusion. Followup Instructions: Provider [Name9 (PRE) ] [Last Name (NamePattern4) 6559], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2203-1-21] 10:00 ICD9 Codes: 5990, 2760, 4241, 4280, 4019, 2724, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8877 }	Medical Text: Admission Date: [2186-8-6] Discharge Date: [2186-8-11] Service: MEDICINE Allergies: Naprosyn / Vicodin / Ciprofloxacin Attending:[First Name3 (LF) 348] Chief Complaint: seizure Major Surgical or Invasive Procedure: None History of Present Illness: 84F history of multiple strokes, associated seizure disorder, presumed multi-infarct dementia and expressive aphasia who has been on cipro/flagyl x 1 week for diverticulitis presented from her NH after being found down. She was initially brought to [Location (un) 21541] Hospital earlier in the day after being found slumped in a chair at approximately 11am. She was initially disoriented, able to deny pain to EMS, however was then observed to have seizure-like activity with tonic-clonic jerking with post-ictal deceribrate posturing. . At [Hospital ] hospital her VS were 187/90 97 10 97.6 99% 10L, She underwent NCHCT which was unremarkable. She was transfered to [Hospital1 18] per family request. . Per daughter, pt's seizure in [2186-1-19] presented with aspects of partial complex seizure: she was found to be disoriented and staring at the ceiling at her nursing home, and was unarousable in ED and had observed rapid eye movement. Neurologist (Dr. [Last Name (STitle) ] decreased Keppra in [Month (only) 547] from 1000mg [Hospital1 ] to 500mg [Hospital1 ] as he thought that speech slurring/slowness may be due to Keppra. She had a prolonged post-ictal phase, with convalescence lasting 1 month. . At baseline, pt is AO x 3, is able to remember events from the past few days, independent of ADLs, lives in private apt in nursing home for 24h supervision as she has difficulty with executive function, remembering meals and medications and IADLs. Ambulates independently with no residual motor impairments from prior strokes, does have a mild expressive aphasia. She has a history of "stress incontinence" and has worn a diaper on and off. Recent family meeting with neurologist about bringing her home affirmed that they did not feel comfortable leaving her without 24-hour supervision. Past Medical History: - paroxysmal afib on coumadin - CKD - Nephrolithiasis - OA - HTN - HL - depression - C7 compression fracture - Schmorl's node - transient global amnesia - memory impairments - macular degeneration - s/p BSO - bilateral parieto-occipital infarcts and smaller bilateral frontal infarcts - syncope in [12-26] - recent dx of diverticulitis [7-27] w/ treatment wih cipro/flagyl. - seizure d/o (attributed to prior CVAs) Social History: Lives in [Location ], [Location (un) 111504] Estates. Daughter [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 111505] is HCP, [Telephone/Fax (1) 111506]. Former tobacco abuse. No ETOH or illicits. Independent of ADLs, requires assistance with IADL's, has impaired executive functioning. Family History: mother with CVA Physical Exam: Vitals: T:98.6 BP:127/55 P:88 O2:95% RA General: Sleeping, NAD. Arousable to voice. HEENT: Sclera anicteric, MMM, oropharynx clear. Neck: supple Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi. Slight decrease in breath sounds R anterior/lateral field. 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 Neuro: Opens eyes to command and noxious stimuli, pleasant, responds to commands regarding exam (squeeze hands, deep breaths, wiggle toes etc.), able to feed herself, inattentive at times Pertinent Results: Labs on admission [2186-8-6]: WBC-14.6# RBC-3.80 Hgb-11.6* Hct-36.0 MCV-95 MCH-30.6 MCHC-32.3 RDW-13.3 Plt Ct-339 Glucose-189* UreaN-16 Creat-0.9 Na-140 K-4.5 Cl-103 HCO3-28 . Labs on discharge [2186-8-11]: WBC-11.0 RBC-3.60* Hgb-10.9* Hct-33.2* MCV-92 MCH-30.2 MCHC-32.7 RDW-13.6 Plt Ct-352 PT-20.6* PTT-34.2 INR(PT)-1.9* Glucose-106* UreaN-11 Creat-0.8 Na-139 K-4.3 Cl-102 HCO3-27 AnGap-14 . Anticoagulation: [2186-8-6] PT-30.2* PTT-43.5* INR(PT)-3.0* [2186-8-11] PT-20.6* PTT-34.2 INR(PT)-1.9* . Micro: [2186-8-6]: BCx - one bottle grew GPC in clusters, likely contamination [2186-8-7]: MRSA negative . NCHCT [2186-8-6] (from OSH): IMPRESSION: No intracranial hemorrhage. Unchanged right and left parietal encephalomalacia. . NCHCT [2186-8-6] ([Hospital1 18]): There is no intracranial hemorrhage, mass effect, shift of normally midline structures or hydrocephalus. The ventricles are stable in size and configuration. Encephalomalacia of the right and left parietal lobes is unchanged from at least one year prior. No fracture is identified. The visualized paranasal sinuses and mastoid air cells are well aerated. . [2186-8-6] CXR: New bibasilar opacities worrisome for aspiration or pneumonia. . EKG: NSR at 85. Normal axis and intervals. possible <1mm STD in V5-V6, aside from that, no change from prior. . EEG [2186-8-7] IMPRESSION: This is an abnormal portable EEG due to runs of mixed theta delta activity in the left temporal region. There were no spikes or frank discharges. The above findings likely reflects a markedly increased focal irritabilty. No electrographic seizures were noted. Brief Hospital Course: [Hospital1 18] ED- VS: T100.4 P72 BP 150/76 R24 O2 94% NRB. She was noted to be somnolent, but arousable to noxious stimuli and moving her extremities spontaneously but not following commands. CXR was concerning for aspiration and pt received CTX, azithro and flagyl. Neurology felt pt had a seizure, possibly caused by cipro vs infection, and keppra was increased. She was given ASA for an elevated troponin in the absence of ECG changes. Pt was transferred to MICU for hypoxia and mental status changes. Upon improvement, pt was transferred to floor for further care. . # Seizure/Altered Mental Status: Patient was witnessed to have a tonic clonic seizure episode with subsequent obtundation at OSH, but had no seizures since her admission to [Hospital1 18]. Per neurology, keppra was increased to 1000mg [Hospital1 ]. EEG was unremarkable for continued seizure activity but did suggest markedly increased focal irritabilty in left temporal region. Her mental status improved throughout her hospital stay (AOx3 at discharge), but per family, she had not returned to her baseline cognition before her discharge. . # Pneumonia: It was unclear whether PNA preceeded or followed seizure and pt was initially for both aspiration and community acquired pneumonia. Changed to CAP treatment with Azithro/CTX. Patient remained afebrile with SaO2 of 95-97% RA on floor. . # Elevated tropnin: Likely due to demand ischemia or strain pattern in setting of seizure. Troponin trended downwards throughout hospitalization. Patient with normal CKs, no prior h/o CAD, was ruled out for MI with serial enzymes. EKG unchanged from prior. Pt was discharged on ASA 81 mg. . # Diverticulitis - dx on OSH CT 1 week ago, symptoms resolved per daughter. Abd exam benign. Cipro was discontinued given seizure and diverticulitis was treated with flagyl/CTX which pt was receiving for PNA. . #Anticoagulation - Pt on coumadin for atrial fibrillation. Her INR and her coumadin was adjusted accordingly. INR at discharge was 1.9. Pt was instructed to take coumadin 4mg PO on night of discharge and with INR monitoring at rehab with goal 2.0-3.0. . # Code: Confimed FULL . # Communication: Daughter/HCP [Name (NI) ] [Name (NI) 111505] . #Dispo: [Hospital3 ] Rehab Medications on Admission: Lipitor 10 mg at bedtime metoprolol 50 mg [Hospital1 ] Keppra 500 mg [Hospital1 ] Senna Colace Warfarin dose as determined by [Hospital 197] Clinic, most recently 2mg T, Th; 4 mg other nights. Alendronate 70mg Q week Tylenol Flagyl 500mg PO Q8 started [7-30] Ciprofloxacin 250mg [Hospital1 ] started [7-30] Flonase nasal spray daily . Allergies: Naprosyn, vicodin Discharge Medications: 1. Outpatient Lab Work Please monitor INR with goal 2.0-3.0. Warfarin dosage should be adjusted accordingly. Most recent home regimen: 2mg T, Th; 4 mg other nights 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 4. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID: PRN as needed for Constipation. Disp:30 Capsule(s) Refills:2 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID: PRN as needed for constipation. Disp:30 Tablet(s) Refills:2 9. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:2 Tablet(s) Refills:0 10. Coumadin 2 mg Tablet Sig: 1-2 Tablets PO once a day: Please check INR and dose coumadin accordingly. INR Goal [2-21]. Tablet(s) 11. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 12. Flonase 50 mcg/Actuation Spray, Suspension Sig: 1-2 puffs Nasal qday: PRN as needed for allergy symptoms. Discharge Disposition: Extended Care Facility: Cape Code Nursing & Rehabilitation Center - [Location (un) 10072] Discharge Diagnosis: Primary: Pneumonia, seizure disorder . Secondary: presumed multi-infarct dementia, paroxysmal atrial fibrillation, hypertension Discharge Condition: Medically stable. No fever or seizures since admission. Breathing well on room air. Discharge Instructions: You came into the hospital because you were found after a fall at your nursing home. After that, you were observed to have a seizure at an outside hospital and were having trouble breathing. We diagnosed you with pneumonia and started you on antibiotics. We also consulted neurology who believe that your seizure may have been brought on by the ciprofloxacin you had taken for your diverticulitis or due to the pneumonia. You seemed confused, but continued to improve on antibiotics and a higher dose of keppra. . We have increased your keppra dosage to 1000mg twice a day; please continue this dose until you discuss this medication with your neurologist, Dr. [Last Name (STitle) ]. We have also given you a course of antibiotics for your pneumonia. Please continue to take all your other medications as they are prescribed to you. . Please call your doctor or return to the hospital if you experience any of the following: shortness of breath, fever, chest pain/palpitations, seizure, passing out, worsening confusion, worsening headache, or any other symptoms for which you would seek medical attention. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 640] [Last Name (NamePattern4) 3445], MD (Neurology) Phone:[Telephone/Fax (1) 44] Date/Time: [2186-10-4] at 1:30pm . Please call your Primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Name (STitle) ] at [Telephone/Fax (1) 14888] to set up an appointment for hospital and rehab follow-up. ICD9 Codes: 486, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8878 }	Medical Text: Admission Date: [2136-7-31] Discharge Date: Date of Birth: [2069-7-20] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient was admitted on [2136-7-31] with a chief complaint of confusion. The patient is a 66 year old female with a history of Lithium toxicity who presented with increasing confusion, lethargy and dehydration for the last five days. The patient claims that on the day of admission she fell out of bed with increased confusion. The patient had an episode of increased Lithium toxicity in [2135-7-12] with similar complaints. PAST MEDICAL HISTORY: Past medical history includes depression, hypothyroidism and chronic renal insufficiency. MEDICATIONS ON ADMISSION: 1. Prozac 2. Lithium ALLERGIES: No known drug allergies. SOCIAL HISTORY: No alcohol, no drug use, had a 30 pack year smoking and had no children. PHYSICAL EXAMINATION: Physical examination on admission included a temperature of 102, heartrate 45 ,blood pressure 127/55. General: The patient was confused, unaware and unalert. Head, eyes, ears, nose and throat: Pupils are equal, round, and reactive to light and accommodation, extraocular movements intact. Extremely dry mucous membranes. Neck was supple, no lymphadenopathy was felt. Chest was clear to auscultation bilaterally. Cardiovascular: Bradycardia. No murmurs, rubs or gallops. Gastrointestinal, soft, nontender, nondistended with positive bowel sounds. Rectal, stool was guaiac negative. Extremities, no cyanosis, clubbing or edema. Skin had no evidence of any rashes. LABORATORY DATA: Electrocardiogram on admission had bradycardia with 46 rate per minute, old right bundle branch block compared with an electrocardiogram of [2136-8-10] which was the same. Labs on admission included a white count of 20.1, hematocrit 40.7, platelets 472,000. 88.9% neutrophils, 0 bands, 7 lymphs, 3 monocytes. Chem-7 was 140/4.9, 96/31, BUN with creatinine of 45/3.0, glucose 146. Urinalysis had a trace protein and otherwise negative. Lithium on admission is level of 1.6, TSH was done and was pending. Chest x-ray was negative. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit for aggressive hydration. Blood cultures were done. The patient also had a head computerized tomography scan and an lumbar puncture performed at that time. The patient had an arterial blood gases done at 7:45 on the day of admission which revealed 7.41, 53, and 63 with lactate of 2.3 and free calcium of 2.08. The night the patient was admitted the patient began developing some electrocardiogram changes including progression of loss of P waves near the right bundle branch block over serial electrocardiograms. The patient down to 30s and Atropine was given. Her heartrate then recovered. The patient then developed severe swelling of her vocal cords. The patient was intubated for airway protection and began aggressive hydration and Lasix diuresis to push calcium down. Central line and arterial lines were placed at that time. The patient had her ionized calcium monitored that went from 2.08 down to 1.65 on [8-1]. In addition the Lithium levels went down to 1.1. TSH came back, it was to 6.3 at that time. Cerebrospinal fluid Gram stain had no polys seen, no organisms. The cultures were pending, otherwise the lumbar puncture was normal. Chest x-ray at that time also with elevated right hemidiaphragm. The patient on [8-2] had an echocardiogram performed which was essentially unchanged from the previous study from [2134]. Left ventricular function was 55%, ascending aorta was mildly dilated. The aortic valve leaflets were mildly thickened, no aortic regurgitation, 1+ tricuspid regurgitation, borderline pulmonary hypertension. Precordium had a fat pad versus small effusion of question. The patient remained somewhat hypotensive in the unit with heartrates in the bradycardiac range of 30s to 50s. The patient was worked up for DIC with a fibrinogen level of 247, D-dimer less than 500, also CKs were negative and troponin I were negative. Urinalysis remained clear. The patient had hypotensive episodes, was febrile and was with infiltrates versus effusion on chest x-ray with chronic renal insufficiency. The patient was then started on antibiotics for what was presumed to be pneumonia. The patient was started on Levofloxacin, Vancomycin and Flagyl for a ten day course of Levofloxacin and seven day course of Vancomycin and a seven day course of Flagyl. Endocrinology was consulted due to the patient's increased hypercalcemia as well as the patient's hypothyroidism. It was felt that the increased calcium was probably due to the Lithium toxicity as well as the hypothyroidism. The patient was continued on the current medication of Synthroid. From an infectious disease standpoint the patient remained febrile and had an lumbar puncture which was negative for any source of infection. The patient had multiple blood cultures which none ever having grown any organisms. The patient also had a bronchoscopy for finding organisms which was negative. No stressor or any evidence of any infection was ever found. The patient remained intubated in the Newborn Intensive Care Unit due to what they thought was pneumonia or sepsis like syndrome and hypertension and decreased respirations. The patient was extubated on [2136-8-15] as the patient's oxygenation and respiratory drive improved. The patient was transferred to the floor on [2136-8-16]. The patient's oxygen saturations were 94% on 2 liters and was stable. The patient was being transferred to the Medicine Service for further evaluation of her psychological issues which she developed while she was in the Intensive Care Unit, monitoring of her calcium and thyroid status and correction of hypernatremia with continuing monitoring of her blood pressure which had been stabilized. The patient is being followed by Psychiatry, Endocrine and Physical therapy at that time. Because she was found to be sating fairly well on 94% on 2 liters by nasal cannula, it was planned to decrease her oxygen as tolerated. Her pneumonia had resolved and no treatment was needed at that time. Her blood pressure was stable and she came to the floor and her previous hypotensive state was attributed to hypothyroidism, but she was now being treated with Synthroid. From a Psychiatry standpoint, we obtained RPR which came back negative, and B12 and Folate were within normal limits. An magnetic resonance imaging scan of her head was obtained which also was negative for any acute events or acute ischemia. On [2136-8-17], it was noted on examination that she had some proximal weakness of her right upper extremity with 2/5 strength in the right upper extremity, abduction. This was later attributed to brachyopathy secondary to just having her longstanding stay in the Intensive Care Unit. In subsequent days it appeared to resolved with increasing strength. Given her persistent low level hypernatremia, we obtained a urine osmolality on [2136-8-16] which revealed a urine osmolality of 176 and a urine sodium of 44. At that time her serum sodium was 149. Because of her relative hypernatremia, her expected urine osmolality should have been slightly higher. Given her long history of Lithium use we attributed her hypernatremia thus to nephrogenic diabetes insipidus secondary to Lithium use. We then started her subsequently on DDAVP. On [2136-8-20] at approximately 7:45 AM the patient had a witnessed tonoclonic generalized seizure which lasted 2 to 3 minutes. Her oxygen saturation decreased and she was placed on 100% nonrebreather after which her oxygen saturation recovered into the mid 90s. The patient never recovered to her pre-seizure mental status following the event. Approximately one hour later she suffered another generalized tonoclonic seizure witnessed by the house officer and nursing staff. The patient did not lose fecal incontinence. The patient had a Foley catheter and the patient was afebrile at the time. She was found to be confused and restless postictally and with only partial recovery of her mental status over the following hours. The patient was loaded with 1000 mg of Phenytoin intravenously. Then there were no further events or seizure activity. Upon neurological consult we discontinued any other Phenytoin treatment and she has not had any recurrence of her seizures. The etiology of her seizures was attempted to be found, however, all cultures were negative. Chest x-ray was negative and given her old cerebrospinal fluid cultures being negative and a negative magnetic resonance imaging scan of her head several days prior to the event there was no clear etiology upon further workup. But, given the fact that she had no recurrence of seizures and her electrolytes were stable at the time, it was concluded that it would be safe to discontinue any antiseizure medications. From [2136-8-20] until the day of discharge the patient was stable. Vital signs were stable and there were was no recurrence of seizure activity. The patient remained clinically stable from [8-20] to [8-23], when the patient was going to be discharged. Her temperatures remained afebrile as well as her blood pressures remained relatively well at 130/80. Physical examination had no change from previously when the patient was taken out of the unit. Urine cultures remained negative. Chest x-rays remained negative. Urine osmolality and urine sodium continued to show the patient had some evidence of some nephrogenic diabetes insipidus. The patient was stable upon discharge with no further electrolyte abnormalities other than her mild hypothyroidism as well as her hypernatremia. DISCHARGE MEDICATIONS: 1. Synthroid 150 mcg by mouth once a day 2. Colace 100 mg by mouth twice a day 3. Multivitamin one tablet by mouth once a day 4. Nystatin Swish and Swallow 5 cc four times a day 5. Nystatin Powder apply to affected areas twice a day 6. DDAVP 10 mcg per spray, one spray to one nostril twice a day 7. Albuterol/Atrovent metered dose inhaler, 2 puffs inhaled every 4 hours as needed for shortness of breath 8. Boost shakes by mouth three times a day DISCHARGE DIAGNOSIS: 1. Sepsis-like syndrome which needed some intubation 2. Status post hypotension 3. Respiratory distress 4. Hypercalcemia which eventually was treated successfully which resulted in hypocalcemia which was then treated and calcium levels eucalcemic on discharge. 5. Nephrogenic diabetes insipidus, probably secondary to her Lithium toxicity. The patient will continue on DDAVP for increased serum sodium 6. Depression/bipolar disorder, the patient will be followed by Psychiatry as an outpatient as well as given psyche medications 7. Chronic renal insufficiency 8. New onset seizures which were initially treated with intravenous-loaded Dilantin, however, did not occur after the patient was stopped on that medication 9. Hypothyroidism which was treated with Synthroid FOLLOW UP CARE: The patient will follow up with Dr. [First Name (STitle) ] for further evaluation and workup. The patient was stable upon discharge with marked improvement from her status on the Medical Intensive Care Unit. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 16316] Dictated By:[Last Name (NamePattern1) 6234] MEDQUIST36 D: [2136-8-23] 17:01 T: [2136-8-23] 18:43 JOB#: [Job Number ] ICD9 Codes: 486, 0389, 4589, 2765
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8879 }	Medical Text: Admission Date: [2152-4-29] Discharge Date: [2152-5-6] Date of Birth: [2072-7-6] Sex: F Service: MEDICINE Allergies: metoprolol Attending:[First Name3 (LF) 1257] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: BiPap History of Present Illness: 79 yo F with Afib on Coumadin, 3+ mitral regurgitation, and recent ICU admission for pneumonia, presenting with worsening shortness of breath during past 2 weeks. . In the ED, initial vital signs were T 97.3 BP 133/97 HR 110 RR 22 Sat 80%/RA. She was initially put on a non-rebreather, with ABG showing 7.32/57/92. Labs were otherwise notable for WBC 14.3, INR 4.1, BNP [Numeric Identifier 17406]. CXR showed bilateral pleural effusion, diffuse bilateral ground glass opacities, concerning for multifocal pneumonia. She was given cefepime 2 gm IV, vancomycin 1 gram IV, and levaquin 750 mg IV. She was put on Bipap, with apparent improvement in her dyspnea. Vitals on transfer to floor, HR 94 BP 116/80 RR 25 Sat 97%/CPAP. . On arrival to the floor, the patient denies any complaints other than shortness of breath. She said that her breathing was improved on Bipap. Review of systems was otherwise negative in detail. Past Medical History: Atrial fibrillation on Coumadin Osteoporosis Mitral valve prolapse with 3+ MR. Moderate secondary pulmonary hypertension. S/P TAH for leiomyoma [2108]. Cyst on back removed in [2103]. S/P tonsillectomy. Episode of shingles. Breast fibroadenoma left, [2137]. Social History: She is a retired Professor of writing at [State 17405], [Location (un) 86]. She does not smoke. Moderate alcohol consumption, no more than two glasses of wine. Lives with her husband, recently both came back from [Name (NI) ] where he was performing research. Patient and husband developed cold after meeting someone in [State ] who was ill. 20 pack years smoking history. Quit smoking 40 years ago. Family History: Father died of congestive heart failure in his 70's. Mother died of congestive heart failure at age 88. She is married with three stepchildren and four grandchildren. Physical Exam: General: Sleepy but arousable. Tolerating Bipap. Answers yes/no questions appropriately. HEENT: Anicteric sclerae. Moist mucous membranes. Neck: Supple. JVD present. Resp: Diffusely rhonchorous. Decreased breath sounds at bases. CV: RRR. Normal s1, s2. Difficult to appreicate presence or absense of murmur over breath sounds. Abd: +BS. Soft. NT/ND. Ext: Cool. 1+ bilateral lower extremity edema. Neuro: History limited by Bipap mask, but answers yes/no questions appopriately. PERRL. Moves all extremities. Pertinent Results: [2152-4-29] 10:30PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.019 [2152-4-29] 10:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-TR [2152-4-29] 10:30PM URINE RBC-1 WBC-13* BACTERIA-FEW YEAST-RARE EPI-0 [2152-4-29] 10:30PM URINE HYALINE-1* [2152-4-29] 10:30PM URINE MUCOUS-RARE [2152-4-29] 10:25PM TYPE-ART O2-100 O2 FLOW-15 PO2-299* PCO2-62* PH-7.28* TOTAL CO2-30 BASE XS-1 AADO2-368 REQ O2-64 INTUBATED-NOT INTUBA COMMENTS-SIMPLE FAC [2152-4-29] 10:25PM LACTATE-1.1 [2152-4-29] 09:59PM LACTATE-2.4* K+-4.2 [2152-4-29] 09:45PM GLUCOSE-116* UREA N-39* CREAT-0.9 SODIUM-141 POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-28 ANION GAP-15 [2152-4-29] 09:45PM proBNP-[Numeric Identifier 17406]* [2152-4-29] 09:45PM CALCIUM-8.8 PHOSPHATE-4.0 MAGNESIUM-2.3 [2152-4-29] 09:45PM DIGOXIN-1.2 [2152-4-29] 09:45PM WBC-14.3* RBC-4.22 HGB-12.9 HCT-40.7 MCV-96 MCH-30.6 MCHC-31.7 RDW-14.9 [2152-4-29] 09:45PM NEUTS-88.8* LYMPHS-8.1* MONOS-2.3 EOS-0.3 BASOS-0.6 [2152-4-29] 09:45PM PLT COUNT-790* [2152-4-29] 09:45PM PT-40.1* PTT-31.5 INR(PT)-4.1* . CXR (portable AP) [2152-4-29]: bilateral pleural effusion, diffuse bilateral ground glass opacities, concerning for multifocal pneumonia . EKG: Atrial fibrillation with ventricular rate 104. Partial right bundle branch block. ST-depression in I, V4-V6. TWI in II, III, aVF, V3. Compared with prior study [2152-4-26], ST-depression in I and TWI in II, III, aVF is new. Brief Hospital Course: 79 year old woman who presented with pulmonary edema from atrial fibrillation, acute diastolic heart failure, and prolapsed and regurgitant mitral valve. She initially presented with progressive shortness of breath with chest x-ray read as "multifocal pneumonia". She had leukocytosis, elevated lactate, and tachycardia in the setting of "suspected recurrent aspiration pneumonia". She tolerated BiPAP and did not require intubation. She was recently admitted to the ICU with pneumonia; The MICU staff treated her again with vancomycin, cefepime, levofloxacin for suspected aspiration pneumonia. However, I believe she had pulmonary edema and she appeared fluid overloaded with jugular venous distension and peripheral edema with very suggestive CXR of edema. Her atrial fibrillation was rate controlled with increased doses of Diltiazem ( 90 MG Q 6 hours then 360 of Cardiazem CD; she could not swallow the latter and therefore she was discharged on the short acting). Her Coumadin was held for supra therapeutic INR and the rate was controlled with digoxin and Diltiazem. She was then treated with Coumadin and Heparin bridge as well as IV Lasix and her antibiotics were stopped. She was found to have severe esophageal narrowings by EGD (upper narrowing and GE narrowing with dilated esophagus between) that made TEE difficult. MICU team ordered TSH/CRP/RF/B12/folate/cortisol and were all normal. They also ordered RUQ ultrasound. She tolerated thin liquids and regular consistency solids without any overt or soft signs of aspiration. She denied any pneumonia prior to these recent 2 episodes. She did not have symptoms consistant possible reflux and aspiration and she was be advanced to thin liquids and regular consistency solids. She did not undergo TEE with cardioversion because of the severe esophageal narrowing. Dr. [Last Name (STitle) ] strongly cautioned against doing a TEE. Under anesthesia, he could not pass a standard 8 mm scope. He had to use an ultra-thin 4.5 mm scope, leave a wire, dilate up with [Last Name (un) 17407] dilators to 12 mm. Only then, he could pass his scope over a wire-guide to do the injections (at the GEJ, 100 Units of Botox was injected successfully in four quadrants into the LES). The upper narrowing was most likely from an osteophyte and the lower from achalasia (!?). She was asked to keep head of bed elevated at 45 degrees at all times to minimize risk of gastroesophageal reflux and aspiration and to avoid eating for 3 hours prior to sleep. In any case she did well and was discharged home after she received adequate diuresis, good rate control, and several days of antibiotics. She will need her valve fixed SOON. Discharge Medications: 1. digoxin 125 mcg Tablet [Last Name (un) ]: One (1) Tablet PO DAILY (Daily). 2. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). Disp:30 Tablet,Rapid Dissolve, DR(s) Refills:2 3. warfarin 2 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO Once Daily at 4 PM. Disp:60 Tablet(s) Refills:2 4. furosemide 20 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). Disp:20 Tablet(s) Refills:2 5. Outpatient Physical Therapy 3 time a week 6. diltiazem HCl 90 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO four times a day. Disp:120 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: pulmonary edema atrial fibrillation acute diastolic heart failure prolapsed and regurgitant mitral valve cardioversion esophageal narrowings that was treated with Botox injections. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted because of pulmonary edema (water in the lungs) from atrial fibrillation (fast and abnormal heart rhythem), diastolic heart failure (weak heart), and prolapsed (floppy) and regurgitant (leaky) mitral valve. You DID NOT HAVE TEE (echo from the mouth) with cardioversion. We also found esophageal narrowings that was treated with Botox injections. Keep head of bed elevated at 45 degrees at all times to minimize risk of gastroesophageal reflux and aspiration Avoid eating for 3 hours prior to sleep. We adjusted several medications. Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [2152-5-15] at 11:00 AM With: [Year (4 digits) ] [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: WEDNESDAY [2152-5-31] at 9:20 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: MEDICAL SPECIALTIES When: WEDNESDAY [2152-7-26] at 2:30 PM With: DR. [First Name8 (NamePattern2) 3688] [Last Name (NamePattern1) ] [Telephone/Fax (1) 612] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage ICD9 Codes: 5070, 4280, 4019, 4168, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8880 }	Medical Text: Admission Date: [2187-12-1] Discharge Date: [2187-12-14] Date of Birth: [2119-3-20] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 695] Chief Complaint: -severe abdominal pain -N/V -diarrhea Major Surgical or Invasive Procedure: Exploratory laparotomy, abdominal washout and drainage of bile leak. Tube Cholangiogram [12-13] History of Present Illness: 68M Klatskin/cholangio CA s/p open cholecystectomy ([11-19]) complicated by Klebsiella bacteremia, VRE/Yeast bile infx, TnI leak/agitation, presents c nausea/vomit and peritonitis. Past Medical History: CAD and silent MI, hypertension, hypercholesterolemia, benign prostatic hypertrophy, erectile dysfunction. Social History: Lives alone, social support reported by patient Family History: Non-Contrib Physical Exam: ill appearing, icteric, jaundiced NAD Reg CTA Distended/diffuse tenderness + BS PTC drains capped Pertinent Results: On Admission: [2187-12-1] 11:35AM WBC-8.5 RBC-4.07# Hgb-13.5# Hct-42.3# MCV-104* MCH-33.3* MCHC-32.0 RDW-15.0 Plt Ct-614# PT-13.4 PTT-25.2 INR(PT)-1.2* Glucose-153* UreaN-7 Creat-1.0 Na-140 K-4.6 Cl-101 HCO3-24 AnGap-20 ALT-115* AST-165* LD(LDH)-418* AlkPhos-314* Amylase-133* TotBili-7.9* DirBili-4.6* IndBili-3.3 Lipase-214* Albumin-3.0* Calcium-8.4 Phos-4.1 Mg-1.4* Nutrition Labs: [2187-12-6] 05:00AM BLOOD Triglyc-229* TIBC-138* Ferritn-418* TRF-106* VitB12-431 Folate-7.1 Thyroid Labs: [2187-12-12] TSH-9.1* T4-6.8 T3-77* Free T4-1.0 Discharge Labs: [2187-12-14] 05:21AM BLOOD WBC-11.6* RBC-3.32* Hgb-10.6* Hct-32.6* MCV-98 MCH-31.9 MCHC-32.5 RDW-17.0* Plt Ct-268 Glucose-151* UreaN-16 Creat-0.6 Na-133 K-4.2 Cl-100 HCO3-24 AnGap-13 ALT-135* AST-166* AlkPhos-180* TotBili-5.4* Albumin-2.3* Calcium-8.0* Phos-3.6 Mg-2.0 Brief Hospital Course: 68M Klatskin/cholangio CA s/p open cholecystectomy ([11-19]) complicated by Klebsiella bacteremia, VRE/Yeast bile infection, agitation, presents with nausea/vomiting and peritonitis. On day of admission patient underwent Exploratory laparotomy, abdominal washout and drainage of bile leak. During the procedure, a necrotic anterior bile duct and extensive bile peritonitis was found. No perforations were identified in the small and large bowel, however saline flushed through the left-sided transhepatic catheter produced a large amount of fluid leaking from the hilum of the liver. Dissection further up into the hilum of the liver gave visualization of the transhepatic catheters as they coursed through the common bile duct. There was a large segment of the anterior wall of common bile duct that was necrotic and there was a large hole in the bile duct. It was felt that a Roux hepaticojejunostomy could not be done due to the tumor present so transhepatic catheters were opened to drain to widely drain the hilum. Two #10 - #19 French [Doctor Last Name 406] drains were placed in the hilum of the liver to bulb suction. Patient was initially transferred to the SICU post-op. He was started on Fluconazole, Linezolid and Meropenem. Bile cultures obtained at the time of surgery from the peritoneum showed GRAM STAIN (Final [2187-12-2]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. TISSUE (Final [2187-12-6]): PROTEUS MIRABILIS. SPARSE GROWTH. (Sensitive to Meropenem) SACCHAROMYCES CEREVISIAE. RARE GROWTH. ANAEROBIC CULTURE (Final [2187-12-6]): NO ANAEROBES ISOLATED. Patient also had Vanco resistant Enterococcus recovered from Bile and fluid cultures on [12-9], Sensitive only to Linezolid. On [12-12], Meropenem was d/c'd due to potential for causing mental status changes per neuro recommendations. Started on Cefepime IV to cover Proteus in bile. Patient will continue IV antibiotics through [12-18] and then convert to long term PO Augmentin per ID recommendations. During the post-op period, abdominal exams were noted to produce tenderness on palpation. Abdominal CT performed on [12-6] to assess status of continuing abdominal tenderness and distention showed interval decrease in the amount of ascites and no evidence of obstruction. The abdomen was distended, which resolved slowly over time with return of bowel function. C Diff negative from [2187-12-11] Seen by OT/PT. OT in agreement with team assessment of cognitive impairment, easy distractability and poor insight. Patient is a fall risk. Patient was started on home dose of escitolpram, but was subsequently d/c'd due to concerns for mental status changes. TPN was started on [12-4] with goal 1750 kcals (25 kcals/kg) and 1.5 g protein/kg. Patient required feeding by staff once cleared for diet post-op. Patient being followed by the wound care service for 3 stage 2 ulcers at the sacrum. Hydrocolloid dressings to be changed every 3 days with use of air mattress being employed. Liver enzymes started to trend down by post op day 3, however, they started to trend back up over the next week. Bilirubin stable around 5. Pullback Cholangiogram on [12-13] showed both right and left internal-external biliary drains demonstrating opacification of the common bile duct, common hepatic duct, and intrahepatic ducts. There is contrast extravasation from the common hepatic duct along the right undersurface of the liver. This will be treated with drains. Successful replacement of right and left internal-external biliary catheters, with the pigtails secured within the duodenum done [12-13]. Dual lumen PICC line placement on [12-12] by IR. Final tip position is in the caudal superior vena cava. Catheter is ready to employ. Patient will benefit from social work consult while at the rehab facility. Has been followed at [Hospital1 18] by [First Name8 (NamePattern2) 2270] [Last Name (NamePattern1) 1764]. Thyroid testing showed patient to be hypothyroid. Started on Levoxyl and will need TSH drawn at 1 week and one month. Dates in discharge plans Medications on Admission: escitalopram 20', heparin 5000''', isosorbide dinitrate 30", RISS, SLN 0.3 PRN, protonix 40', percocet, lopressor 32.5", ursodiol 300''', thiamine 100' (linezolid 600", cipro 500') Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Isosorbide Dinitrate 20 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 8. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit Injection ASDIR (AS DIRECTED): Please follow sliding scale. 9. Linezolid 600 mg/300 mL Parenteral Solution Sig: One (1) Intravenous Q12H (every 12 hours): Please discontinue on [12-18]. 10. Fluconazole in Normal Saline 400 mg/200 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours): Please discontinue on [12-18]. 11. Cefepime 2 g Recon Soln Sig: One (1) Recon Soln Injection Q12H (every 12 hours): Please discontine [12-18]. 12. PICC line care PICC line care per facility protocol. Double Lumen PICC 13. Outpatient Lab Work Please draw labs for TPN usage Chem 7, CA, Mg, Phos, LFT's, Albumin, Triglycerides, CBC and fax to Transplant office [Hospital1 18] at [Telephone/Fax (1) 697] attn: [Doctor First Name ] 14. Outpatient Lab Work Patient will need TSH drawn on [12-21], and [2188-1-11]. PLease fax to [Telephone/Fax (1) 697] 15. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three times a day: Please start on [12-19] once IV antibiotics have been completed. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Klatskin/cholangioCA complicated by peritonitis w/ Common Bile Duct leak s/p ex-lap/drainage on [12-1]. Discharge Condition: stable Discharge Instructions: Please call Dr. [Last Name (STitle) ] [Telephone/Fax (1) 673] if you have the following: -fever >101.4 -vomiting -excessive drainage from [Doctor Last Name ]/ptc drains or lack of drainage -severe abdominal pain -any other concerning signs/symptoms Continue TPN. D/C IV antibiotics and fluconazole on [12-18]. Patient will then start on Augmentin for long term therapy on [2187-12-19] Please change sacral hydrocolloid dressing q 3 days. Followup Instructions: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2187-12-26] 9:20 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2187-12-14] ICD9 Codes: 0389, 412, 4019, 2720, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8881 }	Medical Text: Admission Date: [2111-11-10] Discharge Date: [2111-11-11] Date of Birth: [2031-12-30] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2712] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname 90888] is a 79[Hospital ] transfer from OSH with a nonverbal/noncommunicative baseline due to mental retardation and schizophrenia who presented in respiratory distress. . At the OSH, he had a desaturation to 55% on RA. He has an active DNR/DNI, and was placed on noninvasives. He received vancomycin and solumedrol for pneumonia versus COPD exacerbation. Per EMS en route, his oxygenation improved with application of the BiPAP mask. ABG there revealed 7.39/40/24 on BIPAP 20/10. Received solumedrol prior to transfer. . On arrival to [Hospital1 18] ED, his initial vitals were pulse 92 BP108/76 RR24, sat 95%RA. He was found to be nonverbal with an examination revealing diffuse rhonchi throughout both lung fields. He was tachypneic but satting 95% on RA. He had a lactate of 3.4, leukopenia to 1.1. A CXR revealed possible left perihilar infiltrate raising concern for HCAP. Levofloxacin and metronidazole were added to his regimen and he was admitted to the MICU for further management. . On arrival to the unit, his initial VS were: T94.5 axillary, P76, BP93/58, Sat 95% 50% face tent. He could not provide further history. BiPAP was removed on admission with maintenance of his sats in the mid 90s on face tent. Thick secretions were noted. . Past Medical History: - schizophrenia - mental retardation - COPD - CKD (unknown baseline) - tardive dyskinesia - hypothyroidism - GERD Social History: lives in [Hospital 2251] nursing home Family History: Unknown Physical Exam: On admission: Vitals: T94.5 axillary, P76, BP93/58, Sat 95% 50% face tent General: grunting, grumbling, swearing HEENT: Sclera anicteric, MM dry NECK: supple, cannot assess JVD due to positioning LUNGS: auscultation procluded by vocalizations, but no wheezing. Wet cough. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: TTE: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular function is not well visualized due to suboptimal views. Left ventricular systolic function appears grossly preserved with possible regional wall motion abnormality (EF ?50?). There may be apical hypokinesis but regional wall motion is not well seen. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . LENIs; IMPRESSION: 1. No deep vein thrombosis is seen bilaterally from the common femoral to the popliteal veins. Note is made that the patient did not tolerate evaluation of calf veins. 2. Small left popliteal [Hospital Ward Name 4675] cyst. . CXR: Evaluation is limited due to patient positioning. The lung volumes are low. There are left perihilar and right infrahilar opacities consistent with aspiration pneumonia. There is no pneumothorax amd no large pleural effusions. Brief Hospital Course: Mr. [Known lastname 90888] is a 79yoM with a history of MR, schizophrenia, transferred from OSH for respiratory distress, admitted to the MICU for monitoring 1. HEALTHCARE ASSOCIATED PNEUMONIA: He presented with desaturations at the OSH and arrived on BiPAP, which was rapidly weaned to face tent upon admission to the MICU, where he maintained his saturations in the mid to upper 90s. A CXR showed evidence of a left lingular pneumonia, and so he was broadly covered empirically with vancomycin, cefepime, and levofloxacin pending cultures. Levofloxacin was stopped on [2111-11-11] to avoid further QTC prolonging meds, and vancomycin was dced on discharged given no growth x48h. The pt will be continued on Cefepime 2g IV q12h to complete an 8day course (last day [11-18]). On discharge his O2 sats were stable on RA. 2. SEPSIS: He presented with borderline low blood pressures with MAPS in the 50s, leukopenia, tachycardia, and tachypnea, elevated lactate. With suspected pneumonic and urinary infectious source, sepsis was likely. He was fluid resuscitated, and broadly covered with antibiotics as above. He received stress dose hydrocortisone since he is on prednisone 5mg daily at baseline for COPD. His blood pressure remained stably low. His lactate downtrended. On day of discharge he received hydrocortisone 50mg IV q8h, and will be discharged on his home dose of prednisone 5mg daily. 3. ELEVATED TROPONIN: His trop was elevated to 0.16 on admission with a BNP>[Numeric Identifier 2686]. CK and MB fractions were negative. EKG showed lateral TWI which were seen on previous EKGs. A demand ischemia seems possible from sustained tachycardia. Trops were downtrending on serial assays. 4. ELEVATED BNP: BNP was >[Numeric Identifier 2686] on admission without a history of CHF. Clinically, he appeared hypovolemic on admission exam, so acute CHF was not suspected. A limited echo revealed a likely EF of 50% though no wall motion abnormality could be seen or excluded. 5. HYPERNATREMIA: He presented with a Na to 150 which downtrended with fluid resuscitation. 6. ACUTE KIDNEY INJURY: He has CKD with unclear baseline Cr, though presented with [Last Name (un) ] to cr 2.0. Urine lytes showed sodium avidity with FeNa 0.08%. Creatinine improved with fluids. 7. SCHIZOPHRENIA: He has been institutionalized since age 18, and was continued on his outpatient anti-psychotic regimen including risperidone, risperdal consta, olanzapine, and valproic acid. Restraints necessary for attempted violent behavior. He appeared at his mental status baseline per niece's report. He often refused meals and oral medications. 8. HYPOTHYROIDISM: continued levothyroxine ---- Transitional Issues: - The patient should be continued on Cefepime 2g IV q12h until [11-18] to complete an 8 day course. - PICC line was placed for administration of IV abx. This should be discontinued on completion of antibiotic course. Medications on Admission: - levothyroxine 112mcg daily - divalproex 875mg daily 6am, noon, 1000mg every 6pm - risperidone 1 mg TID - omeprazole 20mg daily - risperdal consta 25mg IM every 2 weeks (due on [11-11]) - multivitamin with mineral - prednisone 5mg daily - zyprexa 15mg [Hospital1 ] - sodium bicarb 650mg [Hospital1 ] - scopolamine patch behind ear every 72 hrs - vitamin d 800units QHS - acetaminophen 650mg q4hrs prn - procrit 40K units prn HCT<30 (has not received in months) - dulcolax 10mg suppository qd prn - fleet enema prn - milk of mag 30mg daily prn - risperdal 0.5mg q4-6 hr prn agitation Discharge Medications: 1. risperidone 0.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 5. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for agitation. 6. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. olanzapine 15 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. risperidone microspheres 25 mg/2 mL Syringe Sig: One (1) Syringe Intramuscular Q2W (WE): Last dose [11-11]. 9. divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: Seven (7) Tablet, Delayed Release (E.C.) PO q6am, qnoon. 10. divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: Eight (8) Tablet, Delayed Release (E.C.) PO q6pm. 11. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO once a day. 12. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day. 14. Procrit 40,000 unit/mL Solution Sig: One (1) dose Injection PRN as needed for HCT <30. 15. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [2-8] Tablet, Delayed Release (E.C.)s PO once a day as needed for constipation. 16. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal PRN as needed for constipation. 17. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mg PO once a day as needed for heartburn. 18. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q12H (every 12 hours) for 13 doses. Disp:13 Recon Soln(s) Refills:0 19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [Location (un) 2251] Nursing and Rehabilitation - [Location (un) 2251] Discharge Diagnosis: Healthcare Associated Pneumonia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [Known lastname 90888], It was a pleasure participating in your care. You were admitted for difficulty breathing, decreased oxygen saturation and low blood pressure. You were found to have pneumonia, likely due to aspiration. You were started on broad spectrum antibiotics, given IV fluids, and we temporarily increased the dosage of your steroids. You have now improved and are ready to return to your nursing facility. You will continue on Cefepime 2g IV q12h through [11-18]. . Please START the following medications: - Cefepime 2g IV q12h through [11-18] Followup Instructions: Please follow up with your primary care doctor within 1 wk. ICD9 Codes: 0389, 486, 5849, 2760, 5859, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8882 }	Medical Text: Admission Date: [2100-11-8] Discharge Date: [2100-11-12] Date of Birth: [2034-1-2] Sex: M Service: CARDIOTHORACIC Allergies: Pollen Extracts Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: s/p Coronary Artery Bypass Grafting x 1 (left internal artery grafted to left anterior descending)/Aortic Valve Replacement (#23 mm Tissue valve) on [2100-11-8] History of Present Illness: This is a a 66 year old male with dyspnea on exertion and history of aortic stenosis. While being evaluated for radical prostatectomy he had a stress test showing subendocardial ischemia and underwent cardiac cath which showed coronary artery disease and aortic valve pathology. He is now referred for surgical evaluation. Past Medical History: Coronary artery disease Aortic stenosis Hyperlipidemia Prostate cancer Sclerotic rib lesion ( not metastatic per urology) Arthritis Bilateral cataract surgery Social History: Race: Asian American Last Dental Exam: 6 months ago Lives with: Wife Occupation: Retired electrical engineer Tobacco: Denies ETOH: Denies Family History: Notable for lung cancer in his father. [Name (NI) ] history of premature coronary artery disease or valve disease. Physical Exam: admission: Pulse:72 Resp: O2 sat: 100% RA B/P Right:140/51 Left: 142/59 Height:5'8" Weight:151 (68.4 kg) General:NAD, well-appearing Skin: Warm[x] Dry [x] intact [x] HEENT: NCAT[x] PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur: 4/6 SEM radiates to carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds +[x] Extremities: Warm [x], well-perfused [x] Edema-none ecchymosis Right groin/thigh at cath site Varicosities: None [] Neuro: Grossly intact, nonfocal exam,MAE [5-12] strengths 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: murmur radiates to carotids Pertinent Results: [2100-11-8] Intraop TEE: PRE-CPB: 1. The left atrium is mildly dilated. No thrombus is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 4. Right ventricular chamber size and free wall motion are normal. 5. 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. 6. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Moderate to severe (3) aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. Mild (1) mitral regurgitation is seen. Post-CPB: 1. Well-seated bioprosthetic valve in the aortic position. 2. Preserved biventricular systolic function. 3. Aortic contour normal post-decannulation. [2100-11-8] 11:30AM BLOOD WBC-7.5 RBC-3.03# Hgb-8.2# Hct-24.6# MCV-81 MCH-27.2 MCHC-33.4 RDW-13.9 Plt Ct-115* [2100-11-10] 04:40AM BLOOD WBC-12.3* RBC-3.43* Hgb-9.5* Hct-28.1* MCV-82 MCH-27.6 MCHC-33.8 RDW-14.1 Plt Ct-118* [2100-11-8] 11:30AM BLOOD PT-13.9* PTT-45.8* INR(PT)-1.2* [2100-11-8] 12:43PM BLOOD UreaN-11 Creat-0.7 Na-141 K-3.9 Cl-113* HCO3-24 AnGap-8 [2100-11-12] 04:50AM BLOOD UreaN-25* Creat-1.0 Na-134 K-4.3 Cl-96 Brief Hospital Course: Mr. [Known lastname ] was admitted and underwent single vessel coronary artery bypass grafting and aortic valve replacement 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 incident. His CVICU course was uneventful and he transferred to the floor on postoperative day one. He experienced a brief bout of atrial fibrillation but converted back to a normal sinus rhythm with the administration of IV amiodarone and then oral dosing. He was begun on a beta blocker, diuresed towards his preoperative weight and progressed well. Chest tubes were removed on post-op day one and pacing wires on post-op day 3. Physical Therapy worked with him for mobility and strength. He appeared to be doing well on post-op day 4 and was discharged home with VNA services. Medications on Admission: Zocor 40mg daily, Aspirin 81mg daily, Amoxicillin prn dental 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. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:14 Tablet(s) Refills:0 8. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 2 weeks. Disp:28 Tab Sust.Rel. Particle/Crystal(s) Refills:0 9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Take to two 200 mg tablets twice daily for 1 week. Then one 200 mg tablets twice daily for 1 week. Then 1 200 mg tablet daily until stopped by cardiologist. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Coronary artery disease and Aortic Stenosis s/p Coronary Artery Bypass Grafting x 1(LIMA-LAD)/Aortic Valve Replacement (#23 mm Tissue valve) Past medical history: Hyperlipidemia Cataracts s/p Bilateral cataract surgery Prostate cancer Sclerotic rib lesion (not metastatic per urology) Arthritis Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Edema: none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 170]) on [2100-12-9] at 1:45pm Cardiologist:Dr.[Last Name (STitle) 14522] on [2100-12-14] at 3;15pm Please call to schedule appointments with: Primary Care: Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 30837]) in [1-9] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2100-11-12] ICD9 Codes: 4241, 4019, 2720, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8883 }	Medical Text: Admission Date: [2197-8-4] Discharge Date: [2197-8-16] Date of Birth: [2197-8-4] Sex: F Service: NB ID: Baby Girl [Known lastname 1968] #2 ([Known lastname ]) is a former 34 [1-20] wk SGA triplet who is being discharged from the [Hospital1 18] NICU. HISTORY: Baby Girl [Known lastname 1968] #2 is the 1430 gram product of a 34- [1-20] week triplet gestation born to a 35 year old G3 P0 now 3 woman. Prenatal screens included A positive, direct Coombs negative, hepatitis surface antigen negative, RPR nonreactive, rubella immune, GBS unknown. Past obstetric history notable for a spontaneous abortion at 11 weeks, another spontaneous abortion at 8 weeks, and a history of infertility. This pregnancy was Clomid assisted, with tri-amnionic, tri-chorionic triplet gestation. Pregnancy was uncomplicated. Mother presented in spontaneous onset preterm labor proceeding to cesarean delivery for multiple gestation under spinal anesthesia. There was no intrapartum fever or other clinical evidence of chorioamnionitis. No intrapartum antibacterial prophylaxis was administered. Membranes were ruptured at delivery, yielding clear amniotic fluid. The infant emerged vigorous, was orally and nasally bulb suctioned and dried, with brief supplemental O2. Subsequently she was pink in room air. Apgars were 7 and 8. PHYSICAL EXAMINATION: On admission, birth weight was 1430 grams (10th percentile), head circumference 30.5 cm (25th percentile), length 40 cm (10th percentile). Anterior fontanelle was soft and flat. Non dysmorphic, palate intact. Neck normal. No nasal flaring. Red reflex normal bilaterally. Chest without retractions. Good breath sounds bilaterally. No crackles. Cardiovascular - Well perfused. Regular rate and rhythm. Normal pulses, normal S1 and S2. No murmur. Abdomen soft, nondistended, no organomegaly. Bowel sounds active. Anus patent. Three-vessel umbilical cord. Normal external female genitalia. Moves appropriately for gestational age. HOSPITAL COURSE BY SYSTEM: 1. RESPIRATORY. [Known lastname ] has remained stable in room air without issue. She has had no evidence of apnea or bradycardia of prematurity. 2. CARDIOVASCULAR. She has had no issues. 3. FLUIDS AND ELECTROLYTES. Birth weight was 1430 grams. She was initially started on 80 cc/kg/day of D10W. Enteral feedings were initiated on day of life #2, and were advanced to full volume feedings without difficulty. She initially required PO and PG feeds, but gradually transitioned to all PO feedings. She is currently p.o. feeding greater than 150 cc/kg/day of BM 26 or Enfacare 26 calories per oz, with consistent weight gain. BM caloric supplementation is with Enfacare powder. Weight at discharge was 1655 gm. 4. GASTROINTESTINAL. Peak bilirubin was on day of life #5, when it was 7.3/0.2. Infant received phototherapy for a total of 4 days, and the issue has since resolved. 5. HEMATOLOGY. Hematocrit on admission was 53.4. She has not required any blood transfusions during this hospital course. She was started on iron supplementation given the growth restriction. 6. INFECTIOUS DISEASE. A CBC and blood culture were obtained on admission. CBC was benign. Blood culture remained negative at 48 hours, at which time antibiotics were discontinued. 7. NEURO. Infant has been appropriate for gestational age. 8. THERMOREGULATION. Infant was initially maintained in isolette, and gradually weaned to open crib with stable temp. CONDITION ON DISCHARGE: Stable. DISPOSITION: To home. PRIMARY PEDIATRICIAN: Dr. [Last Name (STitle) 63486] [Telephone/Fax (1) 63489]. FEEDS AT DISCHARGE: BM 26 cals/oz with Enfacare powder or Enfacare 26 cals/oz by concentration. MEDICATIONS: Ferinsol 0.15 mL (25 mg/mL) PO daily. DISCHARGE PLANNING: Hearing screen was passed bilaterally. State newborn screens have been sent per protocol and have been within normal limits. Infant received hepatitis B vaccine #1 on [2197-8-15]. Car seat screening was not performed secondary to infant's small size, and infant was discharged on car bed. FOLLOW-UP: VNA in 1 day, PMD in 2 days. DISCHARGE DIAGNOSES: 1. Premature triplet #2. 2. Intrauterine growth restriction. 3. Rule out sepsis with antibiotics. 4. Hyperbilirubinemia. DR [Last Name (STitle) ] [Name (STitle) ] 50.ABQ Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2197-8-13] 20:56:34 T: [2197-8-13] 21:34:48 Job#: [Job Number 63490] ICD9 Codes: 7742, V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8884 }	Medical Text: Admission Date: [2143-3-21] Discharge Date: [2143-4-1] Date of Birth: [2081-12-20] Sex: M Service: MEDICINE Allergies: Penicillins / Talwin / Ambien Attending:[First Name3 (LF) 12] Chief Complaint: Altered mental status. Major Surgical or Invasive Procedure: Percutaneous cholecystectostomy tube placement. PICC placement on [2143-4-1] History of Present Illness: Mr. [Known lastname 92900] [Last Name (Titles) ] 61 yo M with stage IIIa NSCLC, HCV cirrhosis, CAD, HTN, depression who presents to the MICU after being found somnolent at rad onc clinic today. Per report, the patient was found to be unsteady on his feet and fell in front of the nursing station. EMS arrived and he was found to be responsive to painful stimuli, with pinpoint pupils. FSBS 319. He was given 1mg narcan with transient improvement in his somnolence. The patient is now more awake and states that he felt otherwise well over the last few days except for throat pain and mild HA. He took is medications this AM but on the way to his appointment began to feel cloudy and blurry and woozy. He got out of the car and felt like he was going to fall. Onec he got to the clinic, he felt much more sleepy and unsteady and fell. Per report, he did not hit his head/neck of lose consiousness. Per his wife, he reportedly took both his AM and PM medications which includes his opiates and valium. . In the ED, T 97.1, BP 106/62, HR 84, RR 18, 100%2L. The patient was given zofran 4mg, narcan 1mg x2 and then started on a narcan drip at 0.4mg/hr. He underwent CXR, CT head, and C spine, tox screen. EKG with inferior Q waves, unchanged from prior. . ROS: As per above, otherwise denies f/c, CP, SOB, vomitting, abd pain. He endorses sore throat, and leg pain. He denies diploia, numbness or weakness in his extremities. Past Medical History: <br><b>PAST MEDICAL HISTORY: </b> Stage IIIa NSCLC (see below) DM2 Hepatitis C cirrhosis Coronary artery disease s/p stenting x2 to the RCA HTN Depression <br><b>PAST ONCOLOGIC HISTORY: </b> In [11-26] he was admitted for workup of dyspnea and this nodule was noted on a CT angiogram. He was discharged to home and as an outpatient, a PET CT scan as well as CT-guided needle biopsy were obtained. PET scan disclosed this nodule to be FDG avid with an SUV of 3.4. No mediastinal adenopathy or FDG uptake was noted. A CT guided biopsy confirmed poorly differentiated large cell type nonsmall cell lung cancer. Cervical mediastinoscopy and flexible bronchoscopy on [2143-1-4] demonstrated metastatic carcinoma in 4R lymph nodes. Considering his co-morbidities, felt to be a poor surgical candidate and favored chemoradiotherapy along without surgery. Currently undergoing therapy with RT and navelbine. Social History: Mr. [Known lastname 92900] is a retired police officer and veteran of [Country 3992]. He is married with three children. He smoked for approximately 20 years (3 packs per day). He drinks only socially. He denies IVDU. Family History: Father gastric ca, died age 64 Father EtOH, cirrhosis Mother died of MI age 38 Brother died of suicide, age 38, shot himself Uncle with psychologic issues "after returning from war" Physical Exam: VS: afebrile, BP 117/61, HR 80, RR 14, 100% 2L Gen: initially sleepy but easy to arouse, now awake and oriented HEENT: EOMI, PERRL 5mm->2cm and symmetric, anicteric sclera, MMM, OP clear Neck: supple, no LAD, no point tenderness down spine, full ROM without tenderness Heart: RRR no m/r/g Lung: CTAB no wheezes or crackles Abd: obese, sfot mild LUQ/flank tendereness, no rebound or guarding + BS Ext: warm well perfused no c/c/e Skin: moist, no rash or bruising Neuro: awake alert and oriented, talking clearly, CNII-XII intact, full ROM extremities with 5/5 strenght in all muscle groups. No dysmetria or asterixis. No clonus, sensation grossly intact. Gait not assessed Pertinent Results: On Admission: [2143-3-20] 10:40AM WBC-1.8# RBC-3.92 HGB-8.9* HCT-30.4* MCV-78* MCH-22.7* MCHC-29.3* RDW-19.7* [2143-3-20] 10:40AM GLUCOSE-201* UREA N-10 CREAT-0.8 SODIUM-132* POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-27 ANION GAP-13 [2143-3-20] 10:40AM PLT COUNT-170# [2143-3-21] 11:50AM GLUCOSE-239* UREA N-11 CREAT-1.1 SODIUM-131* POTASSIUM-4.5 CHLORIDE-96 TOTAL CO2-25 ANION GAP-15 [2143-3-21] 11:50AM ALBUMIN-3.2* CALCIUM-8.2* PHOSPHATE-3.1 MAGNESIUM-1.8 [2143-3-21] 11:50AM VIT B12-939* FOLATE-14.2 [2143-3-21] 11:50AM PLT SMR-LOW PLT COUNT-129* [2143-3-20] 10:40AM GRAN CT-1100* . CT C-spine: 1. No fracture or malalignment. MRI is more sensitive for ligamentous injury and cord contusion. 2. Extensive degenerative change with ankylosis of C5-C6 and anterior osteophyte fusion extending from C4 through C7. There is moderate central canal stenosis and severe neural foraminal narrowing, most severe at C5-C7, as described above. 3. Tracheal secretions place patient at increased risk for aspiration. 4. Lipoma in the posterior neck soft tissues, unchanged. 5. Redemonstration of right apical spiculated lung nodule, consistent with known malignancy. . CT Head: No acute intracranial process. No interval change compared to prior study. . Abdominal CT [2143-3-23]: 1. Findings may suggest acute cholecystitis with worsening inflammatory change when compared to [2143-2-19]. Recommend surgical consultation since these features may simply reflect underlying liver disease and third spacing, especially since a prior HIDA scan was negative. 2. Cirrhosis and splenomegaly. Patent portal vein. . Abdominal CT [2143-3-27]: 1. No evidence of pulmonary embolism or aortic dissection. 2. Cholecystostomy tube in place, within a decompressed gallbladder with significant gallbladder wall edema and mild pericholecystic stranding. No abscess or fluid collection associated with the gallbladder. 3. Unchanged spiculated right upper lobe mass consistent with adenocarcinoma. 4. Cirrhosis and findings of portal hypertension. 5. Patchy atelectasis at the lung bases. Superimposed pneumonia is not excluded. . Bile: ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 4 S TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: 61 yo M with stage IIIa NSCLC, HCV cirrhosis, CAD, HTN, depression, presents with altered mental status. . . Altered Mental Status: Patient had double-dose of his sustained released morphine accidentally prior to radiation therapy. In the ER he was started in a Narcan drip improving rapidly. He was monitored for 24 hours in the MICU Green, where the drip was shut off immediately upon arrival. HE was stable and was sent to the oncology floor. His morphine doses were held as well as amitriptilin. He had normal LFTs. . Acute on Chronic Cholangitis: Patient developed in the hospital RUQ pain and increase bilirubin and fever up to 103. He underwent an abdominal CT scan that showed worsening of his chronic cholecystitis with large amount of fluid surrounding the gallbladder. Patient was hydrated and started on Vancomycin / Ciprofloxacin / Flagyl. Surgery was consulted, who suggested percutaneous-IR-guided drainage of the gallbladder. The following day patient underwent IR-drainage. Surgery recommended leaving the drain permanently. Patient kept having RUQ pain and fever despite prior interventions. Antibiotics were switched to Vancomycin / Cefepime / Flagyl. Blood cultures were drawn on daily basis and were negative. Then, biliary tract cultures grew ESCHERICHIA COLI that was ciprofloxacin resistant (Cefepime and ceftriaxone sensitive). Infectious disease team was consulted. Two days after switching the antibiotics patient became afebrile. Vancomycin was stopped since the pt is MRSA negative and the infection source is the biliary tract. The following day he was switched to ceftriaxone and oral flagyl. He kept being afebrile. He will have an indeterminate course of antibiotics at this time. Therefore, he will be followed by infectious disease team as outpatient who will determined when to stop antibiotics. . NCSLC: undergoing chemoradiation currently. He became neutropenic while in the hospital and then counts recovered. He will continue with radiotherapy as outpatient. . HCV cirrhosis: Currently appears compensated. Synthetic function at baseline. Transaminases at baseline. No signs of encephalopathy. Has grade II varices per EGD in [2140]. Lactulose / Rifaximin / Propranolol were continued. . Chronic Pain: Patient has back pain and chest pain due to his malignancy and treatment. His pain medications were slowly uptitrated until his home-dose morphine SR. He was discharged with PO Dilaudid for breakthrough. . CAD: Stable. EKG with stable inferior Q waves. ASA, beta-blocker and ACEI were continued. . Diabetes: Cont HISS with lantus. . Depression: Stable. Cont Paxil, amitryptiline . HTN: Stable. Cont ACE-I, propranolol . FEN: Low salt diet, monitor electrolytes . PPX: Pneumoboots, bowel regimen, PPI . ACCESS: PIV . Code: DNR/DNI. had extensive discussion with patient . Dispo: Home with VNA. Home Infusion: Critical Care System [Location (un) 8985], MA [Telephone/Fax (1) 92901] and [Telephone/Fax (1) 86700] Fax: [Telephone/Fax (1) 86701] Medications on Admission: Amitriptyline 50 mg PO HS Diazepam 5 mg PO Q12H as needed. Gabapentin 600 mg PO TID Insulin Aspart 100 unit/mL Solution per outpatient sliding scale. Lantus 58 units Subcutaneous at bedtime. Lisinopril 10 mg PO once a day. Lorazepam 0.5-1 mg PO every eight hours as needed for nausea. Morphine 15 mg PO Q8H Morphine 15 mg PO every eight hours as needed for pain Omeprazole 20 mg PO DAILY (Daily). Zofran 4 mg PO every eight (8) hours as needed for nausea. Paroxetine HCl 20 mg PO DAILY Klor-Con 10 10 mEq PO twice a day. Prochlorperazine Maleate 5 mg PO every six (6) hours as needed Propranolol 40 mg PO BID Aspirin 81 mg PO DAILY (Daily). Lactulose Thirty (30) ML PO three times a day Rifaximin 400 mg PO TID Furosemide 20 mg PO BID Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). Disp:270 Capsule(s) Refills:0 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Propranolol 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO Q8H (every 8 hours) as needed. 8. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Amitriptyline 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 11. Insulin Please resume your home insulin dosing 12. Prochlorperazine Maleate 5 mg Tablet Sig: One (1) Tablet PO four times a day as needed for nausea. 13. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 14. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours): Patient will continue indefinetelly and follow with ID, who will decide when to stop pending clinical improvement. Disp:21 gram Refills:0 15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): Patient will continue indefinetelly and follow with ID, who will decide when to stop pending clinical improvement. Disp:63 Tablet(s) Refills:0 16. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4 hours) as needed for pain: Please be aware of sedative effect of this medication. DO not take with alcohol and do not drive or do high-risk activities. Disp:90 Tablet(s) Refills:0 17. Saline Flush 0.9 % Syringe Sig: One (1) Syringe Injection once a day. Disp:30 Syringe Refills:2 18. Heparin Flush 10 unit/mL Kit Sig: One (1) Syringe Intravenous once a day. Disp:30 Syringes Refills:2 19. Line care Please do line care per protocol. 20. Insulin Please resume your home-dose insulin regimen. 21. Labs Weekly cbc, chem7, lft's. Please fax the results to the infectious disease nurses at ([Telephone/Fax (1) 6313]. If you have questions regarding antibiotics please contact RNs in ID office or covering physician [Last Name (NamePattern4) ]: ([Telephone/Fax (1) 14199]. 22. Percutaneous cholecystostomy tube. Please do flushes three times a day with normal saline flushes. 23. Saline Flush 0.9 % Syringe Sig: One (1) Suringes Injection three times a day: Please flush cholecystectomy tube three times a day. Disp:90 Syringe Refills:2 24. Dressing changes Please do daily dressing changes in the cholecystostomy tube placement. Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary Diagnosis: Opioid overdose Acute on Chronic cholangitis . Secondary Diagnosis: Stage IIIa NSCLC DM2 Hepatitis C cirrhosis Coronary artery disease s/p stenting x2 to the RCA HTN Depression Discharge Condition: Stable, pain controlled, breathing comfortably on room air, tolerating PO. Discharge Instructions: You were seen at [Hospital1 18] for sleepiness and altered mental status. The most likely etiology was your double-dose of morphine. You required an antidote of morphine in the ICU and you improved. You were watched for more than 24 hours. Then you were tranfered to the floor and your pain regimen was re-established. You had your raditaion therapy. Then later in the admission, most likely in the setting of low white blood cells, you had an acute on chronic cholecystitis (inflammation of gallbladder and bile ducts) with a lot of fluid that was much worse than before. You were seen by surgery who recommended percutaneous drainage. Interventional radiology placed the drain. You kept having fevers, so we consulted the infectious disease and changed the antibiotics. You have been afebrile and are tolerating diet and ambulating. You will need to follow with infectious disease doctors and with your oncologist. You will need to follow with Dr. [Last Name (STitle) ] to assess fof further therapy (i.e. chemotherapy) once your infection is better. . Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: None. . If you have fever, chills, rigors, changes in the abdominal pain, nausea, vomit, unable to keep food or liquid down please come to our ER. Followup Instructions: Provider: [Last Name (NamePattern4) ]. [First Name (STitle) ] [Doctor Last Name ] Phone:[Telephone/Fax (1) 3752] Date/Time:[2143-5-23] 10:45 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 62] Date/Time:[2143-7-23] 11:20 . You will require weekly cbc, chem7, lft's. Please fax the results to the infectious disease nurses at ([Telephone/Fax (1) 6313]. If you have questions regarding antibiotics please contact RNs in ID office or covering physician [Last Name (NamePattern4) ]: ([Telephone/Fax (1) 14199]. . Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 27106] office will contact you with the following appointment. They are making a special slot for you. . Please follow with your oncologist: Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2143-4-19] 10:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 23551], MD Phone:[Telephone/Fax (1) 447] Date/Time:[2143-4-19] 10:00 ICD9 Codes: 5715, 2930, 4019, 3572, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8885 }	Medical Text: Admission Date: [2101-9-23] Discharge Date: [2101-10-4] Date of Birth: [2081-3-16] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 11415] Chief Complaint: Status-post MVC vs. tree Major Surgical or Invasive Procedure: ORIF Right femur fracture [2101-9-23] ORIF Right calcaneus fracture History of Present Illness: Pt. is a 20 yo man; driver in MVC vs. tree at 40-50mph. +LOC 1-2min. Air bag was deployed and there was significant damage to the front-end of car. He was not ejected; was extricated by bystanders at the scene. Tx to [Hospital1 18] by airflight from [Location (un) 1475]. Past Medical History: none Social History: + EtOH, no tob, no IVDU Family History: noncontributory Physical Exam: In ER, per trauma surgery initial note: 90/palp improved to 120/56, P88, R18, T98.6, O295%RA HEENT: small head abrasion, PERRLA4-5mm Chest: b/l BS, small L chest abrasion CVS: RRR, nlS1S2 Abd: soft, -FAST exam Ext: RLE splint in place. + R thigh swelling. Right DP pulse palpable. Moves all other extremities spontaneously Rectal: Nl tone, trace guaiac + GU: no blood at meatus. Foley passed easily Spine: no TTP CTLS splne Pertinent Results: [2101-9-23] 02:40AM URINE RBC-[4-2]* WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 RENAL EPI-0-2 BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2101-9-23] 03:40AM PT-14.7* PTT-28.6 INR(PT)-1.4 [2101-9-23] 03:40AM FIBRINOGE-192 [2101-9-23] 03:40AM WBC-25.4* RBC-4.72 HGB-14.6 HCT-40.6 PLT COUNT-285 [2101-9-23] 03:40AM PT-14.7* PTT-28.6 INR(PT)-1.4 [2101-9-23] 03:40AM ASA-NEG ETHANOL-249* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2101-9-23] 03:40AM AMYLASE-67 [2101-9-23] 03:40AM GLUCOSE-115* UREA N-12 CREAT-0.8 SODIUM-137 POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-20* ANION GAP-19 [2101-9-23] 05:31PM CALCIUM-8.2* MAGNESIUM-1.4* Brief Hospital Course: [9-23]: Pt admitted to TSICU. Injuries: -pulmonary contusions -R femur fx -R calcaneus fx -grade 2 splenic laceration 5cm w/ encapsulated hematoma -blood in pelvis Pt. developed blood-loss anemia. Hct was monitored. Received 2u PRBCs. Begun on Ancef IV [9-24]: -ORIF R femur -received addnl 4u PRBC and 6u FFP [9-25]: -developed fever. W/u negative. Remained on Ancef. -evaluated by neurosurgery due to anteriolisthesis of C2 on C3 seen on C-spine CT. -f/u flex/ex films neg and c-spine was cleared, c-collar was removed. [9-26]: -b/l LE CT done to evaluate for rotational deformity of R femur s/p ORIF. -abx were stopped [9-30]: -Pt taken to OR for correction of rotation of IM nail in femur and ORIF of right calcaneous. -Lovenox restarted post-operatively. [10-4]: -bivalve cast placed and pt was discharged in stable condition. Will follow up with Dr. [Last Name (STitle) 1005] in clinic in two weeks. Medications on Admission: none Discharge Medications: 1. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain for 2 weeks. Disp:40 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 2 weeks: continue to take as long as you are taking the percocet to prevent constipation. Disp:28 Capsule(s) Refills:0 3. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily) for 4 weeks. Disp:28 syringe Refills:0 4. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours) for 1 weeks. Disp:14 Tablet Sustained Release 12HR(s) Refills:0 Discharge Disposition: Home With Service Facility: Gentiva Discharge Diagnosis: Right mid-shaft comminuted femur fracture, status-post ORIF Right calcaneal fracture, status-post ORIF Discharge Condition: stable Discharge Instructions: --take all medications as prescribed --keep all followup appointments watch incision sites for redness/drainage and call your doctor with any concerns. Go to the ER if you experience fevers, chills, chest pain, or shortness of breath. Physical Therapy: Non-weightbearing RLE Treatments Frequency: sutures will be removed at your first post-operative visit. Followup Instructions: Follow-up with Dr. [Last Name (STitle) 1005]. Please call [Telephone/Fax (1) 8746] for an appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235] MD, [MD Number(3) 11417] Completed by:[2101-10-4] ICD9 Codes: 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8886 }	Medical Text: Admission Date: [2181-10-29] Discharge Date: [2181-11-24] Service: Cardiac Surgery HISTORY OF PRESENT ILLNESS: On [2181-10-26] Mr. [Known lastname 36153] [Last Name (Titles) 5058] in the evening with chest pressure across lower chest radiating to his back with a fast, irregular heartbeat. He was transferred to [Hospital 1562] Hospital via EMS. There he was found to be in atrial fibrillation and was converted to sinus rhythm with Lopressor and Digoxin. His EKG showed ST depression in leads 2, 3 and AVF and was subsequently ruled in for an MI by enzymes with peak CK at 260 with 39 MBs, peak troponin at 8.5. Echocardiogram at [Hospital 1562] Hospital showed inferior posterior akinesis with an ejection fraction of 40%. The patient was transferred to [Hospital1 188] for cardiac catheterization and further work-up. PAST MEDICAL HISTORY: Hypertension, elevated cholesterol, COPD/asthma, cataracts, status post bilateral hernia repair, chronic renal insufficiency, history of tobacco abuse, history of etoh use. ALLERGIES: Sulfa. MEDICATIONS: Aspirin 325 mg po q day, Plavix 75 mg po q day, Prinivil 20 mg po q day, Lipitor 20 mg po q day, Nitro Paste, Lovenox 70 mg subcu q day, Nadolol 40 mg q day, Fioricet 1-2 tablets prn, Serevent MDI 2 puffs [Hospital1 ], Albuterol MDI 2 puffs [Hospital1 ], AeroBid MDI 2 puffs [Hospital1 ]. PHYSICAL EXAMINATION: This is a thin 77-year-old gentleman in no apparent distress. Lungs clear. Heart, S1 and S2 regular rate and rhythm. Abdomen without hepatosplenomegaly, nontender, positive bowel sounds. Lower extremities, 2+ pulses bilaterally. Extremities without edema. Carotids without bruits. LABORATORY DATA: White blood cell count 11, hematocrit 38, platelet count 241,000, sodium 141, potassium 4.8, BUN 37, creatinine 1.3, PT 11.8, INR 1.0. EKG as stated above. Cardiac catheterization performed at [Hospital1 190] showed an ejection fraction of 40%, 80% LAD lesion, 50% diagonal lesion, 100% OM lesion and 100% RCA lesion. The patient referred to cardiac surgery for further evaluation. On [10-30] the patient was taken to the operating room by Dr. [First Name (STitle) 10102] for a CABG times three, LIMA to LAD, SVG to OM and SVG to diagonal. The patient was transferred to the Intensive Care Unit on Levophed and Dobutamine. In the operating room the patient was noted to have severe bullous lung disease and bilateral pleural tubes were placed which noted to have significant air leaks after the chest was closed. In the Intensive Care Unit the patient was noted to have excessive chest tube output with significant episodes of hypotension. The patient was returned to the operating room on the evening of [10-30] for re-exploration for bleeding. The patient continued to require inotropic support with Dobutamine and Neo-Synephrine upon return to the Intensive Care Unit. The patient was weaned from his inotropics by postoperative day #1. Multiple attempts at weaning patient from the ventilator failed and on postoperative day #2 a pulmonary consult was obtained due to the patient's significant history of COPD. On postoperative day #3 the patient was transferred to the SICU service to assess for further ventilator weaning as patient was unable to be weaned from mechanical ventilation. Postoperative day #4 the patient developed an elevated temperature to 101. The patient was pancultured, antibiotics were started, Vancomycin and Ceftazidime. Later that day patient was weaned and extubated from mechanical ventilation and was quickly reintubated for respiratory distress. At that time it was noted that patient still had vigorous air leak from his chest tubes. The patient transiently required Neo-Synephrine to maintain blood pressure after reintubation. On postoperative day #5 the patient developed new onset atrial fibrillation, was started on IV Amiodarone. The patient again developed elevated temperature to 101. Sputum culture from [11-2] showed E. coli and Moraxella. Antibiotic coverage was changed from Vancomycin, Ceftazidime to Levaquin. The patient was again extubated on postoperative day #6 and subsequently developed respiratory failure. It was attempted to place patient on bilateral positive airway pressure ventilation which quickly failed and patient was reintubated for respiratory failure. At that time it was noted that patient had an elevated white blood cell count of 20. Sputum culture showed gram positive cocci, coag positive, Vancomycin was restarted. On postoperative day #8 the patient acutely developed hypotension, systolic blood pressures in the 50's, subsequently resolved with fluid bolus. EKG at that time was negative for any ischemic changes. CPK and troponin was drawn and those were negative. The patient required Neo-Synephrine to maintain blood pressure. A right upper quadrant ultrasound was performed on [11-7] due to abdominal pain, elevated white blood cell count, periods of hypotension This showed stones and sludge in the gallbladder, no evidence of acute cholecystitis. On the morning of postoperative day #9 the patient again acutely developed hypotension, systolic blood pressure in the 50's, the patient was noted to be in rate controlled atrial fibrillation, no clear etiology for the hypotension was identified. Attempted cardioversion times three at 300 joules which was successful. The patient was able to be atrially paced via his epicardial wires. The patient was reloaded with IV Amiodarone. The patient still had bilateral pleural chest tubes in place with occasional air leaks. Hypotension subsequently resolved with Neo-Synephrine and IV fluid infusion. The patient was noted to be having periods of agitation and was started on prn Haldol and Ativan with the addition of Clonidine to control agitation. Postoperative day #10 the patient continued to require Neo-Synephrine to maintain blood pressure as well as continued to have periods of atrial fibrillation and periods of sinus rhythm. The patient was noted to have multiple loose bowel movements and a culture for Clostridium difficile was sent which was subsequently negative. On [11-10] patient developed atrial fibrillation with rapid ventricular response and hypotension. The patient was cardioverted to sinus rhythm with 200 joules. The patient was bolused again with IV Amiodarone and a cardiology consult was called. Cardiology felt the periods of atrial fibrillation were due to patient's multiple medical problems and recommended continuing the IV Amiodarone and thought that as patient's condition improved, the atrial fibrillation would subsequently resolve. On postoperative day #12 the patient was noted to have continued hallucinations. The patient was continued to be medicated with Haldol and Ativan as needed. The patient was again noted to have a rising white blood cell count to 18 and his left pleural chest tube was removed as the tube had not had an air leak for several days. On postoperative day #13 all narcotics and Haldol were discontinued due to the hallucinations. Vancomycin was discontinued at the request of the infectious disease department as no positive sputum culture had been obtained. The patient continued on Levaquin for the previous positive sputum culture of E. coli and Moraxella. On postoperative day #14 the patient self extubated. The patient immediately had a tenuous respiratory status which slowly improved with vigorous pulmonary toilet and Vancomycin was again restarted for culture that showed gram positive cocci in sputum. The patient remained in Intensive Care Unit for pulmonary toilet. On postoperative day #16 the right pleural chest tube was removed, the patient was started on Diamox due to a metabolic alkalosis. The patient was also noted to have signs and symptoms of aspiration and felt that it was unsafe to give patient enteral feeds. The patient was started on TPN for nutrition. On postoperative day #17 the patient was noted to have a left effusion on his chest x-ray. The patient underwent thoracentesis in the SICU. 1300 cc of dark serosanguineous fluid was removed. The patient continued to receive aggressive pulmonary toilet. On [11-19] the patient was transferred from the Intensive Care Unit to the floor. The patient underwent a bedside swallowing evaluation which showed continued signs and symptoms of aspiration. Early in the morning of [11-20] the patient became acutely hypoxic and confused. The patient was readmitted to the Intensive Care Unit and several hours later reintubated for respiratory distress. The patient developed a fever of 102 and was pancultured. On [11-21] the patient underwent a tracheostomy and percutaneous endoscopic gastrostomy placement. The patient was weaned from mechanical ventilation. On postoperative day #23 the patient underwent lower extremity doppler ultrasound to evaluate possibility of deep vein thrombosis. A left iliac vein thrombosis was identified. The patient was started on Lovenox and Coumadin and patient remained in the Intensive Care Unit awaiting placement in a rehabilitation facility. CONDITION ON DISCHARGE: T max 100.2, heart rate 73, sinus rhythm, blood pressure 120/52, respiratory rate 20, oxygen saturation 100% on 50% trach mask. The patient is awake and alert following commands. The patient has a percutaneously placed tracheostomy tube in place. Cardiovascular is regular rate and rhythm without rub or murmur. Chest is clear to auscultation bilaterally. Abdomen is soft, non distended. PEG site is clean. Extremities, 2+ edema bilaterally. LABORATORY DATA: White blood cell count 10.5, hematocrit 30, platelet count 265,000, sodium 138, potassium 3.9, chloride 100, CO2 32, BUN 21, creatinine 1.1, PT 12.1, INR 1.1. Cultures 10-23, sputum culture negative, [11-20] urine culture negative, [11-20] blood culture times two pending, [11-16] pleural fluid culture negative, [11-14] stool culture negative for C. diff, [11-11] catheter tip negative. DISCHARGE STATUS: The patient is to be discharged to a rehabilitation facility in stable condition. DISCHARGE DIAGNOSIS: 1. Status post CABG. 2. Status post tracheostomy. 3. Status post PEG placement. 4. Postoperative atrial fibrillation. 5. Left iliac vein thrombosis. 6. Multiple episodes of respiratory failure. 7. Hypertension. 8. Hyperlipidemia. 9. Chronic obstructive pulmonary disease/asthma. 10. Cataracts. 11. Status post bilateral hernia surgery. 12. Chronic renal insufficiency. DISCHARGE MEDICATIONS: Albuterol and Atrovent nebulizer treatments q 4 hours and prn, Regular insulin sliding scale q 6 hours for blood sugar 150-200 give 4 units subcu, for blood sugar 201-250 give 6 units subcu, for blood sugar 251-300 give 8 units subcu, for blood sugar 301-400 give 10 units subcu. Lopressor 25 mg per G tube [Hospital1 ], Amiodarone 400 mg per G tube q day until [2181-11-28] then decrease to 200 mg per G tube q day, Captopril 6.25 mg per G tube q 8 hours, Digoxin 0.125 mg per G tube q day, Lovenox 60 mg subcu [Hospital1 ], Motrin 600 mg per G tube q 6 hours prn, Coumadin 2 mg po per G tube q day times two days, then check PT and adjust dose for target INR greater than 2.0. Lovenox is to be discontinued when INR greater than 2.0. The patient is to receive 50% oxygen via trach collar. The patient is to have a PT INR checked on [11-26]. The patient is to receive full strength Impact with fiber via G tube at 70 cc per hour. The patient is to be NPO until further speech and swallowing evaluation can be done. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 13625] Dictated By:[Last Name (NamePattern1) 3870] MEDQUIST36 D: [2181-11-23] 18:03 T: [2181-11-23] 19:55 JOB#: [Job Number 36154] ICD9 Codes: 5185, 2851, 5119
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8887 }	Medical Text: Admission Date: [2125-4-14] Discharge Date: [2125-4-17] Service: [Doctor Last Name ] HISTORY OF PRESENT ILLNESS: Ms. [Known firstname ] [Known lastname 39500] is a [Age over 90 ]-year-old female with a history of gastroesophageal reflux disease who presented to [Hospital1 69] at 2 a.m. after two episodes of coffee-grounds emesis as her nursing home. On the night of admission, she vomited 500 cc of coffee-grounds and then subsequently had another episode of 500 cc of frank blood at 8:45 p.m. She said she had not been feeling well the entire day. In the Emergency Department, the patient had another 700-cc episode of bright red hematemesis. Nasogastric lavage did not clear after one liter. She was originally admitted to the Medical Intensive Care Unit. An esophagogastroduodenoscopy showed a gastric ulceration with a large adherent blood clot on the posterior wall of the mid body of the stomach. The clot was removed revealing an underlying 1-cm cratered ulceration with a visible vessel. Endoclips were applied to the ulceration base. Helicobacter pylori serologies were sent. There was also evidence of a small hiatal hernia, duodenitis, and duodenal ulcerations. When seen in the Medical Intensive Care Unit, the patient had no complaints. She denied any chest pain, shortness of breath, abdominal pain, or lightheadedness. The patient also denied any history of nonsteroidal antiinflammatory drug use or significant alcohol history. She denied any previous bleeding episodes; however, she did report several days of black tarry stools prior to admission and said that overall she was not feeling well. The patient denied any fevers or chills. In the Medical Intensive Care Unit, she was transfused with 2 units of packed red blood cells and was hemodynamically stable. PAST MEDICAL HISTORY: 1. Gastroesophageal reflux disease. 2. Paroxysmal atrial fibrillation with a rapid ventricular rate. 3. Rectal prolapse and hemorrhoid surgery in [2124-12-9]. 4. Colonic polyps (benign). ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Colace. 2. Aspirin 325 mg by mouth once per day. 3. Multivitamin one tablet by mouth once per day. 4. Zoloft 50 mg by mouth once per day. 5. Digoxin 0.125 mg by mouth once per day. 6. Ritalin. 7. Os-Cal. 8. Aricept 5 mg by mouth once per day. 9. Remeron by mouth at hour of sleep. SOCIAL HISTORY: The patient is a nursing home resident. She lives at [First Name4 (NamePattern1) 730] [Last Name (NamePattern1) 731] in [Location 8391]. She reports occasionally smoking approximately five cigarettes per week. The patient reports occasional alcohol use. She denies any other drug use. FAMILY HISTORY: Family history was noncontributory. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed her temperature was 98 degrees Fahrenheit, her heart rate was 94, her blood pressure was 113/41, her respiratory rate was 18, and her oxygen saturation was 98% on room air. In general, she was an elderly female sitting comfortably in a chair. She was in no acute distress. Head, eyes, ears, nose, and throat examination revealed the pupils were equal, round, and reactive to light. The extraocular muscles were intact. The neck was without appreciable jugular venous distention at 45 degrees. There was no lymphadenopathy. Her heart was regular. There was a 2/6 systolic ejection murmur at the left lower sternal border as well as systolic. The lungs were clear to auscultation bilaterally. The abdomen was soft, nontender, and nondistended. She had decreased bowel sounds. The extremities were thin with good pulses. She had pneumatic boots in place. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission with a complete blood count which revealed a white blood cell count of 15, her hematocrit was 30.7 in the Medical Intensive Care Unit after receiving 2 units of packed red blood cells, her hematocrit prior to transfusion was 25, and her platelets were 197. She had a prothrombin time of 12.7, her partial thromboplastin time was 22.6, and her INR was 1. Her serum chemistries were all normal other than a blood urea nitrogen of 80. She had Helicobacter pylori serologies sent at the time of the esophagogastroduodenoscopy. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. GASTROINTESTINAL ISSUES: The patient was admitted with an upper gastrointestinal bleed with an esophagogastroduodenoscopy showing evidence of a gastric ulceration with stigmata of recent bleeding and underlying blood vessel that was clipped at the time of the esophagogastroduodenoscopy. The patient received 2 units of packed red blood cells in the Medical Intensive Care Unit. On the night after transfer to the floor, the patient's hematocrit fell from 30 to 27 and she received another unit. From that time forward, her hematocrit was stable. The patient was hemodynamically stable throughout her admission. The patient was placed on Protonix 40 mg intravenously q.12h. which was subsequently changed to 40 mg by mouth q.12h. The patient's diet was advanced as tolerated. Helicobacter pylori serologies done at the time of the esophagogastroduodenoscopy were positive on the day prior to discharge, and she was started on clarithromycin 500 mg by mouth twice per day, amoxicillin 1 gram by mouth q.12h., and was continued on her Protonix 40 mg by mouth q.12h. The patient was to stay on the Protonix for two months and clarithromycin and amoxicillin for two weeks. Her aspirin will be held indefinitely. The patient was to have followup with the Division of Gastroenterology and will most likely require a repeat endoscopy in several months. 2. CARDIOVASCULAR ISSUES: Per her granddaughter, the patient has a history of paroxysmal atrial fibrillation with rapid ventricular response. It was unclear at the time of admission why she was on digoxin; however, her granddaughter stated that she was placed on it when her atrial fibrillation was first noted. However, the patient has never been anticoagulated. The patient was continued on digoxin 0.125 mg by mouth every day and had no other cardiac events. 3. NEUROLOGIC ISSUES: The patient has an underlying history of dementia and is on Aricept and Ritalin as an outpatient. It was noted two days prior to discharge and on the day of discharge that her memory was somewhat worse with very low short-term memory. Her daughters felt that this was most likely secondary to disorientation and confusion after being in the hospital and displaced from familiar surroundings. The patient was continued on her Aricept, Ritalin, and Remeron. DISCHARGE DIAGNOSES: 1. Upper gastrointestinal bleed. 2. Dementia. 3. Helicobacter pylori infection. 4. Gastric ulceration. MEDICATIONS ON DISCHARGE: 1. Protonix 40 mg by mouth q.12h. (times two months). 2. Clarithromycin 500 mg by mouth twice per day (times 14 days). 3. Amoxicillin 1 gram by mouth q.12h. (times 14 days). 4. Digoxin 0.125 mg by mouth once per day. 5. Multivitamin one tablet by mouth once per day. 6. Ritalin 5 mg by mouth twice per day. 7. Remeron 15 mg by mouth at hour of sleep. 8. Zoloft 50 mg by mouth once per day. 9. Aricept 5 mg by mouth at hour of sleep. CONDITION AT DISCHARGE: At the time of discharge, the patient was confused but redirectable. She was repeatedly asking why she was here and clarifying where she was. She was without other physical complaints. Her vital signs were stable. Her hematocrit was stable at approximately 30. DISCHARGE STATUS: The patient was to be discharged back to [First Name4 (NamePattern1) 730] [Last Name (NamePattern1) 731] nursing home and was to be scheduled for gastrointestinal followup and will need follow up with her primary care physician in the next week. [Doctor Last Name ] [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 5712] Dictated By:[Last Name (NamePattern1) 9820] MEDQUIST36 D: [2125-4-17] 09:27 T: [2125-4-17] 09:41 JOB#: [Job Number 39501] ICD9 Codes: 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8888 }	Medical Text: Admission Date: [2155-4-21] Discharge Date: [2155-5-9] Service: CSU HISTORY OF PRESENT ILLNESS: Mr. [Known lastname ] is an 85 year-old man who underwent coronary artery bypass grafting x2 as well as aortic valve replacement on [2155-4-7] by Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 70]. His postoperative course was uneventful except for atrial fibrillation for which he was discharged on Coumadin. The patient was doing well at home until the day before admission when he developed increasing chest pain and fever. EMS was called and he was taken to [Hospital3 3583] where he was noted to be febrile to 203 in rapid atrial fibrillation with a ventricular response in the 120s and an increased white blood cell count to 18,000 with an INR of 4.2, otherwise unremarkable. His chest x-ray was reportedly negative and he was transferred to the [Hospital1 190] for further work up and care. PAST MEDICAL HISTORY: Is significant for coronary artery bypass graft x2 as well an aortic valve replacement and tissue valve, coronary artery disease, aortic stenosis, prostate carcinoma, paroxysmal atrial fibrillation, rectal bleeding, status post cauterization, cholelithiasis, status post abdominal aortic aneurysm repair in [2145], status post bilateral hernia repairs, status post right lung surgery, chronic renal insufficiency with a baseline creatinine of 1.1, chronic obstructive pulmonary disease. MEDICATIONS AT HOME: Included aspirin 81 mg daily, Colace 100 mg b.i.d., Flovent 110 2 puffs b.i.d., Percocet 5/325 1 to 2 tablets p.o. q 4 to 6 hours p.r.n., Atrovent 2 puffs q.i.d., Protonix 40 mg daily, Lopressor 25 mg b.i.d., Lipitor 20 mg daily, Bacitracin ointment to air lesions, Celexa 10 mg daily and Warfarin which is held from [4-18] on due to an elevated INR. ALLERGIES: Patient states no known drug allergies. PHYSICAL EXAMINATION: At time of admission temperature 99.9, pulse 94, blood pressure 124/70, respiratory rate 24, O2 saturation 94% on 3 liters by nasal cannula. Neurologic grossly intact, moves all extremities without difficulty. Pulmonary with scattered rhonchi, diminished breath sounds at the bases. Cardiovascular: Irregularly irregular with no murmur. Abdomen is soft and nontender, nondistended. Extremities are warm with no edema. Sternum is stable with Steri-Strips. No erythema or drainage. Patient was admitted to CT surgery. He was scheduled for a chest CT as well as a chest x-ray and echocardiogram. He was begun on Vancomycin and levofloxacin pending the results of blood and wound cultures. Chest CT showed a suspicious for small subcutaneous fluid collection. Also a deep infected fluid collection. Superficial exploration relieved the small fluid collection. Culture was sent. The bone appeared to be intact at that time and it was decided to treat the patient conservatively with frequent dressing changes plus or minus the operating room for debridement if there was no significant improvement. Over the next several days the patient's wound showed significant improvement with decreasing amounts of drainage and beginnings of granulation tissue in the wound margins. A PICC line was placed on hospital day #4 for anticipated long term Vancomycin infusions. However, on hospital day 8 it was noted that the patient's sternal drainage had again increased with the wound appearing less stable and at this time decision was made to bring him to the operating room for surgical incisions and drainage of the wound with plus or minus sternal debridement. The patient did indeed undergo sternal debridement once in the operating room. Please the operating room report for full details. He tolerated the operation well and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. At the time of transfer the patient's chest was open with packed sternal wound. He was also seen by plastic surgery at that time. Over the next several days the patient remained in the Cardiothoracic Intensive Care Unit. During that period he was chemically paralyzed and sedated with an open chest wound. He remained hemodynamically stable throughout that period and on [5-1] the patient was brought to the operating room once again for bilateral pectoralis advancement flaps and sternal wound closure. He tolerated this operation well. Please seen the operating room report for full details. Following wound closure he was transferred from the operating room to the Cardiothoracic Intensive Care Unit without complications. Following wound closure the patient's paralytics were discontinued. On postoperative day #1 he was weaned from the ventilator and successfully extubated. He was begun on oral beta blockade and his diet was advanced as tolerated and on postoperative day #3 he was transferred to floor for continuing postoperative care and activity advancement. Over the next week the patient had an uneventful hospital course. His activity was increased with the assistance of nursing and physical therapy. The [First Name8 (NamePattern2) 1661] [Last Name (NamePattern1) 1662] drains in his chest were removed by plastic surgery service and on postoperative day #11 and #8 it was decided that the patient was stable and ready to be transferred to rehabilitation. At the time of this dictation the patient's physical is as follows: Temperature 98.3, heart rate 74 in atrial fibrillation, blood pressure 116/60, respiratory rate 20, O2 saturation 95% on room air. Weight preoperatively 80 kilos, at discharge is 82.5 kilos. LABORATORY DATA: White count 7.3, hematocrit 33.8, platelets 266, sodium 140, potassium 4.0, chloride 101, CO2 32, BUN 13, creatinine 1.1, glucose 97, PT is 18.2 with an INR of 2.1. PHYSICAL EXAMINATION: Neurologically alert and oriented times three, moves all extremities, follows commands, nonfocal examination. Pulmonary: Diminished at the bases with scattered rhonchi, otherwise clear. Cardiac: Irregularly irregular, S1 and S2 with no murmurs. Sternum with running sutures, is open to air, clean and dry. Bilateral deltoid incisions open to air, clean and dry with one [First Name8 (NamePattern2) 1661] [Last Name (NamePattern1) 1662] drain draining serosanguineous fluid. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are warm and well perfused with 1 to 2+ edema. Additionally the patient has a PICC in the left antecubital space, slight without erythema. Patient is to be discharged to rehabilitation. He is to have follow up with Dr. [Last Name (STitle) ] in the plastic surgery clinic one week following transfer for assessment of [First Name8 (NamePattern2) 1661] [Last Name (NamePattern1) 1662] drain. Follow up with Dr. [Last Name (STitle) 70] in four to six weeks and follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] four weeks after discharge from rehabilitation. CONDITION AT TIME OF DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Aortic sclerosis - status post aortic valve replacement. 2. Coronary artery disease - status post coronary artery bypass graft times two on [2155-4-7]. 3. Status post sternal debridement on [4-28]. 4. Status post pectoralis flap advancement and sternal wound closure on [5-1]. 5. Prostatic carcinoma. 6. Abdominal aortic aneurysm repair in [2145]. 7. Status post right lung surgery. 8. Chronic renal insufficiency with baseline creatinine of 1.1. 9. Chronic obstructive pulmonary disease. 10. Status post bilateral hernia repairs. 11. Status post right lung surgery. DISCHARGE MEDICATIONS: Include Combivent 1 to 2 puffs q 6 hours p.r.n., zinc sulfate 220 mg daily times one month, Percocet 5/325 1 to 2 tablets q 4 to 6 hours p.r.n. for pain, ascorbic acid 500 mg b.i.d. x one month, Colace 100 mg b.i.d. while taking Percocet, aspirin 81 mg daily, pantoprazole 40 mg daily, metoprolol 50 mg b.i.d., Lasix 20 mg daily, multivitamin 1 tablet daily, warfarin as directed to maintain the target INR of 2 to 2.5, Vancomycin 750 mg q 24 hours x 2 weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5662], [MD Number(1) 5663] Dictated By:[Last Name (NamePattern4) 1718] MEDQUIST36 D: [2155-5-9] 13:16:41 T: [2155-5-9] 14:08:13 Job#: [Job Number 34280] ICD9 Codes: 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8889 }	Medical Text: Admission Date: [2118-4-17] Discharge Date: [2118-4-25] Date of Birth: [2070-3-9] Sex: M Service: SURGERY Allergies: Penicillins / Codeine / Shellfish Derived Attending:[First Name3 (LF) 695] Chief Complaint: ESRD Major Surgical or Invasive Procedure: deceased donor renal transplant [2118-4-17] History of Present Illness: 48M man w/ ESRD [12-22] HIV associated membranous nephropathy s/p failed renal transplant in [1-/2117] presents for second renal transplant today. Patient reports that he has been in his usual state of health. He denies fevers, chills, nausea, vomiting, dysuria but reports some loose stools. He denies weight loss, and reports that his appetite has been normal. His last BM was this morning and was normal in appearance for him. His last dialysis was friday and his dialyzed on MWF. His Blood group is O and his cPRA is 41% with unacceptable antigens listed as follows: A43, A80, B8, B44, B45, B76, B82. He has not had any class 2 antibodies detected to date. ROS: (+) per HPI (-) Denies pain, unexplained weight loss, fatigue/malaise/lethargy, changes in appetite, trouble with sleep, pruritis, jaundice, rashes, bleeding, easy bruising, headache, dizziness, vertigo, syncope, weakness, paresthesias, nausea, vomiting, hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema, urinary frequency, urgency Past Medical History: 1. ESRD [12-22] membranous glomerulonephritis --s/p DCD KT on [2117-2-6], postop course with delayed graft function requiring HD 2. HIV+ - very durable sustained viral suppression with most recent HIV VL < 48 copies/mL and CD4 count in the 800s (per ID note [2117-3-11]) 3. Hyperlipidemia 4. Avascular necrosis of hips 5. Hyperparathyroidism 6. Hypertension 7. Hyperglycemia due to steroids, now on insulin Social History: Lives with partner of in [Name (NI) 3914]. No children, worked as a customer service manager for [Company ] until medically disabled. Does not smoke, drink ETOH or use recreational drugs. Family History: Father is deceased- had CRF, HTN, DM; Mother is deceased- had colon CA. Twin Brother is deceased from HIV related complications and renal failure; sister is alive and healthy and has offered a kidney. Physical Exam: Vitals: 94.1 86 133/80 18 96RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, obese abdomen, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses, right paramedial incision, no hernias DRE: normal tone, no gross or occult blood Ext: LUE arm clotted AVG, LUE forearm clotted AVG Bilateral palpable peripheral pulses (fem, [Doctor Last Name ], DP) No LE edema, LE warm and well perfused Both feet have very dry skin, sensation impaired bilaterally due to diabetes associated peripheral neuropathy Laboratory: Chem10 138 99 53 3.8 19 13.0 ∆ Ca: 8.4 Mg: 2.2 P: 3.2 ALT: 47 AP: Tbili: Alb: 4.4 AST: 44 LDH: Dbili: TProt: [Doctor First Name ]: Lip: CBC 11.9 ∆ > 30.5 < 311 [Name (NI) 2591] PT: 13.6 PTT: 33.8 INR: 1.2 Urinalysis - +leuk, +nitr, +WBC, +epi (contaminated UA) EKG ([2118-4-18]): normal EKG, sinus rhythm, no ST abnormalities Imaging: CXR [2118-4-18]: no consolidation or effusion Pertinent Results: [2118-4-25] 06:45AM BLOOD WBC-7.2 RBC-3.49* Hgb-9.8* Hct-28.3* MCV-81* MCH-28.0 MCHC-34.5 RDW-15.2 Plt Ct-186 [2118-4-20] 02:56AM BLOOD PT-13.5* PTT-27.8 INR(PT)-1.2* [2118-4-21] 05:55AM BLOOD WBC-7.1 Lymph-2.9* Abs [Last Name (un) ]-206 CD3%-21 Abs CD3-42* CD4%-3 Abs CD4-7* CD8%-17 Abs CD8-35* CD4/CD8-0.2* [2118-4-25] 06:45AM BLOOD Glucose-92 UreaN-54* Creat-11.3# Na-140 K-3.4 Cl-100 HCO3-26 AnGap-17 [2118-4-25] 06:45AM BLOOD Calcium-7.8 Phos-4.4 Mg-2.1 [2118-4-25] 06:45AM BLOOD tacroFK-6.8 Brief Hospital Course: On [2118-4-18], he underwent deceased donor renal transplant with 24 hours of cold ischemia. Surgeon was Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. [Initials (NamePattern4) ] [Last Name (NamePattern4) 406] drain was left in place. Please refer to operative note for details. Postop, he experienced hypotension during the case requiring neo for bp support and PRBCs. He made a little urine in the OR then became anuric after the OR. He was transferred to the SICU for management. Pressor support was weaned off and he was extubated. TTE was done to evaluate hypotension. EF was 55%. He was noted to have mild LVH and mild pulmonary artery systolic HTN. He required IV medication treatment for hyperkalemia. Urine output slowly increased to 1 liter per day and creatinine ranged between [10-2]. He experienced delayed graft function and required hemodialysis. Renal duplex demonstrated appropriate vasculature, no hydro and no perinephric fluid collections. [Doctor Last Name 406] drain output was serosanguinous with a lot of leaking around the [Doctor Last Name 406] drain insertion site. Diet was advanced and tolerated. [Last Name (un) ] was consulted to adjust insulin given elevated glucoses from the steroids. Pain medication was adjusted to oral Dilaudid. IR placed a left IJ triple lumen for meds for poor access. Immunosuppression consisted of ATG 150mg for a total of 4 doses given past response to ATG and DGF. CellCept was well tolerated, Solu-Medrol was tapered to prednisone 20mg daily and Prograf was adjusted to 20mg [Hospital1 ] as trough levels were slow to increase to goal (6.8 on [4-25]). Nephrology followed him throughout his stay. ID and pharmacy renally dosed his ARVs. The decision was made to send him home on dialysis to return on Thursday [4-28] at noon for a 1pm renal transplant biopsy. He would then stay overnight for observation and have HD on Friday [4-29]. PT was consulted and recommended PT at home. [Location (un) 43512] Area VNA was arranged. He was ambulating with a walker at time of discharge. Vital signs were stable. [Doctor Last Name 406] drain was removed and site suture the day of discharge. Medications on Admission: abacavir 300', dialyvite 1', cinacalcet 60', emtricitabine 200 every 4 days, ezetimibe 10', tricor 1tab', insulin lispro RISS, metorprolol tartrate 50'', mycophenolate mofetil 2tabs", prednisone 5', raltegravir 400'', sevelamer 800mg x 8'', sirolimus 6', tenofovir 300 Qmon, zolpidem 20 PO Qhs, calcium carbonate 500''', NPH insulin 9U QAM, and 3U QPM, omega-3 fish oil 3000' Discharge Medications: 1. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. abacavir 300 mg Tablet Sig: Two (2) Tablet PO Q 24H (Every 24 Hours). 6. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO prn every 8 hours as needed for pain. 8. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (TU,FR). 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 11. sevelamer carbonate 800 mg Tablet Sig: Eight (8) Tablet PO BID W/ MEALS (). 12. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO Q72H (every 72 hours). 13. tacrolimus 5 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours). 14. NPH insulin human recomb 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous once a day. 15. NPH insulin human recomb 100 unit/mL Suspension Sig: Three (3) units Subcutaneous at bedtime. 16. Humalog 100 unit/mL Solution Sig: sliding scale units Subcutaneous four times a day. 17. Outpatient Lab Work Every Monday and Thursday: cbc, chem 10, ast, t.bili, UA and trough prograf with results fax'd to [Hospital1 18] Translant Office attn: [Name6 (MD) 5036] [Name8 (MD) 5039] RN coordinator [Telephone/Fax (1) 697] 18. prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [Location (un) 43512] Area VNA Discharge Diagnosis: esrd delayed renal graft function hiv Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Please call the Transplant Office [Telephone/Fax (1) 673] if you have fever, chills, nausea, vomiting, inability to take any of your medications/eat or drink fluid, increased abdominal pain/distension, incision redness/bleeding/drainage, or leaking from old drain site. You should continue with your dialysis schedule on Tues-Thursday-Sat [Location (un) 43512] VNA services have been arranged You will need to have labs drawn every Monday and Thursday. You may shower No driving while taking pain medication No heavy lifting/straining Followup Instructions: Provider: [First Name11 (Name Pattern1) 674] [Last Name (NamePattern4) 675], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2118-4-28] 2:10 Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] TRANSPLANT SOCIAL WORK Date/Time:[2118-4-28] 3:00 Provider: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2118-5-2] 1:00 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2118-4-26] ICD9 Codes: 5856, 2767, 3572, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8890 }	Medical Text: Admission Date: [2141-10-13] Discharge Date: [2141-10-19] Date of Birth: [2092-4-6] Sex: M Service: SURGERY Allergies: Iodine; Iodine Containing Attending:[First Name3 (LF) 668] Chief Complaint: ESRD Major Surgical or Invasive Procedure: [2141-10-14] renal transplant History of Present Illness: 49M with ESRD [1-30] DM1 maintained on HD MWF (right AVF). Last HD [10-13] (full session). Patient feels well. Denies f/c, SOB, CP. Makes little urine (a little bit over a teaspoon/day). No history of abdominal surgeries. Past Medical History: 1. CAD s/p [Month/Year (2) ] to OM1 in [9-2] and [Month/Day (1) ] to RCA in [5-5] 2. End-stage renal disease, on HD since [6-3] (MWF) 3. Diabetes mellitus, type I: Diagnosed at age 20, on insulin, c/b nephropathy, neuropathy, and retinopathy status post multiple laser surgeries. Right upper extremity fistula. Chronic ulcers on left foot. 4. Hypertension 5. Hyperlipidemia 6. Obstructive sleep apnea 7. G6PD deficiency 8. Right fifth toe amputation, [2137-3-29]. 9. History of hepatitis B infection 10. Sexual dysfunction s/p penile prosthesis implantation 11. Kidney transplant, right iliac fossa [2141-10-14]. Social History: The patient lives with his wife and 2 sons in [Name (NI) 669]. Previously worked at NSTAR as a janitor, and is currently on diability. No tobacco or EtOH use. Family History: There is no family history of premature coronary artery disease or sudden death. Mother has diabetes mellitus. Father is healthy and multiple half brothers and sisters. Two children, both boys, are healthy. Multiple aunts and uncles decreased from complications of diabetes. No family hx of Wegener's or [Last Name (un) 95749]-[Doctor Last Name 3532] disease. Physical Exam: 98.6, 70, 160/77, 16, 98RA NAD, A+OX3 RRR CTAB Soft, NT/ND +BS no c/c/e, 2+ femoral pulses b/l, weak DP pulses b/l Right AVF + thrill, no erythema Pertinent Results: [2141-10-14] 12:55AM BLOOD WBC-6.4 RBC-4.00* Hgb-11.3* Hct-36.0* MCV-90 MCH-28.1 MCHC-31.3 RDW-16.6* Plt Ct-254 [2141-10-15] 02:34AM BLOOD WBC-10.9 RBC-3.41* Hgb-9.8* Hct-31.0* MCV-91 MCH-28.7 MCHC-31.6 RDW-16.4* Plt Ct-210 [2141-10-15] 02:53PM BLOOD Hct-23.9* [2141-10-19] 05:12AM BLOOD WBC-5.5 RBC-3.78* Hgb-11.2* Hct-34.0* MCV-90 MCH-29.6 MCHC-33.0 RDW-16.5* Plt Ct-153 [2141-10-17] 05:32AM BLOOD PT-13.2 PTT-27.3 INR(PT)-1.1 [2141-10-17] 05:32AM BLOOD ALT-20 AST-14 AlkPhos-72 TotBili-0.3 [2141-10-14] 02:01PM BLOOD CK-MB-11* MB Indx-8.6* cTropnT-0.25* [2141-10-14] 07:54PM BLOOD CK-MB-23* MB Indx-10.1* cTropnT-0.65* [2141-10-15] 12:35PM BLOOD CK-MB-17* MB Indx-11.2* cTropnT-1.13* [2141-10-15] 10:44PM BLOOD CK-MB-10 MB Indx-8.8* cTropnT-0.72* [2141-10-16] 03:26AM BLOOD CK-MB-NotDone cTropnT-0.65* [2141-10-19] 05:12AM BLOOD Calcium-8.2* Phos-5.7* Mg-1.9 [2141-10-19] 05:12AM BLOOD tacroFK-7.7 Brief Hospital Course: On [2141-10-14], he underwent kidney transplant into right iliac fossa. Surgeon was Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. A double-J ureteral stent was not placed due to small ureteral size. A 19 [Doctor Last Name 406] drain was placed in the retroperitoneum. Induction immunosuppression (ATG, solumedrol and cellcept)were administered. Please refer to operative notes for complete details. After closing, he was hypotensive requiring pressor support. ECG had new ST segment depressions laterally and ST elevation in aVR. A NTG drip was given. Cardiology was consulted. TTE was performed with moderate LVH, MAC, small LVcavity, mild inferior and inferolateral HK but overall preserved EF, and nl RV/septal motion. Cardiac enzymes were checked showing a troponin leak. He was transferred to the SICU where a heparin drip was run. Hypotensive response was felt to be possibly due to ATG. Cardiology recomended lopressor and statin with repeat TTE during this admission. Hct dropped from 35 to 31. He was given PRBC. Heparin drip was stopped and hct stabilized. Home doses of [Doctor Last Name ] and plavix were resumed. A total of 3 doses of ATG were given after premedication with tylenol/benadryl and higher doses of solumedrol as well as slower administration of ATG. Over the next few days, urine output increased to 3-4 liters and creatinine trended down to 5.5. Foley was removed without incident. IV fluids were stopped. Diet was advanced and tolerated. Pain was controlled with oral meds. Extensive medication teaching was done. Steroids were tapered. Cellect was well tolerated. Prograf was up-titrated to 12mg [Hospital1 ] for slowly rising prograf levels (7.7). A repeat TTE was done per Cardiology demonstrating severe symmetric left ventricular hypertrophy. Overall LVSF was normal (LVEF>55%)with possible focal inferior hypokinesis (although not seen consistently in all views). Doppler parameters were most consistent with Grade II (moderate) left ventricular diastolic dysfunction" and moderate pulmonary artery systolic hypertension. Lopressor doses were increased for SBPs up to 190. Home doses of hydralazine were resumed, isosorbide was increased and Norvasc was added with some improvement of BP. Of note, he required an insulin drip for a day to control hyperglycemia from the steroids. This was switched to SQ insulin (NPH and Humalog)with improved glucose control. He was ambulatory. PT cleared him for home with a cane. VNA services were arranged as he was discharged with his JP drain which averaged 90-145cc of serosanuinous fluid. Medications on Admission: Lyrica 25', Humalog SSI (usually 12 units qmeal), Levamir 28 Units [Last Name (LF) 5910], [First Name3 (LF) ] 325', Nefidical 90", Isosorbide 30', Loperamide 2', Lipitor 80', Hydralazine 75''', Toporol 350', Plavix 75', Trazadone 50', Lisinopril 20', Zetia 10' Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days. Disp:3 Tablet(s) Refills:0 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO three times a day. 10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO QAM (once a day (in the morning)). 11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO QPM (once a day (in the evening)). 12. Isosorbide Mononitrate 60 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 13. Tacrolimus 5 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 14. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for incision pain. Disp:30 Tablet(s) Refills:0 16. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 17. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day. 18. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 19. Outpatient Lab Work Outpatient Labs: Sat [2141-10-21] @ [Hospital Ward Name 516], [Hospital Ward Name 1826] Building [Location (un) ] cbc, chem 7 and trough prograf level 20. NPH Insulin Human Recomb 300 unit/3 mL Insulin Pen Sig: Thirty Five (35) units Subcutaneous every morning: and 20 units at supper. Disp:10 pens Refills:1 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: esrd HTN DM CAD hypotensive reaction to ATG Discharge Condition: good Discharge Instructions: Please call the Transplant Office [Telephone/Fax (1) 673] if fever, chills,nausea, vomiting, inability to take any of your medication, abdominal distension, increased incisional pain, incision redness/bleeding/drainage or jp drain site is red. Call if drain output stops You will need to have labs drawn twice weekly at [Last Name (NamePattern1) 8028] Lab every Monday and Thursday prior to 9am [Month (only) 116] shower No heavy lifting/straining No driving while taking pain medication Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2141-10-23] 8:30 Provider: [Name10 (NameIs) 2841] LABORATORY Phone:[Telephone/Fax (1) 2846] Date/Time:[2141-11-6] 1:00 Provider: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2141-11-8] 8:00 Completed by:[2141-10-22] ICD9 Codes: 5856, 5845, 9971, 2762, 3572, 2724, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8891 }	Medical Text: Admission Date: [2193-2-11] Discharge Date: [2193-2-25] Date of Birth: [2147-6-3] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 78] Chief Complaint: headache Major Surgical or Invasive Procedure: [2193-2-11]: EVD placement History of Present Illness: 45F known only for HTN (treated) found to have very severe h/a and vomitting on [2-11]. CT head at OSH shows SAH and patient is transferred to [Hospital1 18] for further eval. Past Medical History: HTN Social History: non-contributory Family History: non-contributory Physical Exam: On Admission: 127/77 55 15 100% Sleepy but arousable; spanish speaking only; Follows simple commands w all 4 ext. Talks very minimally; able to tell her name but not location or time. PERLA, EOMI; Face symetric; Tongue midline; Moves all 4 ext symetrically and with full strength; No pronator drift; Neck tenderness; On Discharge: Non focal Pertinent Results: Labs on admission: [2193-2-11] 06:42PM BLOOD WBC-20.7* RBC-4.71 Hgb-10.6* Hct-34.8* MCV-74* MCH-22.5* MCHC-30.5* RDW-16.8* Plt Ct-476* [2193-2-11] 06:42PM BLOOD Neuts-91.3* Lymphs-7.0* Monos-1.5* Eos-0 Baso-0.1 [2193-2-11] 06:42PM BLOOD PT-12.7 PTT-28.3 INR(PT)-1.1 [2193-2-11] 06:42PM BLOOD Glucose-144* UreaN-8 Creat-0.7 Na-136 K-4.0 Cl-102 HCO3-16* AnGap-22* [2193-2-12] 01:56AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.6 [2193-2-12] 01:56AM BLOOD Phenyto-10.6 IMAGING: CT/A Head [2193-2-11]: CT HEAD: Again seen is diffuse bilateral subarachnoid hemorrhage within the sylvian fissures, basilar cisterns, prepontine and ambient cisterns. Again seen are small bilateral hyperdense collections layering within the occipital horns. There is persistent effacement of the cortical sulci. The ventricular system is unchanged in size and configuration. [Doctor Last Name ]-white matter differentiation is preserved. There is no evidence of acute territorial infarction. Again noted is a mucous retention cyst in the right maxillary sinus. There is mild mucosal thickening involving both maxillary sinuses and several bilateral ethmoid air cells. No evidence of fracture. CTA HEAD: The vertebral arteries are codominant and patent. There is a 2.5 mm outpouching of the V4 segment of the left vertebral artery which may involve the PICA origin (image 188 series 2; image 26 series 300b,image 21 series 301b). There is possible infundibular dilatation or ectasia involving the basilar artery at the origins of the superior cerebellar arteries. The intracranial internal carotid, anterior, middle, and posterior cerebral arteries are patent without evidence of occlusion, high-grade stenosis, aneurysm, or arteriovenous malformation. No additional aneurysms are identified. CTA NECK: The origins of the great vessels at the level of the aortic arch are unremarkable. The paired vertebral arteries are patent in their entirety. Again seen is the 2.5 mm outpouching involving the V4 segment of the left vertebral artery. The extracranial common, internal, and external carotid arteries are normal in course and caliber without evidence of high-grade stenosis or occlusion. There are dependent atelectatic changes, left greater than right. There are mild degenerative changes of the cervical spine, most pronounced at C5-6. IMPRESSION: 1. 2.5 mm outpouching of the V4 segment of the left vertebral artery which may involve the PICA origin. 2. Stable extensive bilateral subarachnoid hemorrhage with mild dilatation of the lateral ventricles, unchanged since the prior examination. [2193-2-20] CT brain IMPRESSION: 1. Mild increase in ventricular size following drain clamping. 2. Evolving SAH and left PICA aneurysm clip. 3. Persistent left parietal hyperdensity likely represents a vascular malformation. MR can be ordered for further characterization. Brief Hospital Course: Patient began experiencing a sever headache and vomiting and presented to OSH on [2193-2-11] and was found to have SAH on CT with a basilar tip aneurysm. She was trasnferred to [Hospital1 18] for further management. She was lethargic but arousable and following simple commands upon presentation. Due to her CT results an EVD was emergently placed by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. She was started on Nimodopine for vasospasm prohylaxis and on the morning of [2193-2-12] she underwent cerebral angiogram which showed a left PICA aneurysm which was subsequently coiled. After the angiogram she was transferred to the ICU where she was placed on vasospasm watch. She remained stable in the ICU and her exam slowly improved. On [2-13] she was awake and oriented to her self, location, and date and strength was full but was slightly lethargic and a language barrier was present as she is spanish speaking only. On [2193-2-15] her exam remained stable and she was much more awake and interactive with the exam. Her EVD was raised to 25. On [2193-2-16] it was noted that EVD was slightly pulled out on imaging thus resecured with staples. On [2193-2-17] the EVD was clamped at 10am and began to experience ICP recordings in the 20's, max was 38- EVD was reopened. She had a second clamping trial and the EVD was successfully removed on [2-21]. In the afternoon, it was noted that CSF was draining from the EVD site in which staples and dermabond was used to close the incision more accurately. It was unsuccessful, CSF continued to drain from the site and sutures were placed to create better closure of incision. Patient was asked to cough and no CSF was observed. Patient was again evaluated by PT for stairs, and they determined over the weekend that she was not yet ready to be discharged to home where she has 3 flights of stairs to climb. THey reevaluated the patient on monday, [2193-2-25] and found that she was safe for discharge - she agrees with the plan. Her incision remains dry. 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. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for headache. Disp:30 Tablet(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Use while taking Tramadol. Disp:60 Capsule(s) Refills:2 Discharge Disposition: Home with Service Discharge Diagnosis: atraumatic SAH, left PICA aneurysm Discharge Condition: Neurologically Stable Discharge Instructions: GENERAL INSTRUCTIONS WOUND CARE ?????? You or a family member should inspect your wound every day and report any of the following problems to your physician. ?????? Keep your incision clean and dry. ?????? You may wash your hair with a mild shampoo 24 hours after your sutures are removed. ?????? Do NOT apply any lotions, ointments or other products to your incision. ?????? DO NOT DRIVE until you are seen at the first follow up appointment. ?????? Do not lift objects over 10 pounds until approved by your physician. [Name10 (NameIs) ] [Name Initial (NameIs) ] normal well balanced [Name Initial (NameIs) ] is recommended for recovery, and you should resume any specially prescribed [Name Initial (NameIs) ] you were eating before your surgery. MEDICATIONS: ?????? Take all of your medications as ordered. You do not have to take pain medication unless it is needed. It is important that you are able to cough, breathe deeply, and is comfortable enough to walk. ?????? Do not use alcohol while taking pain medication. ?????? Medications that may be prescribed include: -Narcotic pain medication such as Dilaudid (hydromorphone). -An over the counter stool softener for constipation (Colace or Docusate). If you become constipated, try products such as Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or Fleets enema if needed). Often times, pain medication and anesthesia can cause constipation. ACTIVITY: The first few weeks after you are discharged you may feel tired or fatigued. This is normal. You should become a little stronger every day. Activity is the most important measure you can take to prevent complications and to begin to feel like yourself again. In general: ?????? Follow the activity instructions given to you by your doctor and therapist. ?????? Increase your activity slowly; do not do too much because you are feeling good. ?????? You may resume sexual activity as your tolerance allows. ?????? If you feel light headed or fatigued after increasing activity, rest, decrease the amount of activity that you do, and begin building your tolerance to activity more slowly. ?????? DO NOT DRIVE until you speak with your physician. ?????? Do not lift objects over 10 pounds until approved by your physician. ?????? Avoid any activity that causes you to hold your breath and push, for example weight lifting, lifting or moving heavy objects, or straining at stool. ?????? Do your breathing exercises every two hours. ?????? Use your incentive spirometer 10 times every hour that you are awake. WHEN TO CALL YOUR SURGEON: With any surgery there are risks of complications. Although your surgery is over, there is the possibility of some of these complications developing. These complications include: infection, blood clots, or neurological changes. Call your Physician Immediately if you Experience: ?????? Confusion, fainting, blacking out, extreme fatigue, memory loss, or difficulty speaking. ?????? Double, or blurred vision. Loss of vision, either partial or total. ?????? Hallucinations ?????? Numbness, tingling, or weakness in your extremities or face. ?????? Stiff neck, and/or a fever of 101.5F or more. ?????? Severe sensitivity to light. (Photophobia) ?????? Severe headache or change in headache. ?????? Seizure ?????? Problems controlling your bowels or bladder. ?????? Productive cough with yellow or green sputum. ?????? Swelling, redness, or tenderness in your calf or thigh. Call 911 or go to the Nearest Emergency Room if you Experience: ?????? Sudden difficulty in breathing. ?????? New onset of seizure or change in seizure, or seizure from which you wake up confused. ?????? A seizure that lasts more than 5 minutes. Important Instructions Regarding Emergencies and After-Hour Calls ?????? If you have what you feel is a true emergency at any time, please present immediately to your local emergency room, where a doctor there will evaluate you and contact us if needed. Due to the complexity of neurosurgical procedures and treatment of neurosurgical problems, effective advice regarding emergency situations cannot be given over the telephone. ?????? Should you have a situation which is not life-threatening, but you feel needs addressing before normal office hours or on the weekend, please present to the local emergency room, where the physician there will evaluate you and contact us if needed. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office on or about 2/29/[2193] for removal of your sutures and a wound check. Please make this appointment by calling [Telephone/Fax (1) 1669]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????([Telephone/Fax (1) 88] Dr. [First Name (STitle) ], - an appointment had been made for you to be seen in 4 weeks. * You will have an [First Name (STitle) 4338]/MRA of teh brain before this appointment. Provider: [Name10 (NameIs) 4338] Phone:[Telephone/Fax (1) 327] Date/Time:[2193-3-28] 2:00 Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 7746], MD Phone:[Telephone/Fax (1) 3666] Date/Time:[2193-3-28] 3:15 Completed by:[2193-2-25] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8892 }	Medical Text: Admission Date: [2163-9-4] Discharge Date: [2163-9-9] Date of Birth: [2097-3-31] Sex: M Service: Trauma Surgery HISTORY OF PRESENT ILLNESS: This is a 66-year-old male, status post motor vehicle crash, prolonged extrication, less than 5 minutes loss of consciousness, restrained driver, hemodynamically stable in transit. No complaints on arrival. PAST MEDICAL HISTORY: Past medical history of hypertension. MEDICATIONS ON ADMISSION: The patient's home medications included Lasix 40 mg p.o. q.d. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed temperature was 97.6, pulse was 87, respiratory rate was 18, blood pressure was 151/74, oxygen saturation was 100%. In general, alert and oriented times three. Moved all extremities. Pupils were equal, round, and reactive to light and accommodation; 3 mm. Right parietal laceration of approximately 6 cm. Trachea was midline. Cardiovascular revealed a regular rate and rhythm. Lungs were clear to auscultation. No crepitus. Abdomen revealed bowel sounds were present. Protuberant and nontender. Rectal was negative. Pelvis was stable. Extremities revealed no deformities. Neck had no stepoff, no deformities. PERTINENT LABORATORY DATA ON PRESENTATION: Initial laboratories with complete blood count which revealed white blood cell count was 11, hematocrit was 38.2, platelets were 201. Coagulations revealed PTT was 13.5, PTT was 26.2, INR was 1.3. Fibrinogen was 226. Amylase was 41. Chemistry-7 revealed sodium was 139, potassium was 4.6, chloride was 105, bicarbonate was 27, blood urea nitrogen was 18, creatinine was 0.9, and blood glucose was 127. Arterial blood gas revealed 7.43/41/159. Lactate was 3.1. Toxicology screen was negative. Urinalysis revealed 3 to 5 red blood cells. RADIOLOGY/IMAGING: The patient had a CT of the head on [9-4] which showed a large bilateral subarachnoid hemorrhage with a right frontal lobe contusion. Chest x-ray was negative. Pelvic x-ray was negative. CT of the cervical spine was negative. CT of the abdomen and pelvis were negative for trauma. A well circumscribed rounded approximately 19-cm X 25-cm mass in the parenchyma of the right adrenal gland. Multiple bilateral simple renal cysts. One of the cysts in the right kidney had possibly ruptured. A CT of the pelvis was negative except for the findings noted above. Thoracic and lumbar spine x-rays were negative. HOSPITAL COURSE: Neurosurgery was consulted. They recommended loading the patient with Dilantin 100 mg intravenously t.i.d., keep blood pressure below 150, hold aspirin and Coumadin; if the patient is on these medications, and correct coagulations as needed. A repeat head CT in the morning. The patient had a repeat head CT on [9-5] which showed a slight increase in the right frontal contusion and the subarachnoid hemorrhage; no shift. The patient had a follow-up head CT on [9-6] to check the size of the hemorrhage which was stable; no changed from [9-5]. The patient's large head laceration was closed using a running locked stitch for hemostasis. In the Trauma Intensive Care Unit, the patient persistently removed collar, trying to get out of bed. He was given Haldol with good effect. A right subclavian line was placed in the Unit. The patient was alert and oriented times two; disoriented to place, moved all extremities. Sensation was grossly intact. The patient stepped down to the floor. The Foley was decided. The patient was able to urinate. However, the patient had gross hematuria; per family. Urinalysis was sent which had greater than 50 red blood cells in the urine. Urology was consulted for the possibly ruptured renal cyst to determine if further imaging was necessary. They determined to just monitor urinalysis and outpatient followup with Urology for the right adrenal mass and renal cyst. No urgent workup was necessary. The patient's neck was cleared with negative flexion extension. No pain on palpation and with range of motion. The patient worked with Occupational Therapy and Physical Therapy. Physical Therapy noted that the patient's gait was unsteady and was at increased risk for fall and would benefit from short term inpatient rehabilitation stay for balance mobility. Neurology/Rehabilitation evaluated the patient and determined that no acute long-term benefit from rehabilitation stay; however, the family wound recommend the need rehabilitation based on the family's ability to provide one-to-one supervision over the coming week after discharge. Recommended changing Dilantin to 300 mg p.o. q.d. and to check a level after three days and to discontinue if no seizures after three months. DISCHARGE DIAGNOSES: 1. Subarachnoid hemorrhage. 2. Right frontal contusion. 3. Adrenal mass of uncertain etiology. 4. Bilateral renal cysts. 5. Hematuria. 6. Previous diagnosis of hypertension. DISCHARGE PLAN: 1. For the subarachnoid hemorrhage and the right frontal contusion; stable per Neurosurgery. Stable examination and on CT. Follow up with Neurology/Rehabilitation as necessary in one month with Dr. [First Name (STitle) ]. 2. Follow up with Neurosurgery in one month (telephone number [Telephone/Fax (1) 274]). 3. Follow up in the Trauma Clinic (telephone number [Telephone/Fax (1) 274]) in two weeks. MEDICATIONS ON DISCHARGE: 1. Dilantin 300 mg p.o. q.d.; check level in five days. 2. Tylenol 325 mg to 650 mg p.o. q.4-6h. as needed (for pain). 3. Lasix 40 mg p.o. q.d. (as previous medication). 4. Percocet one to two tablets p.o. q.4-6h. as needed (for pain). 5. Zantac 150 mg p.o. b.i.d. 6. Colace 100 mg p.o. b.i.d. 7. Dulcolax 10 mg p.r. q.d. as needed (for constipation). [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520], M.D. [MD Number(1) 521] Dictated By:[Last Name (NamePattern1) 21669] MEDQUIST36 D: [2163-9-8] 21:15 T: [2163-9-8] 21:27 JOB#: [Job Number 45560] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8893 }	Medical Text: Admission Date: [2188-2-22] Discharge Date: [2188-2-24] Date of Birth: [2107-8-19] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 1711] Chief Complaint: PCP: [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 72378] . Chief Complaint: Transferred from OSH for NSTEMI/CHF Major Surgical or Invasive Procedure: None History of Present Illness: This is an 80-year-old female patient with history of COPD and presumed CAD and CHF who presented to [Location (un) 16843] ED the day prior to trasnfer to [Hospital1 18] with chief complaint of SOB. CXR was consistent with CHF and BNP was 727. The patient was intubated for hypoxia to 80% on room air. The patient was given solumedrol and lasix in the ED and sent to the ICU. In the ICU, the patient was diuresed with lasix and placed on NTG gtt. Her cardiac enzymes was initially flat but subsequent enzymes returned elevated with CK 1796 and trop I 34. Echocardiogram showed EF approximately 30% without previous baseline. She received plavix 300 mg and Lovenox (last dose at 10 am the day of transfer). She also received Lopressor 2 mg IV and was placed on insulin gtt 4 Units/hour with her last FSBS of 147. She has an elevated creatine at 1.6 and her WBC is now 18.6. She is in a sinus rhythm and EKG shows ST depressions in the inferoanterior leads. . Today, cardiac cath revealed severe 3-vessel disease not suitable for PCI (80% LMCA, RCA 80% ostial, long mid disease to 80%, Lcx with 80%, LAD small vessel with moderate disease at D1). PA 55/38/45, mean PWCP 36, CI 2.26, CO 3.92, LV 110/40. CT surgery was consulted and reviewed the cath but declined surgery secondary to poor target site. The patient was noted to have severe PVD including aortoiliac disease, and IABP was not able to be placed for CHF. Swan ganz was placed to monitor hemodynamics. . Currently, patient is sedated and intubated, therefore unable to answer any questions regarding current symptoms or review of systems. Past Medical History: COPD CAD not previously diagnosed CHF not previously diagnosed HTN Hyperlipidemia GERD Anxiety DM II Social History: Per OSH report, she lives alone and is independent. She has 5 children. Past smoking history but none currently. There is no history of alcohol abuse. Family History: Unknown. Physical Exam: VS - 98.5, 94/51, 88, 14, 95% on AC 0.4/600/14/5 Gen: Sedated, intubated. HEENT: NCAT. PERRL. Neck: Lying flat, difficult to assess JVP. CV: Difficult to auscultate heart sounds due to coarse breath sounds and diffuse wheezes. Chest: Mechanically ventilated, diffuse coarse breath sounds and wheezes. Abd: Soft, ND, decreased BS. Ext: Cool extremities, trace edema bilaterally. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 1+ DP dopplerable PT dopplerable Left: Carotid 1+ DP dopplerable PT dopplerable Pertinent Results: [2188-2-22] 12:30PM BLOOD WBC-17.7* RBC-3.55* Hgb-10.4* Hct-31.8* MCV-89 MCH-29.4 MCHC-32.9 RDW-16.3* Plt Ct-282 [2188-2-24] 04:42AM BLOOD WBC-12.0* RBC-2.93* Hgb-8.8* Hct-25.8* MCV-88 MCH-29.9 MCHC-34.1 RDW-16.3* Plt Ct-233 [2188-2-22] 12:30PM BLOOD Neuts-94.8* Bands-0 Lymphs-3.5* Monos-1.4* Eos-0.2 Baso-0.1 [2188-2-24] 04:42AM BLOOD PT-12.3 PTT-86.6* INR(PT)-1.1 [2188-2-24] 04:42AM BLOOD Glucose-132* UreaN-62* Creat-2.4* Na-139 K-3.9 Cl-104 HCO3-23 AnGap-16 [2188-2-22] 12:30PM BLOOD Glucose-168* UreaN-35* Creat-1.8* Na-138 K-4.7 Cl-104 HCO3-24 AnGap-15 [2188-2-23] 04:35AM BLOOD CK(CPK)-1446* [2188-2-22] 07:59PM BLOOD ALT-60* AST-187* CK(CPK)-[2191]* AlkPhos-97 TotBili-0.6 [2188-2-22] 12:30PM BLOOD ALT-59* AST-182* AlkPhos-95 TotBili-0.5 [2188-2-22] 07:59PM BLOOD CK-MB-131* MB Indx-6.5* cTropnT-4.58* [2188-2-23] 04:35AM BLOOD CK-MB-90* MB Indx-6.2* cTropnT-4.11* [2188-2-22] 12:30PM BLOOD Albumin-3.4 [2188-2-24] 04:42AM BLOOD Calcium-7.7* Phos-5.7* Mg-2.5 [2188-2-22] 07:59PM BLOOD calTIBC-231* VitB12-222* Folate-4.6 Ferritn-141 TRF-178* [2188-2-22] 12:30PM BLOOD %HbA1c-6.5* [Hgb]-DONE [A1c]-DONE [2188-2-24] 04:50AM BLOOD Type-ART Rates-12/ PEEP-5 FiO2-40 pO2-90 pCO2-40 pH-7.40 calTCO2-26 Base XS-0 -ASSIST/CON Intubat-INTUBATED [2188-2-23] 11:51AM BLOOD Type-MIX Temp-36.6 [2188-2-23] 05:15AM BLOOD Type-ART Rates-14/ Tidal V-600 PEEP-5 FiO2-40 pO2-73* pCO2-36 pH-7.44 calTCO2-25 Base XS-0 -ASSIST/CON Intubat-INTUBATED [2188-2-22] 05:41PM BLOOD Type-ART Rates-/14 Tidal V-600 PEEP-5 FiO2-100 pO2-408* pCO2-37 pH-7.42 calTCO2-25 Base XS-0 AADO2-266 REQ O2-51 -ASSIST/CON Intubat-INTUBATED Vent-CONTROLLED . [2-22] Cath COMMENTS: 1. Selective coronary angiography in this right dominant system revealed severe three vessel coronary artery disease. The LMCA was a short diffusely disease vessel with an 80% stenosis. The LAD was a small vessel with moderate disease throughout. The LCx was a small vessel with diffuse disease to 80% in the mid vessel. The RCA had an 80% ostial stenosis and diffuse disease to 80% in the mid vessel. 2. Limited hemodynamics demonstrated pulmonary arterial hypertension with a pulmonary artery pressure of 56/36 mmHg. The left ventricular end diastolic pressure was 36 mmHg. Central aortic pressure was 107/60 mmHg. There was no gradient across the aortic or mitral valve. Cardiac index was perserved at 2.5 l/min/m2. Right ventricular and right atrial pressures were not obtained. 3. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. . [2-22] ECHO GENERAL COMMENTS: Suboptimal image quality - poor parasternal views. Suboptimal image quality - ventilator. Emergency study performed by the cardiology fellow on call. Conclusions: The estimated right atrial pressure is 11-15mmHg. Left ventricular wall thicknesses and cavity size are normal. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is severely depressed with global hypokinesis and akinesis of the distal LV and apex. Right ventricular chamber size is normal. There is mild global right ventricular free wall hypokinesis. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . [2-24] CXR Endotracheal tube and nasogastric tube are in standard position. Cardiac silhouette is mildly enlarged but stable in size. Vascular engorgement and perihilar haziness are present consistent with mild CHF. Within the right upper lobe, a new focal opacity has developed with associated slight elevation of the minor fissure. This is most likely due to an area of atelectasis but aspiration should also be considered in the appropriate clinical setting. Bibasilar retrocardiac opacities are likely due to atelectasis, and there are probable small pleural effusions. Brief Hospital Course: 80 year-old female with CAD, CHF, [Hospital 2182] transferred from OSH for NSTEMI and CHF causing respiratory failure. The patient was transferred intubated and on a ventilator. Cardiac catheterization revealed severe 3-vessel disease. The patient's anatomy was not suitable for PCI and cardiac surgery declined due to poor targets. Echocardiogram revealed ischemic cardiomyopathy with worsened ejection fraction of [9-27]%. The patient was not a candidate for IABP due to severe PVD involving the aortoiliac system. The patient's family was made aware of her poor prognosis. The patient was initially managed in the CCU with lasix gtt despite worsening creatinine. The patient did not improve after 24 hours and blood pressure was tenuous. The [Hospital 228] health care proxy and family were made aware of the poor prognosis. After discussion with the family, the goals of care were changed to comfort. The patient expired [2188-2-24] at 13:15. Medications on Admission: Lasix 80 iv BID ASA 325mg qday Protonix 40mg iv qam metoprolol 2mg iv q6H Lovenox 70mg sc q12h Regular insulin gtt Plavix 300mg qday Solumedrol 125mg q12h Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A ICD9 Codes: 4280, 4254, 496, 5859, 4168, 4439, 2859, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8894 }	Medical Text: Admission Date: [2173-7-29] Discharge Date: [2173-8-17] Date of Birth: [2110-7-30] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6075] Chief Complaint: 1) L PCA infarction 2) Atrial Fibrillation Major Surgical or Invasive Procedure: 1) Bronchoscopy [8-4] 2) PICC line placement [8-4] 3) Tracheostomy [8-10] 4) Open gastrostomy tube placement [8-11] History of Present Illness: 63 yo female with a PMH of HTN. Pt last seen normal the evening prior before going to bed. Per report, pt had a phone conversation with her best friend at 8am that morning, in which she said she would come over for coffee. At roughly 8:30, the friend came over to get the pt, and no one would answer either the phone or the door. Husband returned home from work at 5pm and found the pt in her underwear still in bed and not responsive. He noted that the mail was still in the mailbox and the television was off, but the toilet seat had been lifted up, and he remembers putting it down in the morning before he left. Pt was found lying on her right side curled up, in a normal sleeping position and was noted to be making gurgling noises with drool coming from the side of her mouth. EMS was called and they were unable to arouse the patient. Taken to [Hospital3 6592], where she was intubated for airway protection. T noted to be 102.9, OSH team concerned for meningitis. CT scan obtained prior to lumbar puncture showed large left sided infarction. No LP performed, but pt started on Vanc/Ceftriaxone without blood cx being sent. Cardiac rhythm noted to be atrial fibrillation with rapid ventricular response. Pt then transferred to [Hospital1 18]. Pt arrived in ED intubated and unable to follow commands. She exhibited extensor posturing in the RUE and had spontaneous movement of the three remaining extremities. A CT/CTA was obtained, which showed a large infarction in the L PCA territory, involving the L parieto-occipital cortex, as well as the thalamus and midbrain. The pt was given ASA only given the concern for potential hemorrhagic transformation of such a large infarct. The pt was then admitted to the ICU. Past Medical History: Hypertension Cataracts s/p b/l surgery Social History: Lives in [Location (un) 10072] with her husband of 20 years. Smokes >1ppd for over 30 years. Rarely sees a doctor. Per daughter worked as a [Name (NI) ] for 25 years, but for the last 10 years has been waiting tables at a local diner and helping to babysit her grandchildren. Family History: No hx of CVA/MI Physical Exam: HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: irregularly irregular Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Intubated, arousable and responds to commands. Not able to open eyes. -Cranial Nerves: Pupils 4mm and fixed. No blink to confrontation on the right side. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. Intact corneals, negative oculocephalics, intact gag. -Motor/Sensory: Spontaneous movement of all four extremities. RUE [3-5], RLE/[Doctor Last Name ]/LL extremities 4+. Difficult to assess with limited participation. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 1 1 1 1 1 R 1 1 1 1 1 - Babinski upgoing bilaterally Pertinent Results: [2173-7-29] 09:32PM GLUCOSE-135* UREA N-12 CREAT-0.8 SODIUM-143 POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-26 ANION GAP-14 [2173-7-29] 09:32PM CK-MB-4 cTropnT-<0.01 [2173-7-29] 09:32PM WBC-12.4* RBC-4.86 HGB-14.5 HCT-43.8 MCV-90 MCH-29.8 MCHC-33.1 RDW-15.1 CT/CTA [7-29]: 1. Left posterior cerebral and left posterior choroidal and superior cerebellar arterial territory infarct as seen on the recent CT study of CT Head [2173-7-29] 18:13 hrs. No hemorrhagic transformation since the recent study. 2. Occluded distal left V2 and proximal left V3 segments of the left vertebral artery. Appearances are probably thrombogenic but vasculitis should be considered. 3. Bilateral atheromatous carotid disease at the bifurcation with measurements as described. 4. Centrilobular emphysema and movement artefact degrading the upper lung zones. MRI [7-30]: IMPRESSION: Infarct extends to bilateral thalamic and left parietooccipital, anterior-posterior cerebellar lobes, and midbrain. Hemorrhagic component to left temporal and left midbrain infarct,not seen on most recent head CT and may be new. Recommend CT to better evaluate extent of hemorrhage. Old left inferior PICA cerebellar infarct. TTE [7-30]: The left atrium is mildly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 65%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the abdominal aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. No obvious intracardiac shunt but cannot be excluded with certainty on the basis of this technically suboptimal study CT head [7-31]: IMPRESSION: Infarct extending bilateral thalami, left parietooccipital, anterior and posterior cerebellar lobes and midbrain with hyperdensity likely representing hemorrhagic component within the left mid brain and left temporal lobe are relatively stable since [2173-7-30] and may represent hemorrhagic component to the infarct. CT head [8-2]: IMPRESSION: Stable bilateral thalami, left parieto-occipital, anterior and posterior cerebellar lobes and mid brain hypodensities with stable hemorrhagic components in the mid brain and left temporal lobe. Bronchoscopy [8-4]: - Small amount of thin, clear secretions suctioned - No evidence of consolidation - Moderate to severe trachebronchiomalacia in b/l mainstems estimated based on complete collapse of bronchi during cough CT head on [2173-8-15] Evolving infarctions, without evidence of acute intracranial hemorrhage Brief Hospital Course: Pt was admitted to [Hospital1 18] ICU on [7-30]. Initial anticoagulation regimen consisted of ASA only due to concern for hemorrhagic transformation of her infarction. Blood pressure was initially controlled with beta blockade with goal SBP 120-180. Ceftriaxone was continued due to concern for aspiration PNA, less concern for meningitis given supple neck. MRI obtained on afternoon of [7-30] showed concern for new hemorrhage within the infarct territory, most likely hemorrhagic transformation of ischemic infarction. For this reason the decision to hold further anticoagulation was made. A follow up head CT the next morning showed stable hemorrhage. A TTE obtained on the 30th showed normal LVEF and mild LAE with no visualized clot. On [8-1] the patient was found to have developed a cold right foot. A vascular surgery consult was obtained and dopplerable pulses were found at the R DP and PT arteries. Their recs were for Q1hr pulse checks and warming, no intervention necessary at that time. By [8-2] the pt's medications had been altered to gain better control of both blood pressure and her AFib with RVR with diltiazem gtt and digoxin. Repeat head CT on [8-2] showed stable hemorrhage, and the decision was made to start the patient on warfarin. On [8-5], the patient underwent bronchoscopy. Per report there was very little secretions and no evidence of consolidation in any of the lung fields. What was noted was a complete collapse of b/l mainstem bronchi during cough, which could represent bronchiomalacia. An Interventional Pulmonology consult was obtained which resulted in a decision to perform no intervention because the bronchiomalacia was not likely to be causing her hypoxia. On [8-8], the patient was successfully weaned to minimal ventilator requirements, but failed extubation due to stridor and upper airway obstruction. Tracheostomy was performed on [8-10], open gastrostomy tube placement was performed on [8-11]. On [8-12], the patient was started on Vanc/Zosyn for presumed nosocomial sphenoid sinusitis seen on CT scan. ID consulted and agreed w regimen, their recs were to treat until clinical improvement. The patient was placed on trach mask w 50% Fi02 for 24 hours until the am of [8-13], but was placed on CMV due to tachypnea after suctioning and increased secretions. On [8-16], the family was contact[Name (NI) ] about sending Ms. [Known lastname ] to a ventilator rehab. She was continued on a course of Vanc/Zosyn for a total of 1 week as empiric antibiotics. Neurology felt that her fevers were likely central in origin. She was unable to open her eyes, but was responsive to voice and could move both her right and left UEs. Medications on Admission: Metoprolol 50 mg TID Terazosin 10 mg QD Discharge Medications: Vancomycin 1 g q12 hours IV (end date [2173-8-19]) Zosyn 4.5g IV q6 hours (end date [2173-8-19]) Warfarin 7.5 mg PO qhs (goal INR [2-3]) Aspirin 325 mg daily Diltiazem 60 mg PO QID Albuterol inhaler 6-8 puffs IH q4 hours Ipratropium bromide 6-8 puffs MDI q4-6hours Tylenol Famotidine 20 mg PO BID Fentanyl 25-100 mcg q2hours IV PRN agitation Senna 1tab PRN constipation Docusate 100 mg PO BID Bisacodyl 10mg PR daily PRN constipation Sliding Scale Insulin Simvistatin 40 mg daily Chlorhexidine Gluconate mouthwash oral [Hospital1 ] 15 ml Nystatin oral suspension 5ml PO qid Discharge Disposition: Extended Care Facility: [Hospital 5503] Rehab Discharge Diagnosis: 1) Cerebral Infarction 2) Atrial Fibrillation 3) Emphysema Discharge Condition: Patient was stable for over 1 week with no new symptoms. She is unable to open her eyes due to bilateral 3rd nerve damage. She is also excessively tired due to her thalamic infarcts. She is arousable to voice, and can respond to commands to move her left fingers. At times staff have been concerned that she is not as responsive, but she is quite somnolent and will not be able to open her eyes. She has no source for her fevers. She was started on empiric antibiotics for possible sinusitis to be finished on [2173-8-19]. The neurology attending felt she may have central fevers and that they were not related to infection. Discharge Instructions: Neurologic Status - the patient is unable to open her eyes due to 3rd nerve paralysis. She is also somnolent due to thalamic lesions. She is intermittently responsive to vocal commands and can move her left hand more than her right. She understands what is being said to her and although she looks asleep she is aware of her surroundings. She was started on coumadin for goal INR [2-3]. She was also started on aspirin 325 mg. ID - she should finish a course of vancomycin and zosyn (on [8-19]) for possible sinusitis. Blood, and urine cultures were negative, and chest x-ray showed no signs of consolidation. Resp - patient has poor lung function secondary to emphysema. She required PEEP of 5 with FiO2 of 50% and was receiving albuterol and ipratropium inhalers. Readmitting - patient has had several episodes where nursing felt she had a decline in her mental status, however they were likely due to hypersomnolence. She is unable to open her eyes, but can respond to vocal stimuli and move her left hand on command. She has intermittent temps to 100-101, but no source was identified, and it was thought to be central fever. If the patient has persistent fevers, or has prolonged periods of unresponsiveness then repeat imaging may be warranted. Followup Instructions: Antibiotics - continue vancomycin and zosyn until [2173-8-19] Heme - INR goal range of [2-3] w/ warfarin at 7.5mg at night, continue aspirin 325 mg daily Respiratory - continued on ventilator with PEEP of 5 and FiO2 50%, can try to wean as tolerated with goal sats in the low 90s. Completed by:[2173-8-17] ICD9 Codes: 431, 5070, 4019, 4589, 2724, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8895 }	Medical Text: Admission Date: [2117-7-27] Discharge Date: [2117-8-23] Date of Birth: [2047-3-17] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 3290] Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: Colonoscopy EGD Octreotide Scan History of Present Illness: Mr. [Known lastname 85187] is a 70 year old with a history of chronic diarrhea who presented to [Hospital1 18] with positive blood cultures and arterial clots. He had presented the day prior to admission to Dr. [Last Name (STitle) ] who in his workuop obtained blood cultures and an MRI enterography to assess for intestinal lymphangiectasia. He had blood cultures drawn for a temperature of 101 in the office. On the day of admission Dr. [Last Name (STitle) ] was notified that blood cultures grew GPCs and also his MR enterography showed thrombus in his proximal celiac artery, distal SMA, chronic or subacute infarct of left upper renal pole, small splenic infarct. He was referred to the ED. . In the ED, initial vs were: T99.8 P105 BP135/110 R16 O2 sat99% RA. He vomitted once and was given 4mg IV zofran. He was given 1gm IV vancomycin and 2L normal saline. Rectal exam showed yellow, guaiac positive stools. He was started on a heparin gtt without a bolus. Lactate was 2.3. . Currently, the patient is complaining of heartburn. He has had this problem off and on for the past 3 years. He describes a burning sensation in his larynx without radiation. He states it occasionally causes him to vomit and he did vomit once in the ED. He has 3 bowel movements which are loose stools. He reports that when this started 3 years ago he had up to 8 bowel movements per day. He denies abdominal pain or cramping, melena, hematochezia. He has had 3 EGDs and multiple colonoscopies per his report. He has been on prilosec and zantac in the past but is not taking these currently. He reports a fever while on the plane to come here. He has had a 20lb weight loss in the past year. In the past two weeks, he has been started on Peptamen as well as a low-fat diet. . He reports a fever while on the plane to the US. He reporedly had a MR enterography which was [Doctor First Name ](+) Per HPI (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. No constipation or abdominal pain. No recent change or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: R Kidney Tumor treated with partial nephrectomy 2 years ago S/P Retinal Detachment and cataract surgery bilaterally Inguinal Hernia Repair Appendectomy 4 years ago ? cardiac arrhythmia which he states he was told was insignificant Social History: Notable for a former heavy smoker with 90 pack years, stopped approximately three years ago, distant alcohol intake and significant travel history. Family History: non-contributory Physical Exam: On admission: Vitals: T: 100.3 BP:120/62 P:97 R:24 SpO2: 95% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric Neck: supple Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Irregular, SEM Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: Left leg is warm, well perfused, 2+ DP, Right leg is slightly colder, pulses are present on doppler. Clubbing in fingertips. Pertinent Results: On admission: [2117-7-26] 12:20PM BLOOD WBC-20.0* RBC-4.24* Hgb-13.4* Hct-40.2 MCV-95 MCH-31.6 MCHC-33.4 RDW-13.9 Plt Ct-143* [2117-7-26] 12:20PM BLOOD Neuts-89.1* Lymphs-5.5* Monos-5.2 Eos-0 Baso-0.2 [2117-7-26] 12:20PM BLOOD PT-10.8 PTT-24.8 INR(PT)-0.9 [2117-7-27] 11:30AM BLOOD Glucose-212* UreaN-27* Creat-0.6 Na-129* K-3.2* Cl-95* HCO3-25 AnGap-12 [2117-7-26] 12:20PM BLOOD ALT-27 AST-36 CK(CPK)-57 AlkPhos-54 TotBili-0.3 [2117-7-26] 12:20PM BLOOD TotProt-3.8* Albumin-2.2* Globuln-1.6* Mg-1.9 Cholest-168 [2117-7-28] 03:21AM BLOOD calTIBC-146* VitB12-1357* Folate-12.8 Ferritn-224 TRF-112* . Upon discharge: . Chem10: 138 107 44 (TPN) / 91 4.8 25 0.9 CBC: WBC 8.9 H/H: 8.1/23.8 Plts 332 INR 1.2 Alb 2.1 . Radiology: MR ENTEROGRAPHY ([Numeric Identifier 46893]&[Numeric Identifier 46894]) SBFT Study Date of [2117-7-27] 7:08 AM IMPRESSION: 1. Filling defects in the proximal celiac artery and distal branch of the superior mesenteric artery compatible with thrombus/embolus. 2. Probably subacute infarction of the superior pole of the left kidney with delayed rim of capsular enhancement. As imaging was not targetted towards assessment of renal arterial vasculature, arterial clot is not definitely identified. Nonetheless, this is presumably also from embolic disease. 3. Splenic infarct.Given the multiple arterial thrombi/emboli, recommend echocardiogram to evaluate for potential cardiac valvular disease or right-to-left shunting. 4. Hyperenhancement and jejunal bowel wall thickening. These findings may reflect hypoperfusion secondary to previously described mesenteric vascular filling defects. No discrete mass is identified. 5. Circumferential narrowing within the mid transverse colon but without discrete mass identified. This may reflect spasm, although neoplasm cannot be excluded. Recommend evaluation with colonoscopy if not recently performed. 6. Liver cysts. Left renal cyst. Portable TEE (Complete) Done [2117-7-29] at 11:30:24 AM FINAL IMPRESSION: Large vegetation on the aortic valve. Mild aortic regurgitation. Globally normal systolic function. CHEST (PA & LAT) Study Date of [2117-7-29] 8:46 PM IMPRESSION: Scattered, patchy consolidations throughout the left lung consistent with possible septic emboli. CT scan of the chest with IV contrast is recommended. CTA CHEST/ABD/PELVIS W&W/O C & RECONS Study Date of [2117-7-30] 3:28 PM IMPRESSION: 1. Filling defects in the proximal celiac artery and distal branch of the superior mesenteric artery compatible with thrombus/embolus, unchanged from the MR enterography of [2117-7-27]. 2. Probable subacute infarction of the superior pole of the left kidney. 3. Small splenic infarct. 4. Hyperenhancement and jejunal bowel wall thickening; these findings are concerning for hypoperfusion secondary to mesenteric vascular filling defects. 5. Hypodense lesion within the caudate lobe of the liver likely represents a liver cyst. 6. Two bladder calculi at the right uretrovesical junction. 7. Multiple areas of ground-glass opacification within the upper and lower lobes of lungs, corresponding to areas of opacification seen on the chest x-ray of [2117-7-29] are noted. These may represent infectious process versus minimal pulmonary edema; however, there is no definite evidence of septic emboli. . [8-20] CXR: REASON FOR EXAMINATION: Followup of the patient with known endocarditis. PA and lateral upright chest radiograph was compared to [8-18], [2117]. Bilateral pleural effusion, partially loculated, is unchanged, moderate, left more than right. The evaluation of the cardiac silhouette is difficult due to obscuration of the cardiac borders bilaterally by pleural effusion. Upper lungs are essentially clear. No pneumothorax is present. The right PICC line tip can be seen till the level of low SVC at least. . [8-15] MRI Abdomen: No hypervascular tumors; no evidence of neuroendocrine tumor Brief Hospital Course: Mr. [Known lastname 85187] is a 70 yoM, Greek-speaking only, who initially presented for work-up of chronic diarrhea (protein losing enteropathy, possible lymphangectasia), who was incidentally found to have MSSA endocarditis with arterial thrombus to mesentery; also with PICC line LUE DVT, bil. pleural effusions; recently started on TPN . #Endocarditis: The patient presented to the [Hospital ] clinic with a fever, at which blood cultures were drawn, and were shown to contain GPCs in clusters and pairs. A TEE was performed which showed a large vegetation on the aortic valve with mild aortic regurgitation. MRE showed emboli to the proximal celiac and distal SMA. Blood cultures grew MSSA and the patient is on Nafcillin 2g q4h to complete a 6 week course; last day of antibiotics is [2117-9-7]. He has ID follow-up and will need weekly labs checked (CBC with diff, LFTs, BUN/Cr) and faxed to the [Hospital ] clinic; follow-up appts are schedule with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 6137]. The patient should have a repeat Echo and blood cultures at the end of therapy to be certain he has cleared the infection. . #Pleural Effusions: Due to the patient's protein-losing enteropathy, he has chronically low albumin. Today, albumin is 2.1. He has had problems in the past with pulmonary edema and was on Lasix 40 mg qd at home in [Country 5881]. He had at least 1 admission in [Country 5881] with Pulmonary Edema. On [8-18], the patient had complaints of SOB and was placed on 2L nc. CXR showed bil. pleural effusions. Lasix was started and since the 11th, the patient has maintained stable weight. He was discharged on a regimen of PO Lasix 120 mg qam, and 80 mg q6pm. He may need either up or down titration of this regimen depending on his diuresis. He has also required regular potassium repletion during active diuresis. He was discharged on 20 mEq [Hospital1 ] of PO potassium. . #LUE DVT: The patient was found to have a PICC line associated thrombus in his L UE on [8-6] so the PICC line was removed and a new PICC was placed on the Right. The patient continued to complain of swelling in his L arm, and on [8-16] a repeat UE doppler showed extension of the thrombus into the axillary vein. Hematology recommended anticoagulation therapy for 3 months. The patient was initially on a heparin drip but was transitioned to lovenox and coumadin. On the day of discharge, the patient was still subtherapeutic on coumadin with an INR of 1.2. He was discharged on 7.5 mg coumadin qday as well as lovenox 70 mg [Hospital1 ]. He will need regular follow-up with [Hospital3 ] to reach a therapeutic INR. . #Aterial Thrombus: The patient was discovered to have filling defects in the proximal celiac artery and distal branch of the superior mesenteric artery compatible with thrombus/embolus via MR on [2117-7-27]. . #Atrial Tachycardia: While in the ICU and the beginning of his stay on the floor, the patient was noted to have a murmur (likely aortic vegetation), as well as bursts of tachycardia up into the 150s, which one night required the usage of PO and IV Metoprolol. Cardiology was consulted, and after examining the EKGs felt that the patient's tachycardia was likely atrial tachycardia vs sinus tachycardia with very frequent PAC, and recommended starting him on PO Metopolol. The patient responded well to Metoprolol Tartrate 25 mg PO/NG TID, and did not have any further bursts of tachycardia during his stay. . #Diarrhea: The patient has had chronic diarrhea for the past [3-11] years. He was recently started on a low-fat diet and a medium chain triglycerides, which are a large part of the Peptamen formulation, and found some improvement in his diarrhea, which was therefore thought to be evidence consistent with intestinal lymphangiectasia. Per the GI team, the patient is thought to have a protein-losing enteropathy. The patient has been having approximately 3 episodes of diarrhea a day, which has been fairly stable since his admission to the hospital. A colonoscopy and enterography were concerning for TI and IC valve ulcers, but the gross appearance of the proximal transverse lumen and jejunal were unremarkable. CMV staining of the GI tissue returned negative. Per GI the patient was started on TPN. He was discharged on TPN, cycled at night, as well as Peptamen supplementation. He has a GI follow-up appointment scheduled with Dr. [Last Name (STitle) ]. . #Anemia: On admission, patient's HCT was 35.6. His Hct stabilized during his hospitalization at 23-24. The patient was iron deficient by labs, with low TIBC and low ferritin. The patient did not tolerate PO iron, however, and declined a blood transfusion though he would likely benefit from either of these strategies. . #Thrombocytopenia: On admission, the patient's plt count was 103. It reached a nadir during his stay at 73; Heme/Onc was consulted, and they felt that his thrombocytopenia was likely due to consumption and infection, particularly as it normalized to ~200 at the time of his discharge following treatment of his endocarditis and nutrition via TPN. Flow cytometry was performed per Heme/Onc request, which returned normal. . #GERD: Patient started on a PPI, no complains of GERD symptoms in hospital.. . #Depression: Per pt's son, the patient had increasing depression during this hospitalization. On [8-22], the patient was started on 20 mg qday of Celexa. He was also started on 1 mg PO Ativan qhs prn for anxiety/insomnia, which seemed to give the patient great relief. . The patient was anticoagulated with heparin drip/pneumoboots/lovenox or coumadin for DVT prophylaxis. He remained full code throughout this admission. He had a PCP appointment on the day of discharge to help manage the ongoing diruesis as well as the patient's anticoagulation therpay. Medications on Admission: Chlordiazepoxide-Clidinium (Librax) 5/2.5mg daily Lasix 40mg PO daily Spironolactone 25mg PO daily Peptamen supplement Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [Month/Year (2) ]:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). [Month/Year (2) ]:90 Tablet(s) Refills:2 3. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams Intravenous Q4H (every 4 hours) for 15 days: Please continue to take until [2117-9-7]. [Month/Day/Year ]:90 doses Refills:0 4. Medium Chain Triglycerides 7.7 kcal/mL Oil Sig: Fifteen (15) ML PO TID (3 times a day): Pt may take up to 4-5 times per day as tolerated. [Month/Day/Year ]:30 cans Refills:2 5. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) 70mg dose Subcutaneous Q12H (every 12 hours): Until stopped by PCP. [Name Initial (NameIs) ]:30 70mg dose Refills:1 6. Coumadin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day: Please follow the coumadin regimen prescribed by your new PCP. . [Name Initial (NameIs) ]:90 Tablet(s) Refills:2 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Name Initial (NameIs) ]:30 Tablet(s) Refills:2 8. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. [Name Initial (NameIs) ]:30 Tablet(s) Refills:0 9. Lasix 40 mg Tablet Sig: 2-3 Tablets PO twice a day: Please take 3 tabs (120 mg) each morning and 2 tabs (80mg) each evening . [Name Initial (NameIs) ]:150 Tablet(s) Refills:2 10. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO twice a day. [Name Initial (NameIs) ]:120 Tablet Sustained Release(s) Refills:2 11. Outpatient Lab Work You will need weekly labs drawn including LFTs, Cr/BUN, and CBC with diff. These should be faxed to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 6137] (Infectious Diseases) at [Telephone/Fax (1) 1419] (phone # is [Telephone/Fax (1) 457]). 12. Outpatient Lab Work In addition, your TPN will be followed by [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 553] [Last Name (NamePattern1) ], RN. For her, weekly labs including CBC/diff and CMP should be faxed to [Telephone/Fax (1) 18738]. She will help to manage your TPN regimen. 13. Outpatient Lab Work You will need to have routine INR's drawn and managed by your PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and the [Hospital3 ]. Discharge Disposition: Home With Service Facility: Home Solutions Infusion Therapy Discharge Diagnosis: Primary Diagnosis: - Chronic Diarrhea - Endocarditis - Mesenteric Arterial Thrombi - LUE DVT - Protein losing enteropathy . Secondary Diagnoses: - Sinus Tachycardia with PAC - Chronic diarrhea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 85187], . It was a pleasure taking care of you at the [Hospital1 771]. You were admitted to the hospital after it was discovered on imaging of your abdomen that you had clots in the arteries that supply your intestinal tract; in addition, you had bacteria growing in your blood (known as MSSA). . We then imaged your heart with ultrasound, and saw that you had a bacterial vegetation on one of your heart valves - the aortic valve. We started treating you with IV antibiotics, which you will continue until [9-7]. . In addition, we consulted the GI doctors who performed a colonoscopy and an enteroscopy. These procedures showed that you have ulcers in your colon. Biopsies showed esophagitis, ileitis, and focal inflammation in your colon - possibly as result of the blood clots or as a result of a chronic process that accounts for your ongoing protein-losing diarrhea. We have temporarily started you on IV nutrition, known as TPN, that will be continued after you are discharged from the hospital. . Finally, your hospital course was complicated by a blood clot in your left arm that was associated with the PICC line (IV) that you had placed. For this, you have been started on anticoagulation and will need to complete 3 months of anticoagulation therapy. You will receive lovenox shots twice per day until your INR is therapeutic on coumadin. . In the hospital, we STOPPED the following of your home medications: Please STOP taking the following medications: - Chlordiazepoxide-Clidinium (Librax) 5/2.5mg daily - Spironolactone 25mg PO daily . We STARTED the following medications: Nafcillin 2 g IV every four hours until [9-7] Pantoprazole 40 mg DAILY Metoprolol Tartrate 25 mg THREE TIMES A DAY Coumadin 7.5 mg per day; Your PCP will help manage your anticoagulation; you will need labs drawn (INR) until your regimen is stabilized Lovenox 70 mg TWICE DAILY; 1 shot every 12 hours Ativan 1 mg at bedtime as needed for anxiety/insomnia Celexa 20 mg per day; this medication may need to be further titrated by your PCP We started you on TPN -> the prescription is included in your discharge papers Peptamen (Medium Chain Triglycerides); you should take [3-12] cans per day as tolerated to help supplement your nutrition Lasix (120 mg in the AM, 80 mg at night) Potassium 20 mEq, twice per day . You have many follow-up appointments scheduled. The exact times and locations are below. . Your first appointment is with your new PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. He will help to manage your anticoagulation and your ongoing diuresis. . You also have appointments with the Infectious Disease physicians. They will help to manage your antibiotic therapy. You will need weekly labs drawn including LFTs, Cr/BUN, and CBC with diff. These should be faxed to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 6137] at [Telephone/Fax (1) 1419] (phone # is [Telephone/Fax (1) 457]). . In addition, your TPN will be followed by [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 553] [Last Name (NamePattern1) ]. For her, weekly labs including CBC/diff and CMP should be faxed to [Telephone/Fax (1) 18738]. She will help to manage your TPN regimen. . Finally, when you complete your antibiotic course, please have your doctor check a blood culture to make sure that you have been cleared of your infection. You will also need a repeat Echocardiogram. Followup Instructions: Your appointments are listed below: You have a new primary care doctor, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], to help manage your coumadin (INR) levels as well as your diuresis with Lasix. You have the following appointment: Department: [Hospital3 249] When: MONDAY [2117-8-23] at 3:00 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: INFECTIOUS DISEASE When: MONDAY [2117-8-30] at 10:30 AM With: [First Name4 (NamePattern1) 2482] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage . Department: DIVISION OF GI When: FRIDAY [2117-9-3] at 7:40 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 463] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage . Department: INFECTIOUS DISEASE When: MONDAY [2117-9-20] at 10:30 AM With: [First Name4 (NamePattern1) 2482] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage . When you return to [Country 5881], please make appointments to see your Primary Care doctor, Dr. [Last Name (STitle) 85188], as well as a cardiologist, as well as an infectious disease physician. ICD9 Codes: 5119, 2761, 311, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8896 }	Medical Text: Admission Date: [2200-4-7] Discharge Date: [2200-4-10] Date of Birth: [2146-9-21] Sex: F Service: CARDIAC INTENSIVE CARE MEDICINE CHIEF COMPLAINT: The patient was admitted to the Cardiac Intensive Care Unit Medicine Service on [2200-4-7], with the chief complaint of acute myocardial infarction and fever. HISTORY OF PRESENT ILLNESS: The patient is a 53 year old white female with a history of coronary artery disease, hypertension, hypercholesterolemia and two pack per day tobacco use with previous coronary artery bypass graft surgery presenting to an outside hospital on [2200-4-6], with a two day history of fevers and confusion. The patient had a CT scan of the chest at that time which revealed pneumonia by report in the left lower lobe. While in the outside hospital Emergency Department, the patient complained of chest pain. The patient states that she has had this pain for approximately two weeks with no relief. She was given Levofloxacin for apparent community acquired pneumonia and cardiac enzymes were cycled. The patient was found to have a troponin of 3.98 which rose to 6.10 as well as CK MBs of 17.3 and 15.2 but no CPKs were recorded. The patient's white blood cell count at that time was 20.6. The patient received Lovenox and Aspirin and was transferred to the Cardiac Intensive Care Unit at [Hospital1 346] for further management. Of note, the patient's husband reports that she possibly took approximately 17 tablets of 300 mg of Neurontin in the five days prior to admission. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass graft. 2. Hypertension. 3. Elevated cholesterol. 4. Chronic low back pain. 5. Bronchitis. 6. Question of liver disease. 7. Gastroesophageal reflux disease. 8. Depression. ALLERGIES: Nitroglycerin produces significant decrease in blood pressure. Tape and bee stings. MEDICATIONS ON ADMISSION: 1. Robaxin 750 mg two tablets q4hours p.r.n. 2. Alprazolam 1.5 mg q.i.d. 3. Lipitor 80 mg p.o. q.d. 4. Gemfibrozil 600 mg b.i.d. 5. Zoloft 150 mg q.d. 6. Prilosec 20 mg q.d. 7. Trazodone 150 mg q.h.s. 8. Duragesic patch 100 mcg q72hours. 9. Enteric Coated Aspirin 81 mg q.d. 10. Vancenase inhaler p.r.n. 11. Oxycodone 10 mg q4hours p.r.n. 12. Neurontin 300 mg p.o. b.i.d. to t.i.d. SOCIAL HISTORY: The patient smokes two packs per day of tobacco and drinks alcohol socially. She is married and lives with her husband. FAMILY HISTORY: Notable for positive coronary artery disease although no further or more specific history could be obtained. PHYSICAL EXAMINATION: On admission, the patient's vital signs were as follows: Temperature 98.2, pulse 83, respiratory rate 17, blood pressure 89/50 with a mean of 67, oxygen saturation 98% on nonrebreather. Of note, the patient states that her blood pressure usually runs between 80 and 90 systolic. In general, the patient was alert although had difficulty remembering and formulating thoughts. Head, eyes, ears, nose and throat examination - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Sclera anicteric. Conjunctivae pink. Slight jaundice and pallor. The neck was supple with no lymphadenopathy. The lungs demonstrate coarse rhonchi, question of upper airway sounds transmitted to the anterior and midaxillary line. Cardiovascular regular rate and rhythm, S1 and S2, no murmurs, rubs or gallops. The abdomen was soft, nontender, nondistended, with normoactive bowel sounds. The extremities were warm, 2+ dorsalis pedis pulses bilaterally. No edema. Femoral pulses 2+, no bruits. Rectal examination was guaiac negative per Emergency Department report at the outside hospital. LABORATORY DATA: From the outside hospital, white count 20.6 with 89 neutrophils, 1 band, 5 lymphocytes, 4 monocytes, hematocrit 38.2, platelets 222, MCV 94.9. Sodium 138, potassium 4.1, chloride 98, bicarbonate 37, blood urea nitrogen 16, creatinine 0.7, glucose 111. Prothrombin time 12.3, partial thromboplastin time 28.9, INR 1.05. As previously mentioned, troponin was 3.98 and 6.10 as well as CK MBs of 17.3 and 15.2 although no CPKs obtainable. Albumin 3.4, total protein 6.5, alkaline phosphatase 148, AST 109, ALT 25, total bilirubin 0.3, calcium 8.9. Urinalysis was notable for urine protein of 30. Electrocardiogram showed normal sinus rhythm with a rate of 88 beats per minute. Q-Tc 443, normal axis. ST elevations in leads III, aVF, ST depressions in leads I, aVL and V1 through V3 with a Q wave in lead III. Chest x-ray showed no infiltrate and no pulmonary edema although CT scan did show some question of a left lower lobe infiltrate not seen on chest x-ray. HOSPITAL COURSE: The patient was admitted for management of confusion, fever, elevated white count, chest pain, and question of myocardial infarction in the setting of coronary artery disease, status post coronary artery bypass graft four years prior. CKs were cycled. The patient was held NPO and family members were [Name (NI) 653]. The patient was continued on Levofloxacin as started at the outside hospital and given inhalers p.r.n. A psychiatry consultation was obtained on the morning of [2200-4-7], given the patient's significant degree of disorientation and confusion and labile emotions. The psychiatrist's impression was that the patient was suffering from delirium with waxing and [Doctor Last Name 688] mental status examination with poor memory. At the time of the interview, the patient was agreeing to consider catheterization although it was noted that if she changed her mind given the importance of this procedure that her husband and children should be [Doctor Last Name 653] regarding consent for the procedure and that her capacity to consent at that time should be held in question. Recommendations were made for Haldol p.r.n. as well as Xanax. B12, folate, RPR and TSH were all ordered which returned as normal. The patient also had a head CT at the outside hospital which was unremarkable. CKs were sent at our hospital with initial level of CPK 464, MB 12 and a troponin of 49 obtained. The patient had been placed on Heparin prior to the anticipation of cardiac catheterization. The patient was initially consented to have cardiac catheterization on [2200-4-7], although had an acute decompensation in mental status and anxiety attack and it was determined that she would be at high risk for the procedure at that time. Thus, the procedure was deferred to the morning of [2200-4-8], and findings were as follows: Left ventricular ejection fraction 62%. Inferior hypokinesis. Normal valves. Discrete proximal right coronary artery lesion of 100% stenosis. Left main 100% discrete stenosis. Mid left anterior descending discrete 100% stenosis, 50% discrete midcircumflex stenosis. Bypass graft saphenous vein graft to the right coronary artery was 100% discrete stenosis. Left internal mammary artery to the left anterior descending patent and RIMA to the right coronary artery with a 40% stenosis. No intervention was performed. It was determined that the patient should be maximized on medical therapy only. The patient was prescribed with Aspirin and Plavix at that time and given diuresis for increasing oxygen requirement. The patient returned to the floor in stable condition and was to the Step-Down Cardiac Unit on [2200-4-8]. The patient returned to baseline mental status throughout the remainder of her hospital stay and was determined to be in stable condition by [2200-4-10], to be discharged. The patient was in agreement with this plan. DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post coronary artery bypass graft in [2195], now with occluded saphenous vein graft to be medically managed. 2. Hypertension. 3. Elevated cholesterol. 4. Chronic low back pain. 5. Bronchitis with possible acute pneumonia. 6. Gastroesophageal reflux disease. 7. Depression. DISCHARGE MEDICATIONS: 1. Levofloxacin 500 mg p.o. q.d. times nine days to complete a fourteen day course. 2. Plavix 75 mg one p.o. q.d. 3. Colace 100 mg p.o. b.i.d. p.r.n. for constipation. 4. Neutra-Phos one packet p.o. b.i.d. times thirty days. 5. Prilosec 20 mg p.o. q.d. 6. Enteric Coated Aspirin 325 mg p.o. q.d. 7. Zoloft 150 mg p.o. q.d. 8. Lipitor 80 mg p.o. q.d. 9. Trazodone 150 mg p.o. q.h.s. 10. Fentanyl patch 100 mcg transdermal every three days. 11. Atrovent inhaler two puffs b.i.d. 12. Tylenol #3 p.r.n. 13. Alprazolam 1.5 mg p.o. q.i.d. p.r.n. 14. Gemfibrozil 600 mg p.o. q.d. 15. Neurontin 300 mg p.o. t.i.d. The patient was to follow-up with her regular cardiologist, Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], in one to two weeks after discharge. Consideration is to be made in the future as to whether or not the patient's blood pressure can tolerate addition of either an ace inhibitor or a beta blocker to her medical regimen for mortality benefit. [First Name8 (NamePattern2) 2206] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 18924] Dictated By:[Last Name (NamePattern1) 7118] MEDQUIST36 D: [2200-4-10] 12:15 T: [2200-4-12] 08:50 JOB#: [Job Number 18925] ICD9 Codes: 486, 4019, 3051, 2930
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8897 }	Medical Text: Admission Date: [2123-11-18] Discharge Date: [2123-11-23] Date of Birth: [2047-1-17] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1835] Chief Complaint: Left frontal lobe mass resection Major Surgical or Invasive Procedure: craniotomy/resection History of Present Illness: 76 yo LH male who presented on [11-6] with 7 weeks of "foot twitching" lasting 20 seconds per episode without loss of consciousness or post episode confusion/sleepiness worrisome for partial seizure activity. He presented to ED where imaging revealed enhancing L frontal mass concerning for renal CA metastasis. Past Medical History: Diabetes (diet controlled) Hypertension Bilateral cataract surgery Circumcision Renal CA Social History: He is a retired machinist and he had a 25-pack-year history of smoking and he smoked approximately [2-19] cigarettes per day presently. He drinks 2 caffeinated products per day and no alcoholic beverages. Has very supportive wife and extended family Family History: No evidence of kidney cancer in the family. Physical Exam: Prior to surgery: GEN: alert and oriented x3, comfortable, no acute distress HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without lesion or exudate, moist mucus membranes LYMPH: no anterior/posterior cervical, occipital, supraclavicular, or axillary adenopathy CARDIOVASCULAR: RRR, no murmurs LUNGS: clear to auscultation bilaterally without rhonchi, wheezes, or crackles ABDOMEN: soft, nontender, nondistended with normal active bowel sounds. no masses. no hepatosplenomegaly by percussion or palpation EXTREMITIES: no clubbing, cyanosis, or edema SKIN: no rashes, petechia, lesions, or echymoses NEUROLOGICAL MS: General: alert, appropriately interactive, normal affect Orientation: oriented to person, place, date, situation Speech/[Doctor Last Name ]: fluent w/o paraphasic errors; simple and complex command-following w/o L/R confusion. Repetition, naming intact Calculations: 7 quarters = $1.75 CN: II,III: VFFTC, pupils 4-2 mm bilaterally to light, optics discs sharp and flat III,IV,V: EOMI, no ptosis. Normal saccades/pursuits V: sensation intact to LT/temp VII: Facial strength intact/symmetrical VIII: hears finger rub bilaterally IX,X: voice normal, palate elevates symmetrically [Doctor First Name 81]: SCM/trapezeii [3-20] bilaterally XII: tongue protrudes midline without atrophy or fasciculation Motor: Normal bulk and tone; no tremor, rigidity, or bradykinesia. R pronator drift. R LE externally rotated Delt [Hospital1 ] Tri WE FE Grip IO C5 C6 C7 C6 C7 C8/T1 T1 L 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 IP Quad Hamst DF [Last Name (un) 938] PF L2 L3 L4-S1 L4 L5 S1/S2 5 5 5 5 5 5 5 5 5 5 5 5 Reflex: [Hospital1 ] Tri Bra Pat An Plantar C5 C7 C6 L4 S1 CST L 2 2 2 2 2 Flexor R 2 2 2 2 2 Flexor Sensation: LT, temp intact throughout. Vibration, joint position sense intact. Stereognosis, graphesthesia intact. No Romberg sign. Coordination: Finger-nose-finger, heel-to-shin movements intact, normal mirroring without past-pointing, [Doctor First Name ] intact. Gait: Posture, stance, stride, and arm swing normal. Tandem gait intact. Heel and toe-walking intact. Pertinent Results: [2123-11-18] 12:09PM GLUCOSE-178* UREA N-37* CREAT-1.1 SODIUM-133 POTASSIUM-5.0 CHLORIDE-101 TOTAL CO2-25 ANION GAP-12 [2123-11-18] 12:09PM CALCIUM-8.5 PHOSPHATE-3.6 MAGNESIUM-1.7 [2123-11-18] 12:09PM WBC-8.3 RBC-3.30# HGB-11.0# HCT-32.6# MCV-99 MCH-33.5* MCHC-33.8 RDW-17.2* [2123-11-18] 12:09PM PT-11.4 PTT-20.0* INR(PT)-0.9 [2123-11-18] 08:45AM WBC-6.7 RBC-2.30# HGB-8.1 HCT-24.1# MCV-105 MCH-35.1* MCHC-33.4 RDW-16.5* [2123-11-18] 08:45AM PT-11.9 PTT-22.2 INR(PT)-1.0 [2123-11-17] 01:20PM GLUCOSE-111* UREA N-30* CREAT-1.2 SODIUM-141 POTASSIUM-5.2* CHLORIDE-107 TOTAL CO2-29 ANION GAP-10 [2123-11-17] 01:20PM ALT(SGPT)-30 AST(SGOT)-22 LD(LDH)-248 ALK PHOS-113 TOT BILI-0.2 [2123-11-17] 01:20PM TOT PROT-6.6 ALBUMIN-3.7 GLOBULIN-2.9 CALCIUM-9.6 PHOSPHATE-2.3* MAGNESIUM-1.8 URIC ACID-6.8 CHOLEST-232* [2123-11-17] 01:20PM WBC-9.0 RBC-3.08* HGB-10.1* HCT-32.6* MCV-106* MCH-32.8* MCHC-31.0 RDW-16.4* MRI brain: Status post resection of a left frontal enhancing mass with expected postoperative changes. A tiny amount of enhancement may represent residual tumor or postoperative reactive enhancement. Pathology: The tumor is composed of epithelioid cells with focal clear cell differentiation consistent with metastatic renal cell. Brief Hospital Course: Pt with L frontal mass resection performed which patient tolerated well. However, post operatively, pt without movement of RLE, sensation intact. Otherwise, neurologic exam intact, mental status intact. Pt with some improvement in RLE strength by discharge with some IP and hip extension/abd/adduction at the hip. PT evaluated and recommended discharge to rehab center. OT evaluated and provided orthosis. post op MRI with post changes. Pt started on steroid wean prior to discharge. He has tolerated diet well, and is urinating without any difficulties. He has scalp staples, which should be removed in two weeks ([12-2] - 18/08) in rehabilitation facility or during his appointment at brain tumor clinic on [2123-12-2]. Medications on Admission: ASPIRIN 81 mg--1 tablet(s) by mouth daily ATENOLOL 50 mg--1 tablet(s) by mouth daily COLACE 100 mg--1 capsule(s) by mouth daily HYDROCHLOROTHIAZIDE 25 mg--1 tablet(s) by mouth daily LISINOPRIL 5 mg--1 tablet(s) by mouth daily NORVASC 5 mg--1 tablet(s) by mouth daily PRAVASTATIN 20 mg--1 tablet(s) by mouth daily SUTENT 50 mg--1 capsule(s) by mouth as directed take one tablet daily for 4 weeks, then 2 weeks off. Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8HRS () for 6 doses. 12. Dexamethasone 2 mg Tablet Sig: 1.5 Tablets PO Q8HRS () for 3 doses. 13. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8HRS () for 3 doses. 14. Dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Q8HRS () for 3 doses. 15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for fever/pain. Discharge Disposition: Extended Care Facility: [Location (un) 14468] Nursing & Rehabilitation Center - [Location (un) 1456] Discharge Diagnosis: Renal cell CA metastasis to brain Discharge Condition: stable with RLE weakness Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR. [Last Name (STitle) ] TO BE SEEN IN 4 WEEKS. YOU WILL NEED AN MRI OF THE BRAIN WITH AND WITHOUT GADOLIDIUM WITH APPOINTMENT. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5387], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2123-12-15] 2:00 Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) 3150] Phone:[Telephone/Fax (1) 22] Date/Time:[2123-12-15] 2:00 BRAIN [Hospital ] CLINIC APPOINTMENT ON [2123-12-2] AT 9:00 AM YOUR STAPLES WILL BE REMOVED AT YOUR BRAIN [Hospital ] CLINIC APPOINTMENT Completed by:[2123-11-23] ICD9 Codes: 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8898 }	Medical Text: Admission Date: [2181-1-15] Discharge Date: [2181-1-15] Date of Birth: [2180-12-29] Sex: F Service: Neonatology HISTORY OF PRESENT ILLNESS: [Known lastname 59418] [Known lastname ] is a former 2.045 kg product of a 33 and [3-15] week twin gestation pregnancy, born to a 21 year-old, Gravida II, Para 0 woman. Blood type B positive. Antibody negative. Rubella immune. RPR nonreactive. Hepatitis B surface antigen negative. Group beta strep positive. Pregnancy was notable for twin gestation. The pregnancy was complicated by group beta strep bacteruria, which was treated with erythromycin. The mother was followed closely for concern for twin-to-twin transfusion. She was admitted and treated with Betamethasone prior to delivery. There was rupture of membranes at the time of delivery. She was delivered by elective Cesarean section. This twin number one emerged with good tone and cry. Apgars were 8 at one minute and 9 at five minutes. She was admitted to the Neonatal Intensive Care Unit for treatment of prematurity. PHYSICAL EXAMINATION: Upon admission to the Neonatal Intensive Care Unit, weight was 2.045 kg; length 44 cm; head circumference 32 cm. General: Well appearing, non distressed, preterm female, consistent with 33 and 4/7 weeks gestational age. HEENT: Anterior fontanel open and flat, normocephalic. Palate intact. Red reflex present bilaterally. Neck supple. Chest: Lungs clear bilaterally. Cardiovascular: Regular rate and rhythm, no murmur. Femoral pulses 2 plus bilaterally. Abdomen: Soft, with active bowel sounds. No masses or distention. Genitourinary: Normal premature female. Normal external genitalia. Spine intact. Hips stable. Clavicles intact. Neurologic: Good tone, moving all extremities. Skin: Pink. Mongolian spots located on buttocks and legs. HOSPITAL COURSE: 1. Respiratory: [Known lastname 59418] was in room air her entire Neonatal Intensive Care Unit admission. She did not have any episodes of spontaneous apnea during admission. At the time of discharge, she is breathing comfortably with a respiratory rate of 40 to 60 times per minute. 2. Cardiovascular: An intermittent murmur was noted during the first day of life. This murmur resolved. [Known lastname 59418] has maintained normal heart rates and blood pressures during admission. 3. Fluids, electrolytes and nutrition: [Known lastname 59418] was initially n.p.o. and treated with intravenous fluids. Enteral feeds were started on the day of birth and gradually advanced to full volume. Her maximum caloric intake was 24 calories per ounce. She is being discharged home on Similac 24 calories per ounce. She has been all p.o. feeds for the 72 hours prior to discharge. Discharge weight is 2.46 kg with a length of 33.5 cm and a length of 47 cm. 4. Infectious disease: A complete blood count and blood culture were obtained upon admission to the Neonatal Intensive Care Unit. The complete blood count was within normal limits. The blood culture was no growth at 48 hours. [Known lastname 59418] was not treated with antibiotics. 5. Gastrointestinal: Peak serum bilirubin occurred on day of life two with a total of 5.8 over 0.3 mg/dl direct. A repeat serum bilirubin on day of life five was 5.5 over 0.3 mg/dl direct. 6. Hematologic: Hematocrit at birth was 58.9 percent. Of note, her sister's hematocrit was 56.4 percent. There was no discrepancy in weights or hematocrits at birth. 7. Neurology: [Known lastname 59418] has maintained a normal neurologic examination during admission. There were no concerns at the time of discharge. 8. Sensory: Audiology: Hearing screening was performed with automated auditory brain stem responses. [Known lastname 59418] passed in both ears. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with the parents. PRIMARY PEDIATRIC CARE: To be provided by the [Hospital ] Community Health Center, [Hospital1 26957], [Location (un) 669], [Numeric Identifier 59419]. Phone number [Telephone/Fax (1) 3581]. CARE AND RECOMMENDATIONS: 1. Feeding: Ad lib p.o., Similac 24 calories per ounce. 2. No medications. 3. Car seat position screening was performed. [Known lastname 59418] was observed in her car seat for 90 minutes, without any episodes of bradycardia or oxygen desaturations. 4. State newborn screens were sent on [1-1] and [2181-1-12], with no notification of abnormal results to date. 5. Immunizations received: Hepatitis B vaccine administered on [2181-1-4]. 6. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] 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 two of the following: Daycare during RSV season , a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; or (3) with chronic lung disease. 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 child's life, immunization against influenza is recommended for house hold contacts and out of home caregivers. FOLLOW UP: Primary care pediatrics within five days of discharge. DISCHARGE DIAGNOSES: 1. Prematurity at 33 and 4/7 weeks gestation. 2. Twin number one of twin gestation. 3. Suspicion for sepsis, ruled out. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 55780] Dictated By:[Last Name (Titles) ] MEDQUIST36 D: [2181-1-15] 05:03:49 T: [2181-1-15] 05:37:13 Job#: [Job Number 59420] ICD9 Codes: V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8899 }	Medical Text: Admission Date: [2179-5-13] Discharge Date: [2179-5-23] Date of Birth: [2115-9-8] Sex: M Service: MEDICINE Allergies: Unasyn Attending:[First Name3 (LF) 3531] Chief Complaint: arm pain Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname 3517] is a 63yo M w/hx of CHF (EF 15-20%), s/p ICD placement, severe TR, DM2, CKD (baseline Cr 1.3-1.8), afib on coumadin, elevated LFTs, who presented to the ED with chest pain and L arm pain. By report of wife and patient he has had bad gout over the past several weeks to months. Principally this has been involving his right foot limiting his ability to walk. In the past few days had increasing right arm pain that patient thought was also his gout. Then starting about yesterday, patient had severe left arm pain at the shoulder and the elbow. This is ultimately what prompted him to come to the ED. ROS notable for +sharp midsternal chest pain with coughing, non-productive cough, sinus congestion for several weeks, chills. Patient denied back pain, neck pain, pain with chewing, changes to his urine output or other complaints beyond those noted. . Of note, recent medication changes include uptitration of allopurinol to 250mg PO qday for gout after recent gout flare [4-7]. . In the ED, initial vs were: T101.4 HR71 BP90/42 RR20 100%RA . Blood pressures dropped to the 70s systolic and he was given 1L IVF, a CVL was placed and CVP was 13-16. A R IJ was placed and after dopamine was turned up to 20mcg/min, he was started on Levofed and dopamine was weaned down. He was given Vanc and Levofloxacin and nothing further due to allergy to Unasyn. He underwent non-contrast CT of the abdomen which was grossly normal. CXR was clear. A FAST scan in the ED did not show pericardial effusion, kidneys without hydronephrosis. Received 3L NS, ASA 325, Vanco 1gram Morphine 4mg IV x1. Levo/aztreonam ordered but not given. . On arrival to the floor, patient c/o total body pain, and feeling cold. Past Medical History: Nonischemic cardiomyopathy, LVEF 15-20% ICD placement for primary prevention of sudden cardiac death Diabetes mellitus type 2 insulin dependent Gout Peripheral neuropathy Chronic atrial fibrillation Chronic kidney disease Elevated transaminases, unknown etiology Umbilical hernia repair, [8-/2175] Gallstone pancreatitis s/p ERCP ([2176-6-28]) Internal hemorrhoids Hemoglobin C carrier Social History: The patient is originally from [Country 3515] currently living with his wife. Returned to [Location 3515] this past fall, but came back to US after severe gout flare of his foot. No smoking. He quit alcohol use, no IV drug use. He says his diet is generally difficult because he feels like any food he eats causes gout flare . Family History: No first-degree relatives with coronary artery disease. His mother had breast cancer. . Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: THREE VIEWS, LEFT SHOULDER: Examination is limited by nonstandard views as well as the overlying pacemaker. There is moderate degenerative change at the acromioclavicular joint with narrowing and subchondral sclerosis. The glenohumeral joint appears intact. There is no visualized fracture. . THREE VIEWS, LEFT ELBOW: There is no fracture or abnormal alignment. There is no joint effusion. Mineralization is normal. . NON-CONTRAST CHEST CT: Imaged thyroid gland is grossly unremarkable. There is a left-sided cardiac pacer with the lead terminating in the right ventricle. There is also a right internal jugular intravenous catheter with the tip at the mid-distal SVC. A few subcentimeter mediastinal lymph nodes with no evidence of lymphadenopathy are noted. There is no hilar or axillary lymphadenopathy on this non-contrast study. The aorta demonstrates atherosclerotic calcifications. Atherosclerotic calcifications of the coronary arteries are also seen. Heart is enlarged. There is no pericardial effusion. Bibasilar atelectatic changes and/or pneumonia, left more than right are noted. Mild emphysema is likely present. Calcified granulomas in the right lower lobe (2:46 and 2:30) are noted. There is no pneumothorax or pleural effusion. NON-CONTRAST ABDOMINAL CT: The unenhanced liver, spleen, pancreas, adrenals are unremarkable. Small pericholecystic fluid was also seen on prior study. Both kidneys are in normal anatomic location. A focal, somewhat band-like calcification in the interpolar region of the left kidney is stable since [Month (only) 205] [2177]. There is a probable 2-mm nonobstructive stone in the inferior pole of the left kidney (2:74). There is no hydronephrosis. Abdominal aorta and iliac vessels demonstrate severe atherosclerotic calcifications with no aneurysmal dilatation. There is no retroperitoneal hematoma. Evaluation of the GI tract demonstrates no evidence of bowel obstruction or bowel wall thickening. Tubular blind ending structure in the right lower quadrant likely represents a normal appendix. NON-CONTRAST PELVIC CT: The urinary bladder is collapsed and contains a Foley atheter. Air within the urinary bladder is likely secondary to instrumentation. Bilateral small fat-containing inguinal hernias are seen. The rectum contains stool, otherwise unremarkable. Seminal vesicles are symmetric. The prostate gland measures about 5 cm in transverse diameter. The urinary bladder wall thickening may be secondary to underdistension. A few mildly prominent inguinal lymph nodes are noted. A hypoattenuating structure measuring 2.3 cm in the right lower abdomen to the right of the urinary bladder is stable. . OSSEOUS STRUCTURES: There is no bony lesion to suggest malignancy or infection. . IMPRESSION: 1. Left lower lobe atelectasis or pneumonia. Mild emphysema. 2. Small amount of pericholecystic fluid was also seen on prior study. Please clinically correlate. 2. Probable 2 mm nonobstructive left renal calculus. . [2179-5-13] 08:14AM BLOOD RheuFac-<3 [2179-5-13] 08:14AM BLOOD ANCA-NEGATIVE B [2179-5-13] 08:14AM BLOOD Cortsol-7.1 [2179-5-13] 02:21PM BLOOD Cortsol-6.8 [2179-5-13] 03:10PM BLOOD Cortsol-10.1 [2179-5-13] 04:14PM BLOOD Cortsol-10.7 [2179-5-12] 10:50PM BLOOD Glucose-134* UreaN-61* Creat-4.2# Na-132 K-4.5 Cl-98 HCO3-21* AnGap-18 [2179-5-17] 04:10AM BLOOD Glucose-215* UreaN-89* Creat-1.7* Na-138 K-3.9 Cl-110* HCO3-17* AnGap-15 [2179-5-12] 10:50PM BLOOD PT-37.9* PTT-48.4* INR(PT)-3.9* [2179-5-17] 04:10AM BLOOD PT-20.3* PTT-32.1 INR(PT)-1.9* [2179-5-12] 10:50PM BLOOD WBC-6.3 RBC-3.82* Hgb-10.1* Hct-28.7* MCV-75* MCH-26.3* MCHC-35.1* RDW-19.8* Plt Ct-135* [2179-5-17] 04:10AM BLOOD WBC-9.0 RBC-3.71* Hgb-9.8* Hct-27.8* MCV-75* MCH-26.5* MCHC-35.3* RDW-20.2* Plt Ct-157 Brief Hospital Course: This is a 63 year old male with PMH of severe systolic HF with an EF=25%, afib on coumadin, who presented with hypotension and found to have questionable adrenal insufficiency in the setting of a likely gout flare. . #. Hypotension: Possibly due to adrenal insufficiency, given symptoms of fever, hypotension, diarrhea, high eosinophils, hyponatremia, and hyperkalemia with low cortisol failed ACTH stimulation ([Last Name (un) 104] stim 6->10->10). Confounding factors are that colchicine causes diarrhea and allopurinol induces hypereosinophilia. An abdominal CT without contrast showed no evidence of adrenal pathology. Initially, the patient had fever and tachypnea concerning for septic shock possibly from a pulmonary source as a possible pneumonia was seen on CT scan. He did have a normal lactate and no leukocytosis. Septic arthritis was considered given prominent joint complaints and history of gout, although his joint was tapped by [Last Name (un) ] and was negative for infection. He was on vasopressors on admission, but weaned off over 48 hours. He was subsequently normotensive with a normal lactate. He was started on IV hydrocortisone in the ICU which was transitioned to oral prednisone on [5-16]. [Last Name (un) ] endocrine team recommended a quick prednisone taper to 20mg on [5-19], 10mg on [5-20], then off on [5-21]. The patient's pressures remained stable off of prednisone for greater than 24 hours. Cortisol and free cortisol levels were sent on [5-22] when the patient was off of steroids for 24 hours and he was sent home on prednisone 5mg daily until he can be followed up in the [Last Name (un) ] endocrine clinic. CMV, HIV, RPR, and TSH were all sent to rule out other causes of adrenal insufficiency. HIV, CMV, and RPR negative. TSH was low with high free T4 and low T3 attributed to SICU thyroid. It is therefore unlikely that the patient is panhypopit. The patient said that a PPD placed 3 months prior was negative for Tb. An adrenal MRI was considered to rule out hemorrhage while on coumadin or infection but could not be performed with his ICD in place. . #. Gout: The patient redeveloped right ankle swelling and pain on [5-20] in the setting of decreasing his prednisone from 20mg to 10mg. Allopurinol was continued and he was restarted on daily colchicine. His uric acid level was 5.8 on [5-20]. Colchicine was restarted with a 1.2mg dose followed by 0.6 mg dose on [5-20]. He was started on low dose prednisone 5mg daily both to prevent gout and hypotension (from possible adrenal insufficiency) until he follows up as an outpatient with endocrinology. . #. Infection/sepsis: The patient was febrile and admission blood cultures were growing coag negative staph which was likely a contaminant. CT chest on admission showed an opacity that was read as being consistent with atelectasis vs. PNA. He received empiric broad spectrum antibiotics (Zosyn, vancomycin, flagyl) in the ICU until [5-17], but they were discontinued prior to transfer to the floor. The patient remained afebrile, but developed a leukocytosis with peak WBC count of 12.3 on [5-20] which was likely secondary to a gout flare as the leukocytosis resolved after proper gout treatment and no abx. TTE showed no evidence of vegetations on valves or hardware. [Month/Year (2) 2225] tapped his swollen joint in the ICU and it was negative for infection. His central line was removed on [5-20] and the catheter tip culture was negative. All blood and urine cultures were negative. . #. Hyperglycemia: The patient initially had poor glucose control in the setting of high dose steroids. He required an insulin gtt in the ICU and was started on Lantus/HISS upon transfer from the ICU. His sugars improved dramatically as he was weaned off of steroids and he was discharged on his home Novolog sliding scale. . #. [Last Name (un) ]: The etiology was likely pre-renal given that his UA was bland. His creatinine peaked at 4.2 and improved with IVFs. A renal U/S was normal and his creatinine was his creatinine was back down to his baseline of 1.1 upon discharge. His home Diovan was restarted on [5-22]. Torsemide was held given his hypotension and potential to provoke gout flare. Given his severe CHF, the torsemide may need to be restarted as an outpatient. His ankles did have 1+ edema, but his lungs were clear on discharge. . #. Elevated INR: The patient's INR trended up to 11.5 on [5-14] requiring vitamin K administration. The etiology of this rise was unclear, but may have been secondary to poor PO intake prior to admission. His Coumadin dose was decreased to 2 mg daily before discharge with therapeutic INRs resulting. . #. CHF: The patient has non-ischemic cardiomyopathy with an EF=25% and severe TR. Initially, all of his cardiac meds except for digoxin were held given his hypotension requiring pressors. He was restarted on his home Diovan 40mg on [5-22] and his carvedilol 3.125mg [Hospital1 ] was restarted upon discharge. His home torsemide was not re-initiated given his hypotension and the potential of triggering another gout flare. His digoxin level was low at 0.4 but was not adjusted in the setting of his fluctuating renal function. He should follow-up with Dr. [First Name (STitle) 437] ans an outpatient for further titration of his cardiac meds. . #. Atrial Fibrillation: His home carvedilol was held initially given his hypotension, but was restarted on discharge. His digoxin level was low at 0.4 but was not adjusted in the setting of his fluctuating renal function. He was continued on Coumadin at discharge after it was initially held for an INR=11. . #. Sinusitis: The patient has had several months of sinus congestion and was started on fluticasone nasal spray. . #. Eosinophilia: His absolute eosinophil count on admission was about 900 and has been noted in past labs. This finding was concerning for malignancy, occult parasitic infection, or Churg-[Doctor Last Name 3532]. However, his eosinophilia improved with steroids and ANCA was negative. . #. Communication: Patient and [Name (NI) 3516] (wife) who works in Radiology for [Hospital1 18] and can be reached at home [Telephone/Fax (1) 3518], cell [Telephone/Fax (1) 3519], work [Numeric Identifier 3533] . #. Code: Confirmed full code. Medications on Admission: Allopurinol 250mg PO qday Carvedilol 3.125 PO BID Colchicine 0.6mg PO qday Digoxin 125mcg PO qday Insulin sliding sclae Lantus [First Name8 (NamePattern2) ] [Last Name (un) ] order -> does not need or take Spironolactone 12.5mg PO qAM -> d/c'd as per patient Torsemide 40mg PO BID Valsartan 40mg PO qday Warfarin 4mg M/W/Fri, 3.5mg the other 4 days Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 2. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [1-30] Sprays Nasal QID (4 times a day) as needed for rhinorrhea. 6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day). Disp:1 bottle Refills:2 7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:30 Tablet(s) Refills:2 8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Outpatient Lab Work please check INR twice per week and fax results to [Hospital 191] [Hospital 2786] clinic at [Hospital1 18], fax [Telephone/Fax (1) 3534] 10. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 11. Novolog 100 unit/mL Solution Sig: per sliding scale units Subcutaneous as directed. Disp:1 bottle Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary diagnosis: Hypotension, acute gout flare . Secondary diagnoses: -Idiopathic cardiomyopathy EF=25% -type 2 diabetes -elevated LFTs -atrial fibrillation on coumadin -peripheral neuropathy -chronic kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [Hospital1 69] for evaluation of arm and chest pain. You were found to have dangerously low blood pressure and were admitted to the Intensive Care Unit where IV medications were given to keep your blood pressure up. Initially, it was thought that your blood pressure could be low because of an infection. However, we were not able to find any source of infection. Since infection was not the likely cause of your low blood pressure, we were concerned that you did not have enough of a hormone called cortisol in your blood. Cortisol helps keep the blood pressure at normal levels, and is secreted by a gland above your kidney called the adrenal gland. Your cortisol levels were found to be low, which made us suspect a problem with your adrenal glands. In the meantime, your gout began to flare up and you were treated with colchicine and allopurinol. . It is very important that you follow up with [Hospital ] clinic next week. Until then, please take 5 mg of prednisone per day, as prescribed. This dose will make sure that you have cortisol activity in your system and will thus make sure your blood pressure stays up. . The following changes were made to your home medication regimen: - You should take allopurinol 200mg daily - You should take Flonase for your runny nose - You should change your Coumadin dose to 2mg daily - You should continue on prednisone 5mg Please do not take torsemide or spironolactone until instructed to do so by Dr. [First Name (STitle) 3535]. Followup Instructions: Please follow-up with all of your outpatient medical appointments listed below: . 1. Please call Dr.[Name (NI) 3536] office tomorrow to set up an appointment with him this week. Please keep track of your daily weights. You will need to see Dr. [First Name (STitle) 437] to discuss when to restart your fluid management medications, torsemide and spironolactone. . 2. Please call your PCP, [Last Name (NamePattern4) ]. [First Name (STitle) 3535], at [Telephone/Fax (1) 250], tomorrow to set up an appointment. . 3. The [Last Name (un) ] endocrine clinic should call you with an appointment to follow-up the possibility of your adrenal insufficiency as an outpatient. If you do not hear from them in 1 week, please call ([Telephone/Fax (1) 3537] to schedule an appointment. . 4. Department: [Telephone/Fax (1) ] When: THURSDAY [2179-5-27] at 11:30 AM With: [First Name8 (NamePattern2) 278] [Last Name (NamePattern1) 3538] [Telephone/Fax (1) 2226] Building: LM [Hospital Unit Name ] [Location (un) 861] Campus: WEST Best Parking: [Doctor First Name ]. GARAGE . 5. Department: [Doctor First Name ] When: THURSDAY [2179-6-10] at 11:00 AM With: [First Name8 (NamePattern2) 278] [Last Name (NamePattern1) 3538] [Telephone/Fax (1) 2226] Building: LM [Hospital Unit Name ] [Location (un) 861] Campus: WEST Best Parking: [Doctor First Name ]. GARAGE . 6. Department: [Doctor First Name ] When: WEDNESDAY [2179-7-21] at 1 PM With: [First Name11 (Name Pattern1) 2890] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 2226] Building: LM [Hospital Unit Name ] [Location (un) 861] Campus: WEST Best Parking: [Doctor First Name ]. GARAGE ICD9 Codes: 5849, 2761, 4254, 4280

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