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{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9000 }	Medical Text: Admission Date: [2191-4-12] Discharge Date: [2191-5-7] Date of Birth: [2127-5-5] Sex: F Service: SURGERY Allergies: Penicillins / Codeine / Dilaudid / Keflex / citalopram / Erythromycin Base Attending:[First Name3 (LF) 3223] Chief Complaint: dyspnea,fatigue,pancytopenia Major Surgical or Invasive Procedure: Splectomy History of Present Illness: 63F with a PMH of ITP, Hypogammaglobulinemia on monthly IVIG, Colon CA, s/p resection [4-/2190] and 6 cycles of FOLFOX,Hypertension,DM1 with retinopathy, recurrent bronchitis with bronchiectasis, hepatic cirrhosis on recent biopsy and recent splenectomy for massive splenomegaly of unclear cause c/b shocked liver and ARF now with altered mental status in the setting of persistent significant elevated LFTs and worsening renal failure. Patient has undergone numerous bone marrow biopsies, and per report, they have shown no evidence of malignancy. Last year she was diagnosed with colonic mucinous adenocarcinoma, for which she underwent right hemicolectomy ([Hospital1 756], 5/[2189]). She completed 6 rounds of FOLFAX (last round completed [1-/2191]), during which time she required multiple PRBC transfusions. She was then recently admitted to the [Hospital1 18] Heme/Onc service for symptomatic anemia (HCT 17), for which she received several transfusions. Continued pancytopenic workup was un revealing. During that admission, CT imaging showed an increase in splenomegaly to 23.8cm, prompting concern for splenic lymphoma versus hemophagocytic lymphohistiocytosis. She was discharged home [2191-4-3] with surgical referral for consideration of elective splenectomy. However,she was re-admitted on the medicine service on [2191-4-12] with increasing dyspnea and fatigue and was found to have a pancytopenic with HCT of 13.2 WBC 1.3 and PLT 40. Bone marrow biopsy showed hypocellular marrow and MRI abdomen showed evidence of chronic liver disease with an enlarged liver and enlarged portal and splenic veins suggestive of portal hypertension and massive splenomegaly. The cause of her splenomegaly is unclear and it was wondered whether this may have been related to portal hypertension. Portal pressure measurement showed present but not severe portal hypertension and biopsy showed cirrhosis of unclear cause.Patient elected to undergoe splenectomy. Past Medical History: PMH: - ITP ([2176], requiring IVIG and steroids) - Hypogammaglobulinemia - managed with monthly IVIG - Pancytopenia of unclear etiology (with bone marrow biopsies reporting hypercellular marrow) - Splenomegaly of unclear etiology - Colonic mucinous adenoCA, s/p right hemicolectomy ([4-/2190]) and chemotherapy (FOLFOX x6 cycles, last dose [1-/2191]) - Hyperbilirubinemia initially suspected secondary to hemolytic anemia, however, etiology less clear currently - Recurrent bronchitis with bronchiectasis - Hypertension; Hypercholesterolemia - Type 1 DM c/b retinopathy - Hx parapsoriasis - Hx of pericardial effusion - Hx left transudative pleural effusion s/p thoracentesis ([2191-4-2], path: mesothelial cells, macrophages, and lymphocytes) PSH: - Right hemicolectomy for colon cancer ([4-/2190]) - Right chest port-a-cath placement ([5-/2190]) - Colonoscopy ([2191-3-9]) - Left thoracentesis ([2191-4-2]) Social History: Lives with husband in [Name (NI) 5110], no smoking, EtOh, IVDU, Husband [Name (NI) ] is HCP Family History: Mother - thyroid dz - still living, father - prostate cancer and "lung dz" Physical Exam: 98.5 98.5 63 118/49 18 96%RA General: Awake, cooperative. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. Pulmonary: clear,Decreased BS left base. Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: Abdomen soft,tender, minimal ascites on percussion. Incision:steristrips in place, no erythema. Extremities: [1-7] + pitting edema to knees bilaterally, 2+ radial, DP pulses bilaterally Skin: Multiple bruises. Pertinent Results: Micro/Imaging: [2191-4-29] KUB Unremarkable bowel gas pattern [2191-4-27] CT A/P ? infarction L lobe liver. Large amt ascites. [2191-4-27] Liver duplex Vessels patent [2191-4-26] CT Head negative mass,infarction [2191-4-26] renal US no hydro or stones, diffuse enhancement, large amt free fluid [2191-4-25] UCx Negative [2191-4-24] RUE US no DVT, non-occlusive thrombus in R IJV likely from liver biopsy [2191-4-21] Liver bx Nodular [Last Name (un) ] hyperplasia. Iron deposition and Kuppfer cells. [2191-4-21] spleen large population of CD4/CD8 negative t cells c/w autoimmune [2191-4-20] EGD Grade 2 esophageal varices [2191-4-19] chest x-ray bibasilar atelectasis [2191-4-18] Liver bx no cirrhosis, c/w with nodular regenerative hyperplasia. [2191-4-16] Bone marrow Bx pending. Aspirate hypercellular. [2191-4-15] TTE LVEF 50-55%. [12-6]+ MR. [First Name (Titles) ] [Last Name (Titles) ]. Mild-mod pericardial effusion. [2191-4-14] MRI prelim: ?liver cirrhosis, hepatosplenamogaly, portal HTN Brief Hospital Course: Patient was taken to the operating room on [2191-4-21] with Dr. [Last Name (STitle) 519] and underwent a splenectomy (please refer to the operative note for further details).Postoperatively patient was kept intubated due to fluid administration: 3u PRBC, 2u platelets, 2 albumin. POD 1,patient was self extubated and after a short ICU stay patient was transferred to the surgical floor. Her postoperative course was complicated by altered mental status, shock liver with elevated LFTs and acute kidney injury. POD [12-8] the NGT was out and she was started sips. Her hematocrit was 21 and she was transfused with 1 unit RBC and post transfusion ->24 Postoperatively SBPs for the past few days (on [4-23] they had been in the 120's to 130's). However on POD 4 patient was noted to have brief hypotensive episodes with SBP 90s. She received albumin/blood transfusion as needed for hypovolemia. Patient was noted to have worsening renal function with rising BUN/Creatinine. Of note patient had a positive urinalysis and was currently being treated for a UTI with PO Cipro. Of note, patient had been on vancomycin cefepime pre-operatively when she was neutropenic and spiking fevers, however postoperatively she has been afebrile. Thus the vancomycin and Cefepime were subsequently discontinued. Her urine culture eventually came back and was negative. Her urine output was monitored closely and her creatinine were trended. Serial abdominal exams were performed and of note over the next several days her abdominal distention gradually worsened. POD 5([2191-4-26]) patient was noted to have increase lethargy and confusion and was triggered due to change in mental status. Per nursing staff, patient had intermittent episodes of hallucination. Her morphine PCA were subsequently discontinued as there were concerns of accumulation of morphine building up given ARF. Patient underwent a head CT which was negative and neurology was consulted. There was concern for hepatic encephalopathy given the acute rise in LFTs although the ammonia level was only 35. Regarless, the pt was started on rifaximin and lactulose. Neurology recommendations were to continue to correct metabolic derangements and to increase lactulose titrating to symptomatic improvement and felt no further imaging was needed at this time. Her MS cont to improve and was at baseline by the time of discharge. Nephrology was consulted for further evaluation of patient worsening renal function. Per nephrology, a renal ultrasound was obtained which showed bilateral kidneys without evidence of hydronephrosis or stones. There were large amount of free fluid is noted throughout the abdomen consistent with ascites. Given the granular casts seen on UA, likely diagnosis of ATN was presumed by renal. Patient Nadolol was discontinued due to continued bradycardia w/ episodes of hypotension. Lasix was given prn as pt appeared volume overloaded w/ some LE swellingon exam. Heme oncology continued to follow patient postoperatively and reccommended treating with blood transfusion for a hemoglobin less than 7. Hepatology continued to follow patient and recommended trending ammonia levels which was 35. Patient received 1 dose of lactulose to treat possible hepatic encephalopathy. Patient received additional Lactulose which was titrated until she had several bowel movements. In addition Rifaximin was also added. Patient underwent an abdominal/pelvis CT which showed infarction Left lobe liver. Large amount of ascites. A Doppler study was performed which showed patent portal vein. The pt's LFTs peaked and started to downtrend during her stay. The rise was likely a reflection of her acute infarction. Hepatology recommended repeating a CT scan; however, our team did not feel this was necessary as her LFTs were downtrending and the pt was asymptomatic. There was also concern for PBC given the rise in alk phos, but given a negative liver biopsy and neg autoimmune antibodies, this diagnosis is much less likely and ursodiol was not initiated. POD 7 Transfused 1u PRBC for HCT 23. TBili decreased. However her Creatinine continued to rise to 3.7. However her LFTs continued to trend downward and her mental status gradually improved. POD [7-17] Patient had intermittent complaints of nausea. A KUB was performed which showed an unremarkable bowel gas pattern. Patient received antiemetics as needed. the diet was advanced as tolerated and nutrition were consulted and she was started on calorie counts. She continued to have poor glycemic control (200's-300's). Her insulin sliding scale and Lantus dose were titrated. Patient BUN/creatinine however continued to rise slowly. Her fluids were subsequently discontinued and she was diuresed with several doses of Lasix IV over the next few days. Patient continued to be managed conservatively. Nephrology continued to follow and indicated that there were no immediate need for hemodialysis as creatinine will most likely peak and plateau which it eventually did.The foley catheter was discontinued and she voided without difficulty approximately 1 liter over 24 hours. POD 13 Patient Creatinine peaked at 5.3. She was diuresing well. By the time of discharge, the patient was doing well. Her Cr and LFTs were downtrending. She was ambulating, tolerating a regular diet and urinating adequately. Medications on Admission: Bupropion 150, Lispro SS, Bactrim DS, Lisinopril 40, Simvastatin 40, IVIG monthly, Iron, Vit D, Lantus 28u HS, Clobetasol cream PRN, Lorazepam 0.5'' PRN Discharge Medications: 1. Outpatient Lab Work Basic Metabolic Panel Liver Function Tests Please take this prescription to your PCP appointment with Dr. [Last Name (STitle) ]. You should have labs drawn weekly. 2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. insulin glargine 100 unit/mL Solution Sig: One (1) 28 Subcutaneous at bedtime. 4. lactulose 20 gram/30 mL Solution Sig: One (1) PO every eight (8) hours as needed for constipation. Disp:30 1 Refills:2 5. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours. Disp:25 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: ITP Acute Tubular Necrosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname ], You underwent a splectomy for treatment of your refractory ITP. The procedure went well and was without complications, but you did have a few postoperative complications that kept you in the hospital. You kidney labs started to rise. Nephrology (kidney doctors) were consulted to see you. They believe your kidney took a hit from low blood pressures and this caused some damage to your kidneys. You kidney labs peaked and were trending down at the time of discharge. It is important for you to have labs drawn weekly and the results sent to your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ]. Please take the prescription given to you for labs to your appointment with Dr. [Last Name (STitle) ] next week. You liver function studies were also found to be elevated. This was likely due to damage to your liver. Hepatology (liver doctors) were consulted and followed you during your hospitalization. Most of your labs were trending down at the time of discharge, but some remained elevated. These labs too should be monitored weekly. If you experience any significant abdominal pain, fevers, or any other symptoms concerning to you, please call or come into the ED for further evaluation. Thank you for allowing us at the [Hospital1 ] to participate in your care. Followup Instructions: Name: [First Name11 (Name Pattern1) 8031] [Last Name (NamePattern4) 87629], MD When: Tuesday [5-10] at 10am Location: [Hospital1 641] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 2260] Phone: [Telephone/Fax (1) 2261] Please call [Hospital1 18] Registration to update before your appointments, the number is [Telephone/Fax (1) 10676]. Thank you. Department: SURGICAL SPECIALTIES When: MONDAY [2191-5-16] at 10:45 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520], M.D. [Telephone/Fax (1) 6554] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: WEST [Hospital 2002] CLINIC When: MONDAY [2191-6-6] at 4:30 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 721] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226*] ICD9 Codes: 5845, 5990, 2762, 5715, 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9001 }	Medical Text: Admission Date: [2103-8-17] Discharge Date: [2103-8-19] Date of Birth: [2035-6-1] Sex: F Service: MEDICINE Allergies: Lipitor Attending:[First Name3 (LF) 443] Chief Complaint: exertional angina, hypotension s/p elective cardiac catheterization Major Surgical or Invasive Procedure: left cardiac catheterization s/p placement of [First Name3 (LF) ] x2 right catheterization s/p left inferior epigastric balloon tamponade History of Present Illness: 68 year old female with multiple cardiac risk factors including DM, HTN, Hypercholesterolemia, and prior tobacco abuse, 3 vessel disease s/p multiple presenting s/p cath after re-stenting of proximal and distal circ with complication of a RP bleed. Patient presented to [Hospital1 18] for elective catheterization with 2 week history of exertional CP and negative stress test. Recent catheterization in [2103-5-25] showed new 80% mid lesion LCX and 60% stenosis distal RCA PDA stent, with balloon angioplasty and drug eluting stents in her mid LCX and distal PDA. She was recatheterized, and re-stented in her proximal and distal LCX. As completing the procedure, patient became hypotensive. She was given atropine and pressors and stabilized. However, she again became hypotensive, and dye investigation showed perforation of the inferior epigastric artery. She was given Dopamine and 4 units of blood. Balloon tamponade was performed to stop bleeding, and patient was stabilized, with no other signs of bleeding. On the floor pt was stable. Repeat CT was 35.3. Small amount of oozing was initially seen at sheath sites but this resolved w/pressure. Pt had non-contrast CT of abdomen to assess extent of bleed per attendings request. Pt's blood pressures rose on the floor as she had not had her regular BP meds and thus nitrodrip was added for greater control in the setting of possible rebleed. The patient was seen for multiple episodes of chest discomfort at cardiac rehabilitation on [2103-7-26]. She required a NTG after each machine. patient she states after any exertion like climbing a set of stairs, or making the bed she gets an ache/pressure that starts in her throat and will go to her chest. For the past two weeks her pain has been getting worse. This is accompanied by shortness of breath, she states if she keeps up the activity she will get lightheaded. The pain will last for a few minutes after resting. Patient states the pain has limited her life style. She denies orthopnea, PND, ankle edema, palpitations, syncope. All of the other review of systems were negative. Past Medical History: CAD s/[Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (Prefixes) ] x 6 hypertension hyperlipidemia diabetes mellitus type 2 (diet controlled) hypothyroidism Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. The patient lives with her husband. She has 6 children from a prior marriage. She currently works part time in real estate. Family History: There is no family history of premature coronary artery disease or sudden death. Mother died of heart disease in her 60s. Father died of heart disease in his 70s. Physical Exam: Physical Exam on Admission: VS: T= afebrile BP=156/89 HR=66 RR=15 O2 sat= 96% GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with flat JVP CARDIAC: RR, normal S1, S2. No m/r/g. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, tender to light palpation. +BS EXTREMITIES: No c/c/e. No femoral bruits. Femoral sites clean/dry/ intact PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ . Physical Exam upon Discharge: . GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with flat JVP CARDIAC: RR, normal S1, S2. No m/r/g. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, tender to light palpation. +BS EXTREMITIES: No c/c/e. No femoral bruits. Femoral sites clean/dry/ intact, bruising in left groin site PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Skin: Warm and dry, no lesions Pertinent Results: LABS UPON ADMISSION: . [2103-8-17] 01:00PM BLOOD WBC-5.6 RBC-2.92* Hgb-8.0# Hct-23.9 MCV-82 MCH-27.3 MCHC-33.4 RDW-14.7 Plt Ct-285 [2103-8-17] 01:00PM BLOOD Neuts-66.5 Lymphs-24.9 Monos-5.1 Eos-2.7 Baso-0.8 [2103-8-19] 07:00AM BLOOD PT-14.3* PTT-22.5 INR(PT)-1.2* [2103-8-17] 01:00PM BLOOD Glucose-134* UreaN-29* Creat-1.1 Na-139 K-5.1 Cl-110* HCO3-18* AnGap-16 [2103-8-17] 03:22PM BLOOD Calcium-7.8* Phos-5.7# Mg-1.5 [2103-8-18] 12:08PM BLOOD Cholest-202* [2103-8-18] 12:08PM BLOOD Triglyc-397* HDL-36 CHOL/HD-5.6 LDLcalc-87 LDLmeas-114 [2103-8-17] 02:08PM BLOOD Type-ART O2 Flow-4 pO2-201* pCO2-43 pH-7.25* calTCO2-20* Base XS--8 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] [2103-8-17] 07:36PM BLOOD Type-[Last Name (un) ] Temp-36.4 pO2-31* pCO2-50* pH-7.27* calTCO2-24 Base XS--5 [2103-8-17] 02:08PM BLOOD K-4.9 [2103-8-17] 07:36PM BLOOD Lactate-1.5 K-5.0 [2103-8-17] 02:08PM BLOOD Hgb-9.1* calcHCT-27 O2 Sat-98 . LABS UPON DISCHARGE: . [2103-8-19] 07:00AM BLOOD WBC-7.0 RBC-3.86* Hgb-11.3* Hct-32.6* MCV-84 MCH-29.4 MCHC-34.8 RDW-15.2 Plt Ct-211 [2103-8-19] 07:00AM BLOOD PT-14.3* PTT-22.5 INR(PT)-1.2* [2103-8-19] 07:00AM BLOOD Glucose-108* UreaN-29* Creat-1.4* Na-142 K-4.5 Cl-108 HCO3-27 AnGap-12 [2103-8-19] 07:00AM BLOOD Calcium-9.3 Phos-2.9 Mg-2.1 . CARDIAC CATHETERIZATION [2103-8-17]: . 1. Selective coronary angiography in this right dominant system demonstrated single vessel coronary artery disease. The LMCA was normal without significant stenosis. The LAD has insignificant plaquing with widely patent stents. The LCx has a severe 90% mid vessel stenosis with in stent restenosis and the second OM has a 70% stenosis. The RCA has insignificant plaquing. 2. Limited resting hemodynamics revealed elevated left sided filling pressures. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. . CT ABD/PELVIS: [2103-8-17]: Large retroperitoneal hematoma exerting mild mass effect on the bladder as described above, with a small area of hyperdense material which may reflect more acute bleeding. Serial hematocrit checks are encouraged. 2. Prominent portocaval lymph nodes, as above. 3. Probable small right adrenal adenoma, as above. 4. Probable gallbladder sludge. Brief Hospital Course: Madelyne [Known lastname 79054] is a 68 year old female with hypertension, hyperlipidemia, history of smokin, with known 3 vessel disease and history of multiple [Known lastname ], who presented for cardiac catheterization and re-stenting of the proximal and distal circumflex artery. Her procedure was complicated by a retroperitoneal bleed, prompting admission and monitoring in the CCU. . # Retroperitoneal bleed: Patient became hypotensive s/p elective catheterization, and was found to have a laceration of the left inferior epigastric artery. A stat Hct was approx. 24, and contrast study showed laceration and retroperitoneal bleeding. Venous access obtained on right and balloon tamponade was maintained to stop bleeding. ABG demonstrated pH 7.25, with normal CO2/o2 and decreased bicarb, and hct 24. The patient was placed on Dopamine to maintain her pressures, but was quickly weaned with hemostasis. Patient transfused 4U PRBC, post transfusion hct 35. The patient was transferred to the CCU for observation overnight. Blood pressures returned to sBP 150s, and she was started on nitro gtt. A non-contrast CT body was obtained which showed large RP bleed surrounding the rectum. Pain management with Percocet 5/325 PO PRN, with morphine PRN for breakthrough pain. . # CAD s/p [Known lastname ] in LAD and LCX: Ms. [Known lastname 79054] presents with longstanding CAD with multiple stents (app. 6). Patient underwent elective catheterization for 2 weeks exertional CP after negative stress test, which showed 70-80% re-stenosis of LXC [Known lastname ]. Two [Known lastname ] were placed at the distal and mid-portion LXC. Patient noted pre-procedural CP had resolved. She was continued on home ASA, Plavix, Atorvastatin. Her home metoprolol and Imdur were held post-procedurally, and restarted after observation overnight. . # Hypertension: The patient became acutely hypotensive s/p cath, related to bleeding. She was transfused 4 units. She was started on a dopamine drip briefly in lab but was quickly weaned off. After cath, she was hypertensive sBP 150s so a nitro drip was started for better control of BP in setting of possible re-bleed. The nitro drip was weaned and she was restarted on her home doses of metoprolol. She will restart her quinapril and isosorbide the day after discharge. She will need to follow up with her PCP [Name Initial (PRE) ]/or cardiologist for blood pressure monitoring. . # Diabetes: DM typically controlled at home with glipizide and diet. Insulin Sliding Scale started for acute managment in hospital. On discharge, patient was restarted on home medication of glipizide. # Hypothyroidism: Ms. [Known lastname 79054] has a history of hypothyroidism, treated with Synthroid. C/o fatigue for last several weeks, likely related to cardiac symptoms. However, patient should have TSH checked on outpatient basis to make sure Synthroid in therapeutic range. . The patient was full code for this admission. Medications on Admission: CLOPIDOGREL - 75 mg daily GEMFIBROZIL - 600 mg [Hospital1 ] GLIPIZIDE - 5 mg daily ISOSORBIDE MONONITRATE - 10 mg daily LEVOTHYROXINE - 75 mcg daily METOPROLOL TARTRATE - 25 mg [Hospital1 ] NITROGLYCERIN - 0.4 mg Sublingual PRN for chest pain QUINAPRIL - 20 mg daily SIMVASTATIN - 20 mg daily ASPIRIN - 325 mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual as directed as needed for chest pain: Take 1 pill for chest pain and wait 5 minutes. If chest pain continues, take a second pill and wait another 5 minutes. If chest pain continues, please wait another 5 minutes and take a third pill. 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 9. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 10. Percocet 5-325 mg Tablet Sig: 0.5-1 Tablet PO every [5-8] hours for 5 doses. Disp:5 Tablet(s) Refills:0 11. Isosorbide Mononitrate 10 mg Tablet Sig: Two (2) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Retroperitoneal bleed status post catheterization Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 79054], You presented to the hospital for chest pain and underwent cardiac catheterization which showed blockages in the blood vessels supplying your heart, and you had stents placed to open the obstructions. The procedure was complicated by bleeding from a blood vessel into the space around your kidney, and a balloon was used to stop the bleed and a plug was placed to prevent further bleeding. You received blood transfusions to replace the blood loss. You were monitored in the cardiac intensive care unit, where you did not have any further bleeding. You were felt safe to go home. The following changes were made to your home medications: - Please continue taking your Plavix and Aspirin every day without missing a dose to ensure the stents in your heart do not become blocked. - Please INCREASE the dose of your Simvastatin to 40mg daily. Please let your doctor know if you have any problems with this new dose of the medication - You may use Oxycodone-Acetaminophen tablets (Percocet) -- half to one tablet AS Needed for pain, no more than one tablet every 6-8 hours as needed. Please do not drive after taking this medication. Please be sure to make your followup appointments with your cardiologist and primary care physician. Followup Instructions: Please follow up with your cardiologist within the next [12-2] weeks. You should also follow up with your primary care physician [Name Initial (PRE) 176] 2-4 weeks. Completed by:[2103-8-20] ICD9 Codes: 4019, 2724, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9002 }	Medical Text: Admission Date: [2168-4-4] [Month/Day/Year ] Date: [2168-4-12] Service: SURGERY Allergies: Sulfa (Sulfonamides) / Codeine Attending:[First Name3 (LF) 5880] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: None History of Present Illness: 85 yo female s/p fall from toilet; she was taken to an area hospital where she was found to have a Grade IV renal laceration to her left kidney. She was then transferred to [Hospital1 18] for further care. Past Medical History: HATN MI Afib DJD Mild dementia Arthritis GERD Spinal Stenosis Anemia Hyperkalemia Chronic rhabdo s/p open CCY "80's s/p Right TKR Family History: Noncontributory Physical Exam: Upon admission: T 97.4 po HR 88 BP 150/70 RR 18 Gen: NAD HEENT: EOMI Neck: c-spine immobilized Chest: CTA bilat Cor: RRR Abd: soft, NT, ND GU: Foley intact; + gross hematuria +TTP over left flank Extr: 2+ DP pulses Skin: no rash Musculosk: MAE Neuro: alert & orientd x3 Pertinent Results: OSH CT from [Hospital 1474] Hospital shows multiple nodules including at thyroid, RUL lung, liver. Pt will need followup imaging nonacutely to confirm lesions and/or resolution. RENAL U.S. Reason: Please assess for hydronephrosis/evidence of obstruction, or [Hospital 93] MEDICAL CONDITION: 85 year old woman s/p trauma L kidney REASON FOR THIS EXAMINATION: Please assess for hydronephrosis/evidence of obstruction, or other pathology INDICATION: 85-year-old woman with status post trauma, left kidney. RENAL ULTRASOUND: There is pleural effusion. There is heterogeneity of the left kidney mainly in the medulla with hypoechogenicity, representing laceration/hematoma seen on the prior CT study. There is no perinephric fluid collection identified on this ultrasound. There is mild hydronephrosis versus ectatic extrarenal pelvis. There is small amount of ascites. The atrophic right kidney was not identified on this ultrasound. IMPRESSION: Laceration/hematoma of the left kidney as seen on the prior CT scan. Small ascites. Mildly dilated pelvis which may represent mild hydronephrosis. Echogenicity in the pelvis may represent clot in this area as suggested on the prior CT study. Cardiology Report ECHO Study Date of [2168-4-5] ECHO Conclusions: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with severe hypokinesis/akinesis of the basal half of the inferior and inferolateral walls. The remaining left ventricular segments contract normally. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([1-19]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without evidence for hemodynamic compromise. There are prominent bilateral pleural effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD. Mild-moderate mitral regurgitation. Mild aortic regurgitation. Pulmonary artery systolic hypertension. Bilateral pleural effusions. CLINICAL IMPLICATIONS: Based on [2158] AHA endocarditis prophylaxis recommendations, the echo findings indicate a moderate risk (prophylaxis recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. [2168-4-7] CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: interval change? uretal obstruction? NO CONTRAST PLEASE Field of view: 36 [Hospital 93] MEDICAL CONDITION: 85 year old woman with Grade 4 renal lac, with intermittant low [Last Name (LF) ], [First Name3 (LF) ] need stenting REASON FOR THIS EXAMINATION: interval change? uretal obstruction? NO CONTRAST PLEASE CONTRAINDICATIONS for IV CONTRAST: single kidney w/ limited function, rising cr CLINICAL HISTORY: 85-year-old female with grade 4 renal laceration with intermittent low urine output. Evaluate for interval change. COMPARISON: [2168-4-4]. TECHNIQUE: Non-contrast multidetector CT acquired axial images of the abdomen and pelvis from the lung bases to the pubic symphysis. Coronal and sagittal reformatted images were obtained. CT OF THE ABDOMEN: There are large bilateral pleural effusions and adjacent compressive atelectasis, unchanged from [2168-4-4]. Again seen are two small round high-density foci within the subcutaneous tissue of the left upper thorax (series 2, image 1) which likely represents metallic foreign bodies. There is a tiny low-density lesion within segment III of the liver which is not characterized on this non-contrast study. The gallbladder is not identified. The spleen, pancreas, adrenal glands, and intra-abdominal loops of large and small bowel are unremarkable. Left kidney demonstrates retained contrast from prior imaging, although decreased compared to prior exam. The appearance of the kidneys is unchanged, without evidence of hematoma or hydronephrosis. The previously noted filling defect/clot within the left renal pelvis is not evaluated given lack of intravenous contrast. The right kidney is extremely atrophic. No lymphadenopathy or discrete fluid collection is identified within the abdomen. CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum, uterus, and adnexa are within normal limits. A moderate amount of air is seen within the bladder with tiny gas bubbles lateral to a Foley balloon likely within a lateral recess. Intrapelvic loops of small bowel are unremarkable. There are numerous sigmoid diverticula without evidence of diverticulitis. Free fluid is seen within the pelvis, the extent to which is unchanged from [2168-4-4]. BONY WINDOWS: Degenerative changes are present within the hips. Multiple rib fractures as well as a potential fractured osteophyte at L2 is again identified. There is extensive subcutaneous edema. IMPRESSION: 1. Compared to prior CT from [2168-4-4], the appearance of the left kidney is unchanged. There is no evidence of hematoma or hydronephrosis. Without intravenous contrast, the previously noted filling defect within the left renal pelvis and ureter is not assessed. 2. Large bilateral pleural effusions and adjacent compressive atelectasis, unchanged. Brief Hospital Course: She was admitted to the Trauma Service. Abdominal CT scan revealed multiple left renal lacerations, Urology was immediately consulted. She was transferred to the Trauma ICU after stabilized in the Emergency department; placed o strict bedrest; serial Hct's were followed q 4 hours; foley had been placed in the ED, there was gross hematuria; repeat CT scan was recommended as followup within 48 hours, this was performed and was unchanged. Discussions regarding possible stenting took place if she became obstructed. Follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 770] is being recommended in 1 month. Her urine output began to decrease and her creatinine began to rise, it was initially 1.1 then increased to 1.2, peaking at 1.6 on HD#3. Nephrology was then consulted for ? ATN. A renal ultrasound was recommended (see Pertinent results); her calcium was corrected. Her creatinine eventually improved back to 1.1. She will need to follow up with her primary Nephrologist after [Last Name (NamePattern1) ] from rehab. Physical and Occupational therapy were consulted and have recommended short term rehab stay. Medications on Admission: Dig .125' Toprol XL 200' Colace 100'' ASA 81' Nexium 40' Detrol LA 4' Levoxyl 125' Fosamax 70 q Sat Senna Predsinolone eye gtts [Last Name (NamePattern1) ] Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 7. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily): Apply OS. 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily): hold for HR <60; SBP <110. 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection [Hospital1 ] (2 times a day). 13. Fosamax 70 mg po every Saturday [Hospital1 ] Disposition: Extended Care Facility: [Hospital 39225] & Rehab Center - [Hospital1 1474] [Hospital1 ] Diagnosis: s/p Fall Grade IV left kidney laceration Left pleural effusion Bilateral rib fractures [Hospital1 ] Condition: Stable [Hospital1 ] Instructions: Avoid any activites that may cause physical contact to your left flank area because of your recent injury to your left kidney. Report any signs of blood in your urine to the staff at the rehab facility immediately. Followup Instructions: Follow up in Trauma Clinic in [1-19] weeks. Call [Telephone/Fax (1) 6429] for an appointment. Follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 770], Urology, in 1 month. Call [Telephone/Fax (1) 164] for an appointment. You will also need to follow up with your primary Nephrologist after [Telephone/Fax (1) ] from rehab as recoemmended by the Nephrology team who saw you during your hospitalization. Call for an appointment. You must follow up with your primary care doctor [First Name (Titles) ] [Last Name (Titles) ] from rehab for a thyroid finding on CT imaging. Completed by:[2168-4-12*] ICD9 Codes: 5119, 5180, 4019, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9003 }	Medical Text: Admission Date: [2154-9-22] Discharge Date: [2154-10-2] Service: MEDICINE Allergies: Augmentin / Imodium A-D / Influenza Virus Vaccine Attending:[First Name3 (LF) 2145] Chief Complaint: PNA sepsis Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: 83 yo man with CAD s/p CABG and CHF, DM who lives at [Location (un) 19404] found this am unresponsive on his bed. EMS called and on arrival FS of 20, given 1amp D50 and started to move extremities, but still poorly responsive. Was noted to be desatting in the field with Sats of 85% on NRB and so was intubated for hypoxic resp failure. . On arrival in ED, initial vital signs were T100 P70 BP100/37 R34. He was noted to have a RML and LLL pna and started on levo and flagyl. Sepsis protocol was initiated for leukocytosis, bandemia and elevated lactate. He was started on levophed for BP support asnd has received 10+ L NS. Pt had minimal UOP despite high CVP initially. Past Medical History: CAD s/p CABG, s/p pacer x 2 CHF, unknown EF DM, type 2 on insulin hx of claudication arthritis HTN s/p cholesytectomy hx of nephrectomy secondary to a chronic infection dementia Social History: Resides atSoldier's home. A former smoker smoking three packs a day for more than 30 years. He has not smoked in 45 years. He denies alcohol use. Wife died a few yrs ago during open heart surgery for aortic valve repair. Family History: NC Physical Exam: (after transfer to medicine for comfort care, s/p large CVA) Gen: pt unresponsive HEENT: pupils fixed and dilated Cardio: no heart sounds Resp: no breath sounds Neuro: pt not responsive to noxious stimuli Pertinent Results: [2154-9-22] 11:21PM LACTATE-3.3* [2154-9-22] 09:30PM TYPE-[Last Name (un) ] TEMP-36.6 PO2-39* PCO2-52* PH-7.27* TOTAL CO2-25 BASE XS--3 [2154-9-22] 09:30PM LACTATE-2.9* [2154-9-22] 09:18PM GLUCOSE-137* UREA N-23* CREAT-1.2 SODIUM-135 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-21* ANION GAP-15 [2154-9-22] 09:18PM PT-16.5* PTT-29.4 INR(PT)-1.8 [2154-9-22] 04:40PM LACTATE-4.6* K+-3.7 [2154-9-22] 04:35PM GLUCOSE-229* UREA N-24* CREAT-1.5* SODIUM-134 POTASSIUM-3.6 CHLORIDE-95* TOTAL CO2-26 ANION GAP-17 [2154-9-22] 04:35PM CORTISOL-51.0* [2154-9-22] 04:35PM ALT(SGPT)-25 AST(SGOT)-26 CK(CPK)-59 ALK PHOS-65 AMYLASE-77 TOT BILI-0.8 [2154-9-22] 04:35PM LIPASE-15 [2154-9-22] 04:35PM cTropnT-0.09* . CXR [9-22] IMPRESSION: 1. Endotracheal tube approximately 7 cm superior to the carina. 2. Multifocal pneumonia concerning for aspiration. . CT head [9-22] IMPRESSION: 1. Hypodense region within the right posterior temporal lobe with associated ex vacuo dilatation of the right occipital [Doctor Last Name 534] of the lateral ventricle, findings consistent with chronic infarction. 2. Chronic small vessel ischemic disease. 3. No intracranial hemorrhage or mass effect. . CT head [9-25] IMPRESSION: 1) Interval development of large left MCA distribution infarction, with probable clot in the hyperdense proximal MCA. There is no evidence of a hemorrhagic component. 2) Stable encephalomalacia in the right posterior temporal lobe. . CT head [9-27] IMPRESSION: Evolving left MCA distribution infarction, with slightly more edema and mass effect compared to the prior day's study. Brief Hospital Course: /P: 83M with h/o CAD, HTN, DM found unresponsive and hypoglycemic, now with multifocal pna concerning for aspiration, large left MCA stroke . Pt was found down in the field with hypoglycemia and respitaory failure. He was intubated in the field and transferred to [Hospital1 18] for further care. There he was found to be in septic shock due to multi-focal PNA. He had end organ damage to kidneys, heart, lungs. He was treated with levo, flagyl, vanco. He was maintained on mechanical ventilation and on pressors. On antibiotics he slowly improved from a respiratory standpoint. His sedation and ventilation were weaned. After extubating the patient he was found to be unresponsive to verbal/painful stimuli. He was also noted to have a new right sided facial droop and he was not moving his right side. CT head then demonstrated a massive evolving left sided MCA infarct. Neuro stroke service was consulted. Follow up CT showed progression of the infarct as well as old right sided infarcts. Neuro felt his prognosis was extremely poor given the extent of his infarct. Family meeting was held and the patient was made DNR/DNI/CMO. He was then transferred to the floor from the MICU. He was maintained on morphine, ativan, scopolamine, tylenol for comfort. Palliative care was consulted and it was initially decided to transfer the patient to hospice. However, on the AM of anticipated transfer, it was noted that the patient was having significant periods of apnea, though he exhibited no signs of distress. Transfer was placed on hold, and the patient died later that afternoon. Medications on Admission: insulin 70/30 44u sc QAM, 24 QPM lisinopril 20 QD effexor XR 75mg HCTZ 25 QD aspirin 81mg QD MVI lovastatin 10mg tylenol prn digitek 250mcg QD x 4days coreg 3.125 QD colace depakote 250 [Hospital1 ] salsalate 500mg TID terazosin 1mg QPM aricept 10 Discharge Disposition: Expired Discharge Diagnosis: Left MCA infarct Multilobar Pneumonia Respiratory failure DM Septic Shock Acute renal failure NSTEMI Hypoglycemia Discharge Condition: expired. Discharge Instructions: expired Followup Instructions: expired [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2158] Completed by:[2154-10-2] ICD9 Codes: 0389, 5845, 4280, 5990, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9004 }	Medical Text: Admission Date: [2188-9-26] Discharge Date: [2188-10-1] Date of Birth: [2151-9-25] Sex: F Service: [Last Name (un) ] Allergies: Augmentin / Tylenol/Codeine No.3 Attending:[First Name3 (LF) 1556] Chief Complaint: s/p being struck by [Doctor Last Name ] Major Surgical or Invasive Procedure: None History of Present Illness: 37 y/o female was struck by a [Doctor Last Name ]. She was intubated for combativeness at [Hospital3 ] Medical Center. There she was noted to have a left frontal subdural, frontal SAH, non-displaced occiptial fracture, and multiple left sided rib fractures. She was transfered to [Hospital1 18] for further management, hemodynamically stable, on dilantin and mannitol. Past Medical History: Asthma Migraines cholecystectomy Social History: Lives w/ husband in [Name (NI) 583]. No ETOH, no tobacco, no IVDU. Family History: Non-contributory Physical Exam: 102.0 135/72 HR 135 Intubated 100% Gen: Intubated, sedated HEENT: C-collar, PERRL, 3 cm superficial occiptal laceration Cardiac: tachycardiac, regular rhythm, no MGR Pulm: diffuse rhonchi Abd: obese, infraumbilical scar, non-tender, non-distended GU: foley, guiac neg Ext: right femoral central line, trace edema, 1+ pulses bilaterally Pertinent Results: Head CT: Anterior frontal and parafalcine subdural hematoma with anterior frontal subarachnoid hemorrhage. Non-depressed fracture of the occipital bone. CT Abdomen/Chest: No solid organ or aortic injury. Bilateral dependent atelectasis, most pronounced in the left lower lobe with associated small pleural effusion. Multiple posterior left rib fractures. Brief Hospital Course: 37 y/o female who was hit by [Doctor Last Name ] and sustained multiple injuries including left frontal subdural, frontal SAH, non-displaced occipital fracture/with overlying superficial laceration, and multiple posterior left sided rib fractures. Other studies which included L-spine, T-spine, Pelvis x-ray, and CT c-spine were negative for evidence of injury. The patient was evaluated by neurosurgery and admitted to the T/SICU. There the patient was continued on Dilantin w/ frequent neurochecks, SBP maintained < 150, and maintained euvolemic. Repeat head CTs x 3 remained unchanged. The head laceration was stapled closed. On HD 3 the patient self extubated and was stridorous afterwards. She was given albuterol nebs, racemic epinephrine, and decadron w/ improvement in her breathing. On HD 4 the patient was transfered out of the ICU. The patient was discharged home on HD 6 with her rib pain and headache better controlled. She will follow up in the trauma clinic in 1 week for removal of her head staples and with neurosurgery in [4-22] weeks for a repeat head CT. Medications on Admission: Albuterol PRN Advair Diskus Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 2. Phenytoin 50 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) for 1 days. Disp:3 Tablet, Chewable(s) Refills:0 3. Hydromorphone HCl 4 mg Tablet Sig: One (1) Tablet PO Q3-4H () as needed for pain for 10 days. Disp:50 Tablet(s) Refills:0 4. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for thick secretions for 10 days. Disp:qs ML(s) Refills:0 5. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain for 10 days. Disp:50 Tablet(s) Refills:0 6. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) Inhalation every six (6) hours. Discharge Disposition: Home Discharge Diagnosis: 1. frontal subdural 2. frontal SAH 3. non-displaced occipital fracture 4. superficial occipital laceration which was stapled closed 5. left sided rib fractures Discharge Condition: Good Discharge Instructions: Please call your primary care doctor or go the the Emergency Department if you experience worsening pain, fevers, chills, nausea, vomiting or have other concerns. Followup Instructions: 1. Follow up with Dr. [Last Name (STitle) 739] ([Telephone/Fax (1) 88] in [4-22] weeks for a repeat head CT. 2. Follow up in the trauma clinic [Telephone/Fax (1) ] in 1 week to have your head staples removed. ICD9 Codes: 5180
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9005 }	Medical Text: Admission Date: [2173-4-13] Discharge Date: [2173-4-21] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor Last Name 10493] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Endotracheal Intubation Bronchoscopy History of Present Illness: 89 year old man with hx atrial fibrillation, HTN, BPH, bronchiectasis presenting with cough for the past week. Per family member, he was having a worsening productive cough. He was evaluated by his PCP who thought it was an sinus allergy and prescribed a nasal spray. She denied his having a fever. She denied he had chest pain or particular shortness of breath. He had a mild headache yesterday. Today, he said to her that he did not feel well which prompted a trip to the ED. In the ED, his initial vital signs were notable for 98.5 (100.2rec) 178/128 22 94%4L. He subsequently stated that he had shortness of breath. A CXR was unchanged from prior. He had progressive respiratory fatigue and was intubated with etomidate prior to having a CTA chest. Following intubation, he dropped his blood pressure to 70s systolic which improved following IVF and removal of the propofol. . ROS: per the patient's wife: denies chest pain, abd pain, dysuria, back pain. no leg swelling. Past Medical History: 1. Newly diagnosed Atrial fibrillation 2. HTN 3. CAD s/p RCA PTCA '[59]. Repeat cath [2163]: 40% mid LAD, 40% mid LCX, luminal irregularities RCA. Last stress mibi [3-23]: No ECG or anginal sxs. Normal myocardial perfusion at the level of stress achieved, Calculated LVEF of 56%. 4. Hypercholesterolemia 5. BPH s/p TURP 6. s/p tympanomastoidectomy Social History: The patient lives with a girlfriend. [Name (NI) 4084] smoked. Drink socially, no illicit drugs. He is a retired salesman. A possible asbestos exposure in the past. Family History: Notable for a mother who died of a myocardial infarction in her 80's. Father died of a myocardial infarction in his 80's. Physical Exam: VS: 98.5 129/63 80 22 100% initial vent: AC 500 x 16 FIO2 1 PEEP 5 PIP 28 Plat 20 GEN: intubated, sedated HEENT: AT, NC, pupils 2->1 bilat, normal response to oculocephalics, no conjuctival injection, anicteric, MMM, Neck supple, no LAD, no carotid bruits. IJ to mid thyroid cart CV: irreg irreg, nl s1, s2, no m/r/g PULM: inspiratory wheeze bilat. crackles at bases. good ABD: soft, NT, ND, + BS, no HSM EXT: warm, dry, +1 distal pulses BL, no femoral bruits NEURO: sedated. moving all 4 extremities in response to noxious stimuli PSYCH: unable to assess Pertinent Results: [2173-4-13] 09:30AM WBC-8.5# RBC-5.19 HGB-15.0 HCT-46.4 MCV-89 MCH-29.0 MCHC-32.4 RDW-13.5 [2173-4-13] 09:30AM NEUTS-70 BANDS-14* LYMPHS-10* MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2173-4-13] 09:30AM PLT SMR-NORMAL PLT COUNT-221 [2173-4-13] 09:30AM GLUCOSE-134* UREA N-24* CREAT-0.8 SODIUM-144 POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-31 ANION GAP-14 [2173-4-13] 09:30AM ALT(SGPT)-45* AST(SGOT)-48* LD(LDH)-323* CK(CPK)-67 ALK PHOS-104 TOT BILI-1.1 [2173-4-13] 11:13AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-NEG [2173-4-13] 05:38PM DIGOXIN-0.3* [2173-4-13] 05:38PM CK-MB-NotDone cTropnT-<0.01 [2173-4-13] 05:38PM CK(CPK)-34* . CXR - Bilateral lower lung pleural plaques are consistent with prior asbestos exposure. An apparent interstitial abnormality is better evaluated on recently performed CTA chest ([2172-3-8]). There is no focal airspace consolidation or pleural effusion. The bony thorax is unremarkable. . CTA chest - (wet read) No PE. Again cardiomegaly, pleural and interstitial abnormalities c/w asbestosis exposure and mild asbestosis. . CXR - (post-intubation) - Post-intubation with endotracheal tube and orogastric tube in satisfactory position. . Echo: The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The right ventricular cavity is markedly 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. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([11-18]+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Severely dilated right ventricle with at least mild pulmonary artery systolic hypertension (may be underestimated as right atrial pressures are probably elevated). Moderate tricuspid regurgitation. Mild to moderate mitral regurgitation. Brief Hospital Course: 89 year old man with history of CAD, HTN, atrial fibrillation, and bronchiectasis who presented dizziness to have progressive hypoxic respiratory failure from presumed pneumonia who also developed urinary tract infection and traumatic hematuria. . 1 Hypoxic respiratory failure: Leading cause given low grade fever and bandemia would be CAP although he did not have an impressive chest xray for infection on admission. After intubation with fluid resuscitation, the patient had bilateral patchy infiltrates superimposed on evidence of chronic parenchymal disease on prior films. The patient was intubated for 4 days. He was treated with double coverage (levo/CTX) for CAP requiring ICU admission. He was extubated and did well, aided by one day of diuresis with lasix, but has been auto-diuresing since. His EKG was not significantly changed from prior. CT was also negative for PE. He completed 5 days of levofloxacin 750mg qdaily and 8 days of ceftriaxone 1g q24hours. He was noted to be deconditioned after extubation and felt to have difficulty clearing secretions so was aided with the use a flutter valve, incentive spirometer, chest pt, regular pt, albuterol and ipratropium nebs, and guaifenesin. He was slowly weaned from supplemental oxygen, with sats in the low 90's on RA. . 2 Rising leykocytosis: After being transferred from the MICU, the patient was noted to have a rising WBC. After a UA came back with moderate bacteria and >1000 WBC, a UTI was suspected and a course of Cipro 500mg PO Q12 hours was started. This was later discontinued after 1 dose and a repeat UA was completely negative. He developed loose stool and was started on empiric Flagyl 500mg PO TID on [2173-4-19] out of concern for C. Difficile (sample negative x1 on discharge; 2nd sample pending). His diarrhea was improving by time of discharge and his WBC had decreased from 15k to 12k after one day of metronidazole. He will continue metronidazole through [2173-5-4]. . 3 Atrial fibrillation: Beta blocker was titrated up in MICU. Digoxin was initially held then restarted, with level noted to be 0.4. Aspirin 325mg was continued throughout. He is chronically not anticoagulated due to fall risk per Dr. [Known lastname 1007]. Before discharge,his BP's were running low (systolic high 90's and low 100's) necessitating holding of the metoprolol and HCTZ. It was decided to decrease the metoprolol to 50mg PO BID, closer to his initial home dose of 50mg PO daily. . 4 Hematuria: He was noted to develop hematuria, presumably from foley placment. Once the foley was removed he continued have bloody urine but never became obstructed. This should be followed up as an outpatient to determine resolution. . 5 Dementia: Alzheimer's type per Dr. [Known lastname 1007]. He was continued on donepizil. He became delerious at night in the icu but improved with haldol/trazadone. On the floor he only needed haldol and remained lucid with good attention. . #CODE: FULL . #COMMUNICATION: patient, [Name (NI) 2013] [Name (NI) 28573] (wife) [Telephone/Fax (1) 28574], [First Name5 (NamePattern1) 553] [Last Name (NamePattern1) 28575] (youngest daughter) [Telephone/Fax (1) 28576] . #DISPO: Stable respiratory status and requiring respiratory rehab. Diarrhea and WBC are improving, and patient ready to be transferred to [Hospital1 100] Senior Life. Medications on Admission: aricept 10 mg daily hctz 12.5 mg daily zocor 20 mg daily zestril 5 mg qAM digoxin 125 mg daily metoprolol 25 mg [Hospital1 ] Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: Primary: Hypoxic respiratory failure from pneumonia, chronic congestive heart failure with diastolic dysfunction, traumatic hematuria, urinary tract colonization, suspected C. Difficile colitis. . Secondary: Dementia, bronchiectasis, benign prostatic hypertrophy, hypertension, atrial fibrilation. Discharge Condition: Ambulating with assistance, eating. Discharge Instructions: Please take all medications as prescribed. Please keep all follow-up appointments. Please notify your doctor or return to the emergency department if you experience chest pain, shortness of breath, abdominal pain, diarrhea, or any symptoms that concern you. Followup Instructions: Please follow-up with Dr. [First Name4 (NamePattern1) ] [Known lastname 1007] within 1-2 weeks of discharge. [First Name11 (Name Pattern1) ] [Known lastname 10491] MD, [MD Number(3) 10495] ICD9 Codes: 486, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9006 }	Medical Text: Admission Date: [2186-6-11] Discharge Date: [2186-6-28] Date of Birth: [2155-9-15] Sex: M Service: MED DISCHARGE SUMMARY ADDENDUM: On [2186-6-27] following a transplant meeting, which deemed the patient's prognosis very poor. The patient's family, including his wife and 2 sisters, decided to withdraw care and pursue comfort measures only. Dialysis was stopped. The patient's endotracheal tube was removed, and he was started on a morphine drip. At 1:30 a.m., on [2186-6-28], the patient expired. His family was at the bedside. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 968] Dictated By:[Last Name (NamePattern1) 12327] MEDQUIST36 D: [2186-7-29] 13:10:15 T: [2186-7-29] 13:49:14 Job#: [Job Number 53597] ICD9 Codes: 5845, 5715
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9007 }	Medical Text: Admission Date: [2148-6-12] Discharge Date: [2148-6-19] Date of Birth: [2122-3-18] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2181] Chief Complaint: suicide attempt Major Surgical or Invasive Procedure: intubation, extubation History of Present Illness: 26 yo F w/ depression, anxiety, asthma, here with overdose of unknown compound. Per her father, she has been depressed recently secondary to a breakup with her boyfriend. Also father states there has been familial issues as well as work issues possbily involving litigation. She has also been drinking alcohol along with her medications. Shitory of alcohol abuse, cigarettes, and marijuana use. She had recently expressed intent to take an overdose of clonazepam and to kill herself to friend in [Name (NI) 4565] over the phone. She spoke with her father of the night prior to admission and appeared very depressed. He was worried and called the police to check on the pt. but there were no outward signs of problems in the apartment. He drove up from NY and found her sprawled out on the floor minimally responsive and with "erratic breathing." There were 2 empty bottle of in the apartment - Klonipin and Seroqule. EMS was called and she was brought to the [Hospital1 18] ED. In the ED: initial vs: HR 112 BP 110/60 RR 12 02 sat 100% NRB-->98%RA She was given 0.4mg narcan without effect. C02 was 32 on capnography. Her head ct was negative. . MICU course - Pt was intubated and started on Clindamycin for possble aspiration PNA. As per MICU team, pt to be treated for total of [4-3] day. Pt was extubated without complication [6-15] AM. Pt also with elevated CKs which trended down with IV fluids. On transfer to the floor, patient is hysterically crying. Stating she is having difficulty breathing. Past Medical History: PMH: depression - bipolar? anxiety asthma multiple ear infections in childhood multiple episodes of PNA/bronchitis in last number of year Social History: [University/College ]graduate student. works with ex-offenders. +tobacco use, +etoh use, h/o marijuana use, states she "hates her job." Family History: mother and sister with depression and SA. Physical Exam: PE: VS: T 95.9 HR 109 BP 132/86 RR 16 02sat 97@ on RA GEN: responds to command, confused, does not respond to questions HEENT: dry MM, pupils are dilated and equal bilaterally, color contacts in place, disconjugated gaze. CV: tachy, no murmurs PULM: CTAB ABD: soft, NT, ND, present but hypoactive BS EXT: WWP, no edema NEURO: does not answer questions, awake and following commands Pertinent Results: [2148-6-12] 06:50PM FIBRINOGE-362 [2148-6-12] 06:50PM PLT COUNT-296 [2148-6-12] 06:50PM PT-14.8* PTT-24.0 INR(PT)-1.3* [2148-6-12] 06:50PM WBC-10.6 RBC-5.03 HGB-15.8 HCT-45.5 MCV-90 MCH-31.4 MCHC-34.8 RDW-12.0 [2148-6-12] 06:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-POS [2148-6-12] 06:50PM OSMOLAL-301 [2148-6-12] 06:50PM ALBUMIN-5.2* CALCIUM-10.3* PHOSPHATE-4.0 MAGNESIUM-2.1 [2148-6-12] 06:50PM LIPASE-13 [2148-6-12] 06:50PM ALT(SGPT)-21 AST(SGOT)-36 LD(LDH)-176 CK(CPK)-1896* ALK PHOS-68 AMYLASE-163* TOT BILI-0.3 [2148-6-12] 06:50PM GLUCOSE-107* UREA N-15 CREAT-1.1 SODIUM-149* POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-22 ANION GAP-23* [2148-6-12] 06:54PM freeCa-1.04* [2148-6-12] 07:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2148-6-12] 07:00PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.007 [2148-6-12] 07:00PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-POS [2148-6-12] 07:00PM URINE UCG-NEGATIVE . admission ECG: normal axis, nsr, rate 108, qt<400, no sttw abn. STUDIES: CT head neg for acute process . EKG - [6-14] -Technically difficult study Sinus rhythm upper normal rate Low lead QRS voltages Normal ECG Since previous tracing of [2148-6-13], heart rate slower . chest x-ray [6-13] - The lung volumes are relatively low. At the bases of the right lung, a focal area of consolidation with air bronchograms is seen. This change would be consistent with aspiration. In addition, there is a small right-sided pleural effusion. The left lung is unremarkable. The size of the cardiac silhouette is within the normal range. The hilar and mediastinal contours are unremarkable. Brief Hospital Course: A/P: 26 yo F w/ pmh of depression s/p overdose on seroqual and alcohol. Now s/p MICU stay with intubation. Now extubated being treated for aspiration PNA and followed closely by psych for suicidal ideation. . # Overdose: - tox screen positive for methadone and tricyclics. Seraquel can give false pos. tricyclic levels. CK levels down, QTc interval closed. - tried to get EKG today, will repeat tomorrow - hold all home psych meds as per psych notes - psychiatry consult- see OMR note for details - haldol 1 mg PO TID PRN for agitation, no valium - social work consult ordered - cont [11-28] sitter - section 12 can't leave AMA - psych transfer to inpatient bed today . # Pulmonary: - pt extubated s/p MICU stay, stable on room air - will start Advair, d/c all other nebs - pt stable on room air, soft call on the aspiration PNA, will d/c all antibiotics at this time . # Depression: hold medications - psych, social work. . #FEN - replete lytes PRN, regular diet - CK elevated on admission, decreased to 400s with fluids, no longer needs IV fluids, renal function excellent, no need to check daily lytes . #ACCESS: none . #PPx: heparin sq, bowel regime . #CODE: FULL . #COMMUNICATION: patient, father [Doctor First Name ] [Telephone/Fax (1) 35969]) . #DISPO: patient is medically stable for treatment in inpatient psychiatric facility with continued outpatient medical managment. . [First Name8 (NamePattern2) ] [Name6 (MD) 35970] [Name8 (MD) ], M.D., M.S. Medications on Admission: albuterol clonazepam 1mg tid fluoxetine 10mg qdaily lamictal 200mg qdaily seroquel 400mg qhs Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for agitation. 3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 4. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Albuterol 90 mcg/Actuation Aerosol Sig: [11-29] Inhalation every six (6) hours as needed. 8. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 9. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). Discharge Disposition: Extended Care Facility: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] -[Hospital1 ] Discharge Diagnosis: 1) Suicide attempt 2) Asthma, depression, anxiety Discharge Condition: stable Discharge Instructions: You were admitted to the hospital after a suicide attempt which invovled seroquel overdose and alcohol use. You were intubated in the MICU. You have been foloowed closely by psychiatry as well as internal medicine during your stay here. You should continue to take all of your medications as prescribed. You should follow up with your PCP once you are discharged for routine medical care. You should continue to see an outpatient psychiatrist as indicated by the psychiatry team. Followup Instructions: As per inpatient psych facility Completed by:[2148-6-19] ICD9 Codes: 5070, 5849, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9008 }	Medical Text: Admission Date: [2146-4-18] Discharge Date: [2146-5-9] Date of Birth: [2064-8-29] Sex: M Service: SURGERY Allergies: Aspirin / Lisinopril / Morphine / Percocet / Amoxicillin Attending:[First Name3 (LF) 695] Chief Complaint: New area of drainage right abdomen Major Surgical or Invasive Procedure: [2146-4-22] cholangiogram [2146-5-4] PTC: gistula tract embolized with gelfoam. internal/external stent exchanged for a covered stent History of Present Illness: 81 y/o male well known to hepatobiliary service. 1 year post Left hepatic lobectomy for intrahepatic cholangiocarcinoma complicated post op by persistent bile leak since the time of surgery. Has had multiple drains, attempted stents, attempted tract embolizations. Most recently he underwent [Month/Day/Year ] on [3-31] showing a metal stent in place which appeared to go into the right main hepatic duct with extravasation of contrast noted at the proximal end of the metal stent. Two 6cm by 10FR Cotton [Doctor Last Name ] biliary stents were successfully placed into the common hepatic duct and coming out of the major papilla. The following day he had tract embolization with silver nitrite and gelfoam pledgets. He was using an ostomy appliance over the remaining hole post embolization with approximately 20-30 cc daily of bilious appearing fluid. The patient reports he felt "like himself" and had gotten back his appetite and some energy until last Friday around noontime when he started feeling fatigued and without appetite. He noted last week that there was a "ridge" on his abdomen, but did not think much about it. At about 4AM today the patient awoke with wetness on his nightclothes and noted a new hole in his abdomen, more lateral than the previously known tract. The drainage appeared slightly bloody to him, he called his VNA who came out early to see him and had him transported to [Hospital1 18] via ambulance. He reports no episodes of fever. The abdomen has been somewhat more painful in the general area of this new opening. He denies nausea or vomiting and has been having regular formed bowel movements. No chest pain or shortness of breath are reported. . Past Medical History: diverticulitis, hyperlipidemia, cardiac murmur,, CAD s/p MI in his 50s. PSH: CABG [2123], knee surgery [2136],partial colectomy [2141] with temporary colostomy with subsequent reversal. States this was not for a malignancy [2146-3-31] [Month/Day/Year ] with cbd stent placed [2146-4-1] drain tract embolization Social History: He is a widower and retired carpenter. He has six children. 57 y.o. dtr with h/o polio died [2145-10-24], one has had an MI, and the third has type I DM, and the other three children are healthy Family History: Mother died of a stroke at age 83, father died of heart failure at age 89. Strong family history of cardiac disease. Physical Exam: VS: 98.2, 65, 155/93. 20, 98%RA, weight 71.6 kg General: Alert and oriented, NAD, appears "down" with quiet affect, sadness over this most recent admission. "I have a few good days and then I get knocked down again". Three pound weight loss noted since last admission. [Month/Day/Year 4459]: skin appears dry, and sl dry mucous membranes. Of note, patient is HOH and does not have his hearing aid with him. Card: RRR, III/VI murmur noted Lungs: Right base with diffuse crackles, otherwise CTA bilaterally. Abd: Soft, tender at area around new skin opening. Dry Dressing in place with purulent/bloody/greenish tinged fluid on dressing and oozing from hole. Old site more midline with greenish, thick drainage noted. More volume coming from new opening. Skin around new opening is erythematous, slightly raised and very tender to the touch. slightly red towards flank on right side. Extr: + pedal pulses, no edema noted, warm and well perfused Neuro: no focal deficit noted, alert and oriented x3, affect depressed. Skin: warm and dry. eryhtematous around opening as described above. GI: no N/V/D . Brief Hospital Course: IV unasyn was started on admission. CT of the abdomen on [4-18] demonstrated interval removal of right upper quadrant drainage catheter with persistent tract to the skin. Small hypodense focus in the right abdominal wall and mild edema of the distal stomach and proximal duodenum was noted. Stable enhancing focus in segment VIII of the liver and stable appearance of multiple air locules adjacent to the surgical clips and biliary catheter in the right upper quadrant without associated fluid collection. Blood cultures were sent and were negative. The abdomenal fistula tract was cultured showing 1+ pmn, no organisms and no growth. On [4-19], the draining area was I&D'd and [Hospital1 ] dry dressing changes were continued. The wound continued to drain serosanguinous fluid. He remained afebrile. WBC decreased from admission wbc of 13.5 to 6.7. On [4-22], a cholangiogram was performed with placement of internal/external percutaneous biliary drain via the anterior ducts. Uncomplicated placement of [Location (un) 2617]-[Doctor Last Name 2418] at the level of the patient's bile leak. PTC demonstrated biliary leak adjacent to proximal end of the right hepatic duct stent. Post procedure, he developed rigors, hypotension and spiked a temperature to 103. Blood cultures were sent and he was treated with zosyn. He was transferred to the SICU for management which included pressor support for sepsis. Once stabilized, he was transferred back to the med-[Doctor First Name ] unit on [4-24]. Blood cultures grew out VRE. Unasyn and zosyn were switched to Daptomycin on [4-25]. A picc line was inserted as iv access became difficult. Repeat daily surveillance blood cultures were drawn and remained negative. A TTE was negative for vegetations. EF was 55%, dilated left atria, trace AR and minimal aortic valve stenosis was noted. On [5-4], a pullback cholangiogram demonstrated no definite biliary leak. A covered balloon expandable stent was placed in the biliary system extending the peripheral end of the previously placed stent for 2 mm. The tract in the perihepatic space was embolized with Gelfoam and Betadine. Prior to this procedure, he was started on Zosyn in addition to the Daptomycin. Both the internal/external biliary drain and the drain in the perihepatic space were exchanged over a wire. He tolerated this procedure well, but did have some rigors and a temperature of 101.6 post procedure. Zosyn was continued in addition to the Daptomycin.The Zosyn was stopped after 48 of remaining afebrile and with negative blood cultures. On [5-6], Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 497] removed the previous endoscopically placed stents. These stents were sent to pathology. This procedure was well tolerated. Of note, the drain in the perihepatic space had some tan, thick drainage at the insertion site. The drain was uncapped with only ~ 20cc/day of thick brown drainage. A small amount of drainage appeared at the insertion site. On [5-9], Daptomycin was stopped after completing 14 days of treatment for VRE. He was ambulating independently, tolerating a regular diet(with supplements) and vitals remained stable. He was seen by Nutrition and given supplements as his appetite and intake had diminished mid hospitalization due to nausea which was likely due to antibiotics and pain medication (vicodin). Vicodin was stopped and Ultram was started. Ultram was stopped as he did have some hallucinations with the Ultram. Tylenol was then used for comfort. LFTs were notable for alkaline phosphatase that remained in the mid 300's to 400 range. [Company 1519] ([Telephone/Fax (1) 12065]was arranged for nursing and PT at home. He was discharged home in stable condition. Medications on Admission: Atenolol 25 mg PO daily, Pantoprazole 40 mg PO daily, MVI daily, Lasix 40 mg daily PRN, last dose about 1 week ago Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): take as needed for leg swelling. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: bile leak s/p left hepatic lobectomy [4-10] septicemia, vre Discharge Condition: good Discharge Instructions: Please call Dr.[Name (NI) 1369] office [Telephone/Fax (1) 673] if fever, chills, worsening abdominal pain, drainade from wound or redness of edge of wound, recurrent drainage from old drain tract Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2146-5-20] 9:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2146-5-18] 9:20 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2146-5-9] ICD9 Codes: 2724, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9009 }	Medical Text: Admission Date: [2133-5-6] Discharge Date: [2133-6-1] Date of Birth: [2068-11-24] Sex: F Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: This is a 64-year-old female with a past medical history significant for critical aortic stenosis and three-vessel coronary artery disease, and chronic congestive heart failure, who presented on [5-6] with acute on chronic shortness of breath. She was found to be in congestive heart failure at the time. The patient had no chest pain, palpitations, nausea, vomiting, abdominal pain, or dysuria. MEDICATIONS ON ADMISSION: Enteric Coated Aspirin, Atenolol. ALLERGIES: NO KNOWN DRUG ALLERGIES. PAST MEDICAL HISTORY: Critical aortic stenosis, valve area of 0.5-0.6 gradient, 31 mmHg. Catheterization with 80% PRCA, 40% LAD, 40% circumflex, moderate PA hypertension, biventricular diastolic dysfunction, gallstones, headaches, arthritis, uterine fibroids. PHYSICAL EXAMINATION: General: The patient was a Russian female in no apparent distress. HEENT: Normocephalic, atraumatic. Sclerae anicteric. Oropharynx without lesion. Extraocular movements intact. Pupils equal, round and reactive to light and accommodation. Neck: Supple. No lymphadenopathy. Unable to assess jugular venous distention. Chest: Clear bilaterally. No crackles appreciated. Cardiovascular: Regular rhythm. Loud systolic ejection murmur increasing to neck. Abdomen: Obese. Macular papular rash diffusely. Abdomen: Nontender and nondistended. No rashes. Extremities: No cyanosis or clubbing. There was 2+ edema to thighs. Psoriatic plaque on soles of feet, elbows. Skin: There was a macular papular diffuse rash on back and trunk. LABORATORY DATA: On admission, white blood cell count was 10.0, hematocrit 31.4, platelet count 310,000; BUN 17, creatinine 0.8, sodium 137, potassium 4.1, chloride 103, bicarb 21, glucose 125. Chest x-ray showed mild congestive heart failure. Troponin was 1.2. Electrocardiogram showed sinus rhythm with tachycardia and inverted T-waves in leads VI, possible left atrial abnormality, rate 101. Cardiac catheterization performed on [2133-4-27], showed three-vessel coronary artery disease, severe aortic stenosis, moderate to severe pulmonary arterial hypertension, moderate to severe left and mild moderate right ventricular diastolic dysfunction. HOSPITAL COURSE: The patient was taken to the Operating Room on [2133-5-11], where she underwent two-vessel coronary artery bypass graft and aortic valve repair with tissue. On postoperative day 0, the patient required right chest tube thoracostomy for a right pleural effusion which she tolerated well. The patient was extubated and transferred to the floor. On postoperative day #5, the patient's sternum was found to be unstable. Chest x-ray was obtained which showed shift of sternotomy wires. She was then taken to the Operating Room on [2133-5-17], where she underwent sternal debridement with left pectoralis major muscle advancement flap, right pectoralis major muscle advancement flap, and local fascia cutaneous advancement flap under general anesthesia. The patient was extubated three days later; however, required reintubation secondary to respiratory distress. She was able to be extubated two days later, and her respiratory status steadily improved. She remained on Levaquin post sternotomy with flaps having had three JPs, one of which was removed and was also treated with Vancomycin for positive blood cultures which grew out coag-negative staph. The patient remained afebrile with wound intact, clean and dry, JPs draining serosanguinous fluid and was felt to be stable for discharge to a rehabilitation facility with further monitoring of the output from her JP drains which will be removed when it is less than 30 cc. The patient is also to continue on Levaquin for the duration of the JP drainage. DISCHARGE DIAGNOSIS: 1. Coronary artery disease. 2. Critical aortic stenosis. 3. Status post coronary artery bypass graft times two with tissue aortic valve replacement. 4. Gallstones. 5. Headaches. 6. Uterine fibroids. 7. Poor respiratory reserve. 8. Status post sternal debridement with bilateral pectoralis flaps. DISCHARGE MEDICATIONS: Colace 100 mg p.o. b.i.d., Aspirin 325 mg p.o. q.d., Flovent 2 puffs t.i.d., Triamcinolone creme b.i.d., Captopril 12.5 mg p.o. b.i.d., Combivent MDI 2 puffs q.6 hours, Lasix 20 mg p.o. q.12 hours, KCl 20 mEq p.o. b.i.d., Multivitamin 1 p.o. q.d., Zantac 150 mg p.o. b.i.d., Lopressor 75 mg p.o. b.i.d., Tylenol 650 mg p.o. q.6 hours p.r.n. pain, Albuterol MDI 2 puffs q.4 hours and p.r.n., Ibuprofen 400-600 mg q.6 hours, Levaquin 500 mg p.o. q.d. DISCHARGE INSTRUCTIONS: The patient is discharged to [Hospital3 4419] Facility for cardiopulmonary rehabilitation and wound care and monitoring of JP drain output. The JP drains are to be removed when output is less than 30 cc per 24-hour period. The patient is to remain on Levaquin for the duration of the JP drainage. The patient is to follow-up with Dr. [Last Name (STitle) 1537] in [6-2] days and with her primary care physician [Last Name (NamePattern4) ] [1-25] weeks. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Name8 (MD) 24658] MEDQUIST36 D: [2133-6-1] 03:27 T: [2133-6-1] 07:04 JOB#: [Job Number 24659] ICD9 Codes: 4241, 4280, 9971, 5185, 5119
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9010 }	Medical Text: Unit No: [Numeric Identifier 76506] Admission Date: [2157-1-31] Discharge Date: [2157-2-7] Date of Birth: [2157-1-31] Sex: F Service: NB HISTORY: Baby Girl [Known lastname 76507] was born weighing 2425 grams and was the product of a 34 and 2/7 weeks gestation pregnancy born to a 29-year-old G1, P0, now 1 mother. Prenatal screens were as follows: blood type A positive, antibody negative, RPR nonreactive, rubella immune, HBsAg negative, GBS unknown. This pregnancy was complicated by cholestasis of pregnancy, irretractable pruritus and hypothyroidism. The mother was treated with betamethasone 4 days prior to delivery. This infant was born by scheduled C- section because of maternal issues. She had Apgar scores of 9 and 9 at 1 and 5 minutes. She voided and passed meconium in the delivery room and was taken to the NICU for further management of prematurity. FAMILY HISTORY: Additional maternal history includes a history of Crohn disease which is treated with Imuran and Pentasa; and, type 1 diabetic treated with an insulin pump. There is also has histo ry of migraines and GERD with history of H. pylori treated with triple therapy, Raynaud syndrome with retinal detachment treated with surgical buckle repair in 1 eye and pneumopexy in the other eye. Mom was also 27 week premature infant at birth. Maternal medications included: 1. Imuran. 2. Pentasa. 3. Insulin. 4. Nephrocaps. 5. Iron. 6. Vitamin C. 7. Cholestyramine. 8. Klonopin. 9. Marinol. SOCIAL HISTORY: Mom denies any illicit drug use. She completed 1 year of pediatric residency and is a graduate of [State 76508] in [Hospital 18488] Medical School, dad is a fourth year medical student at BU. Parents are married. MEASURES AT BIRTH: Birth weight of 2425 grams which is 75th percentile. Head circumference of 33.5 cm which is 75th percentile. Length of 46 cm which is 50th to 75th percentile. PHYSICAL EXAM AT DISCHARGE: Active, alert, female infant. HEENT: Anterior fontanelle soft and flat, intact palate. Normal faces. Bilateral red reflux present, supple neck. Chest: Breath sounds clear and equal bilaterally with slight retraction, comfortable respiratory effort on room air. Cardiovascular: Normal S1/S2. No murmur. Pink and well- perfused. Normal pulses. Abdomen: Soft and round with active bowel sounds. Cord dry. Patent anus. No masses. GU: Normal female genitalia. Musculoskeletal: Straight spine with no sacral dimple. Hips intact. Moves all extremities well. Good tone. Neuro: Active and alert, normal cry. Normal reflexes. Discharge weight 2340 grams, length of 48 cm and head circumference of 33.5 cm done on the day of discharge. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: 1. Respiratory - The infant has remained in room air since admission to the NICU with stable oxygen saturations and no apnea or bradycardic episodes. She has not required any methylxanthine therapy. 2. Cardiovascular - She has maintained cardiovascular stability since birth with normal blood pressures, heart rates, and no audible murmurs. 3. Fluids, electrolytes and nutrition - The infant was started on p.o. ad lib feedings on the newborn day. She never required any IV fluid. Her dextrosticks sticks have remained stable. She is presently feeding ad lib p.o. of breast milk or 20 cal per ounce and taking at least 120 mL/kg/day plus breast feeding. She is voiding and stooling normally. Stools have been heme negative. 4. GI - She had a peak bilirubin level of 10.5/0.3 on [2157-2-4]. Bilirubin on [2157-2-5] was 10/0.3. She has not required phototherapy. 5. Hematology - No blood typing has been done on this infant. The hematocrit at birth was 50.6, and platelet count of 553,000. 6. Infectious disease - CBC and blood culture were screened on admission to the NICU. The CBC was unremarkable. The blood culture remained negative. No antibiotics were given. 7. Neurology - The infant has maintained a normal neurologic exam for gestation age. 8. Sensory - Audiology. A hearing screen was performed with automated auditory brainstem responses and the infant passed in both ears. 9. Ophthalmology - Screening ophthalmologic exams for ROP are not indicated. Of note, father with a history of macular degeneration at a young age. An outpatient assessment for [Female First Name (un) ] is recommended. 10.Psychosocial - Family is active and involved in the infant's care. CONDITION AT DISCHARGE: Good. DISCHARGE DISPOSITION: Home with the parents. NAME OF PRIMARY PEDIATRICIAN: [First Name4 (NamePattern1) 72881] [Last Name (NamePattern1) ], M.D. [Hospital 1426] Pediatrics. [Hospital1 ]. [Location (un) 86], [Numeric Identifier ]. Phone: [Telephone/Fax (1) 37802]. RECOMMENDATIONS: Ad lib p.o. feedings by breast or supplementing with Enfamil 20 calories/ounce. MEDICATIONS: None during her NICU stay; however if feedings are eventually provided predominantly by Breast Milk we recommend iron and Vitamin D supplementation. IRON AND VITAMIN D SUPPLEMENTATION: 1. Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. 2. All infants fed predominantly breast milk should receive vitamin D supplementation at 200 international units which may be provided as multivitamin preparation daily until 12 months corrected age. CAR SEAT POSITION SCREENING: This infant was screened in an upright position while in the car seat and the infant passed the screening. A state newborn screen was sent on day of life 3 on [2157-2-3] and results are pending. IMMUNIZATIONS RECEIVED: The infant received hepatitis B vaccine on [2157-2-2]. The infant does not qualify for Synagis per the most current screening with the family prior to discharge. Immunizations recommended: 1. Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following 4 criteria - a. Born less than 32 weeks gestation. b. Born between 32 and 35 weeks with 2 of the following, either daycare during RSV season, smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings. c. Chronic lung disease. d. Hemodynamically significant congenital heart disease. 2. Influenza immunizations as 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 child's life, immunization against influenza is recommended for household contacts and out of home caregivers. 3. This infant has not received a rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks, but fewer than 12 weeks of age. FOLLOW UP: Follow up appointment is recommended with pediatrician within 2 days of discharge from the NICU. VNA referral has been made with Care Group VNA. DISCHARGE DIAGNOSIS: 1. Prematurity, born at 34 and 2/7 weeks gestation, now 35 and 2/7 weeks post conceptual age. 2. Infant of a diabetic mother. 3. Sepsis ruled out. [Name6 (MD) ] [Last Name (NamePattern4) ], [MD Number(1) 55472] Dictated By:[Name8 (MD) 75423] MEDQUIST36 D: [2157-2-6] 22:36:48 T: [2157-2-7] 00:05:00 Job#: [Job Number 76509] cc:[Last Name (NamePattern4) 76510] ICD9 Codes: V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9011 }	Medical Text: Admission Date: [2111-5-13] Discharge Date: [2111-5-15] Date of Birth: [2054-11-25] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 30] Chief Complaint: neck [First Name3 (LF) ] and pain Major Surgical or Invasive Procedure: None History of Present Illness: 56 yo healthy gentleman who had a recent tooth infection that began 1 week ago and s/p urgent root canal 2 days PTA who presents with left-sided neck [First Name3 (LF) ] and pain. He reports that he developed painful swallowing and difficulty swallowing with dinner last night and that he felt that pills were stuck in his throat. Neck [First Name3 (LF) ] has worsened since root canal 2 days ago. He is unable to fully open his mouth. He denies any difficulty breathing, wheezing or handling his oral secretions. He does report sweats, but denies fevers or chills. He was evaluated at [Hospital1 ] [Location (un) 620] which showed a Neck CT with initial read concerning for airway impingement and abscess. At OSH ED, he was given unasyn 3gm IV x1, morphine 8mg IV total and decadron 10mg IV at 6am and then transferred here. . In the ED, initial vs were: T 98.2 HR 86 BP 153/88 RR 16 O2sat 100%ra . On exam, patient L lower facial [Location (un) ], trismus, but no distress. Labs notable for WBC 20. ENT was consulted and felt that his airway was stable, but final recommendations are pending. Tentative plan is for decadron 10-12mg IV Q8hr. Maxillofacial surgery (Dr. [First Name (STitle) ] was also consulted and will plan to see the patient this afternoon; he recommended keeping the patient NPO. Patient was given unasyn and 1L NS in our ED. ICU admission requested for airwary monitoring. His VS prior to transfer were: 152/60 81 16 98% ra. . In the ICU, the patient reports that his pain is much better currently. Past Medical History: # Tonsillectomy as child at age 3. Social History: Patient works as a building inspector and remodeler. Married with 2 children. He is a current smoker, 1PPD for 25years. He drinks to beers/night, but has not had any alcohol in past 4 days. No IVDU. Family History: Mother died of bone cancer at age 51. Physical Exam: General: Alert, oriented, no acute distress HEENT: NCAT, PERRLA, Sclera anicteric, Neck: supple, JVP 5cm, left submandibular tissue [First Name (STitle) ] and pain but unable to identify a fluctuant focus. Only able to open mouth 1.5-2cm. OP with MM. Unable posterior OP to evaluate for erythema. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ radial, DP & PT pulses, no clubbing, cyanosis or edema Neuro: CN2-12 intact, MAE, sensation grossly intact. Pertinent Results: [2111-5-13] 09:00AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.023 [2111-5-13] 09:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2111-5-13] 08:30AM GLUCOSE-127* UREA N-14 CREAT-0.9 SODIUM-139 POTASSIUM-5.0 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13 [2111-5-13] 08:30AM TSH-1.1 [2111-5-13] 08:30AM FREE T4-1.4 [2111-5-13] 08:30AM WBC-20.9* RBC-5.42 HGB-16.5 HCT-48.8 MCV-90 MCH-30.5 MCHC-33.9 RDW-14.1 [2111-5-13] 08:30AM NEUTS-92.2* LYMPHS-4.8* MONOS-2.2 EOS-0.5 BASOS-0.3 [2111-5-13] 08:30AM PLT COUNT-258 . Panorex [5-13]: IMPRESSION: Findings consistent with the given history of a recent tooth extraction, presumably the right lower second molar. . HISTORY: Enlarged right lobe of thyroid seen on previous x-ray. FINDINGS: The right lobe of the thyroid measures 6.0 x 2.8 x 3.2 cm and contains a heterogeneous, predominantly solid nodule at the mid-to-lower pole. The nodule measures 3.2 x 2.9 x 2.2 cm. Left lobe of the thyroid measures 4.9 x 1.7 x 1.6 cm and contains two small benign-appearing nodules, 0.6 cm in the upper pole and 0.8 cm in the lower pole. CONCLUSION: Bilateral nodules. The nodule in the mid-to-lower pole of the right lobe of the thyroid should be considered for fine needle aspiration. Brief Hospital Course: This is a 56 year old healthy male presenting with neck pain, [Month/Day (1) ], and trismus with evidence of tonsillar and peritonsilar cellulitis admitted to the ICU due to concern for potential airway compromise. He was seen by anesthesia and ENT, imaging was from [Hospital1 18] [Location (un) 620] was reviewed, he was treated empirically with decadron and continued on his antibiotics. He never developed airway compromise, and was transferred to the medical floor, and then home. He was also noted to have multiple thyroid nodules for which outpatient follow-up is recommended. Medications on Admission: # Percocet 5 mg-325 mg Tab Oral 1 Tablet(s) Every 4-6 hrs PRN pain # Amoxicillin 500 mg Cap Oral 1 Capsule(s) Three times daily, started 2 days PTA. # Motrin 400mg PO Q6hrs PRN pain Discharge Medications: 1. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Continue until you see your Dentist on [5-28]. Disp:90 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Peritonsillar Infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for an infection from your recent dental surgery. You were seen by Ear, Nose and Throat (ENT) doctors who noted [Name5 (PTitle) ] in your throat. You were closely watched in the ICU and treated with antibiotics and steriods. Over the course of 24 hours this [Name5 (PTitle) ] disappeared on reexamination by ENT. Your steroids You were discovered to have a nodule in your thyroid that should be followed-up with a biopsy. Followup Instructions: Please call Dr. [Last Name (STitle) 85628] at [Telephone/Fax (1) 85629] to follow-up regarding your recent hospitalization and re-establish primary care. Please call Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1837] for a follow-up in [4-14] weeks Otolaryngology; [Hospital1 69] View Map [Last Name (NamePattern1) 81724] [Location (un) 86], [Numeric Identifier 718] Phone: [Telephone/Fax (1) 41] Fax: [Telephone/Fax (1) 80014] Appointment for thyroid biopsy ----- ICD9 Codes: 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9012 }	Medical Text: Admission Date: [2107-2-26] Discharge Date: [2107-2-27] Date of Birth: [2040-5-3] Sex: F Service: Neurosurgery HISTORY OF PRESENT ILLNESS: This is a 66 year old female who was in her usual state of health until lunch on [2-26], when she developed a sudden onset headache, visual changes and nausea. Emergency medical services was called and the patient was transported to [Hospital6 4620] for care. The patient was oriented times one and combative at the outside hospital and was intubated there. The patient was then transferred to the [Hospital6 2018] for further management. On computerized tomography scan, the patient had a large intracranial hemorrhage in the left parietal lobe, measuring 6 cm with severe midline shift. PAST MEDICAL HISTORY: 1. Headaches; 2. Depression; 3. Osteoarthritis; 4. Recent eye infection. MEDICATIONS: 1. Prozac; 2. Hormone. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives in [Location ] with husband. The patient has two sons. PHYSICAL EXAMINATION: The patient was afebrile. Vital signs were stable. The patient was intubated and sedated. The patient's pupils were fixed and dilated, the left measured 7 to 8 mm, the right measured 6 mm. The patient's lungs were clear. The patient's heart was regular rate and rhythm. The patient's abdomen was soft, nontender, nondistended. The patient had right hemiparesis and the patient's left extremity withdrew from painful stimulation and had decerebrate posturing. The patient had no corneal reflex at the time and had no oculocephalic reflex. The patient was also lacking gag reflex at that time. LABORATORY DATA: Computerized tomography scan as described above. The patient's complete blood count is normal. Chem-7 was normal. Coagulation profiles were normal. HOSPITAL COURSE: The patient was admitted to the Neurosurgical Intensive Care Unit for care. On hospital day #2, the patient had no movement at all in the four extremities. The patient continued to have no cerebellar functions including oculocephalic, corneal, gag and pupillary light reflexes. A family meeting took place at which time the family decided to withdraw care. The patient's time of death was declared at 1605 on [2107-2-27]. CONDITION ON DISCHARGE: Deceased. DISCHARGE STATUS: Morgue. [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 342], M.D. [MD Number(1) 343] Dictated By:[Last Name (NamePattern1) 1909] MEDQUIST36 D: [2107-2-27] 16:21 T: [2107-2-27] 17:25 JOB#: [Job Number 4621] ICD9 Codes: 431, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9013 }	Medical Text: Admission Date: [2148-4-27] Discharge Date: [2148-5-2] Date of Birth: [2092-8-5] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6114] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: intubation right internal jugular line EGD Colonoscopy History of Present Illness: 55 year old male with a history of rectal cancer s/p polypectomy '[41], EtOH use with history of DTs/seizures, type 1 DM and depression who presented to [Hospital3 ] on [2148-4-26] s/p fall at home. The patient lives alone at home and was brought in by his daughter, an [Name (NI) 9168], who received a phone call from her father on [4-26] after he experienced an unwitnessed fall at home (?syncope). Patient was orthostatic hypotensive (SBP110>>90 sitting unable to stand) at home. He appeared incoherent on the phone but complained of stomach aches/vomitting with no fevers/chills over the past 7 days. He also expressed that he had not taken his insulin for 3 weeks (reasons unclear). [Name2 (NI) ] denied any EtOH in the past 10 days and his urine toxicology screen at [Hospital3 ] was negative, although the pt is a poor historian. - In the ED at [Hospital3 ], he was found to have a BS of 397 with a gap of 39 and an ABG of 7.02/15/95/95%. His UA was positive for glucose as well as ketones and bilirubin. In addition, his LFTS were mildly elevated at: ALP 183, ALT 97, AST 145. His chemistries were: Na 127/ K 4.2/ Cl 183/ HCO3 4.2/ BUN/Cr 32/1.8 - His CKs, troponins were flat without EKG changes. He had a WBC of 11.75, Hct of 31.6 and Plt 64. His Hct in [12-12] was 43. - His CXR on admission showed question of left lower lobe infiltrate and he was started on CTX/Azithro in the ED. This was changed to Flagyl/Unasyn in the ICU. - Overnight on [4-26] to [4-27], the patient had a witnessed seizure likely attributed to EtOH withdrawal in which he became incontinent of urine with post-ictal confusion for which he received Ativan. He did not have any repeat seizures. - In addition, he has been having guaiac positive stool but no melena/hematemesis with a Hct drop from 31.6 to 22 for which he was transfused 2 units PRBC on [2148-4-27] (last Hct before transfer was 25 at 4pm). His SBP dropped from 100s to mid 60-low 70s and a central line was placed on [2148-4-27] and he was resuscitated with fluids alone to the 100s without pressors. He also had received at least 6 liters IVF. - Furthermore, on [2148-4-27], the patient desaturated to the 80s on 6 liters NC which then became mid 90s on 100% FM. They attempted BIPAP but failed as the patient has a history of ?obstructed airway. They believe his respiratory distress was secondary to volume overload as corroborated with CXR and intubated the patient on [4-27] at 5:30pm. His vent settings on transfer are AC 500 x 15, FiO2=0.5, PEEP=5. - His mental status at [Hospital3 ] on [4-27] was somnolent but arousable as he opens his eyes to voice but not able to provide a history. At baseline, he is A&Ox3, but difficutly with higher learning questions. He was placed on an insulin drip, IV PPI, and is receiving IV flagyl/unasyn for his bilateral pulmonary infiltrates. Past Medical History: 1) Rectal adenocarcinoma ca s/p excision [2142-5-9]. Colonscopy [2144-5-13] at [Hospital3 ]: Moderate sigmoid diverticulosis. Moderate internal hemorrhoids. No polyps. 2) IDDM diagnosed 6 years ago, sees Dr. [Last Name (STitle) ] at [Last Name (un) ]. On Lantus and humalog SS. 3) Depression 4) EtOH abuse with h/o DTs. No known h/o cirrhosis, varices. 5) ? Diastolic CHF, EF >70% with near obliteration of the LV during systole Echo [12-12], no AS, trace AI, hyperdynamic LV, trace to mild TR, mild MR. 6) Psoriasis: on devonex Social History: Social: The patient has a history of five to ten to 20 years of alcohol abuse, drinking one pint of vodka a day. Tobacco 1ppd for many years. The patient is a former executive of a bank and was fired after 24 years during a merger of his bank. Had a wife and daughter but now lives alone. Family History: Mother with A.D. Cousins with EtOH abuse. Physical Exam: Tc=98.4 P=89 BP=127/86 RR=15 100% on AC 500 x 15 FIO2 .5 PEEP 5 Gen: Sedated, intubated, awakens to voice, appears older than stated age. HEENT: ETT in place, OGT in place. NC/AT. PERRL, anicteric. OP clear. Neck: Right IJ in place and site C/D/I. JVP not appreciated. Lungs: coarse BS b/l anteriorly. CV: RRR, nml S1S2, no m/r/g Abd: soft, ? TTP in RUQ but no HSM. ND. naBS. no bruits, masses. Ext: tr edema b/l LE. Radial, DP pulses 2+ b/l. Skin: diffuse erthematous plaques with scale. Neuro: sedated and intubated. Opens eyes to voice. Pertinent Results: [2148-4-27] 9:32p 89 3.8 \ 10.3 / 44 / 28.1 \ N:72.3 L:21.1 M:4.4 E:0.3 Bas:1.8 PT: 12.9 PTT: 30.7 INR: 1.1 133 104 15 AGap=16 -------------< 136 3.1 16 0.7 Ca: 7.8 Mg: 1.4 P: 1.7 D ALT: 48 AP: 133 Tbili: 1.5 Alb: 3.0 AST: 104 LDH: 247 Dbili: TProt: [Doctor First Name ]: 81 Lip: 7 Other Blood Chemistry: Hapto: 139 HBsAg: Negative HBs-Ab: Negative HBc-Ab: Negative HAV-Ab: Positive IgM-HBc: Negative IgM-HAV: Negative HCV-Ab: Negative Discharge labs: [2148-5-2] 07:55AM BLOOD WBC-3.4* RBC-4.05* Hgb-13.3* Hct-38.2* MCV-94 MCH-32.8* MCHC-34.7 RDW-14.6 Plt Ct-152 [2148-5-2] 07:55AM BLOOD Glucose-106* UreaN-4* Creat-0.6 Na-132* K-3.7 Cl-95* HCO3-28 AnGap-13 [2148-5-2] 07:55AM BLOOD ALT-21 AST-26 AlkPhos-134* TotBili-1.0 [2148-4-28] 07:29AM BLOOD Ret Aut-1.2 [2148-5-2] 07:55AM BLOOD Albumin-3.2* Calcium-8.4 Phos-2.0* Mg-1.3* [2148-4-29] 04:15AM BLOOD VitB12-1594* Folate-8.5 [2148-4-29] 05:45PM BLOOD %HbA1c-6.9* [Hgb]-DONE [A1c]-DONE [2148-4-27] 09:32PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [2148-4-30] 10:33 am STOOL CONSISTENCY: SOFT Source: Stool. FINAL REPORT [2148-5-1] CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2148-5-1]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. [2148-4-29] 2:38 pm URINE FINAL REPORT [2148-5-1] URINE CULTURE (Final [2148-5-1]): NO GROWTH. [2148-4-28] 4:56 am BLOOD CULTURE AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): [2148-4-27] 10:40 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. FINAL REPORT [2148-4-30] GRAM STAIN (Final [2148-4-28]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2148-4-30]): NO GROWTH. CHEST (PORTABLE AP) [2148-4-27] 9:25 PM 1) Tubes and catheters as described. Note that the sidehole of the NG tube appears to be in proximity to the GE junction. This could be advanced several centimeters for better placement. 2) No CHF. 3) Multifocal infiltrates as described. ABDOMEN U.S. (COMPLETE STUDY) [2148-4-29] 3:04 PM Echogenic liver consistent with fatty infiltration. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. Cardiology Report ECHO Study Date of [2148-4-29] Conclusions: 1. The left atrium is normal in size. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is probably normal but the images are not optimal and have limited views of the distal septum. Overall left ventricular systolic function is probably normal (LVEF>55%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 5.The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 6.There is a trivial/physiologic pericardial effusion. Brief Hospital Course: 55 y.o. man with PMHx h/o significant for colon CA, EtOH abuse, type 1 DM now with DKA, multifocal pneumonia on levo/flagyl, possible CHF, hct drop with hypotension. In the [Hospital Unit Name 153] he was placed on an insulin drip, IV PPI, and IV flagyl/unasyn for his bilateral pulmonary infiltrates. He was extubated on changed to levo/flagyl. Insulin and versed drips were stopped on [4-28] in the afternoon. He was extubated [4-28] at 3 pm and called out on [4-29]. 1) resolving Diabetic Ketoacidosis: On admission to OSH, the patient had an ABG of 7.02/15/95/95% with a gap of close to 40 with ketones in his urine. The patient is known to Dr. [Last Name (STitle) ] at [Last Name (un) ] and was last on Lantus 12 units QHS and Humalog SSI 2-15 units in 9'[46] [First Name8 (NamePattern2) ] [Last Name (un) ] records. He was not using his insulin for a week prior ot admission because he "felt sick". He was put on an insulin drip and transitioned to sc insulin, glargine 10 QHS and sliding scale. [Last Name (un) ] followed him in house and he was discharged on 10 of lantus with instructions to continue regardless. 2) Hypoxic Respiratory Failure - The patient was intubated during admission for respiratory failure. Ddx included PNA vs CHF. He had CXR with multilobar PNA, sputum culture with no growth. Blood cultures showed no growth. Possible CHF (Ef 70% in past, but had a LVOT gradient in '[46] with no AS and concentric LVH) as the patient was aggressively fluid resuscitated at the OSH, but his echo showed normal EF and no outflow obstruction. He was treated with levaquin and flagyl, and autodiuresed after extubation without lasix. 3) Anemia: The patient was having guaiac positive brown stool with no melena/hematemesis and found to have an acute drop in his Hct from 32 to 22 with aggressive IVF resuscitation at the OSH. His baseline Hct is 43 (1 year ago). The patient was transfused 2 units PRBC at the OSH; now Hct stable and no TF here. GI was consulted and EGD showed a gastric ulcer, grade 1 esophageal varices and duodenitis. He was continued on [Hospital1 ] PPI. Colonoscopy with diverticulosis and no acute issues. He did not require further transfusion. 4) Blood pressure - He was initially hypotensive and received fluid but then became hyprrtensive and was started on lisinopril. 5) EtOH Withdrawal with seizure - The patient had GTC seizure at the OSH with a negative urine tox screen on presentation on [4-26] but a history of heavy EtOH use and depression. He denied drinking in the 10 days per patient which corroborates with EtOh of 0 at OSH. He was put on a CIWA scale with ativan/valium and given folate, thiamine, agressive electrolyte repletion. He had a social work consult and eill receive social work services as an outpatient. His daughter will also help monitor him at home. 6) Transaminitis: rising LFTS; AST>>ALT--likely due to alcoholic hepatitis. Hepatitis serologies were negative and RUQ ultrasound showed fatty liver infiltration. 7) Thrombocytopenia baseline in [2142] around 60-80. Most likely etiology is alcholic liver disease. No intervention was necessary. 8) Depression: continued celexa Medications on Admission: Outpt Meds: Neurontin, Insulin, Celexa, Prevacid. - Meds on Transfer: Insulin gtt (1U/hr); SC heparin; Protonix 40mg daily, Thiamine; MVI; Folate; Neurontin 600mg [Hospital1 ]; Neutraphos; Flagyl 500mg tid; Unasyn 3g q6; prn APAP; versed gtt. Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Hospital1 ]:30 Tablet(s) Refills:2 2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). [Hospital1 ]:30 Cap(s) Refills:2 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Hospital1 ]:30 Tablet(s) Refills:2 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). [Hospital1 ]:60 Capsule(s) Refills:2 5. Calcipotriene 0.005 % Ointment Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). [Hospital1 ]:1 tube Refills:2 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. [Hospital1 ]:21 Tablet(s) Refills:0 7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. [Hospital1 ]:7 Tablet(s) Refills:0 8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). [Hospital1 ]:60 Tablet, Delayed Release (E.C.)(s) Refills:2 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Hospital1 ]:30 Tablet(s) Refills:2 10. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime: may need to be adjusted based on AM blood sugars- please keep in close communication with your [Last Name (un) ] doctor. [Last Name (Titles) ]:1 bottle Refills:3 11. Humalog 100 unit/mL Solution Sig: as directed per sliding scale units Subcutaneous four times a day: please take per [Hospital1 18] humulog sliding sacle 4 times a day. [Hospital1 ]:1 bottle Refills:2 12. Mag-Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. [Hospital1 ]:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Pneumonia Diabetic Ketoacidosis Anemia Diabetes Type II Hypertension Congestive Heart Failure s/p intubation Hypoxic Respiratory Failure Alcohol Withdrawal and Seizure Thrombocytopenia Depression Transaminitis Discharge Condition: stable. Diabetic Ketoacidosis has resolved. Hypoxic respiratory failure has resolved. Patient with no further seizures. Liver Function tests, and platlet count stable. Patient tolerating a diabetic diet. Patient stable on room air. Discharge Instructions: Please take all medications as perscribed. Please check your insulin 4 times daily or as directed by [Last Name (un) ]. Please report to your primary care physician with [Name9 (PRE) ] Sugars persistently above 250, decreased food intake, fevers, chills, nausea, vomiting, abdominal pain, confusion, pai with urination, bright red blood per rectum. Followup Instructions: Please follow up with your primary care physician [Last Name (NamePattern4) 26542] 1 week of discharge. Please stop drinking. Your liver functions are elevated and you have fatty liver changes due to your alcohol abuse. Please follow up with [Last Name (un) ] in [1-11] weeks. ICD9 Codes: 486, 4280, 2765
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9014 }	Medical Text: Admission Date: [2157-3-16] Discharge Date: [2157-4-18] Date of Birth: [2075-5-3] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 5188] Chief Complaint: Epigastric/RUQ pain Major Surgical or Invasive Procedure: Laparoscopic converted to open cholecystectomy plus liver biopsy History of Present Illness: 81M with MMP and hx of recurrent cholecystitis who presents [2157-3-16] with a one day history of RUQ/epigastric pain Past Medical History: PMH: CRI, baseline 2.5-3.5 NIDDM [11/2139] AMI PVD: s/p RLE bypass [7-/2143], [5-/2148] left Fem [Doctor Last Name ] bypass, [2-3] angioplasty of left Fem-AT bypass stenosis Hyperlipidemia Gallstones s/p [2156-1-2] ERCP w/ CBD [Month/Day/Year ] placement needs [Month/Day/Year 100581] AAA (3cm stable sine [2145]) Elevated Alk Phos [9-/2147] embolic CVA, seven CVA's since most recently in [10-7]. Afib/flutter s/p Ablation [11-5], EPS [11-7] Syncope HTN renal arteries no stenosis by cath [2154-5-17] [5-8] s/p TTE w/ EF to be newly depressed at 30-35% with left ventricular hypertrophy and [12-7]+MR. [Name14 (STitle) ] w/ reversible defect PSH: [2142] R Fem [Doctor Last Name ] in situ [2147] L Fem [Doctor Last Name ] in situ [2150] vein angioplasty L Fem artery Social History: Married for 53 years with three sons. They have assistance with cleaning and cooking at home through elderly affairs assistance. His son manages all their bills and mail and lives upstairs. Wife is legally blind and is a care taker for Mr. [Known lastname 100582]. The patient walks unassisted now. He is very hard of hearing. +80 ppy history, quit [2145]. No EtOH or illicits. Family History: NC Physical Exam: Admission Physical Exam- [2157-3-16] 97.1 51 148/44 18 98%RA HEENT: sleep, arousable, AAOx2, anicteric, mm dry, no JVD Car: reg S1S2, brady, II/VI SEM Resp: Decreased BS w/ occ rhonchi Abd: soft, ND, not specifically tender over the the aneurysm site, +RUQ tender + distented GB; no hernia Ext: 1+ ext edema, col, dry,, +cap refill [2-6] sec Rectal: guaiac (-) Brief Hospital Course: [Known firstname 122] [Known lastname 100582] was evaluated in the emergency department on [2157-3-16]. WBC count was 12.0;Amylase 169; Lipase 89; Alk Phos 150. AST/ALT/T.Bili were WNL. RUQ ultrasound showed moderately distended and mildly edematous thickened gallbladder wall, shadowing gallstones, not overtly changed in appearance since [2157-1-6]. He was admitted to the surgery service under the care of Dr. [Last Name (STitle) 5182]. He was made NPO. Levofloxacin/Flagyl were given for empiric coverage. Plavix was stopped. At HD 3 he was afebrile and his pain was improved. Amylase/Lipase/Alk phos were 81/28/137. WBC count was elevated at 16.9. He remained NPO and on IV antibiotics. AT HD 5 the diet was advanced. At HD 6 his LFTs were trending up. He was made NPO. ERCP was completed on HD 7 which showed an open previous spinchterotomy with bile drainage into the duodenum. A balloon was passed to clear sludge from the common duct. He tolerated the procedure well and was returned to the floor after recovery. At HD 8 he had an episode of ? aspiration with medications. A CXR was performed which showed a small right pleural effusion and consolidation at the medial aspect of the right lung base. His O2 sats were maintained without distress with NC oxygen with no sequelae. At HD 9 he was tolerating a regular diet. LFTs were trending down. Operative date was planned for the following week. At HD 11 he was tolerating a diet and denied pain. He was found to have UTI with psotive UCx for Proteus. [Last Name (un) ] was consulted for blood glucose control and Lantus was added to his sliding scale. At HD 16 he was taken to the operating room where he underwent a laparoscopic converted to open cholecystectomy. He was found to have liver cirrhosis despite only a mildly elevated alk phos preoperatively at 129. AST/ALT/Bili were WNP. There was a moderate amount of bleeding from the liver bed r/t to the cirrhosis with a loss of approximately 1200ml. A liver biopsy was obtained. He tolerated the procedure and was taken to the ICU intubated and sedated. At POD 1 he was on Levophed to maintain pressure. Urine output was low. Hct was 25.4. At POD 2 he failed to extubate and was reintubated. Urine output was marginally improved. At POD 4 cardiac enzymes were cycled for new BBB with (+) elevation of troponin. Cardiology was consulted. He was transfused for a Hct of 22.7. He was afebrile and hemodynamically stable off pressors. Urine output was WNL. He was draining a moderate amount of ascitic fluid from JP drain. TPN was started. Neurology was consulted on [2157-4-9] for an episode of bradycardia and desaturation. They did not find any focal problems. [Name (NI) 6] MRI was done. The patient contunied to progress well. On [2157-4-14] a video swallow was done. The patient was placed on a thin liquids and ground diet. His drain was removed. The patient was transferred to the floor. On [2157-4-18] the patient was discharged to rehab in stable condition Medications on Admission: Amiodarone 200'; ASA 81'; Flomax 0.4'; Lasix 20'; Hydralizine 25'; Isosorbide 30'; Levoxyl 50mcg'; Lipitor 80'; Lopressor 25''; Plavix 75' Discharge Medications: 1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. Disp:qs qs Refills:0 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:0 4. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:30 Tablet(s) Refills:0 7. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: acute calculous cholecystitis Discharge Condition: stable Discharge Instructions: If you have fever>101.4, nausea, vomitting, increased abdominal pain or any other concerns please call you doctor. Please take medications as prescribed. We are discontinuing your lasix. Followup Instructions: Please call Dr[Name (NI) 6045] office for a follow up appointment ([Telephone/Fax (1) 15350] [Name6 (MD) ] [Last Name (NamePattern4) ] MD, [MD Number(3) 5190] Completed by:[2157-4-18] ICD9 Codes: 5715, 5859, 5119, 5990, 5185, 4280, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9015 }	Medical Text: Admission Date: [2200-1-28] Discharge Date: [2200-2-14] Date of Birth: [2142-10-26] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 57 year old female transferred from [Hospital 1727] Medical Center to Dr.[Name (NI) 37249] service for care of dry gangrenous digits. Her current condition is secondary to purpura fulminans, a complication of Pneumococcal sepsis in late [2199-12-14]. The patient is asplenic predisposing her to Pneumococcal sepsis. She is now stable and in need of Plastic and Vascular Surgery care. She has increased pain issues. She has finished a course of intravenous antibiotics and is now on Clarithromycin prophylactically. PAST MEDICAL HISTORY: 1. Asthma. 2. Hypercholesterolemia. 3. Glaucoma. 4. Asplenia. MEDICATIONS ON TRANSFER: 1. Tazolol. 2. Ranitidine. 3. Clarithromycin. 4. Fluoxetine. 5. Singulair. 6. Protonix. 7. Pilocarpine. 8. Lumigan. 9. Prednisone. 10. Solu-Medrol MDI. 11. Senna tablets. 12. Triamcinolone MDI. 13. Diazepam. 14. Lasix p.r.n.. 15. Dilaudid PCA. 16. Maalox. 17. Reglan. 18. Percocet. 19. Slo-[Hospital1 ]. 20. Heparin drip. ALLERGIES: Penicillin and sulfa drugs. PHYSICAL EXAMINATION: Upon admission, vital signs stable; afebrile. The patient is a pleasant middle-aged lady in no apparent distress. Lungs are clear to auscultation, normal sinus rhythm, no murmurs. Chest wall has old ecchymosis over the anterior chest wall, no induration, nontender. Upper extremities have numbness left and right hands, right worse than left. They are insensate. There is no motor function. Bilateral palpable radial and ulnar pulses. Lower extremities mummified left and right distal foot, all toes involved. Entire sole of foot, left and right, dry gangrenous. Dorsum of the foot is edematous but does not have dry gangrene on the left or the right. Necrotic skin over the soles extending over the Achilles tendon area on the left and the right, pretibial edema and ecchymosis, tender. Femoral, popliteal and dorsalis pedis pulses palpable bilaterally. Sensation is intact up to the middle of the forefoot on the dorsum on the left and the right. No sensation or motor function of the toes. Sensation and motor function of the ankle is intact. LABORATORY: Upon admission, white count 18.3, hematocrit 31.3, platelets 778. Sodium 136, potassium 5.1, chloride 98, bicarbonate 26, BUN 12, creatinine 0.5, glucose 169. Coagulation: PT is 13.1, PTT 89.9 and INR is 1.2. HOSPITAL COURSE: The patient was admitted to the Plastic Surgery Service and was under the care of Dr. [Last Name (STitle) 13797]. Chronic Pain Service, Hematology Service, Infectious Disease and Vascular Surgery followed the patient closely. Psychiatric consultation was also obtained secondary to the severity of the situation. The patient was taken to the Operating Room on Tuesday, [2-4], for bilateral below the knee amputations as well as right hand amputation, left small ring finger amputation, left partial middle finger amputation, and a free-flap to the left first web site. On postoperative course, the patient was admitted to the SICU for a few days as ventilation was needed secondary to a large dose of narcotics, hemodynamic monitoring as well as q. one hour free-flap checks. She was transferred to the Floor a few days later after being successfully extubated and her pain was well controlled. Infectious Disease eventually switched her antibiotic dosing to Vancomycin for a few days and then eventually to p.o. Vantin. Her free-flap continued to be viable with good pulses and her wounds all remained clean, dry and intact with no signs of infection. Her pain was managed by the Chronic Pain Service and she was eventually well controlled with 120 mg p.o. three times a day of MS Contin, 35 to 45 mg p.o. q. three to four hours of MSIR, Neurontin 300 mg p.o. three times a day. Infectious Disease recommended that she have the Prevnar Conjugated Pneumococcal Vaccine as well as the HIB and Meningococcal vaccine which she was given on the day of discharge and she should be followed closely by Infectious Disease after discharge in order to continue her Pneumococcal vaccination series. The Infectious Disease team also pursued a coagulopathy work-up as well as immunodeficiency evaluation. No positive results to date. They recommend that she get a second pneumococcal vaccine in four to eight weeks after her first vaccine and four weeks after that, an unconjugated vaccine. She had an echocardiogram to rule out endocarditis which was negative. The patient was eventually discharged to a rehabilitation facility in [State 1727] and will be following up with Plastics and Vascular Surgery Clinics. DISCHARGE DIAGNOSES: 1. Status post bilateral below the knee amputations. 2. Right hand amputation. 3. Left digit amputation with a free-flap to the first web space secondary to purpura fulminans. DISCHARGE MEDICATIONS: 1. MS Contin 115 mg three times a day. 2. Zofran 2 to 4 mg intravenous q. eight hours. 3. Neurontin 300 mg p.o. three times a day. 4. MSIR, 30 to 45 mg p.o. q. three to four hours. 5. Nystatin Powder to the buttock area with each incontinent episode. 6. Dulcolax p.r.n. 10 mg q. day. 7. Colace 100 mg p.o. twice a day. 8. Vantin 200 mg p.o. q. 12 hours. 9. Ambien 5 to 10 mg p.o. q. h.s. p.r.n. 10. Triamcinolone MDI, four puffs twice a day. 11. Solu-Medrol MDI, two puffs twice a day. 12. Senna tablets 2 mg p.o. twice a day. 13. Dilantin 0.005%, one drop o.s. q. h.s. 14. Betaxolol 0.25%, one drop o.s. twice a day. 15. Varmonadine 0.2% solution, one drop o.s. twice a day. 16. Singulair 10 mg p.o. q. h.s. 17. Pantoprazole 40 mg p.o. q. day. 18. Multi-vitamin, one tablet p.o. q. day. DISCHARGE INSTRUCTIONS: 1. Dressings changes q. day with Xeroform and Kerlix q. day. 2. Follow-up with Plastic Surgery Clinic in one to two weeks; call [Telephone/Fax (1) 274]. 3. Follow-up with Dr. [Last Name (STitle) ] from Vascular Surgery in one to two weeks. 4. Follow-up with Infectious Disease p.r.n. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 19095], M.D. [MD Number(1) 19096] Dictated By:[Doctor Last Name 32927] MEDQUIST36 D: [2200-2-14] 11:54 T: [2200-2-14] 12:21 JOB#: [Job Number 13331] ICD9 Codes: 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9016 }	Medical Text: Admission Date: [2161-7-13] Discharge Date: [2161-7-22] Date of Birth: [2109-9-27] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 425] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [2161-7-13] cardiac catheterization with placement of drug eluding stent to proximal LAD [2161-7-15] cardiac catheterization, no interventions History of Present Illness: 51M with PMHx of untreated hypertension and tobacco use previously evaluated in the ED 2 weeks ago for ROMI without ischemic changes on exercise stress now here with anterior STEMI s/[Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (Prefixes) ] 1 to proximal LAD. Patient describes 3 weeks of intermittent left-sided chest pain oftentimes worse with exertion and frequently associated with diaphoresis, and nausea. Denies radiation but does describe it occasionally waking him from sleep. Presented to ED 2 weeks ago where he had ROMI and exercise EKG stress during which he had anginal symptoms but not ischemic EKG changes. He was discharged without resolution of his chest pain. In the interim it has continued and he describes having a severe episode 4 days ago which did not get better with ibuprofen 800mg or 300mg gabapentin (he borrowed from friend) but resolved for 2 hours following 40grams of alcohol but returned thereafter. He was seen today by his PCP who performed an EKG with, per report, STE's and was referred emergently to the ED for ACS. In the ED, initial vitals were 98.2, 100, 158/117, 16, 98% 4LNC Labs and imaging significant for trop 0.87; CBC, Chem 7, and coags unremarkable, EKG with ST @ 102bpm, NA/NI, STE's in V1-V3, TWI's in I, aVL, V4-5 Patient given Aspirin 325mg, Metoprolol 5mg IV x1, Clopidogrel 300mg PO x 1, Metoprolol tartrate 25mg PO x1, Heparin drip started, code STEMI called, taken urgently to cath lab where she had [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 1 to proximal LAD. On the floor, the patient is pain free and calm. He describes that over the past week he has had significant DOE and exertional fatigue. He states it usually takes him 15 mins to walk to work from home but earlier this week it took him 55 mins because he wasn't able to walk fast and had to stop to rest. He denies orthopnea, PND, frequent urination, abdominal pain, V/D, urinary symptoms, or other concerns. REVIEW OF SYSTEMS On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 1 to proximal LAD [2161-7-13] -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: None Social History: He is a travel [Doctor Last Name 360]. 40 pack-year smoking history. He drinks [4-12] whiskey's a day. Lives alone, moved from [Country 532] 30 years ago without family members. Fully independent. Family History: Positive family history of coronary artery disease. His parents both had issues in their 60s including MI's. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS- T= 98.7 BP= 112/88 HR= 65 RR= 20 O2 sat= 99% 2LNC GENERAL- WDWN man in NAD. AOx3. Mood, affect appropriate. HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK- Supple without JVD CARDIAC- PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS- Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi anteriorly. ABDOMEN- Obese, soft, NT, mildly distended. No HSM or tenderness. EXTREMITIES- Small groin hematoma, dressing C/D/I, lower extremities cool and clammy bilaterally with dopplerable but only faintly palpable pulses SKIN- No stasis dermatitis, ulcers, scars, or xanthomas. PULSES- Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+ . DISCHARGE PHYSICAL EXAM afebrile, BP 80s-100s/60s, HR 70s, saturations 100% ra exam unchanged Pertinent Results: ADMISSION LABS: --------------- [2161-7-13] 10:00AM BLOOD WBC-6.5 RBC-4.41* Hgb-15.0 Hct-43.5 MCV-99* MCH-34.0* MCHC-34.4 RDW-13.3 Plt Ct-190 [2161-7-13] 10:00AM BLOOD Neuts-58.6 Lymphs-27.8 Monos-9.5 Eos-2.7 Baso-1.4 [2161-7-13] 10:00AM BLOOD PT-10.1 PTT-30.2 INR(PT)-0.9 [2161-7-13] 10:00AM BLOOD Glucose-129* UreaN-17 Creat-1.1 Na-137 K-4.4 Cl-101 HCO3-25 AnGap-15 [2161-7-13] 10:00AM BLOOD cTropnT-0.89* . PERTINENT LABS: --------------- [2161-7-13] 10:00AM BLOOD cTropnT-0.89* [2161-7-13] 06:40PM BLOOD CK-MB-4 cTropnT-1.28* [2161-7-14] 06:24AM BLOOD CK-MB-3 cTropnT-1.33* [2161-7-15] 03:08AM BLOOD CK-MB-3 cTropnT-1.42* [2161-7-15] 09:39AM BLOOD CK-MB-5 cTropnT-0.92* . MICRO/PATH: NONE ----------- . IMAGING/STUDIES: ---------------- Coronary Catheterization [2161-7-13]: 1. Selective coronary angiography demonstrated single vessel coronary artery disease. The LMCA had no obstructive disease. The LAD had a 95% proximal stenosis. The LCx and RCA had minimal disease. 2. Limited resting hemodynamics revealed normal systemic pressure with central aortic pressure 131/90 with mean 62 mmHg. 3. Successful PCI of the proximal LAD 95% stenosis by direct-stenting with a 2.25 x 16 mm Promus element drug-eluting stent. 4. Successful deployment of Exoseal to right femoral arteriotomy site with excellent hemostasis. FINAL DIAGNOSIS: 1. Single vessel coronary artery disease. 2. Successful PCI of the proximal LAD with a 2.25 x 16 mm promus element drug-eluting stent. . TTE [2161-7-14]: Conclusions No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with mid anterior, mid anteroseptal, distal LV and apical akinesis. A large apical thrombus is seen in the left ventricle (2.0 x 1.2 cm). There is no ventricular septal defect. 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. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. IMPRESSION: Depressed LVEF c/w prior MI with large apical LV thrombus. . . TTE [2161-7-20] The left atrium is elongated. The estimated right atrial pressure is 5-10 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with severe hypokensis/akensis of the distal 2/3rds of the anteroseptum and anterior walls, distal inferior wall, and apex. The remaining segments contract normally (LVEF = 30 %). There is a 1.3cm mural apical thrombus. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with severe regional systolic dysfunction consistent with CAD (prox/mid LAD distribution). Apical mural thrombus. Mild mitral regurgitation with normal valve morphology. Dilated aortic root. Compared with the prior study (images reviewed) of [2161-7-16], , the findings are similar. CARDIAC CATH [2161-7-15]: 1. Right heart catheterization was performed via right femoral venous access with placement of a 5 fr sheath, using a 5 fr Swan-Ganz catheter. Selective coronary angiography of the left coronary tree was performed via right radial access with placement of a 6 fr sheath, using a JL 3.5 5 fr catheter. 2. Right heart catheterization demonstrated mild pulmonary hypertension, likely related to elevated left heart filling pressures (indicated by elevated PCWP). Patient had borderline cardiac output and cardiac index indicating a low flow state in the setting of recent anterior wall MI. 3. Left main was widely patent. The stent in the proximal LAD was patent. There was a 50% mid-LAD lesion unchanged from before. the left circumflex did not have any significant disease. The right coronary is known to have only minimal disease, and was not engaged. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Moderate diastolic ventricular dysfunction causing mild pulmonary hypertension. 3. Patent stent in proximal LAD. _____________________ CT head [2161-7-18]:IMPRESSION: Ethmoid air cell partial opacification. Otherwise normal study. [2161-7-20] TTE: This study was compared to the prior study of [2161-7-16]. Intravenous administration of echo contrast was used due to poor native endocardial border definition. LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal IVC diameter (<=2.1cm) with <50% decrease with sniff (estimated RA pressure (5-10 mmHg). LEFT VENTRICLE: Normal LV wall thickness and cavity size. Moderate regional LV systolic dysfunction. Mural LV thrombus. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildy dilated aortic root. Normal ascending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions The left atrium is elongated. The estimated right atrial pressure is 5-10 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with severe hypokensis/akensis of the distal 2/3rds of the anteroseptum and anterior walls, distal inferior wall, and apex. The remaining segments contract normally (LVEF = 30 %). There is a 1.3cm mural apical thrombus. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with severe regional systolic dysfunction consistent with CAD (prox/mid LAD distribution). Apical mural thrombus. Mild mitral regurgitation with normal valve morphology. Dilated aortic root. Compared with the prior study (images reviewed) of [2161-7-16], , the findings are similar. Brief Hospital Course: Mr. [Known lastname 79024] is a 51 year old male with history of untreated hypertension and tobacco use previously discharged from the ED 2 weeks ago for chest pain with an exercise stress test that reproduced his angina but was without ischemic changes who was admitted with anterior STEMI. He underwent cath with placement of [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 1 to proximal LAD but post-cath course complicated by vfib arrest x2 with successful resuscitation and systolic heart failuer w/ EF of 30% now s/p single chamber ICD placement. ACTIVE DIAGNOSES: ----------------- #Vfib Arrest: Patient underwent stenting for STEMI with one [Last Name (Prefixes) ] placed to the proximal LAD on [2161-7-13]. Post-cath he remained chest pain free. However, on the evening of [2161-7-14] he suffered a vfib arrest on the floor. He underwent 3 cycles of CPR and was defibrillated with return of spontaneous circulation (ROSC). He was bradycardic in the new perfusing rhythm and recieved epinephrine and atropine. Within 5 mintues, he then again converted to polymorphic vtach and underwent 2 additional shocks. Between these shocks, he was given a loading dose of amiodarone 150 mg x1 and then after the repeated vtach he was also started on a lidocaine drip at 1 mg/min without loading dose. After ROSC a second time, he was bradycardic and hypotensive with blood pressures down to 50s/40s. He was started on norepinephrine for hypotension and phenylephrine was added when he was still hypotensive. He was transferred to the CCU. In the CCU, he was further loaded with amiodarone for a total loading dose of 450 mg and started on an amiodarone drip with 1 mg/min for the first 6 hours then decreased to 0.5 mg/min for 2-3 hours and then amiodarone was discontinued completely. His lidocaine drip was continued at the same dosing for 36 hours. The 2 pressors were able to be weaned off within 8 hours. He underwent cardiac cath which was negative for in-stent restenosis or other significant lesions. Ultimately, it was decided that he suffered reperfusion arrhthymia and thus placement of an ICD was not indicated during this hospitalization. Once his blood pressure recovered, his lidocaine drop was stopped and he was restarted on his lisinopril and metoprolol for new onset heart failure post-MI. On the evening of [7-16], he again suffered ventricular fibrillation arrest. He again received 3 direct cardioversions and returned to sinus rhythm with frequent ectopy. He was placed back on lidocaine drip with resolution of ectopy. Mexilitine was started and he continued to have some ectopy but was monitored for 48 hours off of lidocaine and had no additional episodes of Vtach. He had a repeat TTE on [7-20] which showed persistent depressed EF of 30% and given his vfib arrest outside of the 48hrs post MI it was felt that he would benefit from an ICD placement, which was placed on [7-20] without complications. . # Anterior STEMI s/[Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (Prefixes) ] 1 to Proximal LAD: Patient was admitted with 3 weeks of intermittent anginal chest pain with recent ED observation with ROMI with enzymes, serial EKG's, and a moderate risk exercise EKG stress test. He presented to his PCP with STE's in his precordial leads and was sent to the ED where code STEMI was called and patient went to cath lab with [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 1 placed due to 95% proximal LAD lesion. Per history, it seemed that the worst of his symptoms occurred 5 days PTA and he remained with STE's in V1-V3 following the cath lab. He underwent TTE which showed LV thrombus, LVEF of 35% and mid anterior, mid anteroseptal, distal LV and apical akinesis. His persistent STE's were felt to be c/w aneurysm. His peak trop was 1.42 although during this hospitalization he did not [Location 79025] suggesting his insult occurred days prior to his hospitalization. On the floor he was chest pain free and managed post-cath with aspirin 325mg PO daily, prasugrel 10mg PO daily which was switched to clopidogrel 75mg daily given need for warfarin for LV thrombus (see below), metoprolol 12.5mg PO BID, atorvastatin 80mg PO daily, and lisinopril 2.5mg PO daily. # LV Thrombus: Newly diagnosed following recent anterior/apical STEMI. He was started on a heparin drip as well as coumadin with plan to bridge for 24 hours once therapeutic. He will need to be on coumadin for at least 3-6 months. # Alcohol Dependence: Patient with 3-4 drinks of hard whiskey daily. Denies history of withdrawal. Did not score on CIWA while in-house and did not require valium. . TRANSITIONAL ISSUES: -Smoking and alcohol cessation -Medication compliance -f/u in [Hospital ] clinic in 1 week for ICD interogation -Coumadin for 3-6 months for LV thrombus, goal INR [3-13]. Recheck INR on Friday [7-24], Dr. [Last Name (STitle) 3357] to monitor Medications on Admission: Gabapentin 300mg PO TID Ibuprofen 800mg PRN Discharge Medications: 1. Aspirin 81 mg PO DAILY RX Adult Low Dose Aspirin 81 mg daily Disp #30 Tablet Refills:0 2. Atorvastatin 80 mg PO DAILY RX atorvastatin 80 mg daily Disp #30 Tablet Refills:0 3. Clopidogrel 75 mg PO DAILY Start: In am RX Plavix 75 mg daily Disp #30 Tablet Refills:0 4. Diazepam 5 mg PO HS:PRN insomnia 5. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg daily Disp #30 Tablet Refills:0 6. Lisinopril 2.5 mg PO DAILY Hold for SBP<90 RX lisinopril 2.5 mg daily Disp #30 Tablet Refills:0 7. Metoprolol Succinate XL 25 mg PO DAILY Hold for SBP < 90, HR < 50 RX metoprolol succinate 25 mg daily Disp #30 Tablet Refills:0 8. Mexiletine 150 mg PO Q12H RX mexiletine 150 mg twice a day Disp #60 Tablet Refills:0 9. Thiamine 100 mg PO DAILY RX thiamine HCl 100 mg daily Disp #30 Tablet Refills:0 10. Warfarin 5 mg PO DAILY16 RX Coumadin 5 mg daily Disp #15 Tablet Refills:0 11. Outpatient Lab Work Please draw INR on [7-24]. Fax results to Dr. [Last Name (STitle) 3357] Fax: [Telephone/Fax (1) 14816]. ICD 429.79, mural thrombus Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ST elevation myocardial infarction Acute systolic heart failure, ejection fraction 35% Ventricular tachycardia and fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 79024], It was a pleasure taking care of you! You were admitted to [Hospital1 1535] for evaluation and treatment of chest pain. You were found to have had a recent major heart attack with a decrease in your heart function as well as a blood clot in your heart. You underwent coronary catheterization with placement of a stent in the artery of your heart to open it up. You were started on several new medications to help decrease your risk of further heart attacks. After your heart attack and after the stent was placed, you suffered a cardiac arrest twice. Your heart started beating very fast and irregularly, which caused loss of blood pressure for a few minutes and you required chest compressions and shock to get your heart back into normal rhythm. This is an occasional complication of large heart attacks called ventricular arrhythmia. You were cared for in the ICU for a few days and you had an ICD (defibrillator) placed in your heart to help treat this arrhythmias if they were to happen again. The following changes were made to your medications: START TAKING THE FOLLOWING: Aspirin 81 mg daily Clopidogrel (Plavix) 75 mg daily for your stent Atorvastatin (Lipitor) 80 mg daily for your cholesterol Lisinopril 2.5 mg daily for high blood pressure Metoprolol succinate 25 mg daily for your heart Mexiletine 150 mg PO Q12H for your irregular heart beat Warfarin 5 mg daily to break down the clot in your heart. Dr. [Last Name (STitle) 3357] might adjust this dose at follow-up you should get you blood drawn on Friday [7-24] to check the level of warfarin. It was a pleasure taking care of you in the hospital! Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) ] L. Location: [Hospital1 ] HEALTHCARE - [Location (un) ] Address: [State 4607], [Location (un) ],[Numeric Identifier 588] Phone: [Telephone/Fax (1) 4606] Appt: [Last Name (LF) 766], [7-27] at 8:30am Dr. [Last Name (STitle) 3357] will follow the levels of warfarin in your blood. You should get your blood checked on Friday [7-24] so they will have the results before your appointment. Department: CARDIAC SERVICES When: TUESDAY [2161-7-28] at 11:00 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 ***At this visit a follow up appt with an Cardio-Electrophysiologist will be coordinated. ICD9 Codes: 4271, 4280, 4275, 4019, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9017 }	Medical Text: Admission Date: [2107-12-10] Discharge Date: [2108-1-6] Date of Birth: [2107-12-10] Sex: F Service: NB HISTORY: [First Name9 (NamePattern2) 70048] [Known lastname 70047] is a 32-2/7-weeks gestation twin B delivered preterm due to preeclampsia and poor growth of this twin. Mother is a 31-year-old primigravida, IUI conception with estimated date of delivery of [2108-2-3]. PRENATAL SCREENS: Blood type O-positive, antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, group B Strep status negative. COMPLICATIONS: This pregnancy was complicated by gestational hypertension leading to preeclampsia. Also poor growth of this twin with absent end-diastolic flow. Estimated fetal weight on [12-9] of 750 grams. Mom was beta complete on [12-3]. They elected to delivery babies by cesarean section on the date of [12-10] due to ongoing concerns of preeclampsia and poor growth of twin B. No intrapartum antibiotic prophylaxis. No maternal fever. Artificial rupture of membranes at delivery. This twin emerged with spontaneous movement and respiratory effort, but cyanotic. Improved color with blow-by oxygen. Apgar scores were 6 at 1 minute and 7 at 5 minutes of age. She was transferred to the newborn intensive care unit for further evaluation and management of prematurity and severe growth restriction. PHYSICAL EXAM ON ADMISSION: Weight 709 grams (less than 5th percentile), length 32 cm (less than 5th percentile), head circumference 25 cm (5th percentile). Nondysmorphic facies. Growth-restricted baby girl. Anterior fontanelle soft, open, and flat. Red reflex difficult to visualize due to small palpebral opening likely within normal limits, but warrants recheck in a few weeks. Lips, gums, palates intact. Mild retractions overall trending towards improvement. Decreased breath sounds, but O2 saturations 98% on room air. Regular rate and rhythm without murmur, 2+ peripheral pulses including femorals. Abdomen: Benign without hepatosplenomegaly or masses, 3-vessel cord, normal female external genitalia for gestational age. Normal back and extremities with stable hips. Skin: Pink and well perfused. Appropriate tone and responsitivity. Examination of the placenta showed a normal mature placenta. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: [Month (only) 70048] was comfortable in room until day of life 8 when she was started on CPAP for increased apnea and bradycardia. She was back to room air by day of life 12 and then briefly on flow nasal cannula from day of life 13 to day of life 15, again, for increased apnea of prematurity. Caffeine was started on day of life 8 for apnea of prematurity. She remains on caffeine citrate at the time of transfer. [Month (only) 70048] received 2 mEq of sodium bicarbonate on day of life 6 for a metabolic acidosis which resolved soon thereafter. Cardiovascular: [Month (only) 70048]'s blood pressure has been stable throughout her hospitalization. She has not required fluid boluses or pressors for blood pressure support. Fluid, electrolytes, and nutrition: IV fluids of D10W were started at 80 cc per kilogram via double lumen umbilical venous catheter upon admission to the newborn intensive care unit. Enteral feeds were initiated on day of life 2 at 10 cc per kilogram per day. She was briefly NPO on day of life 6 for a metabolic acidosis, but was restarted on feeds the following day, and she reached feeds of 140 cc per kilogram by day of life 14. She has been maintained at a volume of 140 cc per kilogram per day due to a history of spit. Her caloric density has been increased to breast milk 32 calories per ounce. Her last electrolytes on [12-22] showed a sodium of 140, potassium of 5.1, a chloride of 106, and a bicarbonate of 23. Her weight at time of discharge is 1,140 grams, length 36 cm, and head circumference 27.5 cm. GI: Phototherapy was started on day of life 1 for a bilirubin of 5.2/0.2. Phototherapy was discontinued on day of life 8 for a bilirubin of 2.4 with a rebound bilirubin of 1.6/0.6 on day of life 9. Endocrine: A newborn screen that was sent on [12-24] was significant for a TSH of 35.5. Follow-up thyroid function tests on [12-30] showed a TSH of 71, a T3 of 119, a T4 of 8, a TVA of 1.14, a T-uptake of 0.88, a T4 index of 7, and a free T4 of 1.1. She was started on Synthroid on [12-31] at 10 mcg. The dose was increased to 12.5 mcg just for ease of dosing (easier to prepare [2-7] tablet of Synthroid as opposed to liquid). The last thyroid function tests on [1-2] showed a TSH of 25, a T3 of 100, a T4 of 8.4, T3 RU of 1.02, a thyroglobulin level of 0.98, a fee T4 of 1.3, and a T4 index of 8.6. She had a normal thyroid ultrasound on [1-3]. [Month (only) 70048] is due for another set of thyroid function tests including a TSH, a T4, and a free T4 on [1-7]. The contact endocrinologist at [Hospital3 1810] is [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 174]. She is to be followed 1 month after discharge with Dr. [Last Name (STitle) ] at [Hospital3 1810], phone number [Telephone/Fax (1) 37116]. Hematology: [Telephone/Fax (1) 70048]'s blood type is not known. She has not received any blood products during her hospitalization. Infectious disease: Upon admission to the NICU, a CBC with differential and a blood culture was drawn. The CBC showed a white count of 5.4, a hematocrit of 48.9, a platelet count of 221 with 18% polys and 0% bands. Blood culture that was drawn at that time was negative. She did not receive antibiotics at that time. [Telephone/Fax (1) 70048] had a 48-hour rule out on day of life 8 for increased apnea and bradycardia. CBC at that time showed a hematocrit of 37, a white count of 16.8, platelet count of 277 with 31% polys and 1% bands. She did receive 48 hours of vancomycin and gentamicin at that time. Neurology: [Telephone/Fax (1) 70048] had a normal head ultrasound on [12-19]. Sensory: A hearing screen has not yet been performed. [Month (only) 70048]'s eyes were most recently examined on the [12-28] and found to be immature to zone III with a followup recommended in 3 weeks. Psychosocial: [Hospital1 69] social work has been involved with the family. The contact social worker can be reached at [Telephone/Fax (1) ]. CONDITION AT TIME OF TRANSFER: Stable in room air, tolerating full volume feeds. Being followed by endocrinology for hypothyroidism. DISCHARGE DISPOSITION: Transfer to [Hospital3 ] via ambulance. Name of primary pediatrician: This infant and her twin will be seen at [Hospital 246] Pediatrics. CARE RECOMMENDATIONS: Feeds at time of transfer: Breast milk enriched to 32 calories per ounce with 4 calories of HMF, 4 calories of MCT, and 4 calories of Polycose. Medications: Synthroid at 12.5 mg per day, iron supplements, and vitamin E 5 units per day. Car seat position screening: Not yet performed. State newborn screening status: As mentioned earlier, state newborn screen on [12-24] significant for elevated TSH. Immunization received: None. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following 3 criteria: 1) born at less than 32 weeks; 2) born between 32-35 weeks with 2 of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings; or 3) with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the 1st 24 months of the child's life, immunization against influenza is recommended for household contacts and out-of-home caregivers. Discharge appointment has been arranged with Dr. [Last Name (STitle) ] at [Hospital3 1810] for her hypothyroidism. Dr.[Name (NI) ] phone number is [Telephone/Fax (1) 37116]. The contact endocrinologist at [Hospital3 1810] is [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 174]. DISCHARGE DIAGNOSIS LIST: 1. Prematurity at 32-2/7 weeks. 2. Intrauterine growth restriction. 3. Rule out sepsis. 4. Hyperbilirubinemia. 5. Apnea of prematurity. 6. Hypothyroidism. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 56662] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2108-1-6] 18:06:44 T: [2108-1-6] 19:06:34 Job#: [Job Number 70049] ICD9 Codes: 7742, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9018 }	Medical Text: Admission Date: [2102-7-20] Discharge Date: [2102-7-21] Date of Birth: [2032-12-6] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[Doctor First Name 1402] Chief Complaint: S/p atrial fibrillation ablation, now requiring temporary pacing from cath lab Major Surgical or Invasive Procedure: Pulmonary vein ablation. History of Present Illness: This is a 69 yo female with a PMH persistent paroxysmal atrial fibrillation (s/p three DC cardioversions, last one [5-15]) with uptitration of flecainide and digoxin, persistent left superior vena cava with moderate TR with thickened tricuspid valve, history of SVT s/p ablation, hypertension, who was admitted to the CCU from the cath lab following elective a fib PVI ablation, intially requiring temporary pacing. . During the procedure, two morphologies of left atrial tachycardia were demonstrated. DC cardioversion was required, and found to have bradycardia with rates in the 20s. She was initially paced with a temp wire upon transfer to CCU overnight for further monitoring. . Over the past year, has had multiple recurrences of atrial fibrillation with uptitrated doses of flecainide. Has had three prior cardioversions, last one in [5-15]. Per prior EP note, has not complained specifically of palpitations or SOB, though feels better overall when she is in sinus rhythm. . On review of systems, she 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. She 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. . Upon reaching the floor, patient with no acute complaints. Past Medical History: 1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: -CABG: None. -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: - atrial fibrillation s/p three DC cardioversions (last one [5-15]) - history of SVT, s/p ablation many years prior in [State 4565] - persistent left superior vena cava with moderate TR and thicked tricuspid valve - bicuspid aortic valve - OSA; on BIPAP at home - hypothyroidism - Klippel-Feil syndrome (muscular atrophy in left hand [2-7] nerve impingement) s/p cervical fusion in [2096] - s/p laminectomy in lumbar area - s/p ulnar nerve surgery - osteoarthritis - s/p ductal carcinoma in situ of left breast, s/p lumpectomy - s/p tubal ligation - history of cholecystectomy - hammer toe surgery -Asthma Social History: Tobacco history: Patient is widowed and lives alone. She has two adult children. -ETOH: 3 drinks per week. -Illicit drugs: Quit in [2071]. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T=99.5 BP= 93/51HR=57 RR=16 O2 sat= 98% GENERAL: WDWN F in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 4 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 3/6 systolic murmur in left 4th intercostal space radiating to the left axilla. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, bibasilar crackles, diffuse wheezes. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Has bilateral entry points post procedure with no active bleeding or hematomas. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . Pertinent Results: [2102-7-21] 03:04AM BLOOD WBC-9.0 RBC-3.73* Hgb-11.6* Hct-33.3* MCV-89 MCH-31.0 MCHC-34.8 RDW-14.3 Plt Ct-270 [2102-7-20] 07:10AM BLOOD WBC-7.5 RBC-4.67 Hgb-14.1 Hct-41.4 MCV-89 MCH-30.3 MCHC-34.1 RDW-14.3 Plt Ct-343 [2102-7-20] 07:10AM BLOOD Neuts-69.7 Lymphs-20.3 Monos-6.1 Eos-3.0 Baso-0.9 [2102-7-21] 03:04AM BLOOD Plt Ct-270 [2102-7-21] 03:04AM BLOOD PT-31.3* PTT-32.3 INR(PT)-3.1* [2102-7-20] 07:10AM BLOOD Plt Ct-343 [2102-7-20] 07:10AM BLOOD PT-27.8* INR(PT)-2.7* [2102-7-21] 03:04AM BLOOD Glucose-139* UreaN-19 Creat-1.0 Na-140 K-4.1 Cl-102 HCO3-30 AnGap-12 [2102-7-20] 07:10AM BLOOD Glucose-95 UreaN-26* Creat-1.1 Na-142 K-3.9 Cl-100 HCO3-38* AnGap-8 [2102-7-21] 03:04AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.8 [Hospital1 18] ECHOCARDIOGRAPHY REPORT TEE (Complete) Done [2102-7-20] at 4:39:16 PM FINAL Echocardiographic Measurements Results Measurements Normal Range TR Gradient (+ RA = PASP): 38 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: Dilated RV cavity. AORTA: Simple atheroma in aortic arch. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [First Name (Titles) ] [Last Name (Titles) 9833] throughout the procedure. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). The patient was under general anesthesia throughout the procedure. No TEE related complications. Results were reviewed with the Cardiology Fellow involved with the patient's care. Conclusions No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. The right ventricular cavity is dilated There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 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: No thrombus in left atrial appendage. Dilated right ventricle and right atrium with moderate tricuspid regurgitation and moderate pulmonary hypertension. [2102-7-21] CXR: final read pending [2102-7-20] PVI report: pending Brief Hospital Course: 69yo female with a PMH of persistent paroxysmal atrial fibrillation with uptitration of flecainide and digoxin, who was admitted to the CCU from the cath lab following elective a fib PVI ablation on [2102-7-20]. During the procedure, two morphologies of left atrial tachycardia were demonstrated. She became bradycardic after the procedure, and DC cardioversion was required. The patient was found to have bradycardia with rates in the 20s, and she initially required a temporary pacing wire. She was transfered to the CCU overnight for further monitoring, but did not require further pacing via the wire overnight. The wire was removed the following morning, and the patient's HR had improved. On the morning of [2102-7-21] she developed some mild SOB and had decreased O2 sats on room air. She was given 10mg IV furosemide, had good urine output in response to the diuretic, and her O2 sats improved. She was able to get out of bed to the chair and ambulate, with O2 sats remaining in the mid-high 90s on room air. Orthostatic blood pressures were obtained, and the patient was hemodynamically stable. She was started on diltiazem for rate control, as her heart rate was somewhat elevated to the 90s-low 100s with exertion. She was instructed to resume taking Coumadin, and will have her INR checked as an outpatient. She was also given the [Doctor Last Name ] of Hearts monitor, and will follow-up with Dr. [Last Name (STitle) ] in [Hospital ] clinic in [4-11] weeks. She was also instructed to stop taking Digoxin and Flecainide. She will follow-up with her cardiologist one week after discharge. Medications on Admission: AMLODIPINE - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth once a day - CONJUGATED ESTROGENS [PREMARIN] - (Prescribed by Other Provider) 0.625 mg/gram Cream - apply twice week - DIGOXIN - (Prescribed by Other Provider) - 250 mcg Tablet - 1 Tablet(s) by mouth once a day - FLECAINIDE - (Prescribed by Other Provider) - 50 mg Tablet - 3 Tablet(s) by mouth every morning, 2 tablets every evening - FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (Prescribed by Other Provider) - 100 mcg-50 mcg/Dose Disk with Device - 1 puff IH twice a day - LEVOTHYROXINE - (Prescribed by Other Provider) - 100 mcg Tablet 1 Tablet(s) by mouth once a day - POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 20 mEq Tab Sust.Rel. Particle/Crystal - 1 Tab(s) by mouth daily - TORSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 2 Tablet(s) by mouth every morning - WARFARIN - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth once a day 1 tablet on Tues/Thursday/Saturday, 1.5 all other days - ASCORBIC ACID - (Prescribed by Other Provider) - 1,000 mg Tablet 1 Tablet(s) by mouth daily - CALCIUM CARBONATE - (Prescribed by Other Provider) - 600 mg (1,500 mg) Tablet - 1 Tablet(s) by mouth twice a day - ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other Provider) - Dosage uncertain - LORATADINE - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth daily - MULTIVITAMIN - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. Diltiazem 30 mg one PO DAILY 2. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s)* Refills:0 3. Estrogens Sig: One (1) DAILY (Daily). 4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Inhalation [Hospital1 ] (2 times a day). 5. Levothyroxine 100 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 7. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA). 9. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO 4X/WEEK ([Doctor First Name ],MO,WE,FR). 10. Ascorbic Acid 1,000 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Calcium Carbonate 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Ergocalciferol (Vitamin D2) Oral 13. Loratadine 10 mg Tablet Sig: One (1) Tablet PO qd (). 14. Multivitamin, Stress Formula Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Atrial fibrillation Hypertension Obstructive Sleep apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital following a pulmonary vein ablation. After the procedure your heart rate became slow, and you required a temporary pacemaker for a short amount of time. You no longer are requiring pacing, and the pacemaker wire has been removed. You also developed some shortness of breath, which has improved after we gave you diuretics. Please resume Coumadin. Please get INR checked on [2102-7-24]. Send daily EKG recordings to Dr. [Last Name (STitle) ] with the [Doctor Last Name ] of Hearts monitor. Please STOP taking Digoxin and Flecainide. Please also stop taking Amlodipine, as your blood pressure has been low. Please continue taking all other medications you were taking before your admission to the hospital. As your heart rate was fast on teh day of discharge we have started you on diltiazem which will hhelp sloe your heart rate. If you feel your heart is beating slowly or you have further symptoms please contact cardiology. Followup Instructions: PT/INR check at [Hospital 197] Clinic [2102-7-24]. Dr. [Last Name (STitle) ] in 1 week. Dr. [Last Name (STitle) ] in 1 month. His office will contact you to make an appointment. ICD9 Codes: 9971, 4019, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9019 }	Medical Text: Admission Date: [2134-9-30] Discharge Date: [2134-10-5] Service: Acove - Medicine [Hospital Ward Name 516] CHIEF COMPLAINT: Fatigue and low back pain of two months. HISTORY OF PRESENT ILLNESS: This is a 79-year-old man with progressive fatigue and lower back pain of [1-3] months, found to have a hematocrit of 26% in his primary care physician's office and was therefore referred to the [Hospital1 346] Emergency Room. Initial vital signs in the Emergency Room triage, temperature 97.4, blood pressure sitting up was 98/42, heart rate 70 and standing upright was 94/40 with heart rate of 67. Patient also was found to be guaiac negative. CT of the abdomen was done which was negative for abdominal aortic aneurysm. In the Emergency Room the patient did receive one unit of packed red blood cells because of low hematocrit and was also empirically started on Levo and Flagyl because of some radiographic evidence of possible pneumonia vs atelectasis. Upon presentation the patient denied any chest pain, shortness of breath, abdominal pain, nausea, vomiting, hematemesis. He did have two episodes of bright red blood per rectum which he recalled happened at home several weeks ago. Patient also upon presentation in the Emergency Room reported some back pain and therefore a CT angio was performed. CT angio was negative for aortic dissection. The patient also evaluated for myocardial infarct by EKG and serial cardiac enzymes which result was negative for MI. PAST MEDICAL HISTORY: Significant for two sets of aortic valve replacements, [Initials (NamePattern4) ] [Last Name (NamePattern4) 3843]-[Doctor Last Name ] valve, revision due to endocarditis that occurred in [2131]. Also has history of coronary artery disease, status post two MIs, history of congestive heart failure with ejection fraction between 30 and 35%. Also has benign prostatic hypertrophy and is status post TURP. Had a right hip replacement, history of spinal stenosis and history of Parkinson's disease. Additionally, patient has a history of atrial fibrillation for which he was taking the Coumadin. MEDICATIONS: Outpatient medications include Sinemet at a dose of 50/200, taking two tabs four times per day, Lopressor which she takes 25 mg [Hospital1 ], Colace 100 mg [Hospital1 ], also daily dose of Vitamin E, Vitamin C, 81 mg of po aspirin, daily lactulose, Coumadin which he takes either 5 mg or 2.5 mg on alternating days, Celebrex which he takes 100 mg [Hospital1 ] and B12 which he takes 1,000 units daily. SOCIAL HISTORY: Patient reports remote tobacco history, quit approximately [2096]. Patient lives with his wife and has a visiting nurse who comes once a month to check his blood and also denies any smoking history. ALLERGIES: The patient has no known drug allergies. FAMILY HISTORY: Notable for a brother who died at age 32, complications of diabetes, and a father who died age 62 from congestive heart failure. HOSPITAL COURSE: Given patient's anemia, a GI source was considered. The patient underwent colonoscopy during hospital course. The colonoscopy was positive for melanosis coli, believed to be secondary to chronic laxative use. So recommendation from gastroenterology was to discontinue laxatives, in particular Senna containing laxatives and also recommended to follow a high fiber diet. Melanosis was seen in the cecum and colon, descending colon, transverse colon, ascending colon. There were also diverticula noted in the descending colon, transverse colon, otherwise the rest of the colonoscopy was normal. EGD was also performed, notable for a large sized hiatal hernia, a single submucosal nodule with distribution in the lower third of the esophagus. The duodenum was found to be normal and some cold biopsies were obtained from the second part of the duodenum. Speech and swallow study was also done given patient's history of choking. Speech and swallow found that patient had difficulty with flow, soft, thick and thin liquids given the greater potential after aspiration for thicker fluids, they recommended combination of soft solids with thin liquids. During this hospital course it should also be noted that the patient with the concern of bleeding had been held on his Coumadin and so near the latter end of his hospital course he has been covered in terms of his coagulative protection with Lovenox. Following the recommendations of gastroenterology and the absence of a site of gross bleeding, plan was made to discharge the patient home with services. DISCHARGE DIAGNOSIS: 1. Parkinson's disease. 2. Dysphagia. 3. Anemia. 4. Melanosis coli. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: Lovenox 60 mg subcu [Hospital1 ] to be taken until the patient's INR becomes therapeutic, Warfarin at alternating doses of 5 mg daily alternating with 2 mg daily with INR to be checked this Friday, [2134-10-8], with the patient's primary care physician. [Name10 (NameIs) ] Enalapril 5 mg daily, Sinemet 50/200 two tablets po qid, Vitamin C 500 mg daily, Vitamin E 400 IU daily and Metoprolol 25 mg po bid, Atorvastatin 10 mg po q d and Levofloxacin 25 mg po q d times two days to finish up a week long course for the possible pneumonia seen on the radiograph. As mentioned, the patient's INR should be checked on Friday, [2134-10-8] and the plan is to discontinue the Lovenox once the Coumadin produces a therapeutic INR. It was also recommended that the patient undergo swallow physical therapy to help reduce the risk of aspiration. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 5712] Dictated By:[Last Name (NamePattern1) 8562] MEDQUIST36 D: [2134-10-5] 21:15 T: [2134-10-5] 21:21 JOB#: [Job Number 38328] ICD9 Codes: 2859, 4019, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9020 }	Medical Text: Admission Date: [2142-3-26] Discharge Date: [2142-4-17] Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 9240] Chief Complaint: abdominal, L groin pain Major Surgical or Invasive Procedure: ERCP with major papillotomy History of Present Illness: This 84 yo female with multiple medical issues including diabetes has been experiencing several months history of nausea and NBNB vomiting. SHe was initially scheduled for outpatient evaluation by her pcp. [Name10 (NameIs) ] presented [2142-3-26] with worsening abominal pain and was initially worked up for gastroparesis, with normal gastric emptying study. She became hypotensive with syncope and anemic [3-31], prompting transfer to [Hospital Unit Name 153] and requiring 3U PRBCs for what was discovered to be internal bleeding secondary to L groin and R psoas hematomata. After transfusion, she stabilized in the [Hospital Unit Name 153]. Vascular consultation suggested conservative management as she is a poor operative candidate. Her L knee was tapped [4-1] for swelling and tenderness; crystal analysis was consistent with pseudogout. She was transferred to the floor [4-2] for continued rehabilitation and placement. No clear cause of the spontaneous hematomata were identified. There was no known trauma. Initial PTT values measured in the hospital were 71, which was attributed to systemization of sQ heparin injections (DVT prophylaxis). She c/o numbness in the right lateral thigh area (suggestive of compression of right lateral femoral cutaneous nerve). Past Medical History: DM on insulin c/b retinopathy CVA x 3 many years ago - no residual neuro defects CAD with RCA stent [2134] hypothyroidism arthritis gout HTN hyperlipidemia Csection x 2 Social History: Born in [Country 18084] and came to US in [2091]. Lives at home with her son. walks independently. Retired [Hospital1 18] housekeeping/supply room worker. denies tobacco (past 1pp week x 30y quit 30y ago), no EtOH, no other drugs, herbs, vitamins. Family History: mother with DM and CAD, no cancer in family Physical Exam: PE-VS 96.9 114/72 83 18 97% RA Pleasant elderly female, cooperative, NAD. HEENT- no icteris, MM dry, no LAD, no goiter, no bruits Lungs CTA B anteriorly RRR S1S2 no m/r/g Abd BLQ ecchymoses from previous injections Groin 2+ B femoral pulses, pain on palpation of L groin but no palpable mass. Extr: Trace BLE edema, L?R knee swelling, 2+B DP pulses Pertinent Results: [2142-3-26] 02:40PM GLUCOSE-182* UREA N-49* CREAT-1.9* SODIUM-136 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-25 ANION GAP-16 [2142-3-26] 02:40PM estGFR-Using this [2142-3-26] 02:40PM ALT(SGPT)-21 AST(SGOT)-28 ALK PHOS-99 AMYLASE-66 TOT BILI-0.5 [2142-3-26] 02:40PM LIPASE-37 [2142-3-26] 02:40PM CALCIUM-10.3* PHOSPHATE-3.4 MAGNESIUM-2.3 [2142-3-26] 02:40PM WBC-12.2# RBC-3.54 HGB-11.4* HCT-33.6* MCV-95 MCH-32.1* MCHC-33.8 RDW-14.8 [2142-3-26] 02:40PM NEUTS-75.1* LYMPHS-18.3 MONOS-4.2 EOS-0.8 BASOS-1.5 [2142-3-26] 02:40PM MACROCYT-1+ [2142-3-26] 02:40PM PLT COUNT-236 [2142-3-26] 02:40PM PT-12.3 PTT-24.8 INR(PT)-1.1 . abd XR: Calcific density seen overlying the left upper quadrant, likely corresponding to splenic artery calcifications seen on prior CT. Tiny calcific density overlying right upper quadrant, possibly within rib costocartilage or small gallstone. . gastric emptying study: Normal gastric emptying . bilat hip XR: Stable mild degenerative changes of both hips without signs for acute bony injury. . abd/pelvic CT: 1. New large hematoma of the left groin and smaller hematoma of the right iliopsoas. A few small foci of hyperdensity within the left groin hematoma suggest slow bleeding into the hematoma. 2. Sigmoid diverticulosis without evidence of acute diverticulitis. 3. Subcentimeter right renal hypodense lesion is too small to characterize but probably a cyst. 4. Stable appearance of the pancreas including pancreas divisum with associated prominent pancreatic duct. . L femoral vasc U/S: 1. Reidentification of known left groin hematoma with no evidence of left common femoral pseudoaneurysm or AV fistula. . MRCP w secretin: 1. Dilated main pancreatic duct and duct of Santorini with divisum. Sanorinicele with persistence of main ductal dilatation and multiple mildly dilated side branches after secretin indicates papillary dysfunction. No mass. Pancreatic exocrine function at the lower limits of normal. 2. Small bilateral pleural effusions. . RUQ U/S: 1. Small gallstones and tumefactive sludge without evidence of cholecystitis. 2. Mildly prominent pancreatic duct consistent with MR results from a day prior. Please see report from MR study for further details. . ERCP: Mildly dilated common bile duct with small filling defects in distal CBD consistent with sludge. Major papillotomy performed. Brief Hospital Course: 1.) Retroperitoneal Hematomata- likely due to accumulation of prophylactic sc heparin. Vascular was consulted. Vascular U/S showed no fistula or other abnormality. Hct subsequently stabilized and vascular did not recommend operative management. Patient walking with minimal pain at discharge. 2.) Biliary Obstruction: due to sludge and pancreatic divisum. ERCP was done with major paillotomy, to which the patient responded well. If her obstruction recurrs she may need a minor papillotomy. Her pain subsequently resolved and she was tolerating a diet. 3.) DM/gastroparesis- cont. [Hospital1 ] NPH, SS insulin, Reglan 4.) Dispo- to rehab Medications on Admission: 1. Aspirin 325 mg daily 2. Valsartan 160 mg daily 3. Atenolol 50 mg daily 4. Levothyroxine 100 mcg daily 5. Imipramine HCl 25 mg daily 6. Atorvastatin 40 mg daily 7. Allopurinol 100 mg daily 8. NPH 20 units [Hospital1 ] 9. RISS 10. Pantoprazole 40 mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Imipramine HCl 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty (20) units Subcutaneous twice a day. 10. Insulin Regular Human Subcutaneous Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: PRIMARY: Biliary Obstruction Pancreatic Divisum Left Spontaneous Retroperitoneal Bleed SECONDARY: Diabetes type 2 Hypertension Coronary Artery Disease Gout Discharge Condition: Good--tolerating food and liquids. Discharge Instructions: 1. Take medications as prescribed. No changes were made in your regimen. 2. Follow up as below. 3. Please call Dr. [Last Name (STitle) 16258] or Dr. [First Name (STitle) 679] with recurrent nausea, vomiting, abdominal pain, fevers, diarrhea, or any other symptoms that concern you. Followup Instructions: Please call Dr. [Last Name (STitle) 16258] for a follow up appointment in next 2 weeks. Please follow up with Dr.[Name (NI) 16937] office: [4-16], Monday 1:15 pm ICD9 Codes: 2449, 2749, 4019, 2724, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9021 }	Medical Text: Admission Date: [2178-10-19] Discharge Date: [2178-11-3] Date of Birth: [2134-8-17] Sex: F Service: TRANSPLANT SURGERY female who presented with celiac disease for four years and diabetes mellitus type 1 forty-two years. The patient came in for a pancreatic and kidney transplant. 1. Celiac disease. secondary to retinopathy. 3. Type 1 diabetes mellitus since age two 4. Osteomalacia. PAST SURGICAL HISTORY: 2. Left ********* catheter and another catheter which was placed on the right side for three years. ALLERGIES: Intravenous iron which leads to anaphylaxis, Percocet and Keflex which lead to severe gastrointestinal upset. MEDICATIONS ON ADMISSION: 1. Magnaprin two tablets t.i.d. 2. Nephrocaps p.o. once a day. 3. Regular insulin sliding scale. 4. NPH at 3:00 p.m. 5 to 6 units. PHYSICAL EXAMINATION: On admission, her examination revealed clear lung sounds, regular rhythm. Left port-a-cath in place, right chest had scar from old catheter. The abdomen was soft, nondistended, nontender. No edema. HOSPITAL COURSE: The patient was taken to the OR for a simultaneous kidney pancreas transplant. No complications. Postoperatively, the patient received thymoglobulin and was NPO. See the operative report for full details of the operation. The patient postoperatively stayed in the Surgical Intensive Care Unit until postoperative day number two and was transferred to the floor on the evening of postoperative day number three which was [2178-10-23]. Electrolytes were being corrected and the patient was closely monitored and had no significant issues while in the Surgical Intensive Care Unit. On postoperative day four, [2178-10-24], the patient was afebrile and vital signs were stable. The [Location (un) 1661]-[Location (un) 1662] was putting out roughly 800 to 1000 cc of peritoneal fluid over 24 hours. We started Baby Aspirin also for thrombosis prophylaxius. FK came back at 3.0 on this day. On postoperative day number five, the patient was afebrile and vital signs were stable. Electrolytes were being repleted. We noted FK level was dropping to 2.5. We continued the thymoglobulin, Prograf 3 mg b.i.d. through the nasogastric tube. On postoperative day six, [2178-10-26], FK level returned at 6.5 and the PCA was discontinued and the patient was put on Percocet and Colace. We started Prednisone, discontinuing the Solu-Medrol taper. The patient was attempted to be advanced to a clear liquid diet and we discontinued the nasogastric tube. Intravenous fluids were reduced to 50 cc/hour and gluten-free diet was attempted, however, failing. On postoperative day seven, the patient continued to be stable. Her blood sugar was 114, 98, 124, 140, and the patient was afebrile. However, at this point, we were noting that the hematocrit had dropped from 31.0 on postoperative day number six to 22.6. Repeat laboratories showed a hematocrit of 24.1, amylase 74, lipase 81, and FK level came back at 8.6 on this day. The patient was transferred to the Surgical Intensive Care Unit for presumed GI bleed which stabilized and required no further therapy other than protonix. Her blood pressure was increased and we added Norvasc 5 mg p.o. to her regimen as well as continuing the TPN which had been started on postoperative day seven, [2178-10-27]. Soon after, she tolerated her diet, TPN was stopped and the patient was soon after discharged. MEDICATIONS ON DISCHARGE: 1. Baby Aspirin 81 mg p.o. q.d. 2. Ganciclovir 450 mg q.d. 3. Norvasc 5 mg q.d. 4. Colace 100 mg b.i.d. 5. Protonix 40 mg once a day p.o. 6. Rocaltrol 0.5 mcg q.d. 7. Reglan 10 mg q.i.d. 8. Prograf 6 mg b.i.d. 9. Prednisone 5 mg once a day. 10. Rapamune 10 mg once a day. 11. Bactrim one tablet once a day. 12. Nystatin one teaspoon four times a day. 13. Percocet or Vicodin as analgesic at rehabilitation. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3598], M.D. [MD Number(1) 3599] Dictated By:[Name8 (MD) 16758] MEDQUIST36 D: [2178-11-2] 17:01 T: [2178-11-2] 18:47 JOB#: [Job Number 18352**] ICD9 Codes: 2762
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9022 }	Medical Text: Admission Date: [2143-11-1] Discharge Date: [2143-11-14] Service: Medical Intensive Care Unit CHIEF COMPLAINT: Apnea, status post percutaneous endoscopic gastrostomy tube replacement HISTORY OF PRESENT ILLNESS: Ms [Known lastname ] is an 85 year old nursing home patient with a past medical history significant for stroke, hypertension, chronic obstructive pulmonary disease who came in on [11-2], for a percutaneous endoscopic gastrostomy tube replacement. The patient was intubated for the procedure and after the procedure the patient was extubated and was maintaining good oxygen saturation of about 92 to 94% on 2 liters of oxygen through the nasal cannula. All of a sudden the patient became apneic and a chest x-ray was obtained which showed a right upper lung collapse which appeared to be secondary to some bronchial mucous plugging. At that time it was decided to reintubate the patient and the patient was reintubated and a bronchoscopy was done and a significant amount of secretion/bronchial mucous plugging was removed. A repeat chest x-ray was done which showed reinflation of the right upper lobe after the bronchoscopy. At that time the patient was in the Post Anesthesia Care Unit. In addition, the patient also became very hypotensive and was started on Lopressor, Neo, 1 mcg/kg/min and her blood pressure improved from systolic of 60s to 70s to 110s. The patient also has a history of Methicillin-resistant Staphylococcus aureus colonization in the past and so the surgery team who did the percutaneous endoscopic gastrostomy tube replacement contact[Name (NI) ] the [Name (NI) ] Intensive Care Unit and asked the patient to be transferred to the [Name (NI) ] Intensive Care Unit for further workup and evaluation. PAST MEDICAL HISTORY: Left atrial myxoma, stroke, hypertension, recurrent pneumonia, chronic obstructive pulmonary disease, diverticulosis, breast cancer, status post left mastectomy, questionable gastric cancer, hiatal hernia, left proximal humeral fracture, status post wide cataract surgery. MEDICATIONS ON ADMISSION: Trazodone 50 mg p.o. q.d., Paxil 20 mg p.o. q.d., Aspirin 81 mg p.o. q.d., Neurontin 600 mg p.o. t.i.d., Calcium carbonate 650 mg p.o. b.i.d., Albuterol, Atrovent nebulizers, Timoptic 0.5%, Xalatan 0.005%, multivitamin one tablet p.o. q.d. ALLERGIES: Digoxin and Erythromycin PHYSICAL EXAMINATION: Physical examination on admission, in general the patient was intubated, was awake and responded to some verbal commands. Head, eyes, ears, nose and throat, pupils equal, round and reactive to light and accommodation. Jugulovenous distension is flat, no lymphadenopathy noted. Lungs, mild wheezing in the bilateral lower lobes. Heart, S1 and S2, regular rate and rhythm, no murmurs, rubs or gallops heard. Abdomen, soft, nondistended, nontender, no hepatosplenomegaly noted. Positive percutaneous endoscopic gastrostomy tube on the left side. Extremities, no edema, no cyanosis and no clubbing, 2+ distal pulses. LABORATORY DATA: On admission white count was 24.9, hematocrit 41.7, platelets 542, sodium 135, potassium 4.6, chloride 98, bicarbonate 25, BUN 27, creatinine 1.0, glucose 274, calcium 9.0, phosphorus 6.6, magnesium 2.0, PT 12.6, PTT 26.9, INR 1.1. Electrocardiogram, normal sinus rhythm, sinus tachycardiac to 110s, no ST elevation noted, normal intervals. Chest x-ray, no evidence of pneumothorax, resolution of right upper lung collapse as compared to the previous x-ray that was done prior to the reintubation. HOSPITAL COURSE: Pulmonary, the patient was initially intubated for the procedure. After the procedure the patient was extubated but became apneic and her oxygen saturation dropped and her chest x-ray showed a right upper lobe collapse, and so the patient was reintubated and a bronchoscopy was done with a significant amount of mucous clubbing, secretions were removed. A repeat chest x-ray after the bronchoscopy showed reinflation of the right upper lobe. An attempt was made on [11-5], to extubate the patient but the patient failed secondary to increase of secretions and at that time it was also thought to volume overload. The patient was receiving a significant amount of fluid boluses because of the patient was hypotension, and as we were trying to wean off of the pressor, she was getting more and more fluid. After the failure of extubation on [11-5], it was decided to extensively diurese the patient and treat the patient for her secretions. Initially the patient was on assist control but then she would be switched over to pressor support of 15 or pressor support of 10, positive end-expiratory pressure of 5, FIO2 of 35% and the patient would tolerate that well. However, whenever an attempt was made to wean her off of mechanical ventilation by lowering the pressor support to 5, the patient would become tachypneic, tachycardiac and the title volumes would decrease and the patient would not tolerate that very well. Despite multiple attempts to wean off of her mechanical ventilation an extensive discussion was held with the family in which it was decided that if we would try to extubate her one more time and she would fail extubation, what would be the next thing to do. At that time her two sons, [Name (NI) ] and [First Name4 (NamePattern1) ] [Name (NI) ], had reached an agreement to go ahead and extubate the patient and if the patient would fail extubation we would make her comfortable but they would not want her to go ahead with any trach at that point. On [2143-11-13] at around 10:15 AM the patient was extubated and after extubation the patient was doing well. Her oxygen saturations were 96 to 98% on 2 liters through the nasal cannula Cardiovascular - Rate and rhythm, the patient was mostly normal sinus rhythm and would get occasional premature atrial contractions and premature ventricular contractions. Electrolytes would need to be rechecked and repeated as needed. Ischemia, no ischemic changes or signs noted on electrocardiogram. Pump, the patient was initially on a pressor, Neo 1 mcg/kg/min, however, that was weaned off within a day or two after the patient transferred to the [Year (4 digits) ] Intensive Care Unit. The patient also received multiple fluid boluses to help her maintain her blood pressure. Infectious disease - The patient is known to have a baseline white blood cell count between the range of 9 to 11. Initially on admission to the [Year (4 digits) ] Intensive Care Unit her white count was 25.6. At that time we decided to start her on broad coverage of Levofloxacin and Flagyl for questionable aspiration pneumonia since she did have the bronchial plugging that lead to the right upper lung collapse. However, that was discontinued in one day or two when the white count came down significantly. At that time it was thought that the reason why she had a elevated white count of 25.6 was probably secondary to the stressfulness of the procedure. In addition, the patient was also started on Vancomycin initially at 1 gm q. 12 hours for her known Methicillin-resistant Staphylococcus aureus colonization. A Vancomycin trough level was obtained which was slightly elevated and so based on the pharmacy recommendations, her Vancomycin was changed to 1 gm q. 24 hours. In addition on [11-7], the patient was also started on Cefepime 2 mg intravenously q. 12 for pseudomonas coverage since her sputum grew out mild to moderate pseudomonas aeruginosa which was sensitive to Cefepime and mild to moderate Methicillin-resistant Staphylococcus aureus. Gastrointestinal - The patient is questionable status post gastric cancer, needs further verification. The patient has a percutaneous endoscopic gastrostomy tube placed. Dressings were changed as per protocol and the patient has been receiving tube feeds through that without any difficulty. Heme - Hematocrit had fallen from 40 to 29. It was initially thought that this drastic fall is secondary to overhydration since the patient was becoming hypotensive. Iron studies were obtained which were found to be unremarkable. Since then her hematocrit had been in the range of anywhere between 25 to 30. The patient was not transfused any units of blood. Fluids, electrolytes and nutrition - As mentioned earlier the patient received multiple boluses since she was initially hypotensive. Her baseline blood pressure is found to be anywhere between systolics of 80s and 90s. The patient was also given Lasix 20 mg p.o. b.i.d. to help with the diuresis since we thought she was volume overloaded. In addition, the patient is also getting tube feeds through the percutaneous endoscopic gastrostomy tube and she was having her electrolytes checked, usually b.i.d. and repeated as needed since she was on the Lasix. Contact - [Name (NI) ] son [Name (NI) ] [Name (NI) ], phone [Telephone/Fax (1) 105889]. Prophylaxis - The patient was on subcutaneous heparin and proton pump inhibitors. Code - The patient is Do-Not-Resuscitate, Do-Not-Intubate. Laboratory data the day before discharge revealed a white count of 11.5, hematocrit 29.7, platelets 537, sodium 138, potassium 4.2, chloride 101, bicarbonate 28, BUN 19, creatinine 1.0 and glucose 91. Calcium 8.5, magnesium 2.0, phosphorus 4.9. DISCHARGE MEDICATIONS: 1. Cefpodoxime 400 mg b.i.d. times seven days 2. Colace 100 mg p.o. b.i.d. 3. Ferrous Sulfate 325 mg p.o. q.d. 4. Flovent 110 mcg 6 puffs i.h. b.i.d. 5. Timolol 0.5% one drop left eye b.i.d. 6. Heparin 5000 units subcutaneously b.i.d. 7. Prevacid 30 mg p.o. q.d. 8. Aspirin 81 mg p.o. q.d. 9. Miconazole nitrate to be applied for yeast infection 10. Trazodone 50 mg p.o. q.h.s. prn 11. Miconazole powder 2% apply q.i.d. prn to affected area 12. Neurontin 600 mg p.o. t.i.d. 13. Calcium carbonate 650 mg p.o. b.i.d. 14. Albuterol/Atrovent nebulizers 15. Multivitamin one tablet p.o. q.d. CONDITION ON DISCHARGE: Fair DISCHARGE STATUS: The patient is being discharged back to her [Hospital3 ] Center where she came from. The Geriatric Fellow, Dr. [Last Name (STitle) ] [Name (STitle) 105892] was informed of her being transferred and he had talked to the [Hospital3 ] Center and has made the appropriate arrangements. DISCHARGE DIAGNOSIS: 1. Chronic bronchiectasis 2. Chronic obstructive pulmonary disease 3. Hypertension 4. Recurrent pneumonia [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Name8 (MD) ], M.D. [MD Number(1) 292] Dictated By:[Name8 (MD) 14914] MEDQUIST36 D: [2143-11-13] 16:20 T: [2143-11-13] 19:32 JOB#: [Job Number 105893] ICD9 Codes: 5180, 496, 4019, 5070
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9023 }	Medical Text: Admission Date: [2142-1-17] Discharge Date: [2142-1-23] Date of Birth: [2101-5-8] Sex: F Service: HISTORY OF PRESENT ILLNESS: Ms. [Known lastname ] is a 40 year-old female with a history of unstable angina. She had presented with substernal chest pressure on exertion that began to occur at rest as well. She ultimately underwent a cardiac catheterization on [2142-1-17] showing a heart with an EF of approximately 70%, left main disease of 70% stenosis, left anterior descending of 30% stenosis, left circumflex of 40% and the obtuse marginal was 30%. Given the degree of severity of the left main disease in the setting of the substernal chest pressure and unstable angina the patient was therefore scheduled for coronary artery bypass graft. Off pump coronary artery bypass graft was done secondary to the fact that the patient has a history of nephrotic syndrome and was at risk for coagulopathy, stroke, etc. PAST MEDICAL HISTORY: Significant for hepatitis B and C treated with interferon. Last treatment was two years ago. Cryoglobulinemia as well as nephrotic syndrome. She does have a history of chronic low back pain and is on Roxicet chronically and there is a question of past history of intravenous drug abuse. ALLERGIES: Lipitor and Atenolol for which she gets a rash. There is a questionable allergy to contrast dye. ADMISSION MEDICATIONS: Not available. HOSPITAL COURSE: She was brought to the Operating Theater on [2142-1-16] by Dr. [Last Name (STitle) 1537] where she underwent an elective two vessel coronary artery bypass graft off pump. The first graft was the left internal mammary coronary artery to the left anterior descending coronary artery. The second graft was the left radial to the oblique marginal. This was done due to the poor size of the saphenous vein grafts that were mapped preoperatively. The patient tolerated the procedure well and was on nitroglycerin drip, propofol and phenylephrine. She was brought to the Critical Care Unit and upon arrival to the unit was noted to go into V fibrillation arrest. Therefore given the proximity to the Operating Room her chest was immediately opened to rule out any tamponade physiology from anastomotic leak or bleed. It was found that she did have blood in the pericardial space. She was therefore brought to the Operating Room for an immediate redo coronary artery bypass graft. She underwent a two vessel coronary artery bypass graft at this time including a saphenous vein graft that was utilized to the left anterior descending as well as to the diagonal in a sequential manner. The intraoperative findings were significant for a dissected left internal mammary coronary artery graft. The left radial to the obtuse marginal artery was still intact, however. After leaving the second procedure the patient was intubated. She had received four 8 units of packed cells in her resuscitation and eight units of fresh frozen platelets as well as 3 packs of platelets. She was on Milrinone, Amiodarone, Diltiazem and neo when she left the operating theatre. In the Intensive Care Unit she was placed on Vancomycin and Gentamycin for the fact that her chest had to be opened at the bedside. On postoperative day one she was still extubated. She was hemodynamically stable. Her postoperative hematocrit was significant for 30 and this was post transfusion, because the immediate postop was 22 and she had received the previously mentioned blood products. Her coagulation panel was normal. Her K was 5.0, BUN and creatinine were 13 and .7, magnesium was 1.6 and that was repleted. She was weaned to extubation. Her Swan-Ganz catheter was left in place for hemodynamic monitoring. Chest x-ray on postoperative day one had shown patchy infiltrates with a right pleural effusion. By postoperative day number two the patient's diet was advanced. She was started on Lasix, aspirin and antihyperlipidemic therapy. Additionally a beta blocker was added. The patient's Swan-Ganz catheter was placed to CVL. She did well over the next day and ultimately was transferred to the floor on postoperative day number three. At this point she was being maintained on a morphine PCA with Toradol and Percocet for breakthrough pain. Given her chronic opioid dependence she did have significant issues of tolerance and therefore was ultimately referred to the Acute Pain Service who had recommended to use Oxycodone 20 mg po q 3 to 4 hours prn as well as morphine sulfate intermediate release 15 mg po b.i.d. Her laboratories on postoperative day number five were significant for a hematocrit of 26 that was stable. Potassium 4.1, BUN and creatinine were 24 and .8 and the remainder of her electrolytes were within normal limits. On postoperative day five was also marked by the onset of persistent substernal chest discomfort, pressure and tightness. Electrocardiogram was done at that time, which showed no significant changes for ischemia or infarction. No dysrhythmia. She remained in sinus. Her chest x-ray at that time additionally showed a left pleural effusion. The right pleural effusion was stable. The left pleural effusion was somewhat new. There was also evidence of a loculated retrosternal collection in the right upper hemithorax, however, this was stable. Her vital signs remained afebrile and hemodynamically stable throughout her entire hospital course once she was out of the Intensive Care Unit setting. The acute Pain Service ultimately titrated her medication regimen for pain control to the aforementioned regimen. DISCHARGE MEDICATIONS: Lasix 20 mg po q.a.m., Colace 100 mg po b.i.d., aspirin 325 mg po q day, Plavix 75 mg po q day, Oxycodone 10 to 20 mg po q 3 to 4 prn, MSIR 15 mg po b.i.d., Imdur 30 mg po q day, Lopressor 50 mg po b.i.d., Amiodarone 400 mg po t.i.d., Ibuprofen 600 mg po q 4 to 6 prn as well as Oxazepam 15 to 30 mg po q.h.s. prn. The patient's vital signs at the time of discharge, she was afebrile with a temperature maximum of 99.0, pulse 70 and sinus, 123/68 blood pressure, 97% on room air saturation. She was in no acute distress. Her sternum was stable. There was no erythema or exudate. Her staples were intact. Her lungs were clear with decreased breath sounds left greater then right. No crackles were present. Her lower extremities were nonedematous, warm and well profuse. She had palpable pulses distally in the dorsalis pedis pulse and posterior tibial pulse bilaterally. The remainder of her examination was unremarkable. DISPOSITION: Discharged to home. DISCHARGE STATUS: Stable. DISCHARGE DIAGNOSIS: Unstable angina status post off pump coronary artery bypass graft followed by redo coronary artery bypass graft on the night of surgery for V tach/V fibrillation arrest. FOLLOW UP: Includes seeing Dr. [Last Name (STitle) 1537] in one month from the time of discharge. Cardiologist will see her in two weeks and she will have follow up in the Wound Care Clinic for wound check in one week from the time of discharge. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Last Name (NamePattern4) 3204] MEDQUIST36 D: [2142-1-23] 10:11 T: [2142-1-23] 10:15 JOB#: [Job Number 25401] ICD9 Codes: 4111, 4275, 5119
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9024 }	Medical Text: Admission Date: [2165-9-7] Discharge Date: [2165-9-9] Date of Birth: [2132-12-17] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4691] Chief Complaint: 32 yo MVC with asystolic traumatic arrest in the field. Pt was resuscitated at [Hospital 882] Hospital, bilateral needle thoracostomies. Regained a rhythm but was hypotensive at [Hospital1 882]. Patient was transferred to [Hospital1 18] for definitive care. Major Surgical or Invasive Procedure: None History of Present Illness: This is a 32 yo man previously healthy, who is s/p MVC on [2165-9-7](car vs pole) -unrestrained driver, ETOH+ . He was ejected from the vehicle and apparently struck his head, sustaining multiple injuries, He was found on the scene unresponsive with fixed/dilated pupils and asystolic per first responders. He underwent CPR for unknown period of time, was intubated, and initially was taken to [Hospital 882] Hosp. There, he had a rhythm but was hypotensive. He was transferred to [Hospital1 18] ostensibly for neurosurgical eval. On study he was found to have SAH as well as SDH and diffuse cerebral edema. He had a C1 subluxation with posterior displacement and a high spinal cord injury. On initial exam here he had fixed/dilated pupils, no corneal reflexes, no response to noxious stimulation and was areflexic with mute Babinski's. Past Medical History: Unknown Social History: Unk Family History: Unk Physical Exam: Physical exam documented at admission to Trauma ICU: T 101.8 HR 104 BP 102/65 96 on the ventilator gen: intub, no sedation, hard collar in place - white male HEENT: R TM was clear/intact prior to cold calorics neck: hard collar cv: distant heart sounds pulm: no ronchi abd: soft positive bowel sounds ext: No edema neuro: no response to verbal or tactile stim including sternal rub - no change in HR or BP cranial nerve exam notable for ocular bobbing periodically - with mvmt of eyelids due to the fact that they are partially opened. perrlb 3->2.5 but sluggish. cold calorics on R ear - no mvmt of eyes horizontally - only ocular bobbing. neg corneals bilat, neg gag, neg nasal tickle, neg cough; no papilledema sensorimotor: trace mvmt of L toe on nox stim but o/w no mvmt in any ext noted dtrs absent except for trace brachioradialis bilat; toes mute bilat Pertinent Results: CTA HEAD at admission IMPRESSION: 1. Subarachnoid hemorrhage. 2. Fracture at the occipital condyle and C1 with subluxation at the occipital C1 joint. 3. No evidence of aneurysm. 4. Irregularity of the lumen of the distal left vertebral artery and basilar artery could be due to spasm. No definite dissection is visualized. 5. Mild decreased caliber of the middle cerebral arteries could be due to early known occlusive spasm CT C SPINE AT admission IMPRESSION: 1. Cranial atlanto subluxation and mild distraction. 2. Comminuted displaced left occipital condyle fracture. 3. Complex C1 fracture involving the anterior arch and right lateral mass. 4. Intraspinal canal gas of unclear etiology. 5. MRI can help in further evaluation. CT Abdomen and pelvis at admission IMPRESSION: 1. Left pneumothorax. Bibasilar opacities are hemorrhage and atelectasis. 2. T4 anterior-inferior "teardrop" vertebral body fracture. 3. Bilateral posterior hip dislocations. 4. Complex left acetabular roof fracture extending to the posterior wall. 5. Multiple left anterior rib fractures (2 through 8) with fractures through the right transverse processes of T5-T6. 6. No definite evidence for intra-abdominal injury MRI head [2165-9-7] IMPRESSION: 1. Slow diffusion involving the caudate and putamen bilaterally, the perirolandic cortex, and the medial occipital lobes bilaterally consistent with a combination of hypoxic ischemic encephalopathy and posterior cerebral artery infarcts. 2. Multiple areas of T2 hyperintensity and slow diffusion as described above including the brainstem and the corpus callosum consistent with a combination of diffuse axonal injury, infarcts, and contusions. 3. Hemorrhagic contusion of the cervicomedullary junction. 4. Small bilateral subdural hematomas as well as extensive subarachnoid hemorrhages better seen on the concurrent CTA. Intraventricular hemorrhage. Brief Hospital Course: 32 yo man who is s/p MVA with closed head injury, traumatic SAH and SDH who was unresponsive and asystolic at the scene, s/p CPR with regain of pulse but unresponsive with minimal brainstem response since those events. He likely had an anoxic arrest in the field due to his devastating cord injury at the cervical-medullary junction. He had several episodes of anoxia during the resuscitation. Neurology and Neurosurgery both evaluated this patient during his short T/SICU stay. His image studies revealed combined closed head injury with C spine injury in the setting of cerebral hypoxia. The family as per the patient previous wishes decided to change the code status to DNR and shortly there after to comfort measures only (CMO). This family meeting involved members of the Neurosurgery, Neurology, Trauma and T/SICU teams including social work. After the patient was made CMO he expired rapidly. Medications on Admission: Unk Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Traumatic Brain Injury. List of injuries: 1. Cranial atlanto subluxation with cord contusion at cervico-medullary junction. 2. Comminuted displaced left occipital condyle fracture. 3. Complex C1 fracture involving anterior arch + right lateral mass 4: left frontal lobe contusion, Sub arachnoid hemorrage 5. Right pneumothorax 6. multiple left anterior rib fractures 7. bilateral posterior hip dislocations 8. left acetabular roof fracture extending to posterior wall 9. left testes high in inguinal ring 10. T4 fracture 11. R radial styloid fracture Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:[2165-11-18] ICD9 Codes: 2762
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9025 }	Medical Text: Admission Date: [2129-6-4] Discharge Date: [2129-6-8] Date of Birth: [2049-3-14] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4162] Chief Complaint: Delirium Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname ] is an 80 yo man with DM2, CKD (baseline most recently ~2.0), HTN, BPH, depression and a recent admission (discharged [5-26]) for volume overload who was found at home today by his son unresponsive. . EMS could not measure his FSBS because it was critically high. In the ED, his initial VSs were 101.6, 231/74, 74, 20, 97% on RA. Initial finger stick was 667 here, serum blood sugarwas 636. Pt received 4 x 10 units of insulin IV (not started on drip) and 4L NS. In addition, he received vancomycin, levofloxacin and metronidazole for his fever after cultures were drawn. . The pt was not able to give any additional history. . The pt's son, who spoke to the pt on the day prior to presentation, reported that he had no complaints one day PTA. He did not c/o chest pain, shortness of breath, pain with urination, nausea, vomiitng, cough, sputum production or headache. The pt's son did report that the pt has been sloppy with his insulin compliance of late due to the recent loss of the pt's wife. Past Medical History: Type II DM CKD, baseline Cr 1.6-2.0 HTN BPH Depression Social History: Denies tobacco, alcohol, recreational drugs. Family History: Noncontributory Physical Exam: On Admission: Vitals: T: 101.6 BP: 191/70 P: 76 R: 27 SaO2: 97% on 2LNC General: Unable to rouse, appears agitated. Does not respond to voice commands. HEENT: NCAT, PERRL but sluggish 4->3, no scleral icterus, MM dry, no lesions noted in OP Neck: supple, no significant JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales Cardiac: RR, nl S1 S2, II/VI systolic murmur heard best at the RUSB, no rubs or gallops appreciated Abdomen: well-healed right lateral scar, soft, not apparently tender, ND, normoactive bowel sounds, no masses or organomegaly noted Extremities: No edema, 2+ radial, trace DP pulses b/l Lymphatics: No cervical, supraclavicular lymphadenopathy noted Skin: no rashes or lesions noted. Neurologic: Difficult to rouse, not responsive to verbal commands. Opens eyes spontaneously. PERRL but sluggish 4->3. Unable to assess cranial nerves secondary to non-cooperative pt. Moves all extremities, reeflexes 2+ at brachioradialis, biceps, patella, diminished to absent at Achilles bilaterally. No abnormal movements noted. Upgoing toes bilaterally. Pertinent Results: [2129-6-4] 09:13PM GLUCOSE-100 UREA N-37* CREAT-2.1* SODIUM-147* POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-30 ANION GAP-15 [2129-6-4] 06:33PM CEREBROSPINAL FLUID (CSF) PROTEIN-57* GLUCOSE-197 [2129-6-4] 06:33PM CEREBROSPINAL FLUID (CSF) WBC-97 RBC-2* POLYS-93 LYMPHS-2 MONOS-5 [2129-6-4] 06:33PM CEREBROSPINAL FLUID (CSF) WBC-88 RBC-2* POLYS-96 LYMPHS-2 MONOS-2 [2129-6-4] 05:05PM URINE HOURS-RANDOM [2129-6-4] 05:05PM URINE UHOLD-HOLD [2129-6-4] 04:33PM CALCIUM-8.4 PHOSPHATE-1.5# MAGNESIUM-2.3 [2129-6-4] 01:12PM GLUCOSE-360 NA+-139 K+-3.5 CL--98* TCO2-33* [2129-6-4] 01:00PM UREA N-41* CREAT-2.2* [2129-6-4] 07:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2129-6-4] 07:00AM URINE HOURS-RANDOM [2129-6-4] 07:00AM URINE GR HOLD-HOLD [2129-6-4] 07:00AM WBC-7.7 RBC-4.89 HGB-12.9* HCT-40.2 MCV-82 MCH-26.4* MCHC-32.2 RDW-14.8 [2129-6-4] 07:00AM NEUTS-78.9* LYMPHS-14.3* MONOS-4.5 EOS-1.2 BASOS-1.1 [2129-6-4] 07:00AM PT-13.0 PTT-26.5 INR(PT)-1.1 [2129-6-4] 07:00AM PLT COUNT-461* [2129-6-4] 07:00AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.021 [2129-6-4] 07:00AM URINE RBC-[5-8]* WBC-0 BACTERIA-0 YEAST-NONE EPI-0 [2129-6-7] 05:41AM BLOOD WBC-9.3 RBC-4.43* Hgb-11.7* Hct-34.4* MCV-78* MCH-26.4* MCHC-34.1 RDW-14.9 Plt Ct-346 [2129-6-6] 05:44AM BLOOD WBC-10.9 RBC-4.31* Hgb-11.3* Hct-34.0* MCV-79* MCH-26.2* MCHC-33.3 RDW-15.0 Plt Ct-339 [2129-6-7] 05:41AM BLOOD Plt Ct-346 [2129-6-6] 05:44AM BLOOD Plt Ct-339 [2129-6-4] 07:00AM BLOOD Neuts-78.9* Lymphs-14.3* Monos-4.5 Eos-1.2 Baso-1.1 [2129-6-7] 05:41AM BLOOD Glucose-93 UreaN-22* Creat-1.7* Na-142 K-3.3 Cl-101 HCO3-35* AnGap-9 [2129-6-7] 05:41AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.2 [2129-6-4] 06:33PM CEREBROSPINAL FLUID (CSF) WBC-97 RBC-2* Polys-93 Lymphs-2 Monos-5 [2129-6-4] 06:33PM CEREBROSPINAL FLUID (CSF) WBC-88 RBC-2* Polys-96 Lymphs-2 Monos-2 [2129-6-4] 06:33PM CEREBROSPINAL FLUID (CSF) TotProt-57* Glucose-197 [2129-6-4] 06:30PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-Test Name FINAL REPORT [2129-6-7] GRAM STAIN (Final [2129-6-4]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2129-6-7]): NO GROWTH. Brief Hospital Course: #HONK/DM2: No known precipitant, although according to pt's son, he likely has not been compliant with his insulin regimen lately. There were no obvious infectious etiologies in spite of his fever in the ED. His U/A was clean, his CXR and lung exam were essentially normal. He had not been c/o headache, and he had no WBC count. An LP done over 12hrs after abx started showed a white count of 98, mostly PMNs, without any organism on gram stain or culture. There was no evidence of an acute coronary syndrome either by history or on EKG. The patient was aggressively volume repleted, treated with insulin drip [First Name8 (NamePattern2) ] [Last Name (un) ] protocol, and rapidly stabilized his blood sugars. Once on the floor, the Pt. tolerated full diabetic diet, FSG initially ranging from 196-238, but improving to 72-189 once his home regimen of insulin (25am/10pm) was restarted. Plan on continuing home regimen with close outpatient f/u. . ## Fever: White count not elevated, no infiltrate on CXR, U/A clean. As above, LP somewhat questionable considering earlier dose of Abx. Pt. was started on meningitis dosing of vancomycin, ceftriaxone and acyclovir for a 10 day course, which will be completed on [6-13]. On the floor the pt. was afebrile, no leukocytosis, no growth on cultures, clean chest film and clean U/A. Also, the pt. was without any symptoms. A PICC line was placed for further Abx therapy and good glycemic control was continued. Consider dosing his Vanc by level, giving 1g for trough less than 15. As before, course will be complete on [6-13]. . ##Delirium: Likely related to HHNS and perhaps fever. Head CT within normal limits. No evidence of other ingestions on tox screens or history per son. Once on the floor the patient was AAOx1-2, and at baseline, according to discussion with son and PCP. [Name10 (NameIs) ] improved versus admission. We continued to re-orient as needed, and assist with feedings/ambulation as needed. . ## HTN: Pt hypertensive to 220s/70s in the ED. Did not received any antihypertensives. First, he was started with IV labetalol with goal SBP in the 160s and chased with PO labetalol once NGT was in place. On the floor, as his renal function improved we restarted first his ACEI and then his [Last Name (un) ]. . ## CKD: Cr 2.0 at last discharge, baseline per records from 1.6-2.0, raised to 2.4 on this admission but now back to 1.6. At discharge he appears hydrated on exam. His I/Os were near-neutral without his home dos aging of diuretics. He may need to restart some dose of these diuretics in the near future. . ##CHF: Pt. with stable weight near 235lbs. PLan to continue daily weights, and restart diuretics when needed for fluid retention. His home regimen was Metolazone 5 mg qam, 30 minutes prior to furosemdie 80mg (daily). Perhaps one could first restart his lasix and then add the metolazone if needed. . ## Elevated troponin: Likely secondary to CKD and ARF. No EKG changes suggestive of ischemia. Pt has no documented hx of CAD, but given DM2, likely has underlying coronary disease. Recheck ruled out MI. . ## Depression: Con't celexa, SW will see pt. soon. . ## FEN/Lytes: Diabetic/Heart healthy full diet. . ## Prophylaxis: Heparin SC 5000 tid, no indication for PPI . ## Code status: FULL CODE, discussed with son, [Name (NI) 449] . ## Contact: [Name (NI) 449] [Name (NI) ] (son) home [0-0-], cell [Telephone/Fax (1) 48800], daughter-in-law [Name (NI) ] [Telephone/Fax (1) 48801] . ## Dispo: TO sub-acute/rehab .. Medications on Admission: Valsartan 80 mg daily Aspirin 81 mg daily Citalopram 20 mg daily Metoprolol Tartrate 50 mg twice daily Furosemide 80 mg qam Ergocalciferol (Vitamin D2) 50,000 qweek Insulin NPH-Regular (70-30) 25 units qam Insulin NPH-Regular (70-30) 10 units q pm Metolazone 5 mg qam, 30 minutes prior to furosemdie Acetaminophen 500 mg [11-30] q6hrs prn pain Lisinopril 40 mg daily Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Citalopram 20 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. 4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 7. CeftriaXONE 2 gm IV Q12H 8. Ampicillin 2 gm IV Q6H 9. Acyclovir 1200 mg IV Q12H 10. Vancomycin 1000 mg IV Q48H according to pharmacy calc of crcl of 18. 11. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 12. HydrALAzine 20 mg IV Q6H:PRN SBP > 160 13. Sodium Chloride 0.9% Flush 10 ml IV DAILY:PRN For PASV picc before and after each use Inspect site daily 14. Insulin NPH 25units sq Qam/ 10units sq Qpm Discharge Disposition: Extended Care Facility: [Hospital3 672] Hospital Discharge Diagnosis: Primary: non-ketotic hyperglycemic hyperosmotic crisis Hypertensive urgency delerium Acute renal failure Secondary: 1. Type II DM 2. CRI, baseline Cr 1.6-2.0 3. HTN 4. BPH 5. Depression 6. CHF Discharge Condition: good Discharge Instructions: Please continue your antibiotics as instructed for the full 10 day course(done on [6-13]). Continue to take your other medications as prescribed. If you experience any symptoms that worry you or your family please return to the hospital for further treatment. Also, please weigh yourself daily to ensure your fluid status is not worsening Followup Instructions: please followup with your PCP [Name Initial (PRE) 176] 3 days of discharge Also, you have the following appointment for the future: Provider: [First Name8 (NamePattern2) 1575] [Last Name (NamePattern1) 15351], DPM Phone:[Telephone/Fax (1) 543] Date/Time:[2129-6-23] 3:40 ICD9 Codes: 5859, 4280, 5849, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9026 }	Medical Text: Admission Date: [2167-12-22] Discharge Date: [2167-12-28] Date of Birth: [2094-1-26] Sex: F Service: MEDICINE Allergies: Iodine Attending:[First Name3 (LF) 1899] Chief Complaint: found down, STEMI Major Surgical or Invasive Procedure: Cardiac Catheterization with Bare Metal Stent to the Mid left anterior descending artery History of Present Illness: This is a 73 yo spanish speaking female with history of DMII, GERD, arthritis, depression who was found down in her bathroom at the [Hospital3 537] this morning. With the fall she sustained a left eyebrow laceration with pain in her head. Per report, she was unable to recognize staff members at the time. Collar was placed. Of note, she reportedly developed left sided chest pain at this point which continued upon arrival to the ED. The patient has little recollection of the events leading up to the ED, but does note that she developed some nausea and vomitting but does not recall chest pain. . EKG in the ED showed significant STE in V2-V5 concerning for anteroseptal infarct. Of note CK/Trop were not elevated. She was started on a heparin and integrellin ggt, and plavix load was attempted but not completed [12-30] patient vomitting. She was taken emergently to the cath lab where thrombus was exported and BMS was placed to the mid LAD. Pt also noted to have transient hypotension after nitroglycerine bolus follwing radial access, as well as an episode of vomiting. Post cath EKG showing AIVR which self resolved. EKG upon arrival to CCU showing q waves in V1-V3 with poor R wave progression . Upon arrival to the CCU she is chest pain free and with out SOB or n/v. She is in a C-collar with left eyebrow lac. Vitals on admision: T: 98.6, BP 108/56, HR: 82, RR: 18, O2: 97% RA . On review of systems, she 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. She 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: DM2, Hypertension 2. CARDIAC HISTORY: - CABG: NONE - PERCUTANEOUS CORONARY INTERVENTIONS: NONE - PACING/ICD: NONE 3. OTHER PAST MEDICAL HISTORY: -Urinary incontinence -Arthritis -Recurrent UTI -Anxiety -GERD -Orthostatic hypotension -TAH/BSO -B/l tubal ligation -Cholecystectomy -Splenectomy (after MVA in [2163]). Social History: Retired RN from [Country 7192]. Formerly smoked 2 ciggs/day for many years but quit 20 yrs ago or drinking. Lives at [Hospital3 537] and is less independent with ADLs than before her fall in sepetember. She has a son who lives close by and is very involved. Family History: -Father had MI at age 66 -Mother died of liver cancer, all of her 7 siblings have diabetes Physical Exam: ON ADMISSION: VS: T: 98.6, BP 108/56, HR: 82, RR: 18, O2: 97% RA GENERAL: Pleasant spanish speaking female in NAD. Oriented x1.5 (knows she is in a hospital but does not know which. Knows the year but not the month orday). HEENT: Left eyebrow laceration with dried blood. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP 7cm while at 60 degrees. 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. 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. 2+ DP/PT pulses b/l. NEURO: A/O x1.5 (doesnt know what hospital or month/day) CN2-12 grossly intact. Strength 5/5 in UE/LE bilaterally withoug focal sensory defecits. Able to move head in all directions with C-collar off. No cervical spine tenderness. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. . ON DISCHARGE: T max: 99.3 T current:99 BP: 84-102/52-78 HR: 73-78 RR: 14-20 O2sat:98% RA 24-hours I/O: 1340/1350, since midnight 0/800 Gen: alert, interactive, oriented x3 with interpreter but has poor short term memory. HEENT: supple, no JVD CV: RRr, no M/R/G, distant RESP: poor effort, clear bilat ABD: soft, NT, ND EXTR: no edema, feet warm Pulses: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+ Skin: L wrist cath site: no ecchymosis or hematoma Neuro: C/O headache, tylenol works well for pain. MAE, strengths equal and 3+ bilat. EOM's intact, follows commands, speech clear. Pertinent Results: ADMISSION LABS: . [2167-12-22] 01:45PM BLOOD WBC-13.2* RBC-3.75* Hgb-12.4 Hct-37.6 MCV-100* MCH-33.1* MCHC-33.1 RDW-13.3 Plt Ct-330# [2167-12-23] 04:06AM BLOOD PT-12.7 PTT-20.3* INR(PT)-1.1 [2167-12-22] 01:45PM BLOOD Glucose-337* UreaN-30* Creat-1.7* Na-137 K-4.8 Cl-99 HCO3-29 AnGap-14 [2167-12-22] 01:45PM BLOOD Calcium-9.8 Phos-4.2 Mg-2.4 [2167-12-23] 04:06AM BLOOD Triglyc-163* HDL-43 CHOL/HD-2.9 LDLcalc-49 [2167-12-23] 04:06AM BLOOD %HbA1c-8.6* eAG-200* . CARDIAC ENZYMES . [2167-12-22] 01:45PM BLOOD CK(CPK)-200 [2167-12-22] 09:55PM BLOOD CK(CPK)-3858* [2167-12-23] 04:06AM BLOOD CK(CPK)-2922* [2167-12-24] 03:07AM BLOOD CK(CPK)-1208* [2167-12-25] 06:20AM BLOOD CK(CPK)-480* [2167-12-22] 01:45PM BLOOD cTropnT-0.01 [2167-12-22] 09:55PM BLOOD CK-MB-156* MB Indx-4.0 [2167-12-23] 04:06AM BLOOD CK-MB-87* MB Indx-3.0 [2167-12-24] 03:07AM BLOOD CK-MB-21* MB Indx-1.7 cTropnT-5.48* [2167-12-25] 06:20AM BLOOD CK-MB-7 cTropnT-5.23* . URINE: . [2167-12-25] 02:51PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2167-12-25] 02:51PM URINE RBC-[1-30]* WBC-[5-6]* Bacteri-MANY Yeast-NONE Epi-0 [2167-12-23] 09:10AM URINE Hours-RANDOM Creat-187 Na-28 K-51 Cl-16 [2167-12-23] 09:10AM URINE Osmolal-716 [2167-12-23] 09:10AM URINE Eos-NEGATIVE . EKG ON ADMISSION: Artifact is present. Sinus rhythm. There is ST segment elevation in the anterior leads consistent with acute myocardial infarction. Clinical correlation is advised. Compared to the previous tracing of [2167-7-27] ST segment elevation is new. . POST CATH EKG: Probable accelerated idioventricular rhythm. Persistent ST segment elevation in the anterior leads suggestive of acute myocardial infarction. Clinical correlation is advised. Compared to the previous tracing of the same day accelerated idioventricular rhythm is new. . CARDIAC CATH [2167-12-22]: - Hemodynamic measurements (mm Hg): Normotension - Native coronary anatomy: Coronary angiography in this right dominant system revealed 1 vessel disease. The LMCA was angiographically normal. The LAD had thrombotic total occlusion in the proximal portion after S1 with no collaterals. The Cx and the RCA had no angiographically apparent CAD. - Interventional details: Change for 6 French XBLAD3.5 guide. Crossed with a Prowater wire into the Diagonal. Dottered across the lesion but this did not restore flow. Performed coronary thrombectomy using the Export catheter and 2 passes. Integrilin was started prophylactically. This restored flow and debulked the thrombus burden. The LAD was direct stented with a 3.0 x 12 mm Integriti stent. Transient slow flow was eliminated with IC TNG and Nipride. Final angiography revealed normal flow, no dissection and 0% residual stenosis in the stent. ESTIMATED BLOOD LOSS: <100 cc SPECIMENS: none COMPLICATIONS: None FINAL DIAGNOSES: 1. 1 Vessel CAD 2. Successful BMS in the LAD. . TTE [2167-12-23]: GENERAL COMMENTS: Suboptimal image quality - poor parasternal views. Suboptimal image quality - poor subcostal views. Suboptimal image quality - body habitus. The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with severe hypo/akinesis of the distal half of the anterior septum, distal anterior, lateral and inferior walls. The apex is aneurysmal and akinetic. The remaining segments contract normally (LVEF = 30-35 %). The estimated cardiac index is normal (>=2.5L/min/m2). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([11-29]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Normal left ventricular cavity size with regional systolic dyfunction and apical aneurysm c/w CAD (mid LAD distribution). Mild-moderate mitral regurgitation. Pulmonary artery systolic hypertension. . CT head [2167-12-22]: FINDINGS: There is no intracranial hemorrhage, edema, shift of normally midline structures, or hydrocephalus. There is no evidence of acute major vascular territorial infarction. Periventricular white matter hypodensities are consistent with chronic small vessel ischemic disease. Paranasal sinuses and mastoid air cells are well aerated. The bony calvarium is intact. IMPRESSION: No acute intracranial process. . Right Shoulder XR [2167-12-23]: IMPRESSION: 1. No evidence of fracture or dislocation. 2. There is narrowing of the acromiohumeral interval, which raises the possibility of rotator cuff tear. 3. Calcific density inferior to the acromion likely reflects subacromial spur, less likely soft tissue calcification, which can be seen in subacromial bursal calcific bursitis or calcific tendinitis. 4. Moderate glenohumeral and acromioclavicular joint degenerative change. . Labs at discharge: K 5.4 => rec'd kayexelate Na 139 BUN: 31 Creat: 1.5 INR 1.0 Hct 29.4 Plt: 215 WBC: 9.0 Brief Hospital Course: 73 yo female with hx of DMII, HLD presenting to [Hospital1 18] s/p unwitnessed fall, found to have anteroseptal STEMI, now s/p cath with BMS to MID LAD # STEMI: Pt found down at her nursing home with no recollection of the events leading up. However, per report, she described left sided chest pain on the way to the ER. Pt with risk factors for CAD (DMII, HLD) but no known personal cardiac history. Family cardiac history significant for father with MI at 66. Upon arrival to the ED, EKG showing STE in V2-V5 consistent with anteroseptal infarct. She was taken emergently to cath where she was found to have lesion of her prox LAD which was subsequently stented with BMS. Of note, post-cath EKG significant for AIVR which self-resolved. She received a plavix load, and she was kept on integrellin ggt for 12 hrs after cath. CKMB was followed and trended down. She was started on ASA 325mg daily, plavix 75mg daily, and atorvastatin 80mg daily. ACE-I was not started initially as her BPs were on the low side requiring fluid boluses. However before discharge she was started on captopril 6.25 mg TID which was tolerated well and changed to lisinopril at discharge. Low dose metoprolol was started at 6.25 mg q6h which was transitioned to toprol-XL formulation on discharge. Of note she had follow-up TTE on [12-23] showing severe hypo/akinesis of the distal half of the anterior septum, distal anterior, lateral and inferior walls. The apex is aneurysmal and akinetic with EF 30-35%. The possibility of starting coumadin for this was addressed, and despite her fall risk, decision was made to start coumadin at 5mg po daily. She remained CP free throughout admission and hemodynamically stable. She should have a follow up echo in [12-31] months to reassess LV function. K was 5.4 on day of discharge, thought [12-30] recent spironolactone. Spironolactone d/c'ed and pt rec'd Kayexelate x1 and K should be checked again on [12-29]. . #Acute Kidney Injury: Pt initially presenting with Cr of 1.7 (had been 0.8-1.1 for a baseline, but noted to be up to 1.7 on prior admissions), likely secondary to hypotension and overall poor PO intake leading up to her STEMI. Urine lytes showed a pre-renal picture. She received 3 fluid boluses for hypotensive episodes shortly after her cath and her Cr subsequently trended down on discharge. ACE-I was started in this setting. . # S/p Fall: Pt with unwitnessed fall in the bathroom, landing on head and suffering left eyebrow laceration. Non-con CT of the head was negative for acute process. She was put into C-collar, but pt without any cervical spine tenderness and able to move head in all directions on exam. C-collar was removed as she was clinically cleared given that she has full range of motion and no tenderness. However, she did report right shoulder pain and difficulty raising her arm along with tenderness to palpation over the lateral aspect. It is unclear if this was chronic or acute. XR shows possible rotator cuff tear and/or possible bursitis/tendonitis, chronic changes. She was set up with outpatient ortho followup. . #Acute Anemia: Pt noted to have Hct drop from 37.6-->32.2 overnight after cath. This was likely in setting of hemodilution from fluids and phlebotomy. Hct was followed and dropped to ~29 but remained stable there throughout admission. . # Hx of Orthostatic Hypotension: Pt with history of orthostatic hypotension for which she was on fludrocortisone as outpt. This was continued in house for 2 days, but in the setting of her STEMI we felt it was important for her to be on an ACE-I, and the fludrocortisone would have an opposite effect from the ACE-I. Orthostatics were checked and were negative, so fludrocort was d/c'd in favor of post-STEMI antihypertensive regimen as above. . # Mental status changes: Pt with baseline dementia for which she is on memantine as an outpt. She was oriented x1.5 on admission(knew year but not month. Knew hospital but not which one). She was noted to have an episode of acute confusion on HD#2 where she thought she was in a department store and was a bit agitated. This occurred again 2 nights later requiring seclusion. This subsequently resolved. UA was sent which was equivocal. This likely is a component of her baseline dementia but should be followed for acute changes. We recommend that she stop her PRN ativan as this could exacerbate. . #DM-2: Pt was continued on HISS in-house. Home lantus was increased from 42-->45 on discharge. Sugars remained stable. . # GERD: continued on home omeprazole in house which was transitioned to ranitidine as an outpatient given interaction with plavix . #Depression: Continued home citalopram Medications on Admission: -Lantus 42U qpm -HISS -ativan 0.5 [Hospital1 ] PRN anxiety -Tylenol PRN -robitussin PRN -omeprazole 20mg daily -celexa 40mg daily -fenofibrate 67mg daily -fludrocortisone -Vit D -Colace -Senna -memantine 10mg [Hospital1 ] Discharge Medications: 1. Outpatient Lab Work Please check INR, Chem-7 and CBC on Tuesday [2167-12-29] and call results to provider at [Hospital3 537] 2. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lantus 100 unit/mL Solution Sig: Forty Two (42) units Subcutaneous once a day. 5. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 8. memantine 10 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 11. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a day. 12. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO four times a day as needed for fever or pain. 13. Robitussin Chest Congestion 100 mg/5 mL Liquid Sig: Ten (10) ml PO three times a day as needed for cough. 14. Humalog 100 unit/mL Solution Sig: 0-12 units Subcutaneous four times a day: as per previous sliding scale. 15. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual [Last Name (un) ] 5 minutes as needed for chest pain: Pt may take up to two tablets, call Dr. [Last Name (STitle) 911] or 911 for any chest pain. 16. metoprolol succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 17. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 18. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Discharge Disposition: Extended Care Facility: [Hospital3 537]- [Location (un) 538] Discharge Diagnosis: ST Elevation Myocardial Infarction Acute Systolic dysfunction S/P Fall Diabetes Mellitus Type 2 Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You had a heart attack and a bare metal stent was placed in your left coronary artery. You will need to take Plavix (clopodigrel) and a full aspirin every day for at least one month and possibly longer. Do not stop taking Plavix and aspirin or miss [First Name (Titles) 691] [Last Name (Titles) 4319] unless Dr. [Last Name (STitle) 911] tells you to. Your heart is weaker after the heart attack and you are at risk for retaining fluid and developing congestive heart failure. Please eat a low sodium diet and make sure you get weighed every day to detect fluid retention. Weigh yourself every morning, call Dr. [Last Name (STitle) 911] if weight goes up more than 3 lbs in 1 day ot 5 pounds in 3 days. . We made the following changes in your medicines: 1. Start taking Aspirin and Plavix (clopidogrel) every day to prevent the stent from clotting off. 2. continue to take Glargine (lantus) and humalog insulin at your previous [Last Name (STitle) 4319] 3. Start taking Atorvastatin to prevent more blockages in your heart arteries 4. Start taking Lisinopril to help your heart pump better 5. Start taking Metoprolol XL to help your heart recover from the heart attack 6. Stop taking Fludracortisone for now as it could be dangerous for your heart 7. Stop taking Omprazole as it interacts with the Plavix, take ranitidine instead until you are done with the Plavix. 8. Stop taking Ativan as you were confused in the hospital and this could make your confusion worse. 9. Start taking nitroglycerin if you have chest pain. You can take up to 2 tablets 5 minutes apart. Please let Dr. [Last Name (STitle) 911] know if you have any chest pain. 10. Start taking coumadin to prevent blood clots. Followup Instructions: Department: Cardiology When: Wednesday [2168-2-10] at 2:40 PM With: [First Name4 (NamePattern1) 919] [Last Name (NamePattern1) 911], MD [First Name (Titles) ] [Last Name (Titles) 14316] [Name8 (MD) ], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Name (NI) 23] Garage Pt should have an echocardiogram scheduled for before or after this appt. Please call [Telephone/Fax (1) 62] to confirm . Department: SURGICAL SPECIALTIES When: FRIDAY [2168-1-22] at 11:15 AM With: [First Name8 (NamePattern2) 161] [Name6 (MD) 162] [Name8 (MD) 163], MD [Telephone/Fax (1) 921] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: FRIDAY [2168-1-29] at 11:00 AM With: [Name6 (MD) 8741] [Name8 (MD) ], MD [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 1905] Completed by:[2167-12-30] ICD9 Codes: 5849, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9027 }	Medical Text: Admission Date: [2118-6-10] Discharge Date: [2118-6-17] Date of Birth: [2036-9-15] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: chest pain Major Surgical or Invasive Procedure: s/p AVR(tissue)/CABGx3(LIMA->LAD, SVG->OM, PDA) [6-10] History of Present Illness: Mr. [Known lastname ] is an 81 year-old gentleman with a history of aortic stenosis, angina, and an abnormal stress echo. He was referred to [Hospital1 18] for surgical correction of his pathology. Past Medical History: coronary artery disease aortic insufficiency hypertension BPH GERD rheumatic fever as child bladder obstruction 8 yrs ago barrette's esophagus gout s/p TURP 20 yrs ago tonsillectomy Social History: Mr. [Known lastname ] is a retired school teacher and lives alone. Family History: Mr. [Known lastname ] brother underwent a CABG at age 60. Physical Exam: Elderly [Male First Name (un) 4746] in NAD AVSS HEENT: NC/AT, PERRLA, EOMI Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids 2+= bilat. without bruits. Lungs: Clear to A+P CV:RRR without R/G, +SEM Abd:+BS, soft, nontender without masses or hapatosplenomegaly Ext:without C/C/E, pulses 2+= bilat. throughout Neuro:nonfocal Discharge AVSS: 98.7,145/72,64,RR20,95% R/A O2SAT Lungs: Bibasilar crackles CV:RRR Abd:+BS, soft, nontender,ND Ext:Trace (B) LE edema Neuro:A&O X3,NAD Wounds: sternal and EVH incision C/D/I, sternum stable. No [Doctor Last Name ]/click Pertinent Results: [2118-6-16] 06:45AM BLOOD WBC-7.1 RBC-4.34* Hgb-12.6* Hct-37.5* MCV-86 MCH-29.1 MCHC-33.6 RDW-13.0 Plt Ct-288# [2118-6-10] 11:19AM BLOOD WBC-15.6# RBC-3.31 Hgb-9.5* Hct-27.9* MCV-84 MCH-28.6 MCHC-33.9 RDW-13.0 Plt Ct-263 [2118-6-16] 06:45AM BLOOD Plt Ct-288# [2118-6-10] 12:01PM BLOOD Plt Ct-238 [2118-6-10] 12:01PM BLOOD PT-15.6* PTT-48.2* INR(PT)-1.4* [2118-6-16] 06:45AM BLOOD Glucose-94 UreaN-25* Creat-1.4* Na-136 K-4.3 Cl-100 HCO3-25 AnGap-15 [2118-6-11] 02:28AM BLOOD Glucose-130* UreaN-25* Creat-1.3* Na-135 K-4.4 Cl-110* HCO3-20* AnGap-9 [2118-6-10] 07:00AM BLOOD %HbA1c-5.6 [Known lastname ],[Known firstname ] P [Medical Record Number 104224] M 81 [2036-9-15] Radiology Report CHEST (PORTABLE AP) Study Date of [2118-6-15] 8:23 AM [Last Name (LF) ],[First Name3 (LF) ] R. CSURG FA6A [2118-6-15] SCHED CHEST (PORTABLE AP) Clip # [Clip Number (Radiology) 104225] Reason: eval pulmonary edema [Hospital 93] MEDICAL CONDITION: 81 year old man with s/p avr, cabg REASON FOR THIS EXAMINATION: eval pulmonary edema Provisional Findings Impression: AJy WED [2118-6-15] 12:19 PM New left lower lobe opacity likely atelectasis with effusion. No evidence for pulmonary edema. Final Report HISTORY: 81-year-old male, status post AVR and CABG, evaluate for pulmonary edema. COMPARISON: Comparison is made to portable AP chest from [6-11] and [2118-6-14] as well as preop PA and lateral chest radiographs from [5-20], [2117]. FINDINGS: The right IJ catheter has been removed. New opacification of the left lower lung obscuring the left hemidiaphragm and costophrenic angle is likely due to atelectasis and pleural effusion, less likely pneumonia. Hazy opacification obscuring the right lower lung could be due to either pleural effusion layering posteriorly or loculated in the major fissure. The remainder of the lungs is clear. Moderate cardiomegaly is stable, without evidence for volume overload. There is no pneumothorax. Metal wiries and vascular clips denote prior sternotomy and coronary bypass grafts. IMPRESSION: 1. New left lower lobe atelectasis and pleural effusion, less likely pneumonia. 2. Increased right pleural effusion, possibly fissural. 3. Stable moderate cardiomegaly; no pulmonary edema. The study and the report were reviewed by the staff radiologist. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3891] Approved: [Doctor First Name ] [2118-6-16] 3:28 PM [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 104226] (Complete) Done [2118-6-10] at 9:13:59 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] R. Division of Cardiothoracic [Doctor First Name ] [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2036-9-15] Age (years): 81 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: AVR/CABG ICD-9 Codes: 786.05, 786.51, 799.02, 440.0, 424.1, 424.0 Test Information Date/Time: [2118-6-10] at 09:13 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3318], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 3318], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW1-: Machine: AW1 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: 1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 50% to 55% >= 55% [Last Name (NamePattern4) ] - Ascending: 3.6 cm <= 3.4 cm [Last Name (NamePattern4) ] - Descending Thoracic: 2.6 cm <= 2.5 cm Aortic Valve - Peak Gradient: 40 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 25 mm Hg Aortic Valve - Valve Area: 1.0 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. [Last Name (NamePattern4) ]: Mildly dilated ascending [Last Name (NamePattern4) 5236]. Simple atheroma in descending [Last Name (NamePattern4) 5236]. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Moderate-severe AS (area 0.8-1.0cm2). Moderate (2+) AR. MITRAL VALVE: Mild (1+) MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Right ventricular chamber size and free wall motion are normal. The ascending [Last Name (NamePattern4) 5236] is mildly dilated. There are simple atheroma in the descending thoracic [Last Name (NamePattern4) 5236]. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis . Peak gradient = 40, mean = 25. Moderate (2+) aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is A-Paced, on no infusions. Good biventricular systolic fxn. Trace MR. [First Name (Titles) ] [Last Name (Titles) 5235]. A prosthetic aortic valve is well-seated with no AI and no leak. Mean residual gradient = 8. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3318], MD, Interpreting physician [Last Name (NamePattern4) ] [2118-6-10] 11:28 [Known lastname ],[Known firstname ] P [Medical Record Number 104224] M 81 [2036-9-15] Cardiology Report ECG Study Date of [2118-6-10] 1:09:08 PM There are three atrial paced beats followed by sinus bradycardia. Consider prior inferior myocardial infarction. Non-specific ST-T wave changes. Compared to the previous tracing of [2118-5-19] atrial pacing is new. Read by: [Last Name (LF) 2889],[First Name3 (LF) 2890] K. Intervals Axes Rate PR QRS QT/QTc P QRS T 39 0 88 446/409 0 6 -15 Brief Hospital Course: Mr.[Known lastname ] was admitted for on [6-10] and underwent elective AVR(tissue)/CABGx3(LIMA->LAD, SVG->OM, RCA).See operative report for further details. He tolerated the procedure well and was transferred to the CVICU. He was extubated on the post op night. The following day he had confusion and word finding difficulties. Neurology was consulted and recommended all narcotics to be discontinued. Over the next 2 days his mental status cleared. On POD#2 he had his chest tubes d/c'd and on POD#3 his epicardial pacing wires were d/c'd and he was transferred to the floor. He continued to progress and required PT to work with him for strength and mobility. He was ready for discharge to rehab on POD#7. Medications on Admission: Avapro 150 mg PO daily Proscar 5 mg PO daily Tricor 145 mg PO daily Nexium 40 mg PO daily Metoprolol 25 mg PO daily ASA 81 mg PO daily Discharge Disposition: Extended Care Facility: [Doctor First Name 391] Bay - [Hospital1 392] Discharge Diagnosis: aortic insufficiency, s/p AVR coronary artery disease, s/p CABG hypertension hyperlipidemia BPH gastric esophageal reflux disease rheumatic fever as a child bladder obstruction 8 yrs ago barrette's esophagus gout 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 appointment after discharge from rehab with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4469]: ([Telephone/Fax (1) 104227] Dr.[First Name (STitle) ] [Name8 (MD) 6144], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2118-7-14] 1:45 Completed by:[2118-6-17*] ICD9 Codes: 4241, 5859, 2724, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9028 }	Medical Text: Admission Date: [2117-5-7] Discharge Date: [2117-5-16] Date of Birth: [2050-1-13] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1835] Chief Complaint: ataxia/falls/headache/brain lesions Major Surgical or Invasive Procedure: suboccipital craniotomy with posterior fossa tumor resection History of Present Illness: 67 yo M presents with 2-3 weeks of difficulty with balance, with 2 recent falls and a few near misses, ataxia, slowed speech, and headache. He presented to his PCP and after [Name Initial (PRE) ] brief workup was sent for an MRI of the brain which shows at least two lesions in the brain, one 4 x 4 cm lesion in the R cerebellum and a smaller L occipital lobe lesion, most consistent with metastasis as well as dilated ventricles concerning for obstructive hydrocephalus. He was sent from [Hospital3 7571]by EMS for neurosurgical evaluation. Past Medical History: HTN, HLD, "pre-diabetic", h/o cataract surgery Social History: previous smoker, approx 70-80 pack-years, previous social EtOH, no illicits Family History: GM with stroke, prostate Ca in F and uncle Physical Exam: O: T: 97.3 BP: 160/101 HR: 66 R 18 O2Sats 99%RA Gen: WD/WN, comfortable, NAD HEENT: Pupils: [2-3] brisk EOMI but with mild R nystagmus. Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, [Location (un) 86], and to date but only after correcting himself ([2017-5-4]-->[2116]) Recall: [12-7] objects at 5 minutes, [2-4] with prompts. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally with mild R-beating 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 tremors. Strength full power [4-8] throughout. No pronator drift Sensation: Intact to light touch bilaterally Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally Coordination: dysmetria on finger-nose-finger, worse on R as well as decreased performance of [Doctor First Name ] on R. Wide based stance with negative Romberg Pertinent Results: CT CHEST ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS [2117-5-8] 1. 1.5 x 2.4 x 1.4 cm homogeneous pleural based mass in the anterior inferior right upper lobe. Further characterization with biopsy is recommended given concern for malignancy. 2. Focal hyperdensity near the left ureterovesical junction in the bladder. Underlying mural lesion cannot be excluded. Further evaluation with ultrasound or MRI should be considered. 3. 3 mm pulmonary nodule in the right lung base. Given concern for malignancy, attention on followup is recommended. 4. No lymphadenopathy within the chest, abdomen or pelvis. MRI WAND: Enhancing hemorrhagic masses in right cerebellum and left occipital lobe are again demonstrated for surgical planning. Post Op Non-contrast head CT: 1. Expected postoperative appearance following right cerebellar mass resection. The extent of resection would be better assessed by MRI. 2. Left occipital mass with surrounding edema is again noted, better seen on prior MRI. Post Op MRI: 1. The patient is status post partial resection of the right cerebellum for removal of enhancing mass. The surgical bed includes blood products, thin peripheral rim of restricted diffusion likely representing postoperative ischemia as well as minimal peripheral enhancement, also likely postoperative (although residual tumor cannot be excluded). There remains mass effect upon the surrounding structures with effacement of the fourth ventricle and minimal right to left shift of the right residual cerebellar lobe. 2. The ventricular size has decreased with a right ventricular drain in place. 3. An enhancing fluid collection is present within the posterior extraaxial space,inferior to the surgical bed, posterior to the cerebellar tonsils-brainstem, at and below the foramen magnum as described above. This may represent postoperative fluid although the sterility of this collection is indeterminate. Short interval followup is recommended. 4. No change in the left paramedian occipital lobe enhancing lesion with surrounding edema. Brief Hospital Course: 67 y/o M presents with frequent fall and balance instability was found to have a R cerebellar and L occipital mass. On examination, patient has minimal dysmetria and ataxia, but is otherwise intact. Patient was started on decadron and PSA was sent and was elevated at 8.3. CT torso was done which revealed a mass in both RUL and RLL. On [5-10], exam remains stable while he awaited the OR. On [5-11] he underwent a suboccipital craniotomy and mass resection. Surgery was without complication and he tolerated it well. Post op head CT revealed no hemorrhage and good placement of EVD. On [5-12] he was neurologically stable but complained of nausea. He was cleared for SQH and decadron wean. He underwent MRI imaging for restaging. On [5-13], his EVD was removed and he was transferred to the Neurosurgical Floor. On [5-14], he remained neurologically intact with only mild dysmetria. His pain was well controlled on oral medications, he was tolerating a regular diet and ambulated with physical therapy, thus he was deemed ready for discharge home. On [5-16] pt was discharged home with home nursing evaluation in stable condition. Medications on Admission: nadolol 40 [Hospital1 ], pravastatin 20 daily, takes 3rd medication but unsure of the name Discharge Medications: 1. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO bid (). Disp:60 Tablet(s) Refills:1 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:50 Tablet(s) Refills:0 10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:90 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) ] Nursing Services Discharge Diagnosis: R cerebellar and L occipital mass, hypertension, hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? Have a friend/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, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. 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, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [6-13] days(from your date of surgery) for removal of your staples and a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [Telephone/Fax (1) 1669]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????You have an appointment with the Brain [Hospital 341] Clinic on [2117-5-24] at 9:30AM. Completed by:[2117-5-16] ICD9 Codes: 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9029 }	Medical Text: Admission Date: [2174-7-13] Discharge Date: [2174-7-16] Date of Birth: [2099-2-2] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 1145] Chief Complaint: CC:[CC Contact Info 32184] Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: HPI: 75F with PMH HTN admitted to CCU after cath. Pt initially transferred to [Hospital1 18] after presenting at [Hospital ] hospital on [2174-7-8] with weakness x 3 days, sudden onset SOB. EMT found pt to have SVT to 180's which spontaneously reverted to sinus in ambulance. At [Name (NI) ] [Name (NI) ], pt had another episode of SVT that broke with 6 mg adenosine. [7-8] dep in V3-V6. Pt ruled on for MI with peak trop 5.67 and peak CK 200. On [7-9] EKG showed additional TWI in II, III, and F. Pt was started on heparin and integrellin gtts, which were D/C'd [7-11] [2-23] vaginal bleed. Vaginal US negative. Taken to cath at [Hospital1 ] [7-11]: 3VD occ prox RCA which fills by collaterals (appears chronic) Lg OM1 off LCx new occlus, elongated mid LAD occ, increased PA pressure, increased SVR, and global HK. Milrinone gtt was started. TTE [7-8]: EF 10-20%, RV dilated and HK, severe global HK. Transferred to [Hospital1 18] for evaluation by CT [Doctor First Name ] for CABG. . CT [Doctor First Name ] evaluated pt and felt not appropriate for surgery given new dx CLL, recent vaginal bleed, poor LV fn, and Cr of 1.4. . Taken to cath at [Hospital1 18] [7-14] for high risk intervention. RA 12, RV 38/6, PA 38/28, W 19, CO 2.64, I 1.65 LMCA: mild diff dz LAD: elongated 70-90% stenosis over middle third of vessel LCx: Occ OM1 with faint collaterals RCA: occ at ostium, filling with L to R collagerals from LAD Cyper stents to LCx-OM and LAD. Afib developed prior to start of procedure, given lopressor. Significant PVD: no angioseal. Past Medical History: PMH: HTN Social History: Soc Hx: married 4 children, lives in FL, +Tob, no EtOH Family History: Mother - MI in her 60s Sibs - CAD Physical Exam: PE: VS: 98.8 133/64 HR 72 R 12 95% RA Gen: NAD, lying flat in bed HEENT: EOMI, PERRL, MMM, sclera anicteric Neck: unable to eval JVP while laying flat Chest: scattered wheezes, bibasilar crackles. CV: RRR Abd: soft NT ND + BS Ext: no edema, 1+ pulse at DP R side, dopplerable DP Neuro: no deficits, moves all 4, A and O X 3 Pertinent Results: Admitting labs were significant for a CK of 51, which trended upwards to a peak of 211 on [2174-7-15], before trending down to 138 at discharge. creatinine of 1.5, hct of 36.9. CK-MB peaked at 22 on [2174-7-15], then trended down to 8 at discharge. Troponin was 0.41 at admission, peaking at 0.94 on [7-15] before decreasing to 0.67 at discharge. Hct was 37.4 on admission, and dropped to 33.1 by discharge. Creatinine was 1.5 on admission, and gradually fell to 1.2 by discharge. Brief Hospital Course: 75F with hx HTN admitted with ant NSTEMI and found to have 3VD at [Hospital1 ], transferred for high risk cath: s/p stent to LAD and LCx-OM1 on [7-14]. Pt was started on Metoprolol 25 mg PO BID (switched to carvedilol 6.25mg PO bid the next morning), ASA 325 mg PO qD, Plavix 75 mg PO qD (loaded with 300 mg in cath lab), captopril 6.25 mg PO TID (gradually increased to 25mg PO tid), and atorvastatin 80mg PO qD. Given EF of [11-10]% and global HK, considered anti-coagulation with heparin or coumadin, but did not do so due to bleeding during hospital stay. OSH reported vaginal bleeding after starting integrillin. Pelvic U/S was normal, and pt refused pelvic exam. Since admission to CCU, has been guiac positive on all stools. Hct has been stable, and pt was told to f/u with PCP for outpatient colonoscopy. Initial and [7-15] CXR consistent with pulmonary edema with bilateral pleural effusions. Ms. [Known lastname 6512] experienced episodes of a-fib in cath lab, and continued to flip between sinus and afib in the CCU until converting back to sinus during the evening of [7-14]. Pt was in ARF on admission to CCU, with Cr 1.4, and 2.2 on transfer from OSH. Baseline 1.1. She was treated with mucomyst and bicarbonate IVF, and monitored closely. She gradually recovered, with creatinine dropping to 1.2 by discharge. Urine cultured Alpha strep and lactobacillus at OSH, pt admitted on Ciprofloxacin. Changed to 7 days of levofloxacin 250mg PO qd for better alpha strep coverage. Ms. [Known lastname 32185] pre-existing hypertension continued to be managed with the use of beta blockers and ACEIs. An atypical CBC differential at OSH led to a new diagnosis of CLL. Heme Onc consulted, and reported the following: "Impression: The patient may have very early CLL. Her increased retics, LDH, and bilirubin may indicate the presence of hemolysis. Plan includes ordering flow studies on her lymphocytes along with Coombs testing. If this is stage zero CLL, no treatment is indicated at the present time, although Coombs positive hemolytic anemia, if present, may need treatment." Flow cytometry supported this dx, with CD519+, CD23+, FMC7-, and CD20dim. Medications on Admission: Milrinone gtt Metoprolol 5 IV q 1-2 hours prn Mucomyst ASA 325 Atenolol 25 Cipro 500 [Hospital1 ] Plavix 75 Protonix 40 Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:4 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: CAD CHF CLL vaginal bleeding Discharge Condition: Stable. Discharge Instructions: Return to the emergency room or call your primary care physician if you have chest pain, shortness of breath or any other symptom that bothers you. Take your medications as directed. Followup Instructions: Please call your primary care physician to schedule an appointment within the next week. You need to have your hematocrit checked within one week and you need to have an outpatient colonoscopy to evaluate the trace amounts of blood in your stool. Also, please make an appointment to see a gynecologist regarding the vaginal bleeding you have. ICD9 Codes: 4280, 5849, 5990, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9030 }	Medical Text: Admission Date: [2124-1-28] Discharge Date: [2124-2-4] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 783] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Esophagoduodenoscopy Transfusion (7 units packed RBCs) History of Present Illness: 87 year old M Alzheimers, prostate cancer, chronic kidney disease who presents with shortness of breath. Limited history from patient due to advanced dementia, consequently following history is mostly from caregiver. After dinner patient appeared pale and fatigued. While waking to bathroom he become diaphoretic and weak (fell to knees, no LOC). No chest pain or any other compliants. Was brought in to ED for further evaluation. . In ED physical exam notably for dark stool grossly heme positive. NGT was placed which returned coffee grinds with 500cc flush. Unfortunately patient pulled NGT before seeing if cleared. Labs notable for HCT 26 (prior baseline 30-37). GI was consulted who felt EGD only necessary if hemodynamically unstable. Patient's VS on presentation to ED were T 97.1 HR 92 BP 122/72 RR 16 SaO2 100%. Protonix 40 mg IV and 2 L NS given. Active type and screen sent. BP ranged from 96-133/60-72, HR 80-103. VS prior to transfer BP 138/75 HR 103 16 98% RA. . On arrival patient complains of abdominal pain, unable to specify further. No other compliants. Past Medical History: - AD -- Ox1 at baseline - Prior episodes of syncope, seen in [Hospital1 18] ED in [2119], determined vasovagal, had Holter monitor - H/O UGIB: Per discharge summary [2107] EGD demonstrated small superficial ulcer in the antrum which was biopsied. Mild gastritis. Question of peptic ulcer disease. - PVD - Prostate CA, BPH - Depression - Spinal stenosis - per prior discharge summaries: HTN RENAL FAILURE ? DIABETES Social History: Originally from Poland. Lives with female partner. Independent in ADLs, requires assistance with some aADLs. He is a retired dentist. Holocaust survivor. Denies any EtOH or cigarette use. Family History: Mother with congenital heart defect Physical Exam: General: Alert, oriented X 1, no acute distress HEENT: pale conjunctiva, sclera anicteric, dryMM, 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, mild tenderness throughout, 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: [2124-1-28] 08:20PM PT-12.1 PTT-21.0* INR(PT)-1.0 [2124-1-28] 08:20PM PLT COUNT-200 [2124-1-28] 08:20PM WBC-11.3# RBC-2.84# HGB-9.1# HCT-26.3# MCV-92 MCH-32.2* MCHC-34.8 RDW-13.5 [2124-1-28] 08:20PM GLUCOSE-252* UREA N-74* CREAT-1.9* SODIUM-141 POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-20* ANION GAP-20 [2124-2-4] 05:50AM BLOOD WBC-8.8 RBC-3.12* Hgb-9.6* Hct-28.9* MCV-93 MCH-30.6 MCHC-33.0 RDW-18.2* Plt Ct-255 [2124-2-2] 01:10AM BLOOD WBC-9.6 RBC-3.10* Hgb-9.3* Hct-27.7* MCV-89 MCH-30.1 MCHC-33.6 RDW-20.3* Plt Ct-141* [2124-2-1] 03:05PM BLOOD Hct-23.6* [2124-2-1] 11:12AM BLOOD Hct-20.3* [2124-1-31] 09:37AM BLOOD Hct-27.2* [2124-2-4] 05:50AM BLOOD Glucose-100 UreaN-29* Creat-1.5* Na-146* K-3.9 Cl-114* HCO3-21* AnGap-15 [2124-2-3] 05:48AM BLOOD Glucose-86 UreaN-30* Creat-1.6* Na-144 K-4.6 Cl-115* HCO3-19* AnGap-15 [2124-1-28] 08:20PM BLOOD Glucose-252* UreaN-74* Creat-1.9* Na-141 K-4.5 Cl-106 HCO3-20* AnGap-20 [2124-1-29] 12:45PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2124-1-29] 07:20AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2124-1-28] 08:20PM BLOOD cTropnT-<0.01 [2124-2-4] 05:50AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.2 [2124-1-29] 07:20AM BLOOD %HbA1c-6.5* eAG-140* [2124-2-2] 07:26AM BLOOD Triglyc-105 [2124-1-31] 02:52PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.019 [2124-1-31] 02:52PM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2124-1-31] 02:52PM URINE RBC-[10-7]* WBC-[1-21] Bacteri-FEW Yeast-NONE Epi-0-2 . . Time Taken Not Noted Log-In Date/Time: [2124-2-3] 12:05 pm SEROLOGY/BLOOD CHEM# [Serial Number 98865]B. FINAL REPORT [2124-2-4] HELICOBACTER PYLORI ANTIBODY TEST (Final [2124-2-4]): NEGATIVE BY EIA. (Reference Range-Negative). . . . Final Report INDICATION: 87-year-old man with dyspnea. COMPARISON: [2122-6-24]. SINGLE UPRIGHT VIEW OF THE CHEST AT 9:10 P.M.: Lungs are clear without consolidation or pleural effusion. Linear opacities at the left lung base are unchanged dating back to [2119], likely reflecting scarring. This results in a slightly blunted appearance of the left costophrenic angle. There is no clear left pleural effusion. There is no right pleural effusion. There is no pneumothorax. The heart size is normal. The aorta remains tortuous. There is no hilar or mediastinal enlargement. Pulmonary vascularity is normal. IMPRESSION: No acute cardiopulmonary abnormality. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) 2671] [Doctor Last Name ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 2483] Approved: SAT [2124-1-29] 1:27 AM . . . Brief Hospital Course: #) Anemia--patient had grossly bloody and melenotic stools in ED and in MICU. NG lavage positive (coffee grounds). Maintained on protonix drip and transfused in total 7U packed RBCs to maintain Hct >25. On HD4 had EGD which showed multiple bleeding duodeunal ulcers which were clotted. Transitioned to Protonix 40mg [Hospital1 ]. On HD6 Hct dropped from stable 24-25 to 20, he had a melenotic bowel movement, and he was transfused one more unit. Thereafter his Hct remained stable at 27-28. Home lasix and flomax held in setting of ongoing blood loss, although he remained hemodynamically stable. He was then transferred to the medical floor where his HCT and vitals continued to be stable. His H pylori was negative and he was to be discharged on 40mg PO BID protonix. GI team did not recommend any routine follow up unless he becomes symptomatic given the patient has severe dementia and would not likely benefit. . #) Alzheimer's dementia--continued on home dose of Namenda and on seroquel 12.5mg [Hospital1 ] for agitation. Also received olanzapine PRN for agitation and had 1:1 sitter. speech and swallow team assessed pt and did video swallow, recommending a thin liq and pureed diet with 1:1 sitter, crushed meds. . #) Acute on chronic renal failure--baseline creatinine at 1.7. Patient remained at his baseline but on HD4 there was a creatinine bump to 2.6 and patient had poor urine output. A Foley was placed which quickly drained 1-2L urine and creatinine began to down-trend. Cr also improved in setting of blood transfusion. We restarted the patient's flomax upon discharge (initially held in concern for hypotension). We also started the pt's home lasix 20mg upon discharge and he should have his electrolytes monitored in the next 2-3 days. . # Depression: continued home seroquel . # BPH: pt sent home with foley due to retention in setting of holding flomax for concern for hypotension with GIB. the pt was discharged with a foley in place and started on his home flomax. . # Prostate cancer: No recent record. Appears to have been treated and not currently active. . # Pain: Continue gabapentin. Hold tramadol as may cause hypotension. Can continue tylenol. . # Communication: son [Name (NI) 3788] [Name (NI) ] [Telephone/Fax (1) 98866], HCP is son [Name (NI) ] [Name (NI) ] [Telephone/Fax (1) 98867], home [Telephone/Fax (1) 98868] # Code: Full Code (confirmed with son [Name (NI) 3788] [Name (NI) ]) HCP is son [Name (NI) ] [Name (NI) ] Medications on Admission: FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth once a day FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day GABAPENTIN - (Prescribed by Other Provider) - 100 mg Capsule - 1 Capsule(s) by mouth at bedtime MEMANTINE [NAMENDA] - 10 mg Tablet - 1 Tablet(s) by mouth twice daily, no later than 2pm QUETIAPINE [SEROQUEL] - 25 mg Tablet - [11-20] Tablet(s) by mouth twice daily TAMSULOSIN [FLOMAX] - (Prescribed by Other Provider) - 0.4 mg Capsule, Sust. Release 24 hr - 1 Capsule(s) by mouth daily TRAMADOL - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth once a day as needed for needed Medications - OTC Ambien 5 mg prn qhs ACETAMINOPHEN - (Prescribed by Other Provider) - 500 mg Tablet - 1 Tablet(s) by mouth daily as needed ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day CYANOCOBALAMIN [VITAMIN B-12] - (Prescribed by Other Provider) - Dosage uncertain DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg Capsule - 1 Capsule(s) by mouth daily as needed MULTIVITAMIN - (Prescribed by Other Provider) - Capsule - 1 Capsule(s) by mouth once a day OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider) - Dosage uncertain PYRIDOXINE [VITAMIN B-6] - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 4. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 5. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day) as needed for agitation. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 11. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO DAILY (Daily). 12. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital 745] health care Discharge Diagnosis: Primary: upper GI bleed - duodenal ulcer, cauterized acute anemia . Secondary: end stage alzheimer's dementia BPH depression Discharge Condition: afebrile, stable vitals . Mental Status: Confused - always Level of Consciousness: Lethargic but arousable Activity Status: Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted due to an upper GI bleed from a duodenal ulcer which was cauterized. You were in the ICU initially requiring numerous units of blood but you ultimately stabilized your blood counts and your vitals. You were started on a medication called protonix. You should stop taking all NSAIDs and aspirin permanently as this may cause another bleeding ulcer. Please stop taking tramadol for now and take tylenol instead. . Please take all medications as prescribed. Please follow up with all appointments. Please do not hesitate to return to the hospital with any concerning symptoms at all. Followup Instructions: Please follow up with your primary care provider as needed. Dr. [Last Name (STitle) 38274],[First Name3 (LF) ] X. [Telephone/Fax (1) 3530] [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799] ICD9 Codes: 5849, 2851, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9031 }	Medical Text: Admission Date: [2139-9-27] Discharge Date: [2139-9-30] Date of Birth: [2082-8-31] Sex: M Service: [Hospital Unit Name 196] Allergies: Penicillins Attending:[First Name3 (LF) 2698] Chief Complaint: chest pain Major Surgical or Invasive Procedure: PCTA with DES x3. History of Present Illness: 57 yo male with obesity, hypercholesterolemia, and chronic low back pain who presents wtih unrelenting chest pain that developed while pt was watching NY giants game. Pt noted "twinge" of CP while driving his wife to the laundromat. Chest pain initially began substernally and ultimately radiated to neck and back. No ripping or tearing quality. Pt denies recent decrease in exercise tolerance or chest pain prior to today, however, on further questioning he reveals that he decreased his worok as a roofer due to being tired and decreased his gym exercise because the gym he goes to no longer has a sauna. Has not worked out in the past 3 weeks. He currently denies chest pain, SOB, PND, DOE, fevers, chills, nausea, vomiting, abdominal pain. . In ED at OSH, EKG showed abnl EKG with septal Qs, T wave flattening throughout).Pt got loaded with Plavix (300mg), heparin gtt, integrillin gtt, nitro gtt, then taken to the cath lab.Cath showed severe 3vd with thrombotic appearing LAD. Pt was referred to [Hospital1 ] for CT surgery evaluation for CABG. Past Medical History: hypercholesterolemia chronic low back pain Social History: Denies tobacco, ETOH, drug use Family History: Mother with DM. Denies CAD. Physical Exam: t98.4, p69, 115/70, rr16, 100% 2L Gen: obese, NAD HEENT: PERRL, EOMI, MMM, clear OP Neck: suppler, no LAD, JVP of 10cm CVS: RRR, nl s1 s2, no m/g/r Lungs: ctab, no c/w/r Abd: soft, NT, ND, +BS, no HSM Ext: no edema, 2+ distal pulses Pertinent Results: [2139-9-27] 10:51PM WBC-10.1 RBC-3.81* HGB-12.3* HCT-35.0* MCV-92 MCH-32.2* MCHC-35.0 RDW-12.7 [2139-9-27] 10:51PM PLT COUNT-207 [2139-9-27] 10:51PM GLUCOSE-129* UREA N-14 CREAT-0.7 SODIUM-136 POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-26 ANION GAP-11 [2139-9-27] 10:51PM CALCIUM-9.0 PHOSPHATE-3.3 MAGNESIUM-1.8 . [2139-9-27]: ECG: Sinus rhythm Long QTc interval Left axis deviation - anterior fascicular block Probable anterior myocardial infarction - age undetermined Possible old inferior infarct T wave inversion in V2-V6- consider ischemia Nonspecific T wave flattening in limb leads Since previous tracing, QRS changes in V6 - ? lead placement; ventricular premature complex absent . [2139-9-27]: CXR: No acute cardiopulmonary abnormality . [2139-9-28]: carotid ultrasound: Duplex ultrasonography was performed at the level of the cervical portions of the bilateral carotid and vertebral arteries. No plaque was found on either side. The velocities, waveforms and velocity ratio in the bilateral carotid and vertebral arteries were normal, with antegrade flow. . [2139-9-28]: Echo: Conclusions: 1. The left atrium is moderately dilated. 2. The left ventricular cavity is mildly dilated. There is severe global left ventricular hypokinesis with preservation of the basal lateral and basal posterior walls. Overall left ventricular systolic function is severely depressed. 3. The aortic root is mildly dilated. 4. The aortic valve leaflets (3) are mildly thickened. 5. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen . [2139-9-28]: Cath 1. Initial access was extremely difficult due to severe tortuosity of the right iliac artery. 2. Selective coronary angiography of the left circulation demonstrated a 95% thrombotic stenosis in the mid-LAD with serial 90% and 80% stenoses in the LCX. 3. Successful PCI of the LAD with a 3.0 x 23 mm Cypher DES. 4. Successful PCI of the LCX with two Cypher DES (3.5 x 13 mm and 3.5 x 23 mm, non-overlapping). 5. Final angiography demonstrated no dissections, no residual stenoses, and TIMI-3 flow in both vessels. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Successful multivessel PCI of the LAD and LCX. . Brief Hospital Course: Assessment and Plan: Now s/p PCI with stenting of LAD and LCx. Has remained stable and chest pain free throughout hospitalization. * 1. CAD: 57 year old male with PMH hyperlipidemia, obesity admitted with acute anterior MI and newly diagnosed three vessel disease transferred for evaluation by CT surgery for potential CABG. Pt was found to have a recent anterior MI with peak troponin of 1700. In the setting of his recent MI, the decision was made to postpone CABG and to undergo PCI. Pt had PCI with stenting of LAD and LCx. Pt remained stable and chest pain free throughout hospitalization. Pt was medically managed with ASA, beta-blocker, ACE, statin. Plavix was started with plans to continue for 9-12mo, during which CABG would be deferred. * 2. Pump: Pt was found to have severe global hypokinesis on echo. Pt appeared to be euvolemic. Pt was started on medical management of his heart failure with a long-acting beta-blocker and ACE. Pt was started on coumadin with a heparin bridge, with plans to continue anticoagulation for 6 months. We recommend rechecking echo in 3 months, if still has EF<30% in setting of CAD would recommend ICD placement. * 3. Rhythm: No events on tele. * 4. Low back pain: We continued percocets prn * 5. PPX: cont sc heparin and ranitidine * 6. Full code Medications on Admission: Darvocet Motrin Pravachol Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (). 2. Pravastatin Sodium 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Need to take for 9-12 months. 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. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO once a day. Disp:90 Tablet Sustained Release 24HR(s) Refills:2 6. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 7. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual once as needed for chest pain: if you experience chest pain, place one tablet under your tongue. You can take up to 3 tablets total, 5 minutes apart. If chest pain persists, call 911. Disp:60 60 Refills:0 Discharge Disposition: Home Discharge Diagnosis: Myocardial Infarction Hypertension Hypercholesterolemia Discharge Condition: Home in stable condition Discharge Instructions: Please continue to take all your medications as directed. If you experience any furhter chest pain, shortness of breath, please call your PCP or go to the ED. It is very important that you take your aspirin and Plavix everyday. Followup Instructions: Please follow-up with your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ]. Call him at [Telephone/Fax (1) 57661] to schedule an appointment within the next week. Please follow-up with your new Cardiologist, Dr. [Last Name (STitle) 1295] ([Telephone/Fax (1) 57662]) ICD9 Codes: 4280, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9032 }	Medical Text: Admission Date: [2137-6-4] Discharge Date: [2137-6-9] Date of Birth: [2079-9-2] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: mild dyspnea on exertion Major Surgical or Invasive Procedure: [6-4] Mitral valve repair (resection of P2/#28 [Company 1543] ring) History of Present Illness: Ms. [Known lastname 105066] is a 57 year-old woman with known mitral valve regurgitation and mitral valve prolapse which has been followed by serial echocardiograms for several decades. Her most recent echocardiogram revealed an increased diastolic dimension and a subsequent MRI showed an effective forward EF of 46%. She was referred for surgical correction of this pathology. Past Medical History: mitral valve prolapse mitral valve regurgitation atrial tachycardia hyperthyroidism thyroid cancer depression vitiligo s/p thyroidectomy s/p c-section s/p tonsillectomy Social History: Ms. [Known lastname 105066] is a school secretary. She is married and has ten children. Family History: Ms. [Known lastname 105067] father underwent a coronary artery bypass grafting at age 60. Physical Exam: At the time of discharge Ms. [Known lastname 105066] was awake, alert, and oriented. Her lungs were clear to auscultation bilaterally. Her heart was of regular rate and rhythm. Her sternum was noted to be stable and her mediastinal incision was clean, dry, and intact. Her abdomen was soft, non-tender, and non-distended. Her extremities were warm and she had trace edema. Pertinent Results: [2137-6-7] 05:30AM BLOOD WBC-7.7 RBC-2.97* Hgb-9.2* Hct-26.8* MCV-90 MCH-31.0 MCHC-34.4 RDW-13.8 Plt Ct-151 [2137-6-7] 05:30AM BLOOD Plt Ct-151 [2137-6-7] 05:30AM BLOOD Glucose-146* UreaN-8 Creat-0.5 Na-135 K-4.6 Cl-102 HCO3-26 AnGap-12 Brief Hospital Course: On [2137-6-4] [Known firstname 105068] [Known lastname 105066] underwent a mitral valve repair with quadrangular resection with a 28mm [Company 1543] ring. This procedure was performed by Dr. [First Name (STitle) ] [Name (STitle) ]. She tolerated the procedure well and was transferred in critical but stable condition to the surgical intensive care unit. She was extubated on post-operative day one and weaned from pressors. Gentle diuresis was commenced and her chest tubes were removed. By post-operative day 2 she was ready for transfer to the surgical step-down floor. Her epicardial wires were removed. She was seen in consultation by physical therapy. By post-operative day five she was ready for discharge to home. Medications on Admission: levoxyl 100 (except 50 on Sunday) zoloft 75 calcium 400 amoxicillin prn for dental procedures Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): while taking pain medication. Disp:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:45 Tablet(s) Refills:0 4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO daily (). Disp:30 Tablet(s) Refills:0 5. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: mitral valve regurgitation mitral valve prolapse hyperthyroidism thyroid cancer depression vitiligo s/p thyroidectomy s/p c-section s/p tonsillectomy 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: Dr. [First Name (STitle) ] [Name (STitle) 1395] (PCP) in 2 weeks. ([Telephone/Fax (1) 8427]. Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in 2 weeks. Dr. [Last Name (STitle) ] in 4 weeks. ([Telephone/Fax (1) 11763]. Completed by:[2137-6-9] ICD9 Codes: 4240, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9033 }	Medical Text: Admission Date: [2124-8-11] Discharge Date: [2124-8-15] Service: THORACIC SURGERY CHIEF COMPLAINT: Left lower lobe mass. HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 37783] is an 86 year-old status post coronary artery bypass graft in [2124-1-18]. Biopsy was obtained, which revealed nonsmall cell carcinoma. He has had no cough or hemoptysis. His pulmonary function tests are satisfactory. Mr. [Known lastname 37783] was subsequently evaluated for resection of this left lower lobe mass. PAST MEDICAL HISTORY: Coronary artery disease status post Mild mitral regurgitation. Diabetes mellitus. Low grade prostate cancer several years ago status post transurethral resection of the prostate. SOCIAL HISTORY: Mr. [Known lastname 37783] is a former smoker. ALLERGIES: Penicillin and Demerol. MEDICATIONS: Glucotrol XL 5 mg q.d., Lasix 20 mg po q day, Lopressor 12.5 mg b.i.d. PHYSICAL EXAMINATION: Vital signs temperature 96. Pulse 64. Blood pressure 184/84. O2 sat 99% on room air. His head is normocephalic, atraumatic. His neck is supple. His lungs were clear to auscultation bilaterally. His heart is regular rate and rhythm with a [2-23] murmur. Abdomen is soft, nontender, nondistended. Normoactive bowel sounds. Extremities are without clubbing, cyanosis or edema. HOSPITAL COURSE: Mr. [Known lastname 37783] was taken to the Operating Room on [2124-8-11] for a left lower lobe resection through a thoracotomy incision. The procedure was performed without complications and Mr. [Known lastname 37783] was followed in the PACU overnight. He was subsequently transferred to the floor on postoperative day one. Due to high chest tube outputs and small air leak, his chest tubes were left in place. On postoperative day two chest tubes were placed on water seal and follow up x-ray revealed no evidence of pneumothorax or recollection of fluid. Chest tubes were discontinued on postoperative day three without incident. Mr. [Known lastname 37783] continued to recover well following surgery. He was tolerating an oral diet and his pain was controlled with oral medications. He was ambulating well with physical therapy and on [2124-8-15] Mr. [Known lastname 37783] was felt stable for discharge to home. Final pathology results are pending. PHYSICAL EXAMINATION ON DISCHARGE: Vital signs temperature 97.9. Pulse 77. Blood pressure 140/60. Respirations 24. O2 sat 94% on room air. His heart is regular rate and rhythm. His lungs are mildly coarse on the left. His incision is clean, dry and intact. Chest tube sites are dressed. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are without clubbing, cyanosis or edema. DISCHARGE MEDICATIONS: Lasix 20 mg q.d., Metoprolol 12.5 mg b.i.d., Glipizide XL 5 mg q.d., Docusate 100 mg b.i.d., Percocet one to two tabs q 4 to 6 hours prn. FOLLOW UP: Mr. [Known lastname 37783] should follow up with Dr. [Last Name (STitle) 175] on [2124-8-24]. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Mr. [Known lastname 37783] is to be discharged to home. DISCHARGE DIAGNOSIS: Lung carcinoma status post left lower lobectomy. Final pathology results pending. [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 178], M.D. [MD Number(1) 179] Dictated By:[Name8 (MD) 415] MEDQUIST36 D: [2124-8-15] 11:11 T: [2124-8-15] 11:29 JOB#: [Job Number 37784] ICD9 Codes: 4019, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9034 }	Medical Text: Admission Date: [2108-10-31] Discharge Date: [2108-12-12] Date of Birth: [2027-2-5] Sex: M Service: CARDIOTHORACIC Allergies: IV Dye, Iodine Containing Attending:[First Name3 (LF) 1505] Chief Complaint: aortic stenosis and coronary artery disease Major Surgical or Invasive Procedure: Aortic valve Replacement ( 23mm St. [Male First Name (un) 923] tissue) & coronary artery bypass grafts x 3 (LIMA-LAD, SVG-Dg, SVG-PDA) [2108-11-7] Mediastinal exploration [2108-11-12] percutaneous tracheostomy [2108-11-27] open cholecystectomy [2108-11-28] History of Present Illness: This 81 year old male had a positive stress test and a history of aortic stenosis. He was acutely short of breath and had worsening symptoms. He [Year (2 digits) 1834] cardiac catheterization on [10-30] which revealed 90% mid LAD lesion, occluded diagonal an occluded right coronary artery a dilated aortic root and moderate aortic stenosis with [First Name8 (NamePattern2) ] [Location (un) 109] of 1 cm2. His EF was 65-70% and he had mitral annular calcification. He was tranferred for operation. Past Medical History: aortic stenosis coronary artery disease hypertension peripheral vascular disease s/p phlebitis [3-6] hypercholestermia h/o [Month/Year (2) 7816]-[Location (un) ] s/p right femoral popliteal bypass [4-5] s/p left femoral popliteal bypass [3-6] s/p right carotid endarterectomy [2097] Social History: Retired, lives with wife. smoking: none ETOH: occasionally., Heavy in past Family History: unremarkable Physical Exam: General No acute distress Skin healing eschar medial left foot HEENT glasses Neck supple full ROM Rt CEA scar Lungs clear Heart Regular 2-3/6 systolic murmur Abdomen soft nontender nondistended + BS Extremeties no edema Neuro grossly intact Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 82089], [Known firstname ] [Hospital1 18] [Numeric Identifier 82090] (Complete) Done [2108-11-15] at 11:38:46 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] R. [Hospital1 18], Division of Cardiothorac [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2027-2-5] Age (years): 81 M Hgt (in): 66 BP (mm Hg): 116/56 Wgt (lb): 186 HR (bpm): 110 BSA (m2): 1.94 m2 Indication: Aortic valve disease. Atrial fibrillation. Pericardial effusion. Prosthetic valve function. Tamponade. Valvular heart disease. ICD-9 Codes: 427.31, 423.9, 423.3, 424.1, V43.3 Test Information Date/Time: [2108-11-15] at 11:38 Interpret MD: [Name6 (MD) ] [Name8 (MD) ], MD Test Type: TEE (Complete) Son[Name (NI) 930]: Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Adequate Tape #: 2008W000-0:00 Machine: Vivid i-5 Sedation: Versed: 3 mg Fentanyl: 150 mcg Patient was monitored by a nurse throughout the procedure Echocardiographic Measurements Results Measurements Normal Range Aorta - Ascending: 3.7 cm <= 3.4 cm Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm Aortic Valve - Peak Velocity: 3.0 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 36 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 22 mm Hg Pericardium - Effusion Size: 0.6 cm Findings This study was compared to the prior study of [2108-11-7]. LEFT ATRIUM: No mass/thrombus in the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: No mass or thrombus in the RA or RAA. LEFT VENTRICLE: Small LV cavity. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated ascending aorta. Mildly dilated descending aorta. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR leaflets move normally. Normal AVR gradient. No masses or vegetations on aortic valve. No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. No mass or vegetation on mitral valve. Moderate mitral annular calcification. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. PERICARDIUM: Small pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [First Name (Titles) ] [Last Name (Titles) 9833] throughout the procedure. The patient was monitored by a nurse in [Last Name (Titles) 9833] throughout the procedure. Local anesthesia was provided by benzocaine topical spray. The patient was under general anesthesia throughout the procedure. No TEE related complications. Conclusions No mass/thrombus is seen in the left atrium or left atrial appendage. No mass or thrombus is seen in the right atrium or right atrial appendage. The left ventricular cavity is unusually small suggestive of underfilling. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve bioprosthesis leaflets appear to move normally. The transaortic gradient is normal for this prosthesis. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. No mass or vegetation is seen on the mitral valve. Physiologic mitral regurgitation is seen (within normal limits). There is a small pericardial effusion with echodense material . IMPRESSION: Small LV cavity size with normal LV systolic function. Small pericardial effusion with echodense material. No SEC or thrombus in the LA/LAA. The bioprosthetic aortic valve is well seated and well functioning. Compared with the prior study (images reviewed) of [2108-11-7] (post bypass images), there is a small pericardial effusion with echodense material. Electronically signed by [Name6 (MD) ] [Name8 (MD) ], MD, Interpreting physician [Last Name (NamePattern4) ] [2108-11-15] 18:25 [Known lastname 82089],[Known firstname ] [Medical Record Number 82091] M 81 [2027-2-5] Radiology Report CHEST (PORTABLE AP) Study Date of [2108-12-9] 10:03 AM [Last Name (LF) ],[First Name3 (LF) ] R. CSURG CSRU [2108-12-9] SCHED CHEST (PORTABLE AP) Clip # [Clip Number (Radiology) 82092] Reason: r/o effusions/atelectasis [Hospital 93] MEDICAL CONDITION: 81 year old man with REASON FOR THIS EXAMINATION: r/o effusions/atelectasis Final Report HISTORY: Rule out effusion and atelectasis. CHEST, SINGLE AP PORTABLE VIEW. Tracheostomy tube present. A feeding tube is present, the tip extends beneath the diaphragm, likely beyond the pylorus. Status post sternotomy. Cardiomediastinal silhouette is enlarged, but stable. Left lower lobe collapse and/or consolidation and associated small amount of pleural thickening and/or fluid is stable. There has been some interval clearing of the opacity at the right lung base. No CHF. No pneumothorax. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 4343] COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2108-12-11] 12:17PM 30.1 Source: Line-quinton [2108-12-11] 02:10AM 7.0 3.34* 10.0* 29.6* 89 29.9 33.8 18.1* 163 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2108-12-11] 02:10AM 107* 68* 1.9* 143 3.8 107 30 10 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili [2108-12-11] 12:17PM 184* 151* 272* 193* 66 1.3 Brief Hospital Course: Following transfer, workup was completed, including carotid ultrasonography and vein mapping. Surgery was delayed for coumadin washout. Dental clearance was obtained. The patient was brought to the operating room on [2108-11-7] where he [Year (4 digits) 1834] AVR (tissue valve) and CABG x3. Please see operative note for further details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in good condition for observation and recovery. By POD 1 the patient was hemodynamically stable, off all vasoactive drips. He was extubated late on POD 1. The patient developed some confusion and lethargy with narcotics and was therefore held an extra day in the ICU. He developed atrial fibrillation which was treated with amiodarone. Renal function worsened in the setting of volume overload. POD# 5 In light of Mr.[Known lastname 82093] worsening renal function with an elevated BUN/Creatnine, and volume overload, a Transthoracic echocardiogram was performed to assess pericardial tamponade. Large clot and free fluid were seen around the right ventricle. He was taken to the OR for reexploration and clot evacuation. Post reexploration he required epinephrine and extubated. His cardiac rhythm went into atrial fibrillation. He was treated medically with Amiodarone which was ultimately discontinued due to bradycardia. On [11-14] patient developed respiratory distress and was emergently reintubated. He was weaned off the epinephrine and required Milrinone to optimize cardiac output/index on [2108-11-15]. Dobhoff was placed and tube feeds were initiated. The patient does have a history of [First Name9 (NamePattern2) 7816] [Location (un) ] syndrome. Due to persistent respiratory insufficiency, and worsening postoperative confusion and agitation, neurology was consulted to determine if this history could be a contributing factor. The neurology team found no evidence that GBS was contributing to respiratory difficulties. Also on POD 8 he was found to be hypothermic and was started on synthroid d/t low T3/T4. He was pan cultured, all of which were negative. On [11-15] he had an echocardiogram d/t worsening renal status/volume overload which showed an EF 55, normal RV and 1+TR. His milrinone and lasix were discontinued with some improvement in renal function. On [11-16] he developed increased RUQ pain and his tube feeds were stopped and he was started on TPN. POD#10 the patient self extubated and was reintubated due to respiratory failure. His post intubation chest xray showed questionable pneumonia and he was started on empiric antibiotics. These were stopped when subsequent cultures were negative. Five days later he was weaned to extubation, requiring Bipap for acidosis, which ultimately led to a reintubation.POD#20 Mr.[Known lastname ] [Last Name (Titles) 1834] a tracheostomy with #8mm Portex trach tube. [11-20] Psychiatry was consulted for worsening depression and acute delerium. they recomended haldol and restarting his Celexa. In addition to Mr.[Known lastname 82093] respiratory insufficiency, his postoperative course was complicated by worsening abdominal distention evident on CT scan by dilated loops of bowel,gallbladder distention and pain on exam. Right upper quadrant ultrasound and HIDA scan were performed and general surgery was consulted. [2108-11-29] he [Year (4 digits) 1834] a diagnostic laproscopy that was converted to an open choleycystectomy for cholecystitis. He was found to have a severely cirrhotic liver. Due to acute kidney dysfunction, with elevating BUN/Creatnine, [11-21] Renal was consulted and hemodialysis was ultimately initiated. [2108-12-2] Mr.[Known lastname 82093] family/proxy had a meeting with the cardiac surgery attending physician and Mr.[Known lastname 82093] code status was changed to DNR. His last run of dialysis was on [12-1] and his renal function has been steadily improving. He has since than slowly begun to progress in which his mental status has improved, trach collar trials were initiated, along with PassyMuir valve trials, thickened nutrition in adjunct with tube feeds were initiated, and he has not required further hemodialysis since [12-3]. Video swallow was done on POD#29 shows mod-severe dysphagia. Mr.[Known lastname ] has remained on the trach collar since [12-5]. On [12-10] he developed a hematoma at the site of his abdominal incision. At the time he had normal coagulation studies and stable hematocrit. The bleeding stopped and the incision was opened by the general surgery team and packed wet to dry. He was felt to be medically ready for discharge to rehab on [12-12] for further conditioning and increase in strength, endurance, and activities of daily living. He has oral sutures from dental extractions preoperatively. As discussed with his dentist, Dr.[First Name (STitle) 1663], Mr.[Known lastname ] could be seen for dental suture removal once he's at the rehabilitation facility. All follow up appointments have been advised. Medications on Admission: Allopurinol 300 mg PO daily HCTZ 50 mg PO daily Colchicine 0.6 mg PO BID Percocet PRN Coumadin Lasix 20 mg PO daily Imdur 45 mg PO daily Discharge Medications: 1. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Dressing abdominal Right flank Abdominal incision - cleanse with normal saline, pack with moist Kerlix, and cover with Dry dressing Change twice daily Please call Dr [Last Name (STitle) 816] office if concerns with abdominal incision ([Telephone/Fax (1) 3618] 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours): changed monday [12-10]. 8. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 9. Acetaminophen 160 mg/5 mL Solution Sig: Five (5) ml PO Q6H (every 6 hours) as needed for pain. 10. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 1294] Discharge Diagnosis: Aortic stenosis s/p AVR coronary artery disease s/p CABG s/p evacuation of mediastinal hematoma Post op atrial fibrillation Respiratory failure s/p percutaneous tracheostomy acute cholecystitis s/p open cholecystectomy cirrhosis Delirium Hypothyroid Acute renal failure requiring hemodialysis peripheral vascular disease hypertension hyperlipidemia gouty arthritis h/o deep vein thrombophlebitis s/p right carotid endarterectomy s/p bilateral popliteal bypass h/o [Location (un) 7816]-[Location (un) ] syndrome renal insufficiency chronic back pain Discharge Condition: good Discharge Instructions: no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks shower daily, no baths or swimming no lotions, creams or powders to incisions report any weight gain greater than 2 pounds a day or 5 pounds a week report any rednesss of, or drainage from incisions report any temperature greater than 100.5 take all medications as directed Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Dr. [Last Name (STitle) ] in 2 weeks at [Hospital1 ] for wound check and post-op follow-up : [Telephone/Fax (1) 6256] Dr [Last Name (STitle) 816] in [11-30] weeks for follow up abdominal incision ([Telephone/Fax (1) 10248] - please call to schedule Dr. [Last Name (STitle) 32255] in 3 weeks Dr. [First Name8 (NamePattern2) 7325] [Name (STitle) ] in 2 weeks ([Telephone/Fax (1) 7328]) Dr.[First Name (STitle) 1663], dentist, #[Telephone/Fax (1) 82094], for dental suture removal during rehab Completed by:[2108-12-12] ICD9 Codes: 4241, 5185, 9971, 4275, 5849, 4019, 5715, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9035 }	Medical Text: Admission Date: [2181-5-26] Discharge Date: [2181-6-8] Date of Birth: [2137-1-1] Sex: M Service: NEUROSURGERY Allergies: Dilantin Attending:[First Name3 (LF) 1271] Chief Complaint: Traumatic brain injury s/p motorcycle accident Major Surgical or Invasive Procedure: Placement of [Last Name (un) ] Bolt on [5-26] Tracheostomy and PEG [2181-6-1] History of Present Illness: 44M motorcycle driver involved in accident, slid approximately 100ft. was reportedly GCS 15 at scene. went to OSH, GCS down to 12 and then required intubation. Head CT there showed diffuse SAH and small R IPH. Pt transferred to [Hospital1 18] ED for further management. Pt was evaluated by trauma in ED and other than abrasions and brain trauma, had no other acute injury. Past Medical History: Previous intracerebral hemorrhage in [2177] diabetes mellitus type II hypertension Social History: Lives alone. Denies tobacco and drugs. Rare alcohol. Works as an EMT. Family History: Mother had stroke, both parents have hypertension and diabetes. Physical Exam: On admission: Intubated, sedated in hard collar and on back board examined in ED. no eye opening,intubated, min itermittent movement of L UE and bilat LE Gen:abrasions on right side of body especially R shoulder Toes downgoing bilaterally On discharge: Tracheostomy in place, opens eyes to voice, eyes track, follows commands in all extremities Pertinent Results: [2181-5-26] 05:20PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 [2181-5-26] 05:20PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 [2181-5-26] 05:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2181-5-26] 05:20PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.036* [2181-5-26] 05:20PM FIBRINOGE-440* [2181-5-26] 05:20PM PLT COUNT-184 [2181-5-26] 05:20PM PT-12.3 PTT-21.6* INR(PT)-1.0 [2181-5-26] 05:28PM GLUCOSE-384* LACTATE-2.8* NA+-136 K+-3.9 CL--94* TCO2-26 [2181-5-26] 05:20PM UREA N-24* CREAT-1.2 [2181-5-26] 05:20PM estGFR-Using this [2181-5-26] 05:20PM LIPASE-52 [2181-5-26] 05:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [5-26] CT Head: IMPRESSION: 1. Interval increase in the prominence of a left subdural acute hemorrhage. 2. Mild increase in a left subarachnoid hemorrhage and unchanged right subarachnoid hemorrhage. 3. Increasingly prominent right frontal intraparenchymal hemorrhage measuring 5 x 7 mm. [5-26] CT Torso: IMPRESSION: 1. No acute fracture. 2. Peripheral round-glass opacities in the right upper lobe concerning for pulmonary contusions. 3. A septated right mid polar and a high-density right lower pole cyst should be further evaluated with a renal ultrasound on a non-emergent basis. 4. ETT terminates ~ 1 cm above the carina, suggest withdrawal by [11-19] cm. 5. Bibasilar atelectasis and possible aspiration. [5-26]: CT C-spine: IMPRESSION: Rotation of C1 on C2 is likely positional. No acute fracture. [5-27]: CT Head: IMPRESSION: 1. New trace IVH. Decreased left SAH and rightward shift. Unchanged diffuse SAH and focal IPH. 2. ICP monitor. 3. Paranasal sinus disease. [5-29]: Chest X ray Diffuse opacities in left lower lung with atelectasis. [5-29]: Sputum gram stain and culture 2+ Gram negative rods, gram positive rods and gram positive cocci. [5-31] CXR In comparison with the study of [5-29], there is continued opacification involving much of the lower half of the left lung. Again this is consistent with volume loss and pleural effusion. However, suggestion of some air bronchograms would be consistent with the clinical suspicion of supervening pneumonia. The right lung remains essentially clear and the monitoring and support devices are unchanged. [6-1] CXR Moderate left pleural effusion with left lower lobe opacity that could represent pneumonia or atelectasis. [2181-6-5] In comparison with study of [6-1], the endotracheal tube has been removed and has been replaced by a tracheostomy tube. Nasogastric tube has been removed. There is enlargement of the cardiac silhouette with engorgement of ill-defined pulmonary vessels consistent with elevated pulmonary venous pressure. Atelectatic changes are seen at the bases and the left hemidiaphragm is poorly seen. This is consistent with atelectasis and effusion, though supervening pneumonia can certainly not be excluded. [2181-6-5] No evidence of right or left lower extremity DVT. [6-5] CTA chest 1. Solitary fresh non-occlusive pulmonary embolism segmental branch of the right middle lobe. No evidence of pulmonary infarction, right heart strain or pulmonary hypertension. 2. Progression of now complete atelectasis of both lower lobes is more likely to account for the patient's shortness of breath. CXR [2181-6-6]: Tracheostomy is in standard position. Left lower lobe opacity is a combination of moderate pleural effusion and left lower lobe collapse. Right pleural effusion is small. There is a platelike atelectasis in the right mid lung. Cardiomediastinal silhouette is unchanged. There is mild cardiomegaly. Brief Hospital Course: Mr [Known lastname ] is a 44M motorcycle accident with traumatic brain injury, he was admitted to the ICU for close neurological exam and placed on seizure prophylaxis medications. During the first few hours of his hospitalization he had a poor neurological exam for which a bolt was placed. His ICPs remained within normal level and the bolt was discontinued on [5-28]. His neurological exam was stable with him MAE's, but did not follow commands. On [5-29] his SBP was liberalized to 160. He was written for transfer to the SDU but his oxygenation decompensated and he dropped to 70% O2 saturations. He was intubated and stat chest x ray showed complete white out of his left lung. A bronchoscopy was performed and secretions were cleared. A gram stain of the sputum showed GPC, GNR and GPR. Antibiotics were started on [5-30] for empiric treatment of VAP. His WBC remained in normal limits and he was afebrile. On [5-31], he remained intubated. His neuro exam improved as per nurses. He is scheduled for a tracheostomy and Percutaneous G-tube placement on [6-1]. He tolerated the procedure well without complications. His sedation was weaned and neurologically he began to improve. On [6-4], he was trasnferred to SDU in stable condition. He was screened for rehab by pt/ot and speech. He was started on Vancomycin for MRSA pneumonia. On [6-5], his WBC raised to 18 and a UA was sent. IT was without sign of infection. sputum culture showed....His oxygen saturation was in the low 90's and a RR in the 30's. CTA showed a small subsegmental PE. While in the scanner, saturation dropped to the 70's. ABG showed a metabolic alkalosis. Medicine was consulted. They recommended continuing Vancomycin to treat MRSA PNA and wanted ID consulted. They recommended transfering the patient to the ICU for closer observation and possible need of vent and frequent chest PT. For his PE it was decided due to the small size it would only be treated with SQ Heparin and full anticoagulation was held due to intracranial hemorrhages. Early on [6-7] he was transferred out of the ICU his most recent sputum and urine cultures were finalized as negative. His respiratory status was much improved now respirations were in the 20s and saturing 98% on 40% FIO2. On [6-8], pat was afebrile and respiratory status was stable. A picc line was placed in routine fashion. ID recommend he continue Vancomycing for 14 days from the date of [6-7]. He was set for d/c rehab in stable condition and will follow-up accordingly. Medications on Admission: Unknown Discharge Medications: 1. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for oral thrush. 2. docusate sodium 50 mg/5 mL Liquid Sig: [11-19] PO BID (2 times a day). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever > 101F. 8. oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q4H (every 4 hours) as needed for pain. 9. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Tablet(s) 11. insulin regular human Injection 12. vancomycin 1,000 mg Recon Soln Sig: One (1) 1000mg Intravenous every eight (8) hours for 13 days. 13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 8957] Discharge Diagnosis: Traumatic Brain Injury Subarachnoid hemorrhage Cerebral edema Hospital acquired pneumonia Respiratory failure Malnutrition oral candidiasis PE metabolic alkalosis Pyrexia 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: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? OK with SQH but hold all anticoagulation ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [Last Name (STitle) 739], to be seen in _4-6___weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. ??????We recommend you see Dr [First Name (STitle) ] in the Traumatic Brain Injury (TBI) clinic the phone number is [Telephone/Fax (1) 6335]. If you have any problems booking this appointment please ask for [First Name8 (NamePattern2) 16367] [Last Name (NamePattern1) 16368]. [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2181-6-8] ICD9 Codes: 5185, 5180, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9036 }	Medical Text: Admission Date: [2147-6-16] Discharge Date: [2147-6-30] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Intubation PICC line placement History of Present Illness: 88 yo F with h/o alzheimer's dementia, HTN, and DM2 transferred from OSH for evaluation by neuro out of concern for ICH. She was found in her bed today at NH diaphoretic, somnolent, lethargic, dysarthric and hypoxic to 80% on 3L NC at which time she was transferred to Good Samiritan ED for further evaluation. She underwent head CT at OSH ED which revealed ? of basal ganglia bleed. She was then intubated for increasing unresponsiveness (only to painful stimuli) and for airway protection in setting of ? head bleed for transfer to [Hospital1 18]. Prior to intubation, she received lidocaine 100mg, etomidate 20mg, succinylcholine 100mg and cerebyx 1gm. . En route, she was hypotensive, initially 94/60 -> 64/31 at 9:50am. This came up with IVF to 97/69, but fell again to 83/44 and thus neosynephrine was started. . In the ED here, initial vitals were T: none recorded BP: 111/72 HR: 76 RR: 14 O2 sat: 100% on AC (settings unclear). She was continued on neosynephrine for SBPs in the 70s and had only received 600cc IVFs prior to transfer to [Hospital1 18]. Here, she received 2L IVFs in the ED and SBPs improved to 100s-110s off pressors. UA was positive for >50 WBCs and many bacteria (no squams) and she received levofloxacin 750mg IV x1. CXR was negative for infiltrate. She received 1mg ativan prior to neurology consult. Per RNs, she was moving all extremities, with good strength in both arms, prior to the ativan (received 1mg IV x2). On review of OSH head CT, neurology felt that basal ganglia finding was more consistent with calcification as opposed to bleed and recommended repeat imaging here. Repeat imaging showed no evidence of acute intracranial process on NCHCT and CTA head and neck. . ROS: Unable to obtain given patient intubated. Past Medical History: -HTN (per tx records however NOT per daughters EVER) -Alzheimer's disease - at baseline talks, interacts normally, but has delusions -Diabetes mellitus; type 2 -Neuropathy -CAD s/p angioplasty at [Hospital1 2025] approx. 10 yrs ago per daughter -Recurrent UTIs -s/p Cataract surgery -Hard of hearing; wears hearing aides Social History: Lives at nursing home (Guardian [Name (NI) ]) in [Name (NI) 1474]. Quit tobacco 10+ years ago, but prior heavy history per daughter. [Name (NI) ] Etoh. Walks with walker at baseline. Family History: Noncontributory Physical Exam: 98.6 92/43 67 14 100% AC 450x14 PEEP 5 FiO2 0.5 GEN: Intubated, non on sedating meds however unresponsive. HEENT: Pinpoint pupils nonreactive to light, symmetric, conjuctival injection, anicteric, OP clear, dry MM, Neck supple, no LAD CV: RRR, distant HS, no m/r/g appreciated PULM: Clear anteriorly ABD: soft, ND, + BS, no HSM appreciated EXT: cool b/l however palpable peripheral pulses including DP/PT NEURO: Rarely moves both lower extremities minimally. Does not follow commands. Pertinent Results: [2147-6-16] CXR (from OSH): Increase of right basal lung markings possibly representing a small infiltrate. Otherwise relatively clear lungs. Chronic changes. . [2147-6-16] head CT (from OSH)--no official report: Per transfer notes, ? basal ganglia bleed. . [2147-6-16] CXR: Adequate position of ET and NG tubes. No acute intrathoracic process. . [2147-6-16] CTA head/neck: 1. Findings consistent with internal globus pallidus calcifications bilaterally. No evidence of acute intracranial process on non contrast head CT. 2. CTA shows moderate internal carotid artery stenosis Brief Hospital Course: 88yo F with h/o CAD, recurrent UTIs, DM2, alzheimer's dementia presents with altered mental status and sepsis. The following issues were investigated during this hospitalization: . # Sepsis/Hypotension/Respiratory Failure: Resolved hypotension and was probably mostly due to hypovolemia on presentation. Did meet criteria for sepsis given WBC count and tachycardia (at OSH) with source of infection, clearly positive UA (culture sent on second sample after received abx and was negative) and had blossomed pneumonia on CXR. CSF seemed like an unlikely source, particularly for bacterial meningitis. However, patient was treated for HSV encephalitis with Acyclovir given RBCs in CSF. This was later discontinued once cultures came back negative. Sputum eventually grew MRSA which was treated with Vancomycin and a 14 day course was completed on discharge. Given a sudden decline in clinical status and increased sputum production, Cefepime was also added for possible hospital acquired PNA and was completed on the day of discharge. Patient was difficult to wean from the vent given copious secretions which were not controlled even with Scopolamine and frequent suctioning. For this reason, a trach was pursued after one failed extubation. . # Altered mental status: Most likely due to metabolic insult of infection (pneumonia/UTI) on already demented baseline. Improved markedly with lightening of sedation. Initial OSH CT head concerning for basal ganglia bleed for which she was transferred however review of that imaging and repeat imaging here negative for bleed. Initially covered for bacterial and viral meningitis/encephalitis with ctx/vanco/amp/acyclovir however CSF cultures negative and by counts on CSF unlikely bacterial. Again, HSV cultures were eventually negative and empiric meningitis regimen was discontinued. Patient was otherwise continued on her dementia medications and upon discharge, was awake and communicative at her baseline. . # CAD: No acute issues . # DM: Maintained on Insulin sliding scale Medications on Admission: Atenolol 25mg daily Aricept 10mg daily Oscal 500mg daily ASA 81mg daily Memantine [Hospital1 ] Metformin 500mg [Hospital1 ] Vitamin B12 500mcg [Hospital1 ] Seroquel 25mg 1mg 6x/wk, 0.5mg qSun Loperamide 4mg q6hrs prn Robitussin 5ml prn Bisacodyl 10mg prn Milk of magnesia 30ml prn Acetaminophen 650mg prn Maalox 30ml q6h prn Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Memantine 5 mg Tablet Sig: Two (2) Tablet PO bid (). 5. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection [Hospital1 ] (2 times a day). 11. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Primary MRSA PNA CHF . Secondary HTN Alzheimer's Disease Diabetes mellitus; type 2 Neuropathy CAD s/p angioplasty at [Hospital1 2025] approx. 10 yrs ago per daughter Recurrent UTIs s/p Cataract surgery Hard of hearing; wears hearing aides Discharge Condition: Stable Discharge Instructions: You were seen and evaluated for respiratory failure, which was felt to be due to pneumonia. You have received treatment for this pneumonia, however, it was difficult to remove the breathing tube that you needed while you were treated. For this reason, we performed a tracheostomy to assist with your breathing. Since you cannot eat with this tracheostomy in place, you also had a gastric feeding tube placed in your stomach. You are now being discharged to a rehabilitation facility where you will continue to be treated. Followup Instructions: You will be followed by physicians at your rehabliitation facility ICD9 Codes: 5070, 5990, 2762, 2760, 4280, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9037 }	Medical Text: Admission Date: [2180-11-27] Discharge Date: [2180-11-30] Date of Birth: [2114-5-16] Sex: F Service: EMERGENCY Allergies: Penicillins / Sulfa (Sulfonamides) / Levaquin / Erythromycin Base / Ivp Dye, Iodine Containing Attending:[First Name3 (LF) 2565] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: PICC placement Femoral Line Placement History of Present Illness: 66 yo F with multiple medical problems including CAD, CHF, cirrhosis (and prior encephalopathy), hx DVT's, aspiration, chronic lower extremity ulcers w/cellulitis on abx presented from home with altered mental status. Per husband, her MS had been worsening gradually over the past 3 days. She was having cough with some sputum production. She was responsive on the morning of admission but very lethargic and also had incontinence. A FSG showed recording of 34 but was corrected to ~150 with administration of juice. However her MS did not improve with improvement in her FSG. . ED: Her BP was around 80's/40's, after 1L -> SBP was >100 (baseline SBP in 90-100). She was DNR/DNI but family was okay with lines in the ED. A L Fem line was placed as no other access could be obtained. CXR - ?LLL PNA, left sided effusion. Vascular [Doctor First Name ] consulted who did not think that the leg was likley source of sepsis. Head CT showed sinusitis. She got vanc/[Last Name (un) 2830]. . [Hospital Unit Name 153]: upon arrival to ICU, I had extensive discussion with the husband who is her HCP. [Name (NI) ] note, patient's functional status had been gradually declining over the last 7 months. The patient and family were frustrated with the fact that the patient had been at home for only 2 weeks of the last 7 months and she had a poor quality of life. The husband did not want any aggressive measures which included no NG tube, no pressors and the goal was to make her comfortable and to try only IV medications if required. . Past Medical History: 1.Type I Diabetes Mellitus--+nephropathy, no A1C available 2.Coronary Artery Disease 3.Congestive Heart Failure--EF 30%, 2+ TR, mod PA HTN per echo in [2180-7-19] 4.CKD stage III with baseline Cr 1.3-1.9 5.Hyperlipidemia 6.Gastritis 7.Venous Stasis 8.Allergic Rhinitis 9.Osteomyelitis 10.RLE wound--after trauma, s/p graft 11.Cirrhosis--thought to be due to NASH; on lactulose, ursodiol and rifamixin in the past 12.hepatic encephalopathy and ?seizures on keppra . Social History: Lives with husband, who is primary caregiver. [Name (NI) ] lives next door and he and wife wife help with her care. Has VNA services. Needs help with ADLs. Quit smoking in [2154]. h/o alcohol abuse. Can walk up four steps with assistance. Family History: non-contributory Physical Exam: ICU admission vitals: 96.7, 87, 103/46, 100/4L Gen: extremly lethargic, open eyes to commands but no verbalization HEENT: PEERL, EOMI, anicteric sclera, dry MM Chest: clear anteriorly, crackles bilaterally at the bases CV: distant heart sound, RRR, nl S1, S2, II/VI SEM Abd: Distended nontedner, no rebound or guarding, edematous. Unable to appreciate h/s. Neuro: extremely lethargic, opens eyes to commands Skin: diffuse bilateral erythema, more pronounced in lower ext, has many areas of torn skin and weeping lesions with ulcerations Pertinent Results: [2180-11-27] WBC-12.0# RBC-4.90 Hgb-12.4 Hct-40.1 MCV-82 MCH-25.2 MCHC-30.8* RDW-19.9* Plt Ct-115* Neuts-81* Bands-9* Lymphs-5* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1* PT-36.7* PTT-54.0* INR(PT)-3.9* Glucose-129* UreaN-102* Creat-2.7* Na-133 K-3.5 Cl-86* HCO3-30 AnGap-21* ALT-24 AST-43* CK(CPK)-42 AlkPhos-343* Amylase-44 TotBili-1.8* Lipase-13 cTropnT-0.05* Albumin-2.9* Calcium-9.4 Phos-6.3# Mg-2.4 Cortsol-40.7 CRP-52.7* [2180-11-29] 08:14AM Vanco-26.3* [2180-11-27] 03:27PM Type-ART pO2-467* pCO2-47* pH-7.45 calTCO2-34* Base XS-8 Intubat-NOT INTUBA [2180-11-27] Lactate-3.8* [2180-11-27] 03:27PM O2 Sat-100 CT HEAD W/O CONTRAST [2180-11-27] 2:12 PM CT HEAD W/O CONTRAST Reason: Please evaluate for intracranial hemorrhage in this patient [Hospital 93] MEDICAL CONDITION: 66 year old woman with multiple medical problems presenting with altered mental status. REASON FOR THIS EXAMINATION: Please evaluate for intracranial hemorrhage in this patient on coumadin or any other explanation for her altered mental status. CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 66-year-old female with multiple medical problems presenting with altered mental status. COMPARISON: CT head of [2180-8-8]. TECHNIQUE: Contiguous axial images through the brain were acquired without IV contrast administration. FINDINGS: No evidence of acute hemorrhage, edema, mass, mass effect, or large vascular territory infarction is present. Ventricular configuration is not changed. Vascular calcifications are noted in the intracranial vertebral arteries and the internal carotid arteries. The patient is status post left cataract surgery. Compared to [2180-8-8], there is new opacification of some ethmoid air cells and mucosal thickening in the left maxillary sinus. The remainder of the visualized paranasal sinuses and the mastoid air cells are well aerated. No fracture is present. IMPRESSION: 1. No evidence of acute intracranial hemorrhage. 2. Left maxillary and ethmoid sinus disease. CHEST (PORTABLE AP) [2180-11-27] 10:53 AM CHEST (PORTABLE AP) Reason: cardiopulmonary process [Hospital 93] MEDICAL CONDITION: 66 year old woman with rhonchi REASON FOR THIS EXAMINATION: cardiopulmonary process HISTORY: 66-year-old female with rhonchi. COMPARISON: A series of chest radiographs from [2180-10-19] through [2180-11-4]. PORTABLE SUPINE CHEST RADIOGRAPH: Since [2180-11-4], there has been interval removal of a right PICC and Dobbhoff tube. There is likely some increase in the moderate-to-large left pleural effusion compared to the study performed nearly a month prior. The left retrocardiac opacity persists, likely representing pleural effusion, associated atelectasis, although underlying pneumonia cannot be excluded. The cardiac silhouette is obscured on the left by the pleural effusion and atelectasis; however, there is likely stable cardiomegaly. Prominence of the pulmonary vessels is consistent with pulmonary venous congestion and indistinctness of the pulmonary vessels likely represents interstitial edema. No focal airspace opacities are seen in the right lung or left upper lung. The bony thorax appears intact. IMPRESSION: Vascular congestion with interstitial edema, overall unchanged from [2180-11-4]. There may be some increase in the left pleural effusion which is now likely moderate to large in size, with associated atelectasis. CHEST (PORTABLE AP) [2180-11-29] 11:29 AM CHEST (PORTABLE AP) Reason: interval change, worsening effusion, chf and/or pna [Hospital 93] MEDICAL CONDITION: 66 year old woman with pna, inc SOB this am s/p volume resuscitation last night REASON FOR THIS EXAMINATION: interval change, worsening effusion, chf and/or pna HISTORY: Shortness of breath. FINDINGS: In comparison with the study of [11-27], the degree of vascular congestion has substantially decreased, though there is still evidence of elevated pulmonary venous pressure and a large left effusion. Right subclavian catheter extends to the lower portion of the SVC. Brief Hospital Course: 66 F with NASH cirrhosis, seizure dz on keppra, DVT on coumadin, chronic LE ulceration now with altered mental status in setting of multiple medical problems including new pneumonia and sepsis. # Sepsis [1-21] wound infections vs. PNA: Transiently hypotensive responded to 1L NS in ED; elevated white count with bandemia. Hypotensive on night of admissionwith worsening UOP to <10cc/hr which trailed off to anuria. Treated with antibiotics and gentle fluid hydration without improvement in sepsis. Family did not want any life sustaining measures including the use of pressor agents. . # Acute oliguric on chronic renal failure: baseline 1.8 until [10-19], then increased to 2.3-2.5. Increased further to 2.7 after IVF boluses. FENA suggested prerenal failure initially, then urine found to have muddy brown casts suggesting ATN. Dialysis was not in accordance with the wishes of the family or patient. . # ALtered Mental Status/Delirium: Differential included hepatic encephalopathy, SBP, sepsis, seizures, keppra (in setting of ARF), cardiogenic shock. HCP did not want any measures including NGT, invasive procedures etc. In this context, home regimen of keppra, lactulose, and rifaximin was continued as patient tolerated po. . # Right Lower Extremity Ulceration: Started on Vanc/Meropenem per vascular during last admission and legs improved rapidly. Vascular did not think that the leg was the likely source of sepsis with no open ulcers there in the ED on this admission. Conservative management with wound care continued during this admission. . # Acute on chronic systolic heart failure: Pt with worsening wet cough and rales on exam after 6L positive on [11-28] to maintain SBP and UOP and with cold extremities concerning for cardiogenic shock picture. Family was offerred trial of dobutamine which was not accepted. . # Diabetes: Long-standing, covered with insulin sliding scale. . # Anticoagulation: on coumadin for DVT, held on admission in setting of supratherapeutic INR. INR reversed for PICC placement [11-29]. . # Access: Right Femoral line placed in ED. In discussion with family, PICC was obtained for cleaner access. . # PPX: supratherapeutic INR . # Code Status: DNR/DNI with goal of aggressive measures but no NG tube on admission, changed to CMO on [11-29] in the setting of new pneumonia, sepsis and acute renal failure. Patient remained hypotensive on the evening of [11-29] and became bradycardic and expired on [2180-11-30] at 3:45PM. Family, PCP, [Name10 (NameIs) ] admitting notified. Medications on Admission: 1. Carvedilol 3.125 mg Tablet QD 2. White Petrolatum-Mineral Oil QHS 3. Camphor-Menthol 0.5-0.5 % Lotion TID 4. Travoprost 0.004 % Drops Sig: hs 5. B Complex-Vitamin C-Folic Acid 1 mg QD 6. Acetaminophen 325 mg Tablet 2 PO Q6H 7. Levetiracetam 500 mg PO BID 8. Rifaximin 400 mg TID 9. Bumetanide 6 mg [Hospital1 ] 10. Miconazole Nitrate 2 % Powder [Hospital1 ] 11. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID 12. Mupirocin Calcium 2 % Cream (1) Appl Topical TID 13. Lactulose 30 ml [Hospital1 ] 14. Nystatin 100,000 unit/g Cream 15. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment [Hospital1 ] 16. Lantus 3units QHS 17. Insulin SS 18. Warfarin 1 mg Tablet QHS 19. Prilosec 20 mg QD Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Sepsis Pneumonia Acute Renal Failure Diabetes mellitus Venous statis ulcers Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None ICD9 Codes: 0389, 5845, 486, 5715, 4280, 3572, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9038 }	Medical Text: Admission Date: [2109-1-25] Discharge Date: [2109-2-7] Date of Birth: [2050-12-22] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Augmentin / Trimethoprim / Macrolide Antibiotics Attending:[First Name3 (LF) 3016] Chief Complaint: Nausea/vomiting Major Surgical or Invasive Procedure: None History of Present Illness: 58 yo F with recurrent stage IIIA NSCLC s/p carboplatin and pemetrexed on [2108-12-26] and recent admission here for gastroparesis who presented 2 days after discharge from here to [Hospital1 1474] with similar symptoms. There she was treated symptomatically. Cardiac biomarkers were checked and noted to be elevated, with a Trop T of 4.9, CK normal, EKG normal. Cards was consulted, and she underwent a stress test that was negative. She was treated with 48 hours of heparin. Per nursing report, stopped heparin [2-6] 'dropping counts' and concern for HIT. No HIT antibody testing in discharge paperwork. GI was also consulted and recommended symptomatic treatment with no EGD necessary, given recent EGD. She was transferred here for further management and concern for possible brain metastases given intractable N/V. Of note, she had an MRI in [11/2108] for same concern, which was negative for metastases. . She triggered on arrival to the floor here at [Hospital1 18] for HTN to 200/100 HR 110. EKG unchanged. HTN likely related to N/V/abdominal pain. . She reported mild epigastric pain. She was diagnosed with gastroparesis in [10/2108] based on a gastric empyting study after presenting N/V. She states that she rarely eats because she's afraid to. She's lost ~ 20lbs. She denies constipation or diarrhea. . ROS: Denies CP, SOB, palpitations, cough, HA, change in vision, dysuria, myalgias or arthralgias. She endorses depressed mood. . Past Medical History: Locoregional Recurrent NSCLC -- [8-/2103] presented with several months of persistent cough unresponsive to antibiotics. -- [10/2103] Chest x-ray demonstrated a density in the left mid lung, which was confirmed by a chest CT. -- [11/2103] chest CT revealing a 1.8-cm left upper lobe spiculated mass with pleural extension consistent with a malignant neoplasm. She also had a 2.6-cm right adrenal mass thought to be a simple adenoma as well as a 2.1-cm left lobe focus of nodular hyperplasia in the liver confirmed on an [2103-11-23] MRI. -- [2103-12-7] staging with PET CT showing increased activity in the left upper lobe nodule. Brain MRI at the time of diagnosis was negative. -- [2104-1-14], she underwent a left upper lobectomy and mediastinal lymph node dissection with pathology revealing adenocarcinoma with bronchioalveolar features well-to-moderately differentiated in a 1.5 cm tumor. She had lymphovascular invasion and one of three peribronchial lymph nodes was positive. There was also a tumor in the periaortic lymph node in the AP window region giving her a T1 N2 stage IIIA nonsmall cell lung cancer adenocarcinoma. -- [2-/2104] She was treated postoperatively with one cycle of paclitaxel and carboplatin, but was hospitalized post infusion on [2104-2-22] with chest pain, which was a ST elevation MI. She underwent emergent catheterization with a 60% LAD stenosis for which she got a Cypher drug-eluting stent. She did not receive further paclitaxel chemotherapy, but was started on a regimen of cisplatin and vinorelbine, which she received a single cycle on [2104-3-26], which was complicated by a MRSA UTI as well as a decrement in her creatinine clearance to 57 mL/min down from over 100. -- She subsequently declined any further chemotherapy and did not receive radiotherapy either. -- She did not continue to follow with her oncologist, but got periodic CT scans via her surgeon and PCP. [Name Initial (NameIs) ] [2107-5-2] CT with no evidence of recurrence, although a small nodule is noted in the left lower lobe measuring 3 mm, which had not been reliably demonstrated on the prior study. No mediastinal adenopathy reported on the [2107] scan. -- [2108-10-21] came to [Hospital1 18] ED with epigastric pain, emesis, and dizziness. She underwent an EGD with gastritis and gastric emptying study consistent with gastroparesis. -- [2108-10-25] CT which confirmed a new soft tissue abnormality in the left mediastinum starting just distal to the aortic arch associated with abnormal density surrounding the left main bronchus posteriorly and small lymph nodes in the left hilum suspicious for lung cancer recurrence. She also had a small pericardial effusion, a 2-mm right upper lobe nodule with associated ground-glass opacity. Again, seen was a 2.5-cm adrenal lesion and a right hepatic lobe lesion. She also underwent on [2108-10-25] an MRI of her L-spine, which was stopped for pain, but did not show metastatic involvement. Anti-[Doctor Last Name ] antibodies were negative. -- [2108-10-26], she underwent a bronchoscopy with EBUS, which showed a station 4L lymph node positive for malignant cells consistent with nonsmall cell cancer. The left main stem bronchus biopsy was only notable for bronchial mucosa and a level 7 node was negative. -- [2108-11-7] PET CT on [2108-11-7], which confirmed a PET avid paratracheal soft tissue density with an SUV of 6.7; a left hilar mass along the left main stem bronchus, which was also PET avid at SUV of 4.9; and a non PET-avid 6-mm right hilar lymph node; and 3-mm right lower lobe subpleural nodule. There was no FDG avidity seen outside of the chest and her adrenal mass is non PET-avid. -- [2108-11-17] MRI Brain: Subtle enhancement in the left parietal leptomeningeal area felt to represent a tiny vascular lesion like a cavernoma. There is also question of an enhancing lesion in the left cerebellum but without associated mass effect or edema. -- [2108-12-1] Chest CT with slight interval increase in adenopathy, no new findings. -- [2108-12-26] C1 of carboplatin/pemetrexed -- radiation therapy at [Hospital 1474] hospital . . OTHER MEDICAL HISTORY: CAD s/p STEMI during paclitaxel, s/p Cypher drug-eluting stent to the LAD on [2104-2-22] Fibromyalgia History of pneumonia Uterine fibroids status post fibroidectomy COPD Incisional hernia Adrenal adenoma Status post appendectomy in [5-/2105] Neuropathy along the thoracotomy site History of MVC with head trauma requiring multiple sutures, no reported intracranial pathology Social History: She lives alone. She is a current smoker (a pack per week, down from a pack/day). She does not drink. Family History: Her father had bladder cancer. Physical Exam: DISCHARGE VS: 98 220/120 110 22 93% RA GEN: Chronically ill appearing F in NAD HEENT: Dry MMM, pale conjunctiva, PERRL Neck: Supple CV: Tachy, regular no mrg Lungs: CTAB Abd: hyperactive BS, soft, mild TTP epigastrically, none elsewhere, slight voluntary guarding over epigastric area Neuro: No focal deficits Psych: Appropriate mood and affect ADMISSION VS: 97.5 108/68 (SBP 102-140) 92 (83-96) 16 97%RA GEN: NAD, AOx3, pleasant HEENT: PERRL, OP clear, MMM, Neck: Supple, no LAD CV: RRR, no m/r/g Lungs: CTA b/l, no rhonchi/wheezes/rales Abd: Soft, NT/ND +BS Skin: No rashes, ulcers, lesions noted Neuro: CNII-XII wnl, motor upper extremity [5-9], lower extremity [5-9]. Gait not observed Pertinent Results: [Month/Day (1) ] Counts [2109-1-27] 03:30AM [Month/Day/Year 3143] WBC-5.1 RBC-3.84* Hgb-10.8* Hct-31.4* MCV-82 MCH-28.1 MCHC-34.4 RDW-16.2* Plt Ct-231 [2109-2-7] 05:30AM [Year/Month/Day 3143] WBC-9.5 RBC-4.10* Hgb-11.5* Hct-34.8* MCV-85 MCH-28.1 MCHC-33.1 RDW-15.9* Plt Ct-271 Coags [2109-2-5] 05:05AM [Year/Month/Day 3143] PT-12.8 PTT-28.5 INR(PT)-1.1 Chemistry [2109-1-27] 03:30AM [Month/Day/Year 3143] Glucose-89 UreaN-5* Creat-0.6 Na-139 K-4.0 Cl-105 HCO3-26 AnGap-12 [2109-2-7] 05:30AM [Year/Month/Day 3143] Glucose-85 UreaN-20 Creat-0.5 Na-136 K-4.5 Cl-101 HCO3-24 AnGap-16 Liver [2109-2-1] 05:52AM [Month/Day/Year 3143] ALT-32 AST-25 LD(LDH)-207 AlkPhos-76 TotBili-0.6 [2109-1-29] MRI Head 1. Interval enlargement of ill-defined contrast enhancement in the anterior inferior left cerebellar hemisphere, most suggestive of progressing metastatic disease, which could be leptomeningeal and/or parenchymal. 2. Stable small focus of cortical contrast enhancement, with a possible leptomeningeal component, in the parasagittal left parietal region, which could represent a stable metastasis, or a vascular malformation such as a cavernoma. [2109-1-30] CSF ATYPICAL. Rare single atypical cell, not sufficient for definitive characterization. [2109-1-30] CSF Immunophenotyping Non-diagnostic study. Clonality could not be assessed in this case due to insufficient numbers of B cells. Cell marker analysis was attempted, but was non-diagnostic in this case due to insufficient numbers of cells. If clinically indicated, we recommend a repeat specimen be submitted to the flow cytometry laboratory. [2109-2-1] CT Head There is also subtle edema in the left thalamus, which could represent acute ischemia. Recommend evaluation with MRI. [2109-2-2] CT Head Stable hemorrhage in the left external capsule and lateral putamen. [2109-2-3] CTA Abd/Pelvis 1. No evidence of mesenteric ischemia. Mild focal narrowing at the origin of the SMA with associated post-stenotic dilatation unlikely of clinical significance with widely patent celiac axis and its major branches. 2. Replaced left hepatic artery. 3. Previously noted 2.5 x 1.3-cm right adrenal nodule can be characterized as an adrenal adenoma. 4. Fibroid uterus. Brief Hospital Course: HOSPITAL COURSE 58yo F with PMH recurrent NSCLC stage IIIA s/p chemo/XRT c/b gastroparesis, a/w persistant N/V, hospital course c/b MICU stay for HTN emergency w IPH, urinary retention, now w well-controlled BP, foley out without retention, no nausea/vomitting, discharged home. . ACTIVE # HTN: Patient was admitted with recurrent HTN episodes to SBP 220 in setting of vomiting and severe nausea, c/b Intraparenchymal hemorrhage as discussed below. Baseline HTN was thought to [2-6] nausea, vomitting, and urinary retention (found on imaging, believed to iatrogentic from anticholinergic medications). Upon resolution of above issues, labile BP improved so that patient no longer required anti-HTN medications. At time of discharge patient's BP was well controlled w SBP 102-140 over 24hrs. She underwent a workup for pheochromocytoma w negative urine metanephs. At time of discharge serum metas were pending. . # Gastroparesis w N/V: Patient with a chronic hx gastroparesis of uncertain etiology ([2-6] radiation v chemo v paraneoplastic v narcotics v tumor infiltration). During hospitalization, patient had improvement in nausea with narrowing of medications (it was thought that baseline nausea was being exacerbated by large amount of medications she was receiving). Patient was advanced to a regular diet and tolerated it. At time of discharge she was continued on standing reglan and ativan with meals (all other anti-emetics discontinued). It was decided to defer a repeat upper GI series to the outpatient setting. . # Urinary Retention: During her hospitalization, patient was found to be retaining large amount of urine and had a foley placed. It was thought that the etiology most likely iatrogenic [2-6] to anticholinergic action of medications (e.g. anti-emetics). Her medications were narrowed, and she had her foley pulled w/o additional retention . # s/p ICH: As mentioned above, on [2-1], in setting of HTN urgency, patient found to have 1.8cm basal ganglia bleed on CT. Neurosurg evaluated and felt that no surgical evacuation was needed. Repeat CT 24hr later was stable. Her aspirin was discontinued. . # NSCLC: Patient w history of NSCLC w metastases. Imaging demonstrated stable metastases, with suspected brain met, but LP showed only 1 atypical cell. Patient was evaluated by neuro-onc (Dr. [Last Name (STitle) 60181] who felt that LP and MRI head should be repeated 1mo after discharge. Further therapy was deferred to outpatient primary oncologist. . # Thrush: Patient found to have thrush during admission, thought to be [2-6] inhaled steriod use. Improved on nystatin and floconazole. At discharge, patient given script to finish 14d fluconazole (d1=[1-29]). . INACTIVE # Asthma/COPD: Well controlled. Patient was continued on home symbicort, albuterol, ipratropium, fluticasone propionate. . # Depression: Continued home celexa. . TRANSITIONAL 1. Code status: Patient remained full code. 2. Pending: At time of discharge, plasma metanephrines were pending and will require follow-up 3. Transition of Care: Patient was scheduled for follow-up with Dr. [Last Name (STitle) ] [First Name (STitle) 60182]. Patient will need to be scheduled for a repeat MRI and LP 4 weeks after discharge. Medications on Admission: Lidocaine 5% Patch 1 PTCH TD DAILY [1-25] @ 2245 View Alprazolam 0.5 mg PO/NG [Hospital1 ] Alprazolam 0.5 mg PO/NG QHS Albuterol Inhaler 2 PUFF IH Q4H:PRN sob Hydrocodone-Acetaminophen [1-6] TAB PO Q4H:PRN pain traZODONE 25 mg PO/NG HS:PRN insomnia Simvastatin 20 mg PO/NG DAILY Metoprolol Succinate XL 25 mg PO DAILY Ipratropium Bromide MDI 2 PUFF IH QID FoLIC Acid 1 mg PO/NG DAILY Docusate Sodium 100 mg PO BID:PRN constipation Fluticasone Propionate 110mcg 2 PUFF IH [Hospital1 ] Budesonide inh [Hospital1 ] Promethazine 12.5 mg IV Q6H:PRN nausea Citalopram 20 mg PO/NG DAILY Plavix 75 mg qd Aspirin 325 mg PO/NG DAILY Pantoprazole 40 mg IV Q24H Metoclopramide 10 mg PO/IV TID Morphine Sulfate 1 mg IV Q6H:PRN pain Lorazepam 0.5 mg IV Q6H:PRN nausea Prochlorperazine 10 mg IV Q6H:PRN nausea Ondansetron 4 mg IV Q8H:PRN nausea Discharge Medications: 1. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:30 Adhesive Patch, Medicated(s) Refills:0 2. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO three times a day: with meals. Disp:90 Tablet(s) Refills:0 3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TIDAC (3 times a day (before meals)). Disp:90 Tablet(s) Refills:0 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. budesonide-formoterol 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) inhalation Inhalation twice a day. Disp:2 inhalers Refills:2 8. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:2 inhalers Refills:2 9. fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:5 Tablet(s) Refills:0 10. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:2 inhalers Refills:2 Discharge Disposition: Home Discharge Diagnosis: PRIMARY Non-small cell lung cancer SECONDARY Intraparenchymal Hemorrhage Gastroparesis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [Known lastname ], It was a pleasure taking care of you at [Hospital1 827]. You were admitted for treatment of nausea, vomiting and high [Hospital1 ] pressure. As a result of your high [Hospital1 ] pressure, during your hospital stay you had a small bleed in your brain. The bleed was monitored by neurosurgery; it stopped, and the team decided that you did not need surgery. Your [Hospital1 ] pressure and nausea were treated with medications and they improved. During your hospital stay you were also found to be retaining urine. This was likely a side-effect of the many anti-nausea medications you were on. Your medications were changed and you no longer retained urine. During this hospitalization MANY changes were made to your medications. To avoid confusion, we ask that you throw away all of your home medications, and fill the following prescriptions: 1) Lidocaine Patch - for pain 2) Metoclopramide (reglan) - for nausea 3) Lorazepam (ativan) - for nausea 4) Pantoprazole (protonix) - for stomach ulcer 5) Citalopram (celexa) 6) Folic Acid (folate) 7) Budesonide-formoterol (Symbicort) - for shortnes of breath 8) Fluticasone - for shortness of breath 9) Ipratropium - for shortness of breath 10) Fluconazole - to treat a fungal infection in your mouth (take until [2109-2-12]) Please see below for your recommended follow-up appointments Followup Instructions: Department: Radiation Oncology When: Monday [2109-2-11] at 9:15 AM With: [Last Name (NamePattern1) 60183] Address: [Street Address(2) 60184].,[Hospital1 1474], [Numeric Identifier 60185] Phone: [Telephone/Fax (1) 60186] Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [2109-2-14] at 9:30 AM With: [First Name4 (NamePattern1) 2053] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [2109-2-14] at 9:30 AM With: [Name6 (MD) ] [Name8 (MD) 831], MD [0-0-] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [Name6 (MD) ] [Name8 (MD) 831] MD, [Doctor First Name 3018] ICD9 Codes: 431, 2761, 4019, 3051, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9039 }	Medical Text: Admission Date: [2193-10-6] Discharge Date: [2193-10-21] Date of Birth: [2131-12-25] Sex: M Service: [Last Name (un) ] CLINICAL HISTORY: Mr. [Name13 (STitle) 12101] is a 61 year old gentleman who is status post a segment 5 liver resection in [2193-3-11] by Dr. [Last Name (STitle) ] for cholangiocarcinoma. On [2193-10-6] he presented via the emergency room with a three week history of increasing abdominal pain, a 72 hour history of intense nausea and vomiting and inability tolerate P.O.'s. Since his original surgery he had been quite well and denies any similar events. He denies any prior abdominal surgery, has had a negative colonoscopy in [2191-3-11]. PRIOR MEDICAL HISTORY: 1. Cholangiocarcinoma, status post resection [2193-3-11]. 2. Tonsillectomy. 3. Colonoscopy in [2191-3-11] which was negative. MEDICATIONS: Aspirin 81 mg P.O. q day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient denies smoking. He is an occasional alcohol drinker. Denies intravenous or other recreational drug use. He is a retired [Company 2318] worker who is divorced but does spend time with his son. FAMILY HISTORY: Mother died at 85 of unknown cause and father died at 92 of cancer. LABORATORIES ON PRESENTATION: White blood cell count of 13.4, hematocrit of 45, platelets of 309. Sodium 135, potassium 4.3, chloride 92, CO2 32, BUN 31, creatinine 1.0 and glucose 111. Lactate noted to be 1.5. AST 35, ALT 26, alkaline phosphatase 168, total bilirubin 2.0. PT 13.0, PTT 23.8, INR of 1.1. CT scan with both P.O. and intravenous contrast performed in the emergency department shows several dilated loops of small bowel. There is a high grade obsturction in the mid small bowel in an area proximal to that obstruction which was concerning for pneumatosis. PHYSICAL EXAMINATION: In the emergency department Mr. [Name13 (STitle) 12101] was described as a frail appearing male clearly uncomfortable. He is alert and oriented times three but easily distracted. He has a maximum temperature of 96.4, pulse of 114, blood pressure of 140/80, respirations 18, satting 19 percent. In general his conjunctiva and mucosa both seem to be dry. Cranial nerves 2 through 12 are grossly intact. Pupils are equal and reactive to light with sclera nonicteric. Trachea is midline. Lungs are clear to auscultation bilaterally. Nose is likewise noted to be nontender, noninflamed. Cardiac examination is regular rate and rhythm, no evidence of any murmurs, rubs or gallops. Abdomen shows a well healed midline incision without any evidence of any herniation. Auscultation shows highly pitched hypoactive bowel sounds. Abdomen is otherwise soft, diffusely tender, nondistended. No evidence of any organomegaly. Rectal examination shows no evidence of masses and is guaiac negative. CLINICAL COURSE: Based on his presentation to the emergency department and CT scan findings examination by Dr. [First Name (STitle) ] in the emergency department felt that the patient would be best served by an emergent exploratory laparotomy. In the emergency department a Foley catheter was placed and less than 100 cc of urine was seen with this. The patient was immediately bolused 4 liters of Crystalloid and urine output gradually began to increase. Shortly thereafter the patient was taken to the operating room. During operation diffuse carcinomatosis was seen. There was a high grade obstruction and mat of cancer tethering down a considerable portion of the bowel. A diverting enterostomy was placed. A decompression gastric tube was placed. Please refer to operative note for full details. Following surgery the patient was extubated and transferred to the post anesthesia care unit. He continued to be very hypotensive and oliguric and ultimately required several liters of Crystalloid boluses. Postoperative laboratories included a white count of 7.7, hematocrit of 36.5, platelets of 320. Sodium was 138, potassium 4.1, chloride 103, CO2 26, BUN 21, creatinine 0.8, glucose 139. On the first postoperative night patient was again persistently oliguric and was dosed several times for this. He was started empirically on Zosyn and his gastric tube was left to drainage. From the post anesthesia care unit the patient was transferred to the Intensive Care Unit. Pain control was provided by p.r.n. analgesia. On the morning of postoperative day three patient was transferred to the normal surgical floor. At that time diuresis was started. Initially patient had a brisk diuresis but intermittently required doses of 20 to 40 mg intravenous of Lasix. Also at that time surgical teams began engaging both the social work resources and palliative cancer resources in discussing the poor prognosis of this patient with him and his family. Through several meetings the treatment and long term prognosis of this patient were discussed at length with the patient. By postoperative day four there was an attempt to cap the patient's gastrostomy tube. This ultimately had to be opened shortly after for distention and for passage of flatus. On postoperative day five patient was initiated on total parenteral nutrition. On the evening of hospital day six the patient had a spontaneous desaturation event. By report he attempted to get out of bed on his own and became vasovagal. Once placed back in bed his oxygen saturations were shown to go down approximately 60 percent on room but quickly returned to [Location 213] when placed on nasal cannula. Initial arterial blood gas on room was 7.46, 44, 36, 26 and 1. On 6 liters of oxygen. This was 7.48, 38, 78 and 283. Of note, the CBC at that time showed a rising white count of 15.8. Full work up for possible pulmonary embolism was started at that time including a VQ scan and ultimately a CTA. Both of these were shown to be negative for pulmonary embolism. Patient was transferred back to the Intensive Care Unit where he continued to stabilize. He was started empirically on Zosyn for suspected pneumonia and consolidation which was seen by CT scan. On hospital day 8 patient was placed with a PICC line. He clinically responded well to Zosyn and ultimately was transferred out of the Intensive Care Unit. On subsequent days his gastrointestinal tract likewise opened up and his diet was slowly advanced from n.p.o. to regular although this total parenteral nutritions continued to be run. On [2193-10-17], postoperative day 11, patient was actually felt to be a good candidate for discharge to rehabilitation. However, he had an episode of abdominal pain and distention and is deemed appropriate to keep hem over the weekend with his gastrostomy tube unclamped. Over the next 48 hours his gastrostomy tube was reclamped. He tolerated this well and tolerated a regular diet. Again total parenteral nutrition was left in place. On the morning of [2193-10-21] after evaluation by the attending surgeon and the entire surgical team it was deemed that the patient was an appropriate candidate for discharge. MEDICATIONS ON DISCHARGE: 1. Patient will continue total parenteral nutrition until weaned off. 2. Albuterol MDI 1 to 2 q 6 hours p.r.n. 3. Ipratropium bromide MDI q 4 hours p.r.n. 4. Sliding scale insulin as needed for total parenteral nutrition. 5. Amitriptyline 25 mg 1 P.O. q h. s. 6. Lopressor 100 mg P.O. B.I.D 7. Alprazolam 0.25 mg P.O. t.i.d. 8. Alprazolam 0.25 mg P.O. q 8 as needed for agitation. 9. Morphine 15 mg tablets 1 to 2 P.O. q 3 hours p.r.n. as needed for pain. 10. Finally Zosyn 4.5 grams intravenous q 8 hours for three days. FOLLOW UP: The patient is scheduled to follow with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and Dr.[Name (NI) 1369] office will likewise contact him to set up a follow up appointment. In addition, the patient has been actively involved with the palliative care team and they are working with him on the best long term options. DISCHARGE DIAGNOSES: 1. Include all prior diagnoses and add carcinomatosis. 2. Recurrent cholangiocarcinoma. 3. Status post enteral diversion and placement of gastrostomy tube. DISPOSITION: The patient is discharged on total parenteral nutrition while tolerating early stage regular diet. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 3432] Dictated By:[Last Name (NamePattern1) 9178] MEDQUIST36 D: [2193-10-21] 09:39:10 T: [2193-10-21] 10:45:22 Job#: [Job Number 25650] ICD9 Codes: 486
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9040 }	Medical Text: Admission Date: [2182-4-24] Discharge Date: [2182-5-9] Date of Birth: [2162-1-23] Sex: M Service: SURGERY Allergies: Aspirin Attending:[First Name3 (LF) 974] Chief Complaint: s/p Multiple gunshot wounds Major Surgical or Invasive Procedure: [2182-4-24] Exploratory laparotomy; repair of colonic injury X2; IVC filter placement [2182-5-3] PICC line placement History of Present Illness: 20 yo male s/p multiple gun shot wounds to his torso resulting in injuries to his lumbar spine, liver, spleen and kidney. He was transported to [Hospital1 18] for further care. Past Medical History: Asthma Previous gunshot wound assault x2 Social History: Lives with his parents Family History: Noncontributory Physical Exam: Upon admission: BP 110/80 HR 76 RR 16 Awake HEENT: EOMI Chest: CTA bilat Cor: RRR Abd: firm; diffusely tender; wound left flank ~ 1 CM Rectum: decreased tone Sensory: absent sensation from thighs down Pertinent Results: Upon admission: [2182-4-24] 09:52PM GLUCOSE-133* POTASSIUM-3.9 [2182-4-24] 09:52PM HCT-38.4* [2182-4-24] 06:54PM HGB-11.7* calcHCT-35 O2 SAT-99 [2182-4-24] 05:15PM AMYLASE-88 [2182-4-24] 05:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2182-4-24] 05:15PM WBC-11.1* RBC-4.37* HGB-14.8 HCT-42.5 MCV-97 MCH-33.8* MCHC-34.8 RDW-12.1 [2182-4-24] 05:15PM PLT COUNT-269 [2182-4-24] 05:15PM PT-12.7 PTT-21.3* INR(PT)-1.1 [2182-4-24] 05:15PM FIBRINOGE-230 CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST Reason: spinal/vascular injury? Field of view: 36 Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 20 year old man s/p GSW to left lower flank, no exit wound, cant feel or move below knees bilaterally - vital signs stable, gcs 15 REASON FOR THIS EXAMINATION: spinal/vascular injury? CONTRAINDICATIONS for IV CONTRAST: None. CT TORSO PERFORMED ON [2182-4-24]. IMPRESSION: Gunshot wound to the abdomen with injuries to the descending colon, bilateral psoas muscles, spinal cord (L3-4 level) inferior pole of the right kidney, and segment VI of the liver. Active extravasation of urine is noted on delayed imaging, though no evidence of active bleeding. Bullet is noted lodged in the liver in segment VI. MR L SPINE W/O CONTRAST [2182-4-25] 1:14 AM IMPRESSION: Status post abdominal and lumbar gunshot injuries as described above. There is evidence of heterogeneous signal intensity in the filum terminale at the level of L3/L4 likely consistent with subarachnoid hemorrhage and multiple bone fragments within the spinal canal. There is no evidence of epidural hematoma or significant narrowing of the spinal canal. At L2/L3, there is evidence of right paraspinal gunshot injury involving the right psoas muscle with extension at the level of the corresponding right neural foramen with possible lesion along the nerve root and the dorsal root ganglion at L2 nerve root, please correlate clinically. Similar findings are observed at L3 on the left side. Free fluid is observed in the abdominal cavity as described in the prior CT of the abdomen. CT ABDOMEN W/CONTRAST [2182-4-28] 9:55 AM IMPRESSION: 1. Multiple dilated loops of jejunum with air fluid levels and wall thickening, ileal decompression. Findigs are c/w SBO. 2. Liver and right renal lacerations stable, no hematoma no assocted adjacent fluid. 3. Tiny amount of fluid seen within the left paracolic gutter and right perirenal space. 4. Foci of free air within the abdomen and pelvis likely due to recent surgery. Brief Hospital Course: He was admitted to the Trauma Service and taken directly to the operating room for exploratory laparotomy, primary repair of left colon colotomy x2, exploration of retroperitoneum, right and left and evaluation of hepatic through-and-through gunshot wound with drainage. There were no intraoperative complications. Postoperatively he was taken to the Trauma ICU where he remained sedated and intubated. On [2182-4-25] he was taken back to the operating room for placement of an inferior vena cava filter. He was eventually weaned and extubated and was later transferred to the regular nursing unit. He developed an ileus; an NG tube was placed, his output was high initially. The NG tube remained in place for several days. A PICC line was placed in preparation for possible TPN. A CT of the abdomen was performed to rule out intra-abdominal fluid collection; none was identified. Bowel function did eventually return and the NG tube was removed. His diet was advanced slowly and he is currently tolerating a regular diet. The PICC line was removed. Orthopedic Spine surgery was consulted for his spine injury; this was non operative. He was evaluated by Physical therapy and was strongly recommended for [Hospital ] rehab post acute hospitalization. He has slowly begun to have intermittent sensation in both lower extremities. Psychiatry was also consulted because patient began to have nightmares of the events surrounding the trauma. It was recommended to try Clonidine 0.1 mg qhs to treat the nightmares and insomnia and to titrate up as needed. Because at the time he was NPO he was started on Clonidine 0.1 mg patch. His overall mood and mental status have improved significantly; he is more engaging and participatory with his care; he even appears to be more optimistic regarding the progress that he has made so far. There have been no behavioral problems. Social work has also been following closely with patient and his family for emotional support. The Center for Violence Prevention & Recovery were also consulted; providing information on victim's compensation and counseling post hospitalization. He does continue to have pain control issues; initially he was on PCA and was later changed to oral Dilaudid with IV for breakthrough pain. The Dilaudid was later changed to Oxycodone prn. His current regimen appears to be more effective. He developed a UTI and was treated with Cipro course. He does have an indwelling Foley catheter and this was changed. He continues to work with PT & OT and had made some progress; he will clearly benefit from a [Hospital ] rehab post acute hospital stay. Medications on Admission: None Discharge Medications: 1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 3. Phenol-Phenolate Sodium Mouthwash Sig: One (1) Spray Mucous membrane Q4H (every 4 hours) as needed for throat irritation. 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal EVERY OTHER DAY (Every Other Day) as needed for constipation. 5. Famotidine(PF) in [Doctor First Name ] (Iso-os) 20 mg/50 mL Piggyback Sig: Twenty (20) MG Intravenous Q12H (every 12 hours). 6. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 7. 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. 8. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for itching. 9. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for spasm. 10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 11. Oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours) as needed for pain. 12. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: s/p Gunshot wound to abdomen Segment VI liver injury Inferior pole right kidney injury Descending colon injury L2/L3 paraspinal injury - L4 paraplegia Urinary tract infection Discharge Condition: Good Followup Instructions: Follow up with Dr. [Last Name (STitle) 1007], Spine Surgery in [2-12] weeks, call [Telephone/Fax (1) 3736] for an appointment. Follow up with Dr. [Last Name (STitle) ], Surgery in 2 weeks, call [Telephone/Fax (1) 2359] for an appointment. You also have an appointment with Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 9001], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2182-6-25] 2:00 Completed by:[2182-5-14] ICD9 Codes: 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9041 }	Medical Text: Admission Date: [2123-10-27] Discharge Date: Date of Birth: [2085-3-7] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 38-year-old man with AIDS referred by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4569] who has fevers to greater than 104, likely pneumonia or other pulmonary process increasing for one month. He reports increased cough, usually nonproductive, but occasional production of bloody sputum. In addition, he has some dark stool which he states is maroon in color in the last few weeks as well as nausea and vomiting. He states that sometimes he vomits blood. Reports left upper quadrant pain times one month with eating. Denies dyspnea or chest pain. He states some pain in his chest with cough only and that's resolved, mild headache like a hot plate on his forehead, mild neck pain, positive urinary frequency and dysuria times weeks. Today, he has had diarrhea, 30 minutes after meals. He states he has been depressed, not sleeping and wants to die without active suicidal ideation. PAST MEDICAL HISTORY: 1. HIV diagnosed in [2118], treated with HAART in [2122-7-2], viral load was 50,000, went to less than 50, but then patient quit his medications after his rectal abscess. Last CD4 count [2123-7-2] was 1, viral load in [2123-6-1] was greater than 500,000. 2. Kaposi's of skin, oral cavity and lung, status post chemotherapy in [2119]. 3. ......... of the skin, buttocks in [2122-4-1]. 4. History of neutropenia exacerbated by Bactrim and resolved with discontinuation. 5. HSV2 resolved [2123-6-1], perianal. 6. History of perianal abscess in [2122], status post surgery. 7. Left upper lobe pneumonia in [2123-7-10], treated with levofloxacin and resolved. 8. Recurrent zoster. 9. Pancreatitis. 10. Oral ulcers and [Female First Name (un) ] esophagitis. 11. Depression. 12. Tinea barba. SOCIAL HISTORY: 45 pack year of tobacco. Formerly 12-24 beers most recently until five days ago. FAMILY HISTORY: Noncontributory. ALLERGIES: Bactrim intolerance. MEDICATIONS: Patient on only one month in [Month (only) 205] acyclovir 800 t.i.d. times 30 days, then b.i.d., azithromycin 250 times five q. week, dapsone 100 q.d., Epivir 150 b.i.d., Indinavir 400 b.i.d., Paxil 20, Prilosec 20, Ritonavir 100 times four b.i.d., stavudine 40 b.i.d. REVIEW OF SYSTEMS: No rigors, fevers and chills and sweats today only. Weight loss 30 pounds in one month. Cough. Bloody sputum. Very weak, appetite is poor, severe watery diarrhea ("like peeing"). Left upper quadrant abdominal pain, nausea and vomiting. Pain at the site of his spinal tap, insomnia. PHYSICAL EXAMINATION: Temperature 104.4. Heart rate 110. Blood pressure 118/68. Respiratory rate 18. In general: Thin, uncomfortable male with soft voice who looks chronically but not acutely ill. Head, eyes, ears, nose and throat: Pupils equal, round and reactive to light. Extraocular muscles were intact. Mucous membranes moist. White patches on cheek and tongue with poor dentition. Neck: Small lymphadenopathy. Cardiovascular: Loud S1, S2, no murmurs, tachycardia but regular. Pulmonary clear to auscultation bilaterally. Abdomen loud bowel sounds, soft, diffusely tender, maximum left upper quadrant, right upper quadrant, suprapubic liver edge down 2 cm, 10 cm total of 10, tender. Extremities: No cyanosis, clubbing or edema. Skin: Brown macules 1 cm scattered on back, right thigh. Rectal: Heme positive, perianal abscess with scarring. Genitourinary: Scars on scrotum, papules with ventral dot right inguinal consistent with molluscum contagiosum. Psychiatric: Depressed mood. Neurological: Alert and oriented times three, normal bulk and tone. LABORATORIES: White blood cell count 2.3, hematocrit 35.5, platelets 112,000, MCV 90. Sodium 130, potassium 3.9, chloride 96, bicarbonate 22, BUN 10, creatinine 0.7, glucose 104. Urinalysis: Ketones 15, protein 100, otherwise negative. Cerebrospinal fluid: Tube 2 glucose 61, 4 no cells clear. Head CT negative. Chest x-ray: Left upper lobe consolidation consistent with pneumonia. Patient admitted to the Medical Service. HOSPITAL COURSE: By system: 1. Infectious Disease: The patient was spinal tapped which was not consistent with meningitis, however, he was treated empirically with Ceftriaxone and noted to defervesce. Therefore, Ceftriaxone was continued. Infectious Disease Service was consulted. PO acyclovir and dapsone were continued. KUB was obtained which was negative except for a small amount of pelvic free fluid. Numerous microbiology studies were sent. The only one which was positive was a sputum that grew out aspergilloses fumigatus. Blood cultures, urine cultures were negative. Ova and parasites was negative. Stool ova and parasites was negative. Stool culture for yersinia, Campylobacter, E. Coli, vibrio, cryptococcus, Giardia were all negative. RPR was negative. Sputum ova and parasites was negative. Toxicology IgG was negative. Cryptococcus antigen was negative. Sputum for acid fast bacilli times three were negative, however, patient was isolated respiratory until this was obtained. The cerebrospinal fluid from [10-27] grew one colony on one plate of ..... bacterium which was .......this was thought most likely to be contaminant. Patient was continued on ceftriaxone as he defervesced and remained afebrile. Also continued on dapsone and acyclovir, however, his white count was noted to drop and the acyclovir was decreased and then stopped. However, after stopping the acyclovir, the patient noted increase in rectal burning and the acyclovir was restarted given the patient's history of herpes and the patient was put on neutropenic precautions. The patient was not restarted on HAART during this acute period as he had been off it previously. On [10-28], a chest CT was obtained which showed a 1.8 x 1.5 cm cavitary lesion in the posterior left upper lobe surrounded by consolidation and ground glass opacity, as well as scattered emphysema. The patient was started on nystatin for thrush and over the next couple of days, the diarrhea seemed to resolve. The Pulmonary Service was consulted and on [11-2], the patient underwent bronchoscopy. BAL grew aspergillus fumigatus, however, it was negative for PCP, [Name10 (NameIs) ] cardia, ova and parasites and acid fast bacilli. Thoracic Surgery was consulted to assess whether the aspergilloma was resectable. They felt that he would need at least four to six weeks of treatment before surgery would be a consideration. Therefore, amphotericin was started with a test dose and then at 0.5 mg /kg/IV/q.d. Gastrointestinal was consulted given continuing abdominal pain without source, heme positive, and history of skin ........and patient with elevated eosinophils on his white count differential. Esophagogastroduodenoscopy was performed on [11-4] which was noted for friability, erythema and congestion in the antrum consistent with gastritis and abnormal mucosa in the duodenum, but otherwise normal. Biopsy was taken. The antrum biopsy showed chronic gastritis with focal intestinal metaplasia. No active gastritis seen. Duodenal biopsy showed no diagnostic abnormalities. Patient was continued on Protonix. 2. Gastrointestinal: As above. Multiple stool studies were sent and all were negative. 3. Respiratory: Patient found to have aspergillosis and started on amphotericin. 4. Fluid, electrolytes and nutrition: Patient noted to have a low sodium on admission of 130 felt consistent with syndrome of inappropriate diuretic hormone. This resolved with fluid restriction. 5. Psychiatric: Patient continued on Paxil. It was discussed with the patient as to whether to have a social worker or psychiatrist and he declined at that time. On [11-9], patient was noted to start having nausea and vomiting. After that, he was found later in the morning, after he had tried to get out of bed, next to formed stool and he was unable to get up at that time. Head CT was ordered but before patient was sent for head CT it was noted that his systolic blood pressure dropped to the 80s. Patient was bolused with one liter of normal saline. Blood pressure only responded slightly. Medical Intensive Care Unit Team was called and was in the room at bedside. Patient was vomiting and curled on his side. Eyelids were noted to flutter and subsequently patient noted to become rigid, then arms came towards chest in tonic-clonic. Patient was nonresponsive. Ativan 4 mg given and Code Team called. Patient intubated for airway protection and transferred to Medical Intensive Care Unit. In the Medical Intensive Care Unit, patient by system: 1. Neurologic: He was loaded on Dilantin. First lumbar puncture showed protein of 524. Other cultures and cytology were negative. He was on acyclovir until HSV, PCR came back negative from cerebrospinal fluid. MRI was negative. Patient continued to have occasional gaze deviation and facial twitching, so, bedside electroencephalogram was obtained which revealed seizures q. 10 minutes. He was loaded on phenobarbital. He was still having seizures, so induced pentobarbital coma. Neurology had been consulted. Electroencephalogram flat line using pentobarbital for 72 hours. During this time, he developed central diabetes insipidus, spiked fevers with negative cultures, which was suspicious for ..........dysregulation. The second lumbar puncture showed protein of 226. Patient believed to have meningitic process, especially active in basilar regions given central diabetes insipidus and neurogenic fevers of unclear etiology. Question of whether this might be partly due to HIV encephalopathy. After three days from [11-11] to [11-14], pentobarbital was weaned to off over 24 hours, continuous electroencephalogram monitoring for 72 hours after started pentobarbital taper with no signs of epileptic activity on electroencephalogram. Bedside electroencephalogram was discontinued and patient was followed clinically. He had occasional eye twitch and facial myoclonus believed not to be seizure activity. He was maintained on phenobarbital and Dilantin, which will be his anti-epileptic coverage for life. Goal levels are 30 for phenobarbital and 17 for Dilantin. On the fourth day after pentobarbital was off, patient noted to have brain stem activity, reactive pupils and corneal reflexes. By day seven, off pentobarbital. He became awake and alert, though not interactive over the next two to three days, he became interactive and vocal after extubation, although not at baseline mental status. He was able to follow commands sporadically, although confused often and quite exhausted. Mental status will be impeded by his high viral load and his cerebrospinal fluid. Central diabetes insipidus resolved but he continued to have fevers, but did not seem to be infectious. At the end of his Intensive Care Unit stay, he appeared to have ICU psychosis requiring a sitter and Haldol. 2. Pulmonary: He was intubated for airway protection. Initially acidotic during seizure that resolved quickly on assist control while on pentobarbital, and then quickly weaned to pressure support. He was extubated with ease after the mental status improved and he had no problems with oxygenation or ventilation. He spent 11 days on the ventilator during which time sputum became colonized with E. Coli not believed to be a pathogen, developed bilateral effusion from fluid overload that resolved with diuresis. Bronchoscopy after mucus plug, off right upper lobe with complete collapse. Plug suctioned at bronchoscopy and right upper lobe atelectasis resolved completely. Left upper lobe aspergilloma remained unchanged per chest x-ray. Patient was maintained on itraconazole as amphotericin had to be stopped after the seizure. 3. Cardiovascular: In the beginning, patient was initially septic appearing requiring pressors. The need for pressors increased during the pentobarbital, on dopamine and vasopressin after the pentobarbital was discontinued, pressors easily stopped and patient had good blood pressure, thereafter, echocardiogram was done while in coma with mildly depressed left ventricular function. After, out of his coma, he had no cardiac issues. He initially developed effusions from fluids he received but auto drive receptor-like episode resolved with resolution of the effusions. 4. Infectious Disease: Dapsone prophylaxis was continued. Itraconazole for aspergilloma. Initially patient on ceftriaxone, Levaquin, Flagyl because he looked like he might have gram negative rods sepsis, but when cultures were negative, the Levaquin and Flagyl were discontinued. He was kept on Ceftriaxone to complete a 24 day course. He was on acyclovir until HSV PCR was negative, ESBL, E. Coli and sputum, but no infiltrates, so believed to be a colonizer. Cultures were always negative even when spiking q.d. Cultures were drawn q. 24-48 hours so fever thought not to be infectious. Renal function was good throughout. Central diabetes insipidus treated with DDAVP and matching out's with resolution of diabetes insipidus. In fact, DDAVP was stopped completely because he became hyponatremic and then sodium became normal. Fluid status and urine osmolarity were monitored and normal saline or D5 water was given prn. 5. Gastrointestinal: Initial loss of bowel sounds during the coma with poor motility that improved with Reglan. Patient was put on TPN during the coma, but after the coma, tolerated tube feeds. Patient with good bowel movement after the coma. Patient stable and transferred to floor on [2123-11-25]. This will be his hospital course from [2123-11-25] to [2123-11-30] by system: 1. Pulmonary: Patient with aspergilloma, continued on itraconazole. 02 saturations and respiratory rate remained stable. Patient remained on nasal cannula oxygen. 2. Infectious Disease: Patient continued to spike fevers every day. Blood cultures and urine cultures were sent. Blood cultures were always negative or pending as were urine cultures. Infectious Disease consult Service continued to follow with the discussion that HAART might be started when Dilantin was weaned off as the two interacted and could not be started reliably concomitantly. Another lumbar puncture was obtained for question of possible neck stiffness and photophobia. That night, tube four had white blood cells, 8 red blood cells, 21 polys, 2 lymphocytes, 52 monocytes, 47 in tube 1, 7 white cells, 22 red cells, no polys, 71 lymphocytes, 24 monocytes, protein of 46 and glucose of 67. That night, he got a dose of Ceftriaxone, however, the next day with review with Infectious Disease Team, it was felt that this was not consistent with meningitis, and so, Ceftriaxone was stopped. Patient was started on Levaquin for possible coverage of pneumonia as he had some crackles on exam. The following day, oxacillin was also started but this was stopped after one day as LFTs were known to elevate. At this time, no source for fevers were definitely discovered. Patient with nasogastric tube, no nasal drainage or facial pain to palpation, however, CT at maxillary facial was obtained and is pending at this time. 3. Neurology: Neurology Team continued to follow the patient. Dilantin and phenobarbital levels were monitored. Patient not noted to have any seizure activity. Patient was started on Keppra, which will not interact with HAART, and after several days of this, Dilantin will fully be weaned to off as Keppra becomes therapeutic. 4. Gastrointestinal: Patient followed by Nutrition and continued on tube feeds, tolerating well, hold on starting po until swallow study. On [12-1], LFTs were checked and noted to have risen. ALT at 57, AST at 176, alkaline phosphatase at 333, therefore, oxacillin was stopped. These may be due both to oxacillin and Dilantin and will be followed. 5. Fluid, electrolytes and nutrition: Patient noted to have drop in his sodium after three water fluid boluses were increased with his tube feeds. These were held and changed to normal saline intravenous for fluid and sodium fully started to rise. Electrolytes were monitored and repleted. 6. Cardiovascular: Patient noted to be tachycardic, felt secondary to fevers and possibly dehydration, therefore, normal saline boluses were given as needed. 7. Prophylaxis: Patient was kept on ........and Protonix. Physical Therapy worked with patient. Addendum to this dictation will be dictated by new intern, [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. This dictation is through [2123-12-1]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4570], M.D. [MD Number(1) 4571] Dictated By:[Last Name (NamePattern1) 4572] MEDQUIST36 D: [2123-12-8] 19:56 T: [2123-12-8] 19:56 JOB#: [Job Number 4573] ICD9 Codes: 2765
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9042 }	Medical Text: Admission Date: [2159-4-6] Discharge Date: [2159-4-16] Date of Birth: [2114-8-15] Sex: M Service: F-ICU HISTORY OF PRESENT ILLNESS: The patient is a 44 year old male with a past medical history for aortic valve endocarditis status post aortic valve replacement with debridement and repair, systolic and diastolic congestive heart failure, severe mitral and tricuspid regurgitation, chronic ventilator dependent secondary to Intensive Care Unit myopathy and neuropathy, chronic Pseudomonal colonization, and hypercalcemia of unclear etiology. He was discharged from the [Hospital1 69] Intensive Care Unit on [3-27], after a six month hospitalization for Pseudomonas pneumonia, recurrent aspiration, TJ tube placement, pancreatitis, and hypercalcemia. The patient was discharged to [Hospital3 ] Rehabilitation. One day later, the patient presented to [Hospital6 3874] with explosive vomiting. He was noted to be febrile and hypotension to systolic blood pressure in the 90s, with baseline blood pressure in the low 100s. His sputum was positive for Pseudomonas. At [Hospital6 3872], the patient received one week of antibiotic therapy with gentamicin. He was weaned off of pressors after one week. Tube feeds were held and the patient was evaluated by the Gastrointestinal and Surgery Department. Upper endoscopy was done by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7640], showing a polyp in the stomach, and otherwise normal. An abdominal CT scan was done, showing gallstones and small ascites. The patient was sent back to [Hospital1 69] for further evaluation. PAST MEDICAL HISTORY: 1. Diastolic congestive heart failure, valvular disease secondary to aortic valve endocarditis with abscess. Status post aortic valve repair, aortic root debridement. Left ventricular ejection fraction of greater than 55%, four plus mitral regurgitation and three plus tricuspid regurgitation. 2. Coronary artery disease status post coronary artery bypass graft in [2158-10-29] ( saphenous vein graft to left anterior descending, saphenous vein graft to right coronary artery ). 3. History of embolic stroke with episodes of endocarditis. 4. History of paroxysmal atrial fibrillation in the setting of endocarditis. 5. Chronic ventilator dependence. 6. Chronic Pseudomonal colonization. 7. Hypercalcemia of unclear etiology. PTH is low, 25 hydroxy Vitamin D levels are low and PTH RP levels are negative. A bone scan was done showing increased uptake in the left shoulder, where on x-ray the patient was noted to have a calcified appearing mass. Subsequent CT scan guided biopsy of this calcified mass in the left shoulder revealed evidence of heterotopic calcification. The patient has been treated with intravenous fluids, diuretics and Calcitonin for his hypercalcemia, and ultimately responded to Pamidronate after eight treatments. The patient has also had Vitamin D levels aggressively repleted. 8. Seizure disorder since age of 12. The patient has been seizure free on Keppra. 9. Chronic malnutrition. 10. Depression. 11. Recurrent aspiration. 12. Bowel dysmotility, previously on Reglan and erythromycin. 13. History of fungemia. 14. Coronary artery disease status post coronary artery bypass graft. 15. History of right hemicolectomy. 16. History of Pseudomonal urinary tract infection. 17. History of diabetes mellitus. 18. History of type 1 renal tubular acidosis. 19. History of gastric outlet obstruction by GJ tube abutting pylorus. 20. History of anoxic encephalopathy. 21. Chronic intermittent chemical pancreatitis. 22. History of multiple pneumonias. 23. History of severe esophagitis. MEDICATIONS ON TRANSFER: 1. Regular insulin sliding scale. 2. Ativan p.r.n. 3. Morphine p.r.n. 4. Haldol p.r.n. 5. Tylenol q. four hours. 6. Phenergan p.r.n. 7. Subcutaneous heparin. 8. Albuterol and Atrovent nebulizers p.r.n. 9. Zofran p.r.n. 10. Epogen 3000 units subcutaneously twice a week. 11. Protonix 40 mg per J-tube q. day. 12. Reglan 5 mg intravenously q. six hours for three doses. ALLERGIES: No known drug allergies. LABORATORY: On admission, white blood cell count 10.3, hematocrit 30.6. Platelets 340. PT 12.8, PTT 32.3, INR 1.1. Sodium 130, potassium 4.5, chloride 106, bicarbonate 16; BUN 17, creatinine 0.6, glucose 84. ALT 30, AST 34, alkaline phosphatase 675, amylase 108, total bilirubin 0.4, lipase 104. Calcium 8.6, phosphate 3.3, magnesium 2.5, albumin 2.6. BRIEF SUMMARY OF HOSPITAL COURSE: Our impression is that this a 44 year old male with multiple medical problems presenting with explosive vomiting. The patient had been previously evaluated for his vomiting being secondary to a mechanical problem with difficulties with his [Name (NI) ] tube. As the patient had previously been evaluated at [Hospital1 346], he was transferred back here for further evaluation. 1. GASTROINTESTINAL: Recurrent vomiting: The initial differential diagnoses for this patient's recurrent nausea and vomiting included GJ tube dysfunction contributing to gastric outlet obstruction, other structural causes of obstruction, for example stricture or ulcer, ischemia or adhesions at his gastric outlet, versus a functional motility disorder (for example gastroparesis, gastric dysmotility). An abdominal x-ray with contrast injected into the J-tube to assess for feeding tube patency was done, which showed satisfactory positioning of the tube. The patient was to have an upper endoscopy done to evaluate for gastric outlet obstruction; however, the patient's sister informed the Medical Team that an upper endoscopy had recently been done about two weeks prior at [Hospital6 3873]. Review of those records revealed an enteral polyp (hyperplastic inflammatory pathology) with no evidence of gastric outlet obstruction. Both the G and J tube passed the gastric outlet and were patent, and were not kinked. These findings were reassuring for ruling out gastric outlet obstruction, and indicated a functional motility disorder as a cause for the patient's recurrent nausea and vomiting. During his hospital stay, the J-tube was used for feeding and the G-tube was set to continuos low suction. Copious amounts of bilious material were suctioned from the G-tube during the initial parts of his hospital stay, which diminished, but persisted throughout the hospital stay. Tube feeds were initiated and slowly advanced to a goal of 85 cc per hour, with initiation of Reglan 5 mg intravenously three times a day, with no recurrent episodes of nausea and vomiting. At this time, all the appropriate work-up for this patient's recurrent nausea and vomiting have been pursued and no further work-up is needed. 2. CARDIOVASCULAR: The patient was not in overt congestive heart failure on admission. He was continued on Lisinopril for afterload reduction, which was increased from 5 to 10 mg per G-tube q. day. 3. PULMONARY: Recurrent aspiration - the patient was placed on aspiration precautions. The patient also has a history of chronic Pseudomonal colonization. Repeat sputum culture done on [2159-4-10], revealed two different colonies of Pseudomonas as well as Enterobacter species. Although the patient continued to have copious secretions through his tracheostomy tube, he was afebrile with normal white blood cell count throughout his hospital stay; therefore, antibiotics were not initiated. With regards to his ventilator settings, the patient was continued on C-PAP plus pressure support during the day and AC-ventilation at night for rest. Current ventilator settings are as follows: During the day the patient is on C-PAP plus pressure support, [7-3] with FIO2 of 40%. At night, the patient is rested on AC-ventilation with total volume 400, respiratory rate of 20, PEEP of 5, FIO2 of 40%. 4. CHRONIC PANCREATITIS: The patient was noted to have pancreatitis of unclear etiology on his prior stay. Amylase and lipase levels were trended on the first few hospital days during this admission and were noted to have decreased from his prior hospital say. The patient tolerated tube feeds well with no abdominal pain. 5. ENDOCRINE: a) Hypercalcemia - the patient was diagnosed with hypercalcemia of unclear etiology on his recent hospital stay. Work-up revealed low normal PTH, low vitamin D levels with PTH RP negative. A osteocalcin level was normal and bone specific alkaline phosphatase levels were elevated, possibly suggestive of Paget's Disease. A biopsy of a soft tissue mass in the left glenohumeral joint was done, which was suspect for malignancy. This region was biopsied which was negative. During a recent admission the patient was treated with two doses of intravenous pamidronate, once with 30 mg and the second time with 50 mg, and the patient was given Calcitriol to replete his vitamin D stores, as these were noted to be low. During the patient's current hospital stay, calcium on admission as normal (9.1 corrected to 10.6 with an albumin of 1.9). Vitamin D levels checked on [3-24] were noted to be low (less than 7.0), so the patient was redosed with high dose Vitamin D, 10,000 Units, and was to then continue taking Calcitriol 0.125 micrograms per J-tube q. day. Pamidronate is to be dosed every three months (next dose is to be administered on [6-24], and dose should be 50 mg). b) Diabetes mellitus type 2: The patient had excellent glycemic control, with fingersticks ranging from 80 to 120 during hospital stay. The patient is to be continued on regular insulin sliding scale. 6. SEIZURE DISORDER: The patient was continued on Keppra with no further episodes of seizure like activity during his hospital stay. 7. DEPRESSION: The patient was continued on Zoloft with the dose increased to 50 mg p.o. q. day. The patient was tearful at times when attempting to communicate, but seemed motivated to get better. 8. NEUROLOGICAL: The patient had an Intensive Care Unit neuropathy and myopathy. He was continued on Physical Therapy and Occupational Therapy with improving upper and lower extremity strength throughout his hospital stay. The patient had a Passe-Muir valve placed on [4-12] and has been able to say a few words since then. 9. ACCESS: The patient had a right arm PICC placed on [4-7]. 10. NUTRITION: The patient was placed on total parenteral nutrition while tube feeds were being held for various radiographic procedures and while tube feeds were being advanced to goal. The patient has now been advanced to goal tube feeds at 85 cc per hour which he is tolerating well without nausea or vomiting and the total parenteral nutrition has been discontinued. 11. COMMUNICATION: Sister is [Name (NI) 21706] [Name (NI) ], who is a Nurse Practitioner [First Name (Titles) ] [Hospital1 69]. She was kept up-to-date on the patient's progress during this hospital stay. 12. FULL CODE. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient to be discharged to rehabilitation facility. DISCHARGE MEDICATIONS: (same as on admission with the except of Zoloft being increased to 50 mg p.o. q. day; Lisinopril increased to 10 mg p.o. q. day. 1. Regular insulin sliding scale. 2. Ativan p.r.n. 3. Morphine p.r.n. 4. Haldol p.r.n. 5. Tylenol q. four hours. 6. Phenergan p.r.n. 7. Subcutaneous heparin. 8. Albuterol and Atrovent nebulizers p.r.n. 9. Zofran p.r.n. 10. Epogen 3000 units subcutaneously twice a week. 11. Protonix 40 mg per J-tube q. day. 12. Reglan 5 mg intravenously q. six hours for three doses. 13. The patient is starting on Calcitriol 0.125 micrograms p.o. q. day. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(2) 8038] Dictated By:[Name8 (MD) 2692] MEDQUIST36 D: [2159-5-31] 12:36 T: [2159-6-4] 20:56 JOB#: [Job Number 21707] ICD9 Codes: 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9043 }	Medical Text: Admission Date: [2104-2-23] Discharge Date: [2104-3-5] Date of Birth: [2038-6-28] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 78] Chief Complaint: Headache and neck pain Major Surgical or Invasive Procedure: [2104-2-25]: Cerebral angiogram [2104-2-29]: Cerebral angiogram for coiling of the PICA and Basilar tip aneurysm History of Present Illness: This is a 65 year old female who presents with a consistent headache and neck pain. She is a patient of Dr.[Name (NI) 89842] at [Hospital1 2025] and had 4 open craniotomies for clippings of 3 R MCA aneurysms, 2 L MCA aneurysms, a R ACA aneurysm, and a PICA aneurysm in [2093] and [2095]. According to [Hospital1 2025] records, all aneurysms were nonruptured and treated intervally. She was last seen in [2097] by Dr. [Last Name (STitle) 1128] and complained of chronic headaches at that time. Per [Hospital1 2025] records, her last known imaging was in [2095-6-11] which showed no remaining aneurysms or recanalization of the treated aneurysms. A head CT at an OSH showed no acute blood, and LP was done in the [Hospital1 18] ER which appeared bloody. Past Medical History: Aneurysms as above HTN High cholesterol Headaches Liver Cyst Depression Cataracts Cardiac Cath Anemia Bil TKR Social History: Spanish speaking primarily. Lives alone, not married, has three children. + Tobacco- [2-14] cigarettes per day. Denies ETOH. Currently unemployed. Family History: unknown Physical Exam: On admission: PHYSICAL EXAM: O: T: 98.0 BP: 157/74 HR: 63 R 16 O2Sats 98% RA Gen: WD/WN, comfortable, NAD. HEENT: normocephalic Neck: Nuchal rigidity Lungs: CTA bilaterally. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [5-15] throughout. No pronator drift Sensation: Intact to light touch Coordination: normal on finger-nose-finger At Discharge: Nonfocal exam. Pertinent Results: Head CT [2104-2-23]: No [Year/Month/Day ] blood. No acute hemorrhage. CXR [2104-3-2] IMPRESSION: AP chest read in conjunction with chest imaging on an abdomen CT performed today, subsequently. Lung volumes are low, exaggerating heart size and pulmonary vascularity. At worst there is mild vascular engorgement. I see no pneumonia. Pleural effusion is minimal on the left. No pneumothorax. CT abdomen [2104-3-2]: FINDINGS: The lung bases are clear with minimal atelectasis of the left lung base. There is 3-mm perifissural ground-glass opacity on the left (2; 1). ABDOMEN: Within the limits of a non-contrast examination, the liver and spleen appear normal. Calcifications in the gallbladder neck indicate gallstones and otherwise normal-appearing gallbladder. The pancreas is unremarkable, as are the bilateral adrenal glands. The kidneys are normal in appearance without hydronephrosis or stones. There is mild-to-moderate calcification of the aorta, which is normal in caliber along its visualized course. There is mild haziness in the retroperitoneum in the paraaortic and aortocaval regions which is likely lymphatic. PELVIS: The pelvic organs are normal in appearance. A Foley catheter is seen within the bladder. No retroperitoneal hematoma is present. Minimal stranding around the right groin is likely the sequela of prior catheterization. There is no fluid collection. Visualized loops of small and large bowel appear normal, with note of diverticulosis. There is no intraperitoneal free fluid or free air. BONE WINDOWS: No concerning lytic or blastic lesion. There is facet degenerative disease, most prominent at the L5-S1 level. No concerning lytic or blastic lesions are seen. IMPRESSION: 1. No retroperitoneal hematoma. 2. 3 mm ground-glass opacity in the perifissural region of the left lower lung. In the absence of risk factors, no further follow up is needed. If patient has risk factor such as smoking, recommend followup CT in 12 months to document stability. 3. Facet degenerative disease at the L5-S1 level in this patient with back pain. Brief Hospital Course: This is a 65 year old female who was admitted for headache and neck pain. Although imaging showed no [Last Name (LF) ], [First Name3 (LF) ] LP was performed which was equivocal. She was admitted to the Neuro-ICU for monitoring as we continued to work-up her headaches to rule out rupture given her complex aneurysmal history. An CTA could not be performed given the amount of artifact and an MRA could not be done because we could not verify the clipping's safety for MRI. On [2-25] she underwent a diagnostic angiogram which showed a basilar tip aneurysm and a partially clipped PICA aneurysm. She remained in the ICU overnight then was transferred to the floor on [2-26]. On [2-29], the patient was taken to the angio suite for coiling of her PICA and basilar tip aneurysms. She tolerated the procedure well. She was trasnfered to the PACU and she remained there on a heprain drip as there were no SICU beds. She had a fever of 102.2F overnight [3-1]. Her heparin drip was stopped. A fever work up was started. She was reporting back pain and a CT abdomen was done and ruled out retroperitoneal hemorrhage. Her Hct was stable. She remained afebrile and exam remained nonfocal. She was sent home on [3-3]. Medications on Admission: Amitriptyline 30mg QHS Ibuprofen PRN Vicodin PRN Gabapentin 100mg TID Lisinopril 40mg Daily HCTZ 12.5mg Daily Loratadine 10mg Daily Flonase 50mcg - 2 sprays to each nostril daily Calcium 600+D- 1 tab TID MVI ASA 81mg Daily Lipitor 20mg Daily Proair HFA 2 puffs 3-4x per day as needed Flovent 110mcg - 1 puff [Hospital1 ] Vitamin C 500mg - 1 tab daily Vitamin E 600 units Fluticasone 1 puff [Hospital1 ] Cromolyn 4% opth solution - 2 gtts into both eyes TID prn Discharge Medications: 1. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 2. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [Hospital1 ] (2 times a day). 6. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:6 12. senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime). 13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Headache PICA aneurysm Basilar tip aneurysm L5-S1 facet djd. Lung Nodule: 3mm LL base Gallstones Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Angiogram with Embolization and/or Stent placement Medications: ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! A CT of your abdomen was performed when you had back pain to ensure that you did not have a hemorrhage. There was no hemorrhage but this study showed gallstones, a lung nodule and degenerative disease of the lumbar spine. You should follow up with your PCP for these findings. You should have a CT chest in 12months to follow up on this. Followup Instructions: Please follow-up with Dr. [First Name (STitle) ] in 4 weeks, no imaging is needed at that time. Please call [Telephone/Fax (1) 4296] to make this appointment. Please follow-up with your Primary Care Doctor regarding your Lung lesion found on CT and gallstones. Completed by:[2104-3-3*] ICD9 Codes: 4019, 2720, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9044 }	Medical Text: Admission Date: [2131-12-3] Discharge Date: [2131-12-8] Date of Birth: [2072-11-16] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 1402] Chief Complaint: Palpitations and lightheadedness Major Surgical or Invasive Procedure: None History of Present Illness: 59 year old female with sarcoidosis, LBBB (known for at least 3 years) presents with lightheadedness and palpitations that lasted for 2 hours on day of admission. She went to OSH where she was found to be in wide complex tachycardia. She was given ASA 325 x 1. Apparently, she has been told she has a bundle [Last Name (un) ] block in the past, and it was felt she may be in SVT with aberrancy. They gave her adenosine which broke her out of SVT and back into sinus rhythm with left bundle, HR 80. She denies any chest pain with this episode. She denies any fevers, chills. . She states very rarely, if she is startled awake from sleep, she will experience palpitations that may last 10-15 minutes, but this has only happened once in the past year. . She was evaluated by a cardiologist 3 years ago when she had epigastric discomfort, later thought [1-18] to GERD. She had a normal exercise stress test. Echocardiogram performed at OSH in [2127] revealed EF of 40-45%. . She reports that she was diagnosed with sarcoidosis approximately [2123] at which time she was found to have hilar/mediastinal LAD. It is not clear whether she has known pulmonary involvment beyond this, but has been seen by pulmonologist, Dr. [Last Name (STitle) ], at [Hospital1 ]. . Following conversion of her tachyarrhythmia, she was transferred to [Hospital1 18] for further evaluation by electrophysiology. Past Medical History: Sarcoidosis LBBB Left breast ca s/p lumpectomy and XRT h/o hyperthyroidism Osteoporosis Social History: Lives with husband. 2 daughters live in [Name (NI) 2848]. No tobacco. 1 drink EtOH with dinner, no other drug use. Family History: Mother with CAD s/p CABG Father with CAD s/p CABG and "valve replacement" Physical Exam: 97.8F HR 90 BP 128/79 RR 18 96%RA Gen: awake, alert, pleasant, sitting up in bed, NAD HEENT: PERRL, EOMI, OP clear, MMM Neck: supple, no JVD CV: Distant HS, normal S1, S2 without mrg, RRR Pulm: CTAB, no w/r/r Abd: Normoactive BS, soft, ND/NT Ext: WWP, no edema Pertinent Results: [12-3] CXR: Symmetric interlobular septal thickening in bilateral lower lobes. This can be due to chronic congestive heart failure, however, there is no acute evidence of pulmonary edema or acute failure. The possibility of underlying interstitial lung disease cannot be totally excluded. Please correlate clinically, especially with PFT. . [12-5] Cardiac MRI: 1. Severely dilated left ventricular cavity size with severe global hypokinesis and focal inferior akinesis and mid-basal septal akinesis/dyskinesis. The LVEF was severely depressed at 28%. The effective forward LVEF was severely depressed at 22%. No MR evidence of prior myocardial scarring/infarction. 2. Normal right ventricular cavity size and function. The RVEF was normal at 59%. No MR evidence of right ventricular fatty infiltration/dysplasia. 3. Moderate to severe mitral regurgitation. Mild tricuspid regurgitation. 4. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was mildly increased. 5. There was a 1 cm lymph node in the supracarinal region. Findings indicate an LV cardiomyopathy. (However, cannot exclude ischemic etiology; coronary arteries were not assessed). The findings were not suggestive of cardiac sarcoid, although this diagnosis cannot be definitely excluded. . [12-6] Cardiac catheterization: 1. Selective coronary angiography of this right dominant system revealed no evidence of coronary artery disease. The LMCA, LAD, LCX, and RCA had no flow-limting lesions. The LAD had a distal myocardial brige. 2. Resting hemodynamics revealed a normal PCPW of 8mmHg. Cardiac index was normal at 2.6l/min/m2. 3. Left ventriculography revealed global hypokinesis with a calculated ejection fraction of 23%. FINAL DIAGNOSIS: 1. Coronary arteries are normal. 2. Severe systolic ventricular dysfunction. . Brief Hospital Course: 59 year old female with sarcoidosis and history of LBBB who presented with palpitations, lightheadedness and wide complex tachycardia. . # Arrhythmia: Rhythm from OSH was reviewed by EP and appeared most likely ventricular tachycardia as opposed to SVT with aberrancy given a change in axis. She had one episode on the floor at [Hospital1 18], associated with lightheadedness, self limited, which also appeared consistent with VT. Given her history of sarcoidosis and LBBB, there was certainly concern for infiltrative granulomatous cardiac disease. A cardiac MRI was obtained to further evaluate for evidence of cardiac sarcoid, which revealed severe LV hypokinesis (EF 28%); however, was not consistent with cardiac sarcoid. Cardiac catheterization was done which did not reveal evidence of coronary artery disease. She had an electrophysiology study at which time she went into complete heart block and she was transferred to the CCU with a temp wire for further monitoring prior to device placement. On [2131-12-7], she had a permanent pacemaker and ICD placed. She tolerated the procedure well. At the time of discharge, she was [Date Range 1988] follow up with Dr. [Last Name (STitle) ] in [Hospital ] clinic, as well as with the device clinic. . # Left Ventricular Systolic Dysfunction: An echocardiogram was obtained to evaluate her known LBBB which revealed global hypokinesis with ejection fraction of [9-30]%. She has never had symptoms of heart failure, but was started on beta blocker and ACEI for LV systolic dysfunction. Cardiomyopathy workup revealed normal thyroid function tests, normal iron studies, and SPEP/UPEP. As above, she underwent cardiac MRI to further evaluate the possibility of cardiac sarcoid, which was not consistent with this diagnosis. She also underwent cardiac catheterization which revealed normal coronary arteries. . # Sarcoidosis: She was originally diagnosed in approximately [2123] when she was found to have hilar/mediastinal LAD on imaging. She was on prednisone and methotrexate for years for ocular involvement, having just discontinued both recently within the last several months. Medications on Admission: actonel qSunday Multivitamin calcium 1500mg/day Discharge Medications: 1. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: Ventricular tachycardia Sarcoidosis Discharge Condition: Stable without symptoms of heart failure, no palpitations Discharge Instructions: Please call your doctor or return to the emergency room if you develop palpitations, lightheadedness, chest pain or any other symptoms that concern you. . Please follow up with your doctors [First Name (Titles) 3] [Last Name (Titles) 1988] below. . Followup Instructions: . Please follow up with Dr. [Last Name (STitle) 27772] (at Dr.[Name (NI) 69032] office) ([Telephone/Fax (1) 70383] [2130-12-28] at 3:15pm. . Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 677], M.D. Phone:[Telephone/Fax (1) 2934] Date/Time:[2132-1-11] 3:00. Please have echocardiogram about [12-18] weeks prior to appointment with Dr. [Last Name (STitle) ]. Order already in POE but no appointment has been made. . Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2131-12-13] 10:30 ICD9 Codes: 4271, 4254, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9045 }	Medical Text: Admission Date: [2109-8-5] Discharge Date: [2109-8-8] Date of Birth: [2059-7-21] Sex: F Service: NEUROLOGY Allergies: Latex / Hydrochlorothiazide / Temazepam Attending:[First Name3 (LF) 618] Chief Complaint: "Pins and needles sensation over right arm and leg" Major Surgical or Invasive Procedure: None. History of Present Illness: The patient is a 50 year old right-handed female with past medical history of TIA, peripheral vascular disease, HTN, hypercholesterolemia, tobacci use, left carotid stenosis 85% who presented as a transfer from OSH for Code Stroke. The patient reported that she was in her usual state of health until the morning of admission. She awoke at approximately 5am with a "pins and needles sensation" over her entire right arm and leg. She was able to get up, walk without difficulty at that time. The parasthesiae lasted for about 1.5 hours. The pt stated that between 8:30 and 9am, her right arm/leg went completely flaccid and the parasthesiae over the right side recurred. She also noted blurring of her vision. She denied ay areas of blindness/amarousis fugax. She also noted a dull frontal headache. She called her husband at work, who came home and called EMS. Per records, EMS arrived at 9:12am. Initial vitals HR: 68, BP 157/106. EMS took her to [Hospital 8641] Hospital. Vitals on arrival were 98.5, P 55, RR 16, BP 156/65, BS 128. Head CT there revealed no intracranial hemorrhage. She received 9mg bolus of tPA at 11:35 am. Per nursing notes at the OSH, the pt was able to move her right side somewhat after administration of tPA. She was transferred to the [Hospital1 18] for further care. Her symptoms were noted to worsen en route where she finished the tPA drip. On arrival to the [Hospital1 18], the pt reported numbness and parasthesiae over her entire right face, arm and leg and she could not move her right arm or leg. She also complained of having difficulty swallowing. Her blurry vision and headache had resolved. NIHSS on arrival to the [Hospital1 18] was 13 with: 2 partial paralysis lower face 3 right arm, no effort against gravity 3 right leg, no effort against gravity 2 limb ataxia in right arm and leg 2 severe sensory loss right hemibody 1 mild to moderate slurring of words On review of systems, the pt. denied recent fever or chills. No night sweats or recent weight loss or gain. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. During her ICU course, her deficits steadily improved. Her work-up was completed. At the time of my encounter, the pt noted that her right-sided weakness has much improved over the time of her hospital stay. She had developed a tremor in the right hand which is also improved per the pt. She offered no comnplaints. Past Medical History: 1. TIAs in past, last [2108-9-26] with bilateral blurring of vision x 30 minutes. Other TIAs (she states [4-30] total) included blurry vision in either eye-->felt by her neurologist to be migraine related. 2. Bilateral common iliac artery stents [1-30] 3. Left carotid stenosis 85% 4. Right carotid stenosis 5. Hypertension 6. Left breast lumpectomy [4-30], benign 7. ?Multiple sclerosis (diagnosis given by her outpatient neurologist for muscle spasms from mid thorax down). 8. Lumbar degenerative disease with facet arthopathy 9. Lumbar gluteal myofascial pain syndrome 10. Bilateral carpal tunnel syndrome status post left release surgery [15]. Migraine headaches 12. Hypercholesterolemia Social History: The pt is married with 3 sons. Homemaker. Smoked 1.5 ppd x 15 years. No alcohol or drug use. Family History: Mother deceased from CAD at age 68. Father deceased from CAD at 72. Physical Exam: Vitals: T: 98.8F P: 64 R: 16 BP: 126/70 SaO2: 95% RA General: Awake, alert, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Skin: no rashes or lesions noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. Able to name [Doctor Last Name 1841] backward without difficulty. Language is fluent with intact repitition and comprehension. There were no paraphrasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. -cranial nerves: Olfaction not tested. PERRL 3 to 2mm and brisk. VFF to confrontation. There is no ptosis bilaterally. Fundoscopic exam revealed no papilledema or hemorrhages; venous pulsations present. EOMI without nystagmus. Sensation intact to light touch over face. No facial droop, facial musculature symmetric. Hearing intact to finger-rub bilaterally. Palate elevates symmetrically in midline. 5/5 strength in trapezii and SCM bilaterally. Tongue protrudes in midline; no fasciculations. -motor: normal bulk throughout. Cogwheel rigidity noted in RUE. Subtle, 4 Hz resting tremor of RUE. Subtle pronator drift on right. Delt Bic Tri WrF WrE FFl FE IO IP Quad Ham TA [First Name9 (NamePattern2) 2339] [Last Name (un) 938] L 5 5 4+ 5 4+ 5 4 5 4+ 5 4+ 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -sensory: No deficits to light touch, vibratory sense, proprioception throughout. -coordination: FNF and HKS WNL bilaterally. -DTRs: 3+ biceps, triceps, brachioradialis, patellar and 1+ ankle jerks bilaterally. + crossed adductor reflex. Plantar response was flexor bilaterally. -gait: Walks with assistance of cane, decreased arm swing on right. Pertinent Results: EKG: Sinus bradycardia at 53 bpm with TWI V1-V3. T wave flat V4. MRI/MRA head [2109-8-5]: 1. Evolving acute infarction in the left posterior limb of the internal capsule and adjacent corona radiata. 2. No visualized flow in the distal M1 segment of the left middle cerebral artery, just before the bifurcation with faint flow in the post-bifurcation branches, likely representing high-grade, but incomplete occlusion in the distal M1 segment. 3. Neck MRA is limited by patient motion. There may be some left internal carotid origin stenosis. Further evaluation is recommended by carotid ultrasound. Transthoracic echocardiogram [2109-8-6]: 1. 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. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Carotid Duplex Doppler Ultrasound [2109-8-6]: FINDINGS: Duplex evaluation was performed of both carotid and vertebral arteries. Moderate plaque was identified on the left. On the right, peak systolic velocities are 75, 62, and 82 in the ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1.2. This is consistent with less than 40% stenosis. On the left, peak systolic velocities are 196, 57, and 109 in the ICA, CCA, and ECA respectively. The ICA to CCA ratio is 3.4. This is consistent with a 60-69% stenosis. There is antegrade flow in both vertebral arteries. IMPRESSION: Moderate left-sided plaque with a 60-69% carotid stenosis. On the right, there is less than 40% stenosis. CTA head [2109-8-7]: FINDINGS: Evaluation of the non-contrast head CT reveals an area of well-defined low density corresponding to the area of previously mentioned infarct. It is consistent with the previously described left posterior limb internal capsule and adjacent corona radiata infarct. No additional lesions are seen. There is no significant mass effect. No shift of the midline structures is noted. A [Doctor Last Name 352]-white matter differentiation is preserved. There are no extra-axial collections. Evaluation of the CTA reveals an area of high density within the mid left MCA (M1 segment). This is present on the pre-contrast images and represents calcium. Just immediately distal to this area, there is no flow seen. Just distal to this, area of no flow with normal appearing horizontal and vertical segments of the distal MCA. It is believed that the MCA is still patent due to the adequate visualization of the distal vessels. The right internal carotid artery and its branches appear normal. The posterior circulation is unremarkable with no evidence of aneurysm. There is a normal basilar and the PCA. IMPRESSION: Hyperdensity in the posterior lobe of the internal capsule and adjacent corona radiata consistent with previously identified infarct. Calcification within the mid left MCA (M1 segment). No flow is visualized just immediately distal to this calcification. However, there is almost immediate visualization of the distal horizontal and vertical MCA branches. Therefore, flow is still likely present. Brief Hospital Course: 1. Stroke: The pt received IV tPA at an OSH with improvement in her symptoms. MRI/MRA on admission was remarkable for infarction in left internal capsule (posterior limb) and corona radiata with no visualized flow in the distal M1 segment of the left middle cerebral artery, just before the bifurcation with faint flow in the post-bifurcation branches, likely representing high-grade, but incomplete occlusion in the distal M1 segment. Subsequent studies have revealed 60-69% stenosis in the left internal carotid artery. CTA of the head has demonstrated patent flow past a L MCA M1 segment calcification. Given her signficant, symptomatic left internal carotid artery stenosis on aspirin and plavix, the decision was made to begin anticoagulation with warfarin and continue 81mg of ASA daily. She was also maintained on statin for hyperlipidemia. She will follow-up in the neurology clinic for consideration of carotid stenting or carotid endarterectomy at a later date. From a symptomatic standpoint, the pt's deficits had much improved by the time of discharge. She did develop a mild, low-frequency tremor of her right hand on hospital day three which was felt to be secondary to peri-infarct irritation. This, in fact, also improved by the time of discharge (although was still observable). She requested home physical therapy to aid in gait and balance training. 2. HTN: The pt's antihypertensive medication was held while in-house to maximize cerbral perfusion. She was asked to resume her regimen on discharge. Medications on Admission: 1. ASA 325 mg po qd 2. Diazepam 3. Atenolol 4. Fluoxetine 5. Lipitor 6. Plavix 7. Estradiol 8. Skelaxin 9. Oxycodone 10. Gabapentin 11. Enalapril Discharge Medications: 1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Enalapril Maleate 20 mg Tablet Sig: Two (2) Tablet PO once a day. 3. Atenolol Oral 4. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO once a day: Have INR checked by PCP who will adjust dose to goal INR [2-28]. [Month/Day (3) ]:30 Tablet(s) Refills:2 5. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous twice a day: Inject [Hospital1 ] until instructed to d/c according to PCP. [Name Initial (NameIs) ]:20 syringes Refills:2 6. Fluoxetine Oral 7. Oxycodone Oral 8. Gabapentin Oral 9. ASA 81mg po daily (pt. was given a paper Rx) Discharge Disposition: Home With Service Facility: [Location (un) 8300] VNA and Hospice Discharge Diagnosis: 1. Left Capsular/lacunar Stroke 2. Left carotid stenosis 3. Right carotid stenosis 4. Hypertension 5. Hypercholesterolemia 6. Tobacco abuse Discharge Condition: Patient is much improved compared to admission. She has regained force in right upper extremity. She has complained of mild right hand tremor, cause might be related to reperfusion, it has since then decreased, but will still be evaluated as an outpatient. Discharge Instructions: Please continue with all medications as listed below. Please attend all follow-up appointments Call your Primary Care Physician or go to the Emergency Room if you develop any of the following symptoms: worsening headache, blurry or double vision, convulsions, dizziness, worsening nausea or vomiting, or any other concerning symptom. Followup Instructions: Please follow up at [Hospital1 63458], [Location (un) 63459], [Last Name (un) 53428], NH at 8:30am on [2109-8-13]. Please call Dr. [First Name (STitle) ] [Name (STitle) ] at [Telephone/Fax (1) 2574] (W/[Location (un) ] 1)for Neurology/Stroke follow-up within the next 1-2 months. [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] ICD9 Codes: 4019, 4439, 2724, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9046 }	Medical Text: Admission Date: [2130-6-26] Discharge Date: [2130-7-1] Date of Birth: [2074-2-17] Sex: M Service: CARDIOTHORACIC SURGICAL HOSPITAL COURSE: The patient is a 56-year-old male who is presenting with symptoms of increased productive cough and findings by bronchoscopy of tracheomalacia. The patient currently presents to the thoracic surgical service for a tracheoplasty and bronchoplasty to rectify these defects. PAST MEDICAL HISTORY: 1) Asthma, 2) GERD, 3) Basal cell-squamous cell CA. MEDICATION AT HOME: 1) albuterol, 2) Flovent, 3) Serevent, 4) Prilosec, 5) Xanax. ALLERGIES: Cephalosporin. PHYSICAL EXAMINATION AT TIME OF DISCHARGE: The patient's vital signs are temperature 98.3, pulse 72, blood pressure 145/70, respirations 18, 92% on room air. IMPRESSION: The patient is a well-developed, well nourished male in no apparent distress, breathing comfortably without any supplemental oxygen. NECK: No evidence of hematoma, no evidence of erythema, no cervical lymphadenopathy noted. HEENT: Sclerae anicteric, mucous membranes moist, no evidence of oral ulcers. Cranial nerves II through XII intact. No cervical lymphadenopathy noted. CHEST: Clear to auscultation bilaterally, no evidence of rales, crackles, wheeze, or rhonchi noted. CARDIAC: Regular rhythm and rate, no murmurs. ABDOMEN: Soft, nondistended, nontender with positive bowel sounds and no evidence of inguinal lymphadenopathy, nor hepatosplenomegaly. EXTREMITIES: No evidence of edema, no evidence of rash. PERTINENT LAB [2130-6-29]: White blood cell 9, hematocrit 32.2, platelets 276, and magnesium 1.8. SUMMARY OF HOSPITAL COURSE: Patient is a previously healthy 56-year-old male who presents with trachea-bronchomalacia. The patient underwent an uncomplicated tracheoplasty and bilateral bronchoplasty with Marlex mesh placement on [2130-6-26]. Postoperatively, the patient was monitored in the CSRU for potential postoperative respiratory complications. By postoperative day #1, the patient remained comfortable, extubated, with chest tube which showed no evidence of air leak. By postoperative day #2, the patient was doing well, continued to improve on chest physiotherapy. Since the patient had been continuing to improve, physical therapy evaluation was sought, and he was begun on endurance training, as well as discharge planning on postoperative day #3. By this time, the patient was transferred to the floor with the chest tube removed while continuing the chest physiotherapy. Because the patient was beginning to clear his own secretions without difficulty, chest physiotherapy was weaned, and the patient's epidural, as well as [Known lastname 8389] were removed on postoperative day #4 in anticipation of discharge. By postoperative day #5, the patient cleared the required Level 5 status of physical therapy, and the decision was made to discharge the patient to home in good condition. CONDITION AT DISCHARGE: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSIS: Status post trachea-bronchoplasty with mesh placement. DISCHARGE MEDICATIONS: 1) percocet 5/325, 1-2 tablets po q 4-6 h prn pain, 2) colace 100 mg po bid. FOLLOW-UP PLANS: 1) The patient was instructed to follow-up with Dr. [Last Name (STitle) 952] in 7 days, and 2) to follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 48006] in 7 days. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3351], M.D. [MD Number(1) 3352] Dictated By:[MD Number(1) 48007] MEDQUIST36 D: [2130-6-30] 11:48 T: [2130-6-30] 11:08 JOB#: [Job Number 48008] cc:[Last Name (NamePattern1) 48009] ICD9 Codes: 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9047 }	Medical Text: Admission Date: [2130-12-25] Discharge Date: [2130-12-27] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1838] Chief Complaint: Intracranian hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: Ms [Known lastname 6955] is a 86 yo RIGHT-handed woman with a PMH remarkable for valvular heart disease (rheumatic disease), AF on AC, HLD, HTN a question of a stroke 3 years ago (unknown deficits) and colon cancer s/p surgery who p/w CNS bleed with an INR of 3.6. She was having dinner with her family when she suddenly syncopized while sitting at the table (son's version). Another version of the events (husband) states that she went to bed after dinner and at 11:00 pm she complained of a sudden throbbing frontal headache and started vomiting. She was taken to [Hospital 487] Hospital: Her BP was 220/ 80, 66 bpm, 18 RR 100% SO2 in RA. Her GSC was initially 12 and complained of a right - sided droop and right hand weakness. Eventually, her GCS worsened (<8) and hence she was ETT'd to protect her airway. She received ativan 8 mg and given her INR 3.6, vitamin K 10 mg iv. A Ct scan with Bleed left frontal plus LEFT lateral ventricle bleed and LEFT hemocontussion. She was transferred by helicopter to [Hospital1 18]. Once at the ED: SBP 183, she received labetalol 10 mg iv. Her SBP remained > 180, so a labetalol drip was started. However, her HR decreased from 80 bpm to 50 bpm and the ED team stopped it and started NTG drip. She was afebrile 98.7F, connected to a ventilator in CMV mode. I recommended the ED team to start profilnine, FFP and hyperventilate the patient. In addition, she was loaded on PHT 20 mg/ kg. Once her CT scan was done, I also started a mannitol load with 1.5 g/ kg. I discussed the prognosis with the family according to the ICH scale. They initially wanted all the measures to be pursued. However, once informed that she would need surgery, they decided to make her DNR. Baseline: IADLs. Walked without a cane. Past Medical History: Valvular heart disease (rheumatic disease), AF on AC, HLD, HTN. Colon Ca s/p surgery Social History: As per husband, [Name (NI) ]: ETOH, Drugs, Tobacco. Lives with her husband. Services: None Family History: NC Physical Exam: Gen: Lying in bed, unresponsive. Intubated. HEENT: NC/AT, moist oral mucosa Neck: supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: Soft, nontender, non-distended. No masses or megalies. Percussion within normal limits. +BS. Ext: no edema, no DVT data. Pulses ++ and symmetric. Neurologic examination: No meningismus. No photophobia. MS: Non-responsive to noxious stimuli. CN: Brain stem reflexes : Corneals - bl. Pupils 2 to 1 bl and symmetrically. Dolls eyes -No gaze deviation. No bobbing or Robbing. No nystagmus. Gag +. Difficult to assess facial weakness with the ETT. Motor: does withdraw to pain in both legs, not in the arms. Tone: Normal. DTR: 1+ throughout. Toes downgoing. Pertinent Results: [2130-12-25] 02:32AM BLOOD WBC-10.2 RBC-4.23 Hgb-11.7* Hct-35.3* MCV-83 MCH-27.6 MCHC-33.1 RDW-16.8* Plt Ct-277 [2130-12-25] 02:32AM BLOOD PT-26.8* PTT-28.8 INR(PT)-2.7* [2130-12-25] 11:40AM BLOOD Fibrino-351 [2130-12-25] 02:32AM BLOOD Glucose-153* UreaN-32* Creat-0.9 Na-135 K-3.9 Cl-101 HCO3-25 AnGap-13 [2130-12-25] 06:27AM BLOOD CK-MB-6 cTropnT-0.30* [2130-12-25] 11:24AM BLOOD CK-MB-6 cTropnT-0.28* [2130-12-25] 09:03PM BLOOD CK-MB-6 cTropnT-0.21* [2130-12-25] 06:27AM BLOOD ALT-72* AST-99* LD(LDH)-293* CK(CPK)-145* AlkPhos-109 TotBili-0.5 [2130-12-25] 06:27AM BLOOD Triglyc-82 HDL-58 CHOL/HD-2.8 LDLcalc-88 [2130-12-26] 02:18AM BLOOD Phenyto-19.1 CT HEAD: Multifocal acute parenchymal hemorrhage with intraventricular extension of blood and associated obstructive hydrocephalus. Associated vasogenic edema and mass effect result in effacement of overlying gyri and mm rightward shift of normally midline structures. Brief Hospital Course: Ms. [Known lastname 6955] is a 86 yo RIGHT-handed woman with a PMH remarkable for valvular heart disease (rheumatic disease), AF on AC, HLD, HTN, question of a stroke 3 years ago (unknown deficits) and colon ca s/p surgery who p/w CNS bleed in the context of an INR of 3.6. Her exam is remarkable for no corneal reflex, pupils 2 to 1 bl and symmetrically. She was not withdrawing to pain in both legs nor in the arms. The most likely cause of her bleed is HTN in the context of her elevated INR. There may be a component of AA. In addition there seems to be a traumatic component in the LEFT frontal lobe (minor bleed and edema). She has an ICH score of 4 which makes her prognosis extremely poor. In addition, she is developing hydrocephalus per imaging. Patient's situation and prognosis was discussed per admitting resident with the family including husband who initially decided on DNR code status and upon further discussion with family, decided on comfort measures only. She was started on morphine drip and ativan as needed to maximize comfort. She was initially admitted to the ICU but once family decided on maximizing comfort, was transferred to the floor where she expired on [2130-12-27]. Family decline autopsy and it was also decline per medical examiner as well. Medications on Admission: Amiodarone 200 qd. Pravastatin 20 qhs. Coumadin. Discharge Medications: Morphine drip Ativan as needed Discharge Disposition: Expired Discharge Diagnosis: Intracerebral hemorrhage with obstructive hydrocephalus Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:[2131-1-6] ICD9 Codes: 431, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9048 }	Medical Text: Admission Date: [2125-12-3] Discharge Date: [2125-12-5] Service: NEUROLOGY Allergies: Hydromorphone / Meperidine / propoxyphene / Percodan / Diphenhydramine / aspirin Attending:[First Name3 (LF) 618] Chief Complaint: Speech disturbance Major Surgical or Invasive Procedure: none History of Present Illness: The pt is a 89 year-old woman with a history of prior right frontal IPH, HTN, HLD and hypothyroidism who is blind and dependent on a cochlear implant for hearing, who presents with acute onset confusion and aphasia. Reportedly she lives in an [Hospital3 400] facility, and she was having breakfast with another resident, and it was noted that she began to develop garbled slurred speech. She was taken to [Hospital6 2561], where on arrival she was noted to have a blood pressure of 207/75. She was given 10mg of labetalol, and underwent a NCHCT which showed a 1.4x1.7cm left posterior temporo-occipital lobe hemorrhage. She was then transferred to [Hospital1 18] for further evaluation. She has a history of a prior right frontal hemorrhage earlier this year, which was thought to be secondary to a combination of amyloid angiopathy and and hypertension or just hypertension. At baseline she reportedly is quite calm, and able to converse well using the cochlear implant. She reportedly can make out faces if they are well lit and close to her right eye. According to her health aid who currently accompanies her, she lives [Initials (NamePattern4) ] [Last Name (NamePattern4) 1820] [Last Name (NamePattern1) ] in [Hospital1 8]. Past Medical History: - Prior right frontal IPH - HTN - HLD - Hypothyroidism - Deaf - dependent on cochlear implant - Legally blind - no vision out of left eye, only slight vision out of right eye. Social History: Lives in [Hospital3 ]. Mobilises with cane and at times walker Registered deaf and blind Has aids who help during the week but these have been stopped due to insurance problems Baseline able to speak coherently Family History: Unknown Physical Exam: Admission Physical Exam: Vitals: T: 97.9 P: 79 R: 18 BP: 167/65 SaO2: 99% on RA General: Awake, cooperative, agitated. 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: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Shouts out 'I can't...I can't...hurt...' Attempted to place cochlear implant in place, which prompted her to start screaming, waving arms and batting at head. Despite additional attempts at adjustment, unable to successfully communicate using it. -Cranial Nerves: Left cornea cloudy, does not blink to threat or appear to be able to track with the right eye. Right surgical pupil. Very slight flattening of the right NL fold. Tongue protrudes midline. -Motor/Sensory: Lifts all extremities antigravity, making purposeful movements with arms, pulling at lines. Withdraws legs purposefully from tickle. -DTRs: [Name2 (NI) ] moving all extremities and does not relax well to assess reflexes. Plantar response was withdrawal bilaterally. Physical exam at discharge: Neuro: Calm, speaks in clear and coherent sentences when she can understand you. Moving all extremities purposefully. Left cornea opacified, tracking on right. No facial asymmetry. Must talk in calm normal voice. Pertinent Results: Laboratory results: Admission labs: [2125-12-3] 05:48PM BLOOD WBC-6.8 RBC-4.53 Hgb-12.1 Hct-38.1 MCV-84 MCH-26.8* MCHC-31.9 RDW-20.2* Plt Ct-454* [2125-12-3] 05:48PM BLOOD Neuts-80.9* Lymphs-10.8* Monos-6.3 Eos-1.7 Baso-0.4 [2125-12-3] 05:48PM BLOOD Glucose-126* UreaN-9 Creat-0.5 Na-130* K-4.1 Cl-94* HCO3-20* AnGap-20 [2125-12-4] 05:27AM BLOOD ALT-19 AST-33 AlkPhos-89 TotBili-0.3 [2125-12-4] 05:27AM BLOOD Albumin-4.1 Calcium-9.1 Phos-3.9 Mg-1.8 . Other pertinent labs [2125-12-4] 05:27AM BLOOD Osmolal-269* . Urine: [2125-12-3] 05:48PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.006 [2125-12-3] 05:48PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [2125-12-4] 10:46AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.009 [2125-12-4] 10:46AM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR [2125-12-4] 10:46AM URINE RBC-22* WBC-4 Bacteri-NONE Yeast-NONE Epi-0 [2125-12-4] 10:46AM URINE Mucous-RARE . Microbiology: [2125-12-3] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] - No growth to date [2125-12-3] URINE URINE CULTURE-No growth [2125-12-3] BLOOD CULTURE Blood Culture, Routine-PENDING - no growth to date . Radiology: [2125-12-3]: OSH CT scan shows 1.4x1.7cm left posterior temporo-occipital lobe hemorrhage without significant edema or [Last Name (un) ] effect. Diffuse atrophy present. . [2125-12-5]: Non-contrast Head CT: 1. Left posterior temporo-occipital lobe hemorrhage essentially unchanged over 46 hours. The relative stability of this hemorrhage, as well as its associated edema, raises the possibility of an underlying structural abnormality such as a mass, although there is no surrounding edema. 2. Global atrophy, predominantly central and preferentially involving the temporal lobes, raising the possibility of underlying Alzheimer disease and possible associated CAA, with "lobar hemorrhage." . EEG: Preliminary read: diffusely slow 7 Hz. no sleep. no epileptiform activity. no focal slowing. Brief Hospital Course: 89 year-old woman with a history of HTN, HLD and prior right frontal hemorrhage, who is legally deaf and blind, dependent on a cochlear implant, presented with garbled non-sensical speech, found to have a new small 1.4x1.7cm left occipital lobe hemorrhage without significant edema or mas effect and cortical atrophy at OSH with marked HTN to SBP 200s. BP was controlled with IV labetalol at OSH and patient was transitioned to a labetalol infusion and admitted to the neuro ICI on [12-3]. Labetalol infusion was stopped on [12-4] due to SBP in 90s which stabilised. She continued to be very agitated and complained of significant back pain s/p fall on [11-28] and seemed to have expressive aphasia. Given her previous hemorrhage, the aetiology was felt likely due to a combination of hypertension and amyloid angiopathy. Has hyponatremia 130 which appears chronic and not in keeping with SIADH. Her sodium improved to 134 prior to discharge. Patient was deemed appropriate for transfer out of the ICU as she had remained clinically stable and no longer required IV anti-hypertensives and was transferred to the neurology floor on [2125-12-5]. Repeat Head CT on [2125-12-5] showed improvement in bleed size. Given the consideration that seizures may be causing her speech problems, she had an EEG which showed diffuse slowing consistent with age but no epileptiform activity or focal slowing. A swallow evaluation showed no signs of aspiration or dysphagia. Physical therapy evaluated the patient and found her to have very unsteady ambulation with a cane. They recommended outpatient PT and recommended her for discharge only with 24 hour supervision. The patient's daughter ensured us that she would have 24 hour supervision with the help of personal care aids who could also help with exercises. Medications on Admission: - Alendronate 70mg weekly - Diltiazem 30mg [Hospital1 ] - Lovastatin 10mg qd - Lisinopril 10mg [Hospital1 ] - Sertraline 100mg daily - MVI - Calcium and vitamin D - Dorzolamide 2% drops 1 drop [Hospital1 ] - Timolol 0.5% 1 drop [Hospital1 ] - Lumigan 0.03% drops [Hospital1 ] - Prednisolone acetate 1% drops [Hospital1 ] - Alphagan 0.1% drops [Hospital1 ] - Levothyroxine 25mcg qd - Ferrex 150mg cap qd Discharge Medications: 1. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). 4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 5. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 6. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 7. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. lovastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: intraparenchymal hemorrhage - left occipital lobe Discharge Condition: Mental Status: Confused - always. (Primarily due to sensory deficits) Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Neuro: Mental status exam severely limited by blindness and deafness (small improvement with cochlear device). Patient able to speak in clear coherent fluent sentences. Moves all extremities spontaneously and equally. Discharge Instructions: You were admitted to the hospital for difficulties with language and confusion. Your brain imaging showed a small bleed in the left occipitial lobe, likely related to a similar cause as the bleed you had previously, high blood pressure and amyloid. A repeat head CT showed the bleed to be resolving. A preliminary EEG read showed no sign of seizure activity. The physical therapy team evaluated and found you to go home with 24 hour supervision. Given that your daughter has agreed to 24 hour supervision, we are sending you home with home PT and VNA services. No changes have been made to your medications. Followup Instructions: Please call registration to update your information: [Telephone/Fax (1) 10676] Please follow up in [Hospital 878] clinic with Dr. [Last Name (STitle) ] in the [Hospital1 18] [Hospital Ward Name 516] [Hospital Ward Name 23] Building: Tuesday [2-5] at 2:30pm Provider: [Name10 (NameIs) ] [Name11 (NameIs) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 2574] Date/Time:[2126-2-5] 2:30 [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] ICD9 Codes: 431, 2761, 2859, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9049 }	Medical Text: Admission Date: [2182-10-21] Discharge Date: [2182-10-24] Date of Birth: [2130-3-30] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2356] Chief Complaint: S/p fall, hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 52 yo F w/ h/o MDS, hypothyroidism, questionable seizures, presents after fall x 2 at home, found to be hypotensive. Pt states that she falls "occasionally" at home, and can predict when she does; she associates with having a seizure. Over the past 4-5 days pt reports not feeling well; first had 2 days of migraines, then during the following days she had persistent n/v, anorexia, and watery diarrhea, several bowel movements per day. She had no po intake. She noted a low grade temp to 99 F four days ago, but has since denied fevers or sick contacts. Yesterday morning while getting up from bed she was light headed, vertiginous, and felt herself falling forward. She states she was unable to keep herself from falling forward and hit her nose. She then hit her neck/back as she flung herself backwards to try to get up. She suffered a nosebleed but no LOC. She finally came to the ED after her PCP's suggestion. In ED here on arrival she was noted to have a BP of 66/40, P 66 which improved to SBP 70s after 2L NS. However, because of persistent hypotension, she eventually received total 9L NS. She was also placed on DA which was gradually weaned off. She had a head CT showing no bleed but + paravertebral soft tissue thickening concerning for ?bleed vs. other fluid. Her neck MRI demonstrated a prevertebral fluid collection without enhancement or evidence of fracture. no cord compresssion appreciated. ROS: denies URI sxs, cough, current nausea, abdominal pain, melena, BRBPR, hematemesis. +sensation of lump in throat, thirst, hunger. Past Medical History: 1. Chronic macrocytic anemia w/ mild pancytopenia 2. Status post bone marrow biopsy [2179-7-28]-MDS v EtOH toxicity 3. Hypothyroidism 4. h/o questionable seizures, but neg 48h EEG and nL MRI in past. 5. Migraine headaches. 6. Questionable history of cardiac arrhythmias. [Doctor Last Name ] of Hearts in past showed some tachys to 180s. 7. Peptic ulcer disease status post Nissen fundoplication. 8. Status-post hemorrhoidectomy. 9. Asthma s/p intubation x 1 in past. 10. Osteoarthritis. 11. b/l cataracts 12. R knee surgery Social History: SH: Lives with her boyfriend in [Name (NI) 4628]. Three college aged daughters. [Name (NI) ] tobacco. Occ EtOH. No drugs/herbals. Used to be a photographer before recent illnesses Family History: Father died of CAD at age 80. Mother-alive and healthy. No family with MDS or leukemia Physical Exam: T 96.3, BP 136/67, P 67, R 24, 100% RA Gen: AAO x 3, sitting up in bed with foam collar on HEENT: PERRLA, EOMI, mmm, clear OP, +laceration +ecchymosis over nose Neck: in foam collar CV: RRR, nl S1, S2 without m/r/g Pulm: CTA bilaterally, faint bibasilar rales Abd: +bs, soft, NT/ND, no masses Back: +ecchymoses Extr: no c/c/e Neuro: normal motor strength of upper extremities bilaterally, moves [Name Prefix (Prefixes) ] [Last Name (Prefixes) 6816] with 4/5 strength U/E [5-1] strenght; difficult to assess all CN given neck collar. CN II-X intact. Pertinent Results: [2182-10-21] 11:10AM WBC-4.3 RBC-2.67* HGB-10.1* HCT-29.7* MCV-112* MCH-37.9* MCHC-34.0 RDW-16.5* [2182-10-21] 11:10AM PLT SMR-LOW PLT COUNT-101# [2182-10-21] 11:10AM NEUTS-79.2 BANDS-0 LYMPHS-14.9* MONOS-3.4 EOS-2.5 BASOS-0.1 [2182-10-21] 11:10AM PT-13.2 PTT-27.7 INR(PT)-1.1 [2182-10-21] 11:10AM ALBUMIN-2.9* CALCIUM-7.6* PHOSPHATE-4.4 MAGNESIUM-1.2* [2182-10-21] 11:10AM GLUCOSE-94 UREA N-13 CREAT-1.6* SODIUM-126* POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-17* ANION GAP-13 [2182-10-21] 11:10AM ALT(SGPT)-11 AST(SGOT)-22 ALK PHOS-93 AMYLASE-23 TOT BILI-0.3 [2182-10-21] 07:40PM GLUCOSE-162* UREA N-7 CREAT-0.8 SODIUM-139 POTASSIUM-3.4 CHLORIDE-119* TOTAL CO2-12* ANION GAP-11 CXR: Interval development of interstitial edema with septal lines and upper zone redistribution CT head: no hemorrhage, paravertebral soft tissue thickening on scout image CT spine: Diffuse infiltration of retropharyngeal space from inferior pharynx to C5 laterally to bilateral carotids CT abdomen: 1. Marked diffuse symmetric wall thickening seen throughout the stomach extending into the first portion of the duodenum, likely represents edema. Given the patient's recent chest x-ray documenting short-interval development of interstitial edema, ?volume overload, possibly vasculitis. 2. Small amount of ascites and pelvic free fluid. 3. Bibasilar atelectasis and small bilateral pleural effusions. 4. No evidence of solid organ injury within the abdomen ECG: NSR at 60 bpm, nl axis, slightly prolonged QTc [10-21] Cervical MRI: FINDINGS: There is no evidence of cord compression or abnormal signal. There is no evidence of discitis or epidural abscess. There is prevertebral fluid accumulation in the upper cervical region. There is no definite evidence of focal disc protrusion or canal stenosis. Alignment is maintained. There is no definite evidence of marrow injury. IMPRESSION: Prevertebral fluid accumulation as described. This could represent an infectious process and abscess formation, although I do not see a great deal of marginal contrast enhancement. There is no evidence of epidural abscess or discitis. The collection does not appear to represent blood nor do I see definite evidence of vertebral fracture Brief Hospital Course: A/P: 52 yo F w/ h/o MDS, multiple other medical problems, here w/ hypotension after several days of n/v/d. 1. Hypotension: We thought that her hypotension was probably secondary to intravascular volume depletion due to several days of nausea, vomiting and diarrhea. She responded to IV fluids and was easily weaned off her dopamine drip with her systolic blood pressures consistently in the 130s with concomitant transfer from the ICU to the medicine floor. We also entertained the diagnosis of sepsis but thought that this was less likely since her WBC was normal, she was afebrile and no longer hypotensive. Blood cultures and urine cultures were drawn. The urine culture was negative and the results of the blood culture are still pending at this time. We did not find evidence for a cardiogenic etiiology of her hypotension since her cardiac enzymes were normal and there were not ECG changes. The diagnosis of adrenal insufficiey was also considered by her electrolytes were normal making this less likely. 2.Nausea/vomiting/diarrhea:We thought that her GI symptoms may have been secondary to a viral infection as they resolved upon admission and did not recur. 3. S/p Fall We were unsure about the etiology of her fall and thought that it could possibly have been due to her hypovolemia leading to orthostasis, questionable vasovagal (although not a classic story), seizures, h/o arrhythmia, holter in past reportedly had + tachyarthymia to 180s in the past and the pt is currently followed by cardiologist. Upon completion of fluid resucitation and the maintenance of a stable of blood pressure, the patient was evaluated by PT and was considered to be safe to go home. Thus, we thought that her fall was probably secondary to orthostatis caused by volume depletion base on its response to re-hydration. 4. Prevertebral fluid collection: The patient was evluated by neurosurgery and this fluid collection was not thought to be secondary to fracture or infection. She was instructed to wear a neck collar and will follow up in neurosurgery clinic two weeks after discharge. (See discharge follow up.) 5. Seizures: She was continued on her neurontin as advised by her PCP. - 6. MDS: She continued to receive epogen. 7. Acute Renal Failure: Her elevated creatinine responded well to re-hydration and thus her acute renal failure was considered to be secondary to hypovolemia. 8. Metabolic acidosis: Upon fluid resuscitation with normal saline the patient devloped a mild metabolic acidosis which resolved with IV bicarb supplementation. 8. Hypthyroidism: The patient's TSH was checked and it was found to be elevated. Although this was felt to be seconary to sick euthyroid syndrome her levothyroxine was emperically increased to 200 mcg per day which the patient tolerated. In light of patient's continued improvement, the paitient's request was honored and she was discharged to home with close follow up. Medications on Admission: 1. Albuterol neb Q6H prn 2. Ipratropium neb Q6H prn 3. Epogen 20,000 unit/mL Solution Sig: 3mL Qweek. 4. Zolpidem 5 mg po qhs prn 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID 6. Levothyroxine Sodium 175 mcg Tablet Sig: One (1) Tablet PO QD 7. Prilosec 20 mg Capsule, 1 [Hospital1 ] 9. Ativan 1 mg Tablet Sig: One (1) Tablet PO TID prn 10. Soma 350 mg Tablet Sig: One (1) Tablet PO tid prn h/a 11. Atenolol 25 mg Tablet Sig: One (1) Tablet PO QAM 12. Atenolol 50 mg Tablet Sig: One (1) Tablet PO QPM 13. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO QD 14. Imitrex 50 mg Tablet Sig: One (1) Tablet PO QD prn migraine 15. Skelaxin 400 mg Tablet Sig: One (1) Tablet PO TID pain Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Levothyroxine Sodium 200 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime). 6. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: [12-28] Tablets PO Q6H (every 6 hours) as needed. 7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please take only 50 mg of atenolol in the morning as your previous dose (morning and evening) may lower your blood pressure too much at this time. 8. Epoetin Alfa 40,000 unit/mL Solution Sig: One (1) injection Injection QMOWEFR (Monday -Wednesday-Friday): as previously scheduled. Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Nausea and vomiting 2. Hypotension 3. S/p fall Discharge Condition: Good, ambulating independently and tolerating po intake without incident. Discharge Instructions: Please call your doctor or return to the emergency room if you feel light headed, experience severe nausea and vomiting, chest pain, shortness of breath. Please take all medications as prescribed. Followup Instructions: Provider: [Name10 (NameIs) ],[Name11 (NameIs) 742] NEUROSURGERY WEST Where: LM [Hospital Unit Name 12011] Phone:[Telephone/Fax (1) 3666] Date/Time:[2182-11-8] 11:00 Provider: [Name10 (NameIs) 326] [Name11 (NameIs) 16380]/US+DXWIRE LOCS RADIOLOGY Where: [Hospital 4054] RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2182-11-14] 2:00 [First Name4 (NamePattern1) 1730] [Last Name (NamePattern1) ] MD [MD Number(1) 2362] ICD9 Codes: 5849, 2765, 2762, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9050 }	Medical Text: Admission Date: [2114-12-6] Discharge Date: [2114-12-9] Date of Birth: [2047-3-21] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (un) 11974] Chief Complaint: ICD firing, VT storm Major Surgical or Invasive Procedure: electrophysiology study and ablation [2114-12-7] History of Present Illness: The patient is a 67 year old female with idiopathic dilated cardiomyopathy (? viral myocarditis 10 years ago) with LVEF of 20% s/p BiV ICD, and recurrent multifocal ventricular tachycardia s/p L VATS for sympathectomy and excision of the left stellate Ganglion on [2114-11-26] in setting of recurrent VT who presents from home with multiple ICD shocks. Since returning home, she has felt well. She has noted intermittent palpitations since yesterday. . The patient has had a long course of admissions since [Month (only) 359] [2113] for recurrent multifocal ventricular tachycardia and ICD firings. She was found to have multiple inducible VTs arising from the septum, lateral wall and apex during EP study in [Month (only) 359], with the septal origin of VT precluded ablation. She was started on mexilitine but continued to have frequent sustained VT. Anterior septal ablation was attempted, but she experienced recurrent VT. She was readmitted and had successful stellate ganglion block and was started on qunidine. About one week later, she had recurrent palpitations and was re-admitted for repeat stellate ganglion block twice. During her most recent admission, she was taken to the operating room with Thoracic Surgery on [2114-11-26] and had a left-sided video-assisted thoracoscopic surgery (VATS) procedure with sympathectomy without issue and was in sinus rhythm afterwards. She was discharged on metoprolol but not any anti-arrhythmics. The patient had been feeling very well until yesterday, when she began to note some palpitations. She was having dinner with her family and felt palpitations and experienced one shock, followed in succession by approximately 3 more shocks. Her husband called Dr. [Last Name (STitle) ] and he advised admission to the CCU. . In the CCU, she has no complaints. Interrogation of her ICD reveals 20 episodes of VT since [2114-11-29], mostly with rate in 110-130s range. . On review of systems, she 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. She denies recent fevers, chills or rigors. She 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: None. 2. CARDIAC HISTORY: Idiopathic dilated cardiomyopathy (?viral myocarditis), EF 20-25%%. -CABG: None. -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: ICD and BiV device 3. OTHER PAST MEDICAL HISTORY: - Osteoarthritis - h/o Gout - Stellate Ganglion Block x2 -left-sided video-assisted thoracoscopic surgery (VATS) procedure with sympathectomy ([2114-11-26]) Social History: Tobacco history: Denies. -ETOH: rare -Illicit drugs: Denies. The patient lives with her husband. Family History: Negative for premature atherosclerotic cardiovascular disease and sudden death. There is no diabetes or hypertension in the family history. Son: viral induced DM1 Father- MI [66] Mother- died at 93 Physical Exam: ADMISSION EXAM VS: Afebrile 92/46 76 18 97%RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP at clavicle. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. ICD pacer pocket scar noted on left anterior wall. 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. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, or xanthomas. healing scars in left axilla c/w VATS scars PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . DISCHARGE EXAM: unchanged, except with slight pericardial rub on exam and minimally tender site of pericardial drain without erythema or hematoma. Pertinent Results: ADMISSION LAB RESULTS [2114-12-6] 09:03PM BLOOD WBC-8.9 RBC-3.80* Hgb-11.8* Hct-34.8* MCV-92 MCH-30.9 MCHC-33.7 RDW-13.7 Plt Ct-263 [2114-12-6] 09:03PM BLOOD PT-10.7 PTT-28.3 INR(PT)-1.0 [2114-12-6] 09:03PM BLOOD Glucose-139* UreaN-35* Creat-1.7* Na-142 K-3.7 Cl-103 HCO3-28 AnGap-15 [2114-12-6] 09:03PM BLOOD ALT-28 AST-28 LD(LDH)-213 CK(CPK)-40 AlkPhos-72 TotBili-0.4 [2114-12-6] 09:03PM BLOOD CK-MB-3 cTropnT-0.05* proBNP-6045* [2114-12-6] 09:03PM BLOOD Albumin-3.8 Calcium-9.2 Phos-3.4 Mg-2.2 DISCHARGE LAB RESULTS [2114-12-9] 05:46AM BLOOD WBC-6.1 RBC-3.22* Hgb-10.2* Hct-30.9* MCV-96 MCH-31.6 MCHC-33.0 RDW-13.5 Plt Ct-181 [2114-12-9] 05:46AM BLOOD PT-11.9 PTT-25.5 INR(PT)-1.1 [2114-12-9] 05:46AM BLOOD Glucose-85 UreaN-23* Creat-1.3* Na-137 K-3.6 Cl-101 HCO3-32 AnGap-8 [2114-12-9] 05:46AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.9 Imaging: [2114-12-6] Left pectoral AICD device is seen with its leads terminating into the right atrium, right ventricle and coronary sinus. Mildly enlarged heart size is stable. There are no lung opacities of concern. There is no pleural effusion. Mediastinal and hilar contours are normal. IMPRESSION: No acute process in the chest. [2114-12-8] CXR: As compared to the previous radiograph, the patient has received a pericardial drain. The size of the cardiac silhouette has minimally increased. There is mild retrocardiac atelectasis, but no evidence of substantial pleural effusions. No pulmonary edema. No hilar or mediastinal abnormalities. [2114-12-8] ECHO:FOCUSED STUDY FOR PERICARDIAL EFFUSION. The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is severe global left ventricular hypokinesis (LVEF = 20 %). Right ventricular chamber size is normal. with mild global free wall hypokinesis. The aortic valve leaflets are mildly 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 (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. No right atrial diastolic collapse is seen. Slight right ventricular invagination during mid-diastole. No MV/TV respiratory variation. IMPRESSION: Mild right ventricular invagination during mid-diastole (best seen on subcostal views) in presence of small circumferential pericardial effusion. Severely depressed left ventricular systolic function. Mild right ventricular hypokinesis. Compared with the prior study (images reviewed) of [2114-10-25], the pericardial effusion is new. [2114-12-8] ECHO: FOCUSED STUDY: Overall left ventricular systolic function is severely depressed (LVEF= 25 %). Right ventricular chamber size and free wall motion are normal. The mitral valve leaflets are mildly thickened. Mild to moderate ([12-17]+) mitral regurgitation is seen. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2114-12-8], right ventricular invagination is not seen. There is slightly more mitral regurgitation. [2114-12-9] ECHO: FOCUSED STUDY: There is severe global left ventricular hypokinesis (LVEF = 25 %). Right ventricular chamber size and free wall motion are normal. Mild to moderate ([12-17]+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Stable, trivial pericardial effusion without echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2114-12-8] the findings are similar. Brief Hospital Course: 67yo female with incessant VT s/p multiple anti-arrythmics, ablations and sympathectomy on [11-29] with recurrent VT today, now s/p attempted endocardial ablation complicated by carotid sinus perforation, epicardial ablation, hemodynamically stable. . Acute Care: # CORONARY SINUS PERFORATION: During the patient's endocardial VT ablation procedure, the coronary sinus was inadvertently perforated. Given this complication, pericardial drain was placed and the patient was kept in the CCU for monitoring. Patient remained stable, and a small pericardial effusion was noted at the time of removal of the drain (24hrs after placement). Echo on the morning of discharge showed trivial effusion without no signs of tamponade, unchanged from the day prior. Aspirin was held, and subcutaneous heparin was deferred given bleeding risk. . # RECURRENT VENTRICULAR TACHYCARDIA: The patient has had multiple attempts at ablation, and multiple trials of anti-arrhythmic medications. Additionally, patient is s/p sympathectomy. She has ongoing VT and the foci seems likely left septal, thought to be a triggered rhythm. Given complications during endocardial ablation, she was only able to undergo epicardial ablation. She was monitored in the CCU and continued to have occasional asymptomatic non-sustained VT overnight. During this admission, metoprolol was held. Sotalol 80mg [Hospital1 ] and mexiletine 150mg TID were started. K+ and Mg were repleted appropriately. Pain was managed with IV morphine initially, tranistioned to a lidocaine patch, and at discharge patient elected to only use tylenol for pain management. Given persistent VT, patient will need further ablation within the next week and consideration of possible heart transplant. . # DILATED CARDIOMYOPATHY: Chronic, LVEF 20%. NY Class III per outpatient notes which has worsened recently from II. On CHF regimen including metoprolol, spironolactone, and torsemide at home. Currently appears euvolemic without signs of overload on physical exam. She has baseline dyspnea which is unchanged. During her admission her regimen was altered; including discontinuation of metoprolol, initiation of sotalol 80mg [Hospital1 ], increasing aldactone to 50mg from 25mg daily, and continuing torsemide at 20mg daily. She will have f/u labs drawn at the end of the week to monitor potassium, and will schedule an appointment with Dr. [Last Name (STitle) ] after the holiday. . Chronic care: # OSTEOARTHRITIS: Continued tylenol up to 2grams daily. . # GOUT: Continued allopurinol. . # Anxiety: Continued alprazolam. . ISSUES TO ADDRESS AT FOLLOW UP: - monitoring of potassium given increase in aldactone (to be drawn on [2114-12-14] and faxed to Dr. [Last Name (STitle) ]. - elevation in TSH to 4.7 - patient will need repeat ablation within the next week or two given intermittent VT. - Patient should be on an ACEI or [First Name8 (NamePattern2) ] [Last Name (un) ]. It was unclear as to why she is not on one, though could be due to her recent [Last Name (un) ]. PCP could not be reached for clarification given the holiday. This should be follow up as an outpatient by her PCP and cardiologist. Medications on Admission: -allopurinol 100mg daily -aspirin 81mg daily -spironolactone 25mg daily -metoprolol succinate 50mg [Hospital1 ] -alprazolam 0.25-0.5mg [Hospital1 ] PRN anxiety -torsemide 20mg daily -magnesium oxide 400mg daily -midodrine 5mg TID -colase PRN -acetaminophen PRN -senna PRN -oxycodone PRN Discharge Medications: 1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. alprazolam 0.25 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for anxiety. 4. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. senna Oral 7. acetaminophen Oral 8. midodrine 5 mg Tablet Sig: One (1) Tablet PO three times a day. 9. sotalol 80 mg Tablet Sig: 0.5 Tablet PO twice a day. 10. spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 11. mexiletine 150 mg Capsule Sig: One (1) Capsule PO three times a day. 12. Outpatient Lab Work Please draw a basic metabolic panel on [2114-12-14] and fax results to Dr. [Last Name (STitle) ] [Name (STitle) ], Fax #[Telephone/Fax (1) 3341]. 13. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day as needed for constipation. Discharge Disposition: Home Discharge Diagnosis: primary diagnosis: ventricular tachycardia secondary diagnosis: dilated cardiomyopathy, chronic systolic heart failure, anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname ], You were admitted to [Hospital1 18] for firing of your ICD. You underwent an electrophysiology procedure called a ventricular tachycardia ablation. You were started on two anti-arrhythmia medications after, sotalol and mexiletine, which you will continue to take after you leave the hospital. This procedure was complicated by some bleeding into the pericardial space. For the bleeding, a temporary drain was placed and then removed 24hrs later. Follow up scans of your heart do not show any significant re-accumulation of fluid. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Please note the following changes to your medications: - START sotalol (Dr. [Last Name (STitle) ] has called this into your pharmacy for you) - START mexiletine - INCREASE spironolactone from 25mg to 50mg once daily - STOP taking metoprolol - STOP taking supplemental potassium Continue all of your other medications as prescribed. Please be sure to follow up with your physicians. You will need to come back for a blood draw at the end of the week (on [2114-12-14]). Followup Instructions: Dr.[Name (NI) 27850] office will contact you to make an appointment. If you do not hear from them within one week, please call their office to schedule yourself an appointment, ([Telephone/Fax (1) 2037]. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 11975] ICD9 Codes: 4271, 4254, 4280, 4240, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9051 }	Medical Text: Admission Date: [2129-11-12] Discharge Date: [2129-11-14] Date of Birth: [2100-6-10] Sex: M Service: MEDICINE Allergies: Peanut Attending:[First Name3 (LF) 2108] Chief Complaint: admitted with GI Bleed, called out of ICU Major Surgical or Invasive Procedure: EGD on [2129-11-12] History of Present Illness: Mr. [Known lastname ] is a 29 year old male with a history of abdominal pain and hemetemesis with a inflammatory gastric polyp resected two days prior to admission who presents with melena, lightheadedness, and new anemia. He was admitted from the [Hospital1 18] ER to the [Hospital Unit Name 153] on [11-12] after an episode of presyncope associated with melena. In addition he had extreme thirst. In the ED, initial vs were: pain 0, T 97.3, HR 114, BP 130/74, RR 16. O2 sat 100% RA. Exam was notable for dark, guaiac + stool per rectum. Labs were notable for hct 27.6 down from baseline of 44. CXR was unremarkable. EKG was sinus tach at 106 with T wave inversions in the lateral leads. Patient was given protonix 40 mg IV bolus and protonix gtt as well as 1L NS and 1 unit of blood. Vital signs on sign-out were BP 120, HR 84 127/77, RR 18, 98% RA, afebrile. In the ICU the patient underwent an EGD which revealed a deep ulcer, no vessel was seen, no active bleeding. His HCT was relatively stable. hemodynamically stable so called out to the medical floor in the p.m. on [11-13]. He underwent transfusion of 2 units PRBC, last at 2 a.m. on [11-13]. He ruled out for an MI. Currently feeling well. Tolerating a regular diet, no nausea, abdominal pain, diaphoresis, lightheadedness, 1 episode of melena the day prior but none since, no BRBPR. No chest pain or SOB. Rest of ROS is negative. Past Medical History: Genital Herpes Gastric polyp s/p ex-lap for abdominal stab wound Social History: Works as an anesthesia tech at [Hospital1 18]. Formerly was in the military. Smokes [2-16] cigarettes daily. Used to drink 1 bottle of beer or hard liquor once or twice on the weekends but has cut back. Last drink was [1-16] of 12 oz bottle of beer on [11-11]. Family History: Unknown, adopted Physical Exam: VS: T 97.6 HR 82 BP 106/67 RR 19 O2 97% on RA GEN: NAD, AOX3 HEENT: MMM, unable to assess JVP CARD: RRR, no m/r/g PULM: CTAB ABD: soft, NT, ND, no masses or organomegaly EXT: WWP, no c/c/e NEURO: AOx3, grossly normal Pertinent Results: [2129-11-13] 12:40PM BLOOD WBC-8.2 RBC-3.52* Hgb-10.1* Hct-29.4* MCV-84 MCH-28.7 MCHC-34.3 RDW-13.2 Plt Ct-196 [2129-11-13] 04:21AM BLOOD WBC-9.5 RBC-3.61* Hgb-10.8* Hct-29.7* MCV-82 MCH-29.9 MCHC-36.3* RDW-13.6 Plt Ct-218 [2129-11-13] 12:38AM BLOOD Hct-27.8* [2129-11-12] 08:05PM BLOOD WBC-13.2# RBC-3.25# Hgb-9.5# Hct-27.6# MCV-85 MCH-29.3 MCHC-34.5 RDW-13.4 Plt Ct-263 [2129-11-13] 04:21AM BLOOD Neuts-54.3 Lymphs-36.2 Monos-6.5 Eos-2.5 Baso-0.5 [2129-11-13] 04:21AM BLOOD PT-13.6* PTT-28.0 INR(PT)-1.2* [2129-11-13] 04:21AM BLOOD Glucose-93 UreaN-24* Creat-0.8 Na-139 K-3.6 Cl-108 HCO3-23 AnGap-12 [2129-11-12] 08:05PM BLOOD Glucose-87 UreaN-43* Creat-1.0 Na-138 K-3.3 Cl-103 HCO3-26 AnGap-12 [2129-11-13] 12:40PM BLOOD CK(CPK)-200 [2129-11-13] 04:21AM BLOOD CK(CPK)-187 [2129-11-12] 08:05PM BLOOD CK(CPK)-253 [2129-11-13] 12:40PM BLOOD CK-MB-2 cTropnT-<0.01 [2129-11-13] 04:21AM BLOOD CK-MB-3 cTropnT-<0.01 [2129-11-12] 08:05PM BLOOD cTropnT-<0.01 [2129-11-13] 04:21AM BLOOD Calcium-7.9* Phos-2.5* Mg-1.9 [2129-11-14] 06:55AM BLOOD WBC-7.8 RBC-3.62* Hgb-10.6* Hct-30.8* MCV-85 MCH-29.2 MCHC-34.4 RDW-13.7 Plt Ct-221 [2129-11-12] chest x ray: No acute cardiopulmonary process. No significant interval change. [2129-11-12] EGD: Ulcer in the pylorus Otherwise normal EGD to duodenal bulb [2129-11-10] EGD: [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] A esophagitis was seen in the GE junction A small size hiatal hernia was seen. An approximately 1.5cm erythematous nodule was seen in the prepyloric antrum along the greater curvature. A mucosal resection was performed and the lesion was totally removed using a band EMR. Otherwise normal EGD to third part of the duodenum [2129-8-25] EUS: [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] A esophagitis A 1.5cm prepyloric antral nodule was noted EUS: Nodule showed ill-defined expansion of the superficial and deep mucosal layer with normal appearing submucosa and muscularis. This appearance was suggestive of a mucosal based polyp e.g. inflammatory, hyperplastic or adenomatous polyp. EUS appearance was not typical for GIST, carcinod or lymph node. EGD [2129-4-1] PERFORMED FOR DYSPEPSIA: Friability, erythema and congestion in the antrum compatible with gastritis (biopsy) Nodule in the pylorus (biopsy) Otherwise normal EGD to third part of the duodenum Brief Hospital Course: This is a 29 year old male with a history of recently ressected inflammatory gastric polyp who presents with melena, presyncope, and hct drop concerning for upper GI bleed. Upper GI Bleed - likely etiology of melena, presyncope, and hct drop to 27.6 from baseline of 43.8. Likely related to recently ressected gastric polyp. The patient was treated with high dose PPI and will continue for at least 6 weeks. Pathology of gastric polyp pending at the time of discharge. Hct stable at the time of discharge. In total the patient rec'd 2 units of PRBC. EKG changes - likely related to tachycardia. No complaints of chest pain or shortness of breath. Ruled out for MI. Medications on Admission: HOME MEDICATIONS: prednisone 50mg daily from [Date range (1) 81788] omeprazole 40mg po bid TRANSFER MEDICATIONS: PROTONIX 40MG IV BID Discharge Medications: 1. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagonsis: Peptic ulcer disease, gastrointestinal bleeding, anemia of acute blood loss Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with bleeding from your stomach. You should continue your medications as prescribed and make your follow up apointments. Please continue to take omeprazole twice daily for at least 6 weeks unless instructed otherwise by your gastroenterologist. Please avoid alcohol, aspirin, and ibuprofen or naproxen for the next 6 weeks. Followup Instructions: Please follow up with your primary care physician for [Name Initial (PRE) ] check up and to have your blood counts checked (hematocrit) within 1 week of discharge from the hospital. ICD9 Codes: 2851, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9052 }	Medical Text: Admission Date: [2153-2-26] Discharge Date: [2153-3-4] Date of Birth: [2092-4-12] Sex: F Service: MEDICINE Allergies: Compazine / Droperidol / Gadolinium-Containing Agents / Demerol / Morphine / Haldol Attending:[First Name3 (LF) 1674] Chief Complaint: MCDS Flare. Major Surgical or Invasive Procedure: ICU stay, no invasive monitoring History of Present Illness: 60 W with long hx of frequent hospital admissions for degranulation syndrome (MCDS), most recently admitted here at [Hospital1 18] from [0-0-] for same, presents with shortness of [Year/Month 1440] consistent with her usual flares of MCDS. Patient says that she noticed some redness in her face and neck 2-3 days ago. She tried to increase her home dose of benadryl but wasn't able to keep the medication down secondary to nausea. She also notes increased chest and abd pain, pruritis, nausea and vomiting, all of which is consistent with her usual flares of MCDS. The patient used her epi pen at home as she usually does. In ED she received benadryl 50mg iv x 1, solumedrol 80mg IV x 1, IV dilaudid, zofran, ativan, and albuterol and combivent nebs. She was admitted to the ICU for close monitoring. By the time she arrived in the ICU, she was comfortable, breathing quietly, and dozing in bed. She says that she has been hospitalized at [Hospital1 336] since her last admission here, with a MRSA infection in her L hand. She also notes that she's had some superficial tongue pain and was started on nystatin swish and swallow by her ID doctor. Past Medical History: Mast cell degranulation syndrome (MCDS) Depression/anxiety Bipolar disorder MI in [2147] after receiving cardiac arrest dose epi instead of anaphylactic dose epi HTN Erosive osteoarthritis GERD, gastritis and esophagitis on recent EGD [2151-1-8] Paradoxical Vocal Cord Dysfunction viewed on fiberoptic laryngoscopy Anemia, iron studies c/w AOCD Hemorrhoids EGD with vegetable bezoar (?[12-7]) Status post hysterectomy and oophorectomy h/o MRSA infection (porthacath associated) portacath placed [3-8] - d/c'd [2-3] MRSA infection portacath placed [2151-6-9] MRSA left arm infection; now is cast . Social History: Pt is divorced. Lives alone. She works as an ER tech in [Hospital3 ]. No tobacco or EtOH or illicit drugs. Son is HCP [Telephone/Fax (1) 21738] Family History: Mother died of MI @ 76, Sister w/ breast cancer and bilateral mastectomy. Physical Exam: T: 98.3 BP: 130/67 P: 95 RR: 18 O2 sat: 95% on 2 L NC Gen: patient appears relaxed, no itching or evidence of acute distress HEENT: perrla, eomi, MMM, OP clear, no evidence of thrush Neck: supple Cor: RRR, S1S2, no M/R/G Pulm: inspiratory wheezes B/L throughout lung fields, poor air movement Abd: soft, obese, diffusely tender to palpation, no rebound or involuntary guarding. Ext: no c/c/e, 2+ dp bilaterally Skin: no rashes noted Pertinent Results: [2153-2-26] 02:05PM BLOOD WBC-10.5# RBC-4.79# Hgb-13.5# Hct-40.9# MCV-85 MCH-28.2 MCHC-33.0 RDW-13.4 Plt Ct-400 [2153-2-27] 02:52AM BLOOD WBC-8.3 RBC-3.96* Hgb-11.0* Hct-33.5* MCV-85 MCH-27.8 MCHC-32.8 RDW-13.3 Plt Ct-312 [2153-2-28] 04:00AM BLOOD WBC-7.8 RBC-4.07* Hgb-11.4* Hct-34.2* MCV-84 MCH-28.0 MCHC-33.3 RDW-13.1 Plt Ct-328 [2153-2-26] 02:05PM BLOOD Neuts-68.2 Lymphs-26.1 Monos-5.2 Eos-0.4 Baso-0.2 [2153-2-28] 04:00AM BLOOD Neuts-88.2* Lymphs-8.4* Monos-3.3 Eos-0.1 Baso-0 [2153-2-28] 04:00AM BLOOD PT-11.7 PTT-24.8 INR(PT)-1.0 [2153-2-26] 02:05PM BLOOD Glucose-138* UreaN-12 Creat-0.9 Na-146* K-3.7 Cl-109* HCO3-23 AnGap-18 [2153-2-27] 02:52AM BLOOD Glucose-131* UreaN-11 Creat-0.7 Na-142 K-4.2 Cl-111* HCO3-24 AnGap-11 [2153-2-28] 04:00AM BLOOD Glucose-143* UreaN-14 Creat-0.7 Na-142 K-3.9 Cl-110* HCO3-25 AnGap-11 [2153-2-28] 04:00AM BLOOD ALT-14 AST-14 LD(LDH)-191 AlkPhos-85 TotBili-0.1 [2153-2-27] 02:52AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.2 [2153-3-1] 12:35PM BLOOD TRYPTASE-PND CXR [2153-2-26] Single bedside AP examination labeled "upright at 18:10" is compared with recent study dated [2153-1-25]; the overall appearance is essentially unchanged. The right-sided port-a-cath reaches the cavo-atrial junction, as before. The lungs remain well-inflated and clear. The cardiomediastinal silhouette and pulmonary vessels are within normal limits and there is no pleural effusion. Heavily calcified left hilar and AP window nodes related to old granulomatous disease are redemonstrated. IMPRESSION: No acute process; old granulomatous disease. CHEST (PORTABLE AP) [2153-2-28] FINDINGS: In comparison with the study of [2-26], there is again no evidence of acute cardiopulmonary disease. Right subclavian catheter extends to the lower portion of the SVC. Brief Hospital Course: 59 y.o. woman with h/o Mast Cell Degranulation Syndrome presented with typical MCDS symptoms including SOB, pruritis, chest and abdominal pain, admitted to MICU for close monitoring, then transferred to medical floor after management of acute attacks. # Mast Cell Degranulation Syndrome: The patient was admitted to the medical intensive care unit. Per her protocol, when her acute flares occurred, she was given zofran, dilaudid, solu-medrol, albuterol nebs, O2 by NC, epinephrine, ativan and benadryl. She had flares multiple times daily during her ICU admission. Attacks seemed to be related to emotional stressors; thus, psychiatry was consulted for assistance in managing anxiety, who recommended that she continue her outpatient medications. Additionally, allergy was consulted, who recommended increasing her solu-medrol dose to 120 mg from 80 mg for her flares. She was also started on prednisone 40 mg daily for improved management of her flares. She was transferred to the medicine floor after stabilization, and she had no other flares. # Hypertension: Continued diltiazem. # Depression/anxiety/bipolar: Psych and anxiety issues seemed to instigate some of her acute flares. She was continued on her outpatient medications of Cymbalta, Seroquel, Adderall, and Ativan prn. Psychiatry was consulted as noted above. # Urinary Tract Infection: While in the hospital, the patient was found to have a urinary tract infection. She was treated with one dose of Meropenem and once the resistance pattern of the infection was determined, her antibiotics were changed to Cefpodoxime. She was discharged with instructions to take Cefpodoxime 200mg twice per day for a total of 5 days. # Postmenopausal symptoms: Held premarin while in hospital. # Osteoarthritis: Continued plaquenil. FULL CODE Medications on Admission: gastrocrom "3 amps" qid (oral cromylin 100mg q6) cardizem CD 180mg po qday premarin 0.3 daily atarax 25mg po bid zantac 300mg po daily cymbalta 60mg po qhs plaquenil 200mg po bid adderal xr 15mg po qday fexofenadine 180mg po bid omeprazole 20mg po bid ambien 10mg po prn zofran 8mg po prn zyflo 600 mg QID Zaditen 1 mg [Hospital1 ] asmanex 2 puffs [Hospital1 ] dilaudid 4mg po prn fioricet prn epi-pen Discharge Medications: 1. Gastrocrom 100 mg/5 mL Solution Sig: One Hundred (100) mg PO every six (6) hours. 2. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 3. Premarin 0.3 mg Tablet Sig: One (1) Tablet PO once a day. 4. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Adderall XR 15 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 9. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 11. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 12. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 13. Zyflo 600 mg Tablet Sig: One (1) Tablet PO four times a day. Tablet(s) 14. Asmanex Twisthaler 220 mcg (120 doses) Aerosol Powdr [Hospital1 ] Activated Sig: Two (2) puffs Inhalation twice a day. 15. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed. 16. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 17. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours: do not operate heavy machinery or drive after you take this medication. Disp:15 Tablet(s) Refills:0 18. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every [4-8] hours as needed. 19. zaditen Sig: One (1) mg twice a day: continue as before. 20. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 5 days. Disp:20 Tablet(s) Refills:0 21. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache. Tablet(s) Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Mast Cell Activating Syndrome 2. Urinary tract infection Secondary Diagnosis: 1. Hypertension 2. Depression/Anxiety 3. Osteoarthritis Discharge Condition: Stable. Ambulating with O2 sats 99-100%. Tolerating medications by mouth and no recent Mast Cell Degranulation Syndrome flares. Afebrile. No dysuria. Discharge Instructions: You were admitted for a mast cell activation syndrome flare. You were treated according to your protocol and improved. Your oxygen level was 99-100% on room air while walking. While in the hospital, you were found to have a urinary tract infection. You were treated with one dose of Meropenem and once the resistance pattern of your infection was determined, you were changed to Cefpodoxime. *Please take the Cefpodoxime 200mg twice per day for a total of 5 days.* Please continue your home medications as prescribed. You have been given a new prescription for ativan for nausea. Do not operate heavy machinery or drive when you are taking this medication. Please make all your medical appointments. If you have any of the following symptoms, please call your doctor or go to the nearest ER: fever>101, chest pain, shortness of [Month/Day (3) 1440], intractable nausea/vomiting, abdominal pain, or any other concerning symptoms. If you notice any burning when you urinate or increased urinary frequency, please follow up with your primary care provider for [Name Initial (PRE) ] repeat urine culture. Followup Instructions: Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2153-4-24] 4:00 Provider: [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 2226] Date/Time:[2153-6-4] 1:30 [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 1677] Completed by:[2153-3-5] ICD9 Codes: 5990, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9053 }	Medical Text: Admission Date: [2135-2-10] Discharge Date: [2135-2-15] Date of Birth: [2066-12-25] Sex: M Service: MEDICINE Allergies: Penicillins / Codeine / Darvon Attending:[First Name3 (LF) 562] Chief Complaint: AMS/ ? benzodiazepine overdose Major Surgical or Invasive Procedure: None History of Present Illness: This is a 68 yo M with past medical history of HTN, HIV, hep C s/p interferon (per patient) who was brought in by EMS with altered mental status after an apparent vicodin overdose. . The patient is not an appropriate historian, however, he says that he took all of his vicodin today in addition to drinking gin. He denies any suicidal gestures but cannot explain why he took all of his medication. When asked who called EMS, the patient reports his building manager, though he not clear as to how he was found or what the initial concern was. . Per report, the patient was recently given a prescription for 110 hydrocone pills for back pain. The patient initially reported that he had taken all the pills. On arrival to the ED, he was found to be altered with slurred speech. . In the ED, initial vs were: T 98.4 P 78 BP 164/91 R 18 O2 sat 96% on RA. Patient was given narcan 0.4 mg x1 with minimal response and 3L of NS. He was transferred to the ICU for close observation and management. . On the floor, the patient is sleep but easily arousable. He can answer questions appropriately though is not clear on details. He reports he is unable to recount his home medications but has them all filled at CVS in [Location (un) 5069]. In addition, when asked if he has any relatives or friends that could be [Name (NI) 653], he states that they do not get along. He is able to protect his airway at this time. His only complaint is of back and leg pain which is chronic. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Past Medical History: HIV - reports he is on HAART but per pharmacy not on medications for this Hep C - states he was on interferon and cleared his infection HTN - not on medication Lumbar stenosis Ant/post lumbar fusion in [2131] Depression Social History: Lives alone. Denies tobacco. Reports occasional marijuana use, states he only drinks socially (usually gin) Family History: N/C Physical Exam: On arrival: Vitals: T:97.4 BP:182/88 P: 78 R: 18 O2: 98% on 3L NC General: Somnolent but arousable, oriented to place and date but not year, NAD HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally though poor inspiratory effort, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Multiple eccymoses on abdomen and on L anterior chest near shoulder, also area of excoriation on R hip without evidence of infection Pertinent Results: Admission labs: [2135-2-10] 03:00PM BLOOD WBC-7.6 RBC-4.30# Hgb-13.6# Hct-39.0# MCV-91 MCH-31.6 MCHC-34.8 RDW-14.3 Plt Ct-219 [2135-2-10] 03:00PM BLOOD Neuts-59.4 Lymphs-34.3 Monos-4.8 Eos-0.8 Baso-0.6 [2135-2-10] 03:00PM BLOOD PT-13.9 PTT-19.8* INR(PT)-1.2* [2135-2-10] 03:00PM BLOOD Plt Ct-219 [2135-2-10] 03:00PM BLOOD Glucose-78 UreaN-13 Creat-0.8 Na-146* K-3.7 Cl-105 HCO3-22 AnGap-23* [2135-2-10] 03:00PM BLOOD ALT-71* AST-105* LD(LDH)-497* CK(CPK)-3115* AlkPhos-92 TotBili-0.4 [2135-2-10] 03:00PM BLOOD cTropnT-0.03* [2135-2-10] 03:00PM BLOOD CK-MB-72* MB Indx-2.3 [2135-2-10] 03:00PM BLOOD Calcium-9.3 Phos-2.8 Mg-1.8 [2135-2-10] 03:00PM BLOOD Ammonia-26 [2135-2-10] 03:00PM BLOOD Osmolal-330* [2135-2-10] 03:00PM BLOOD ASA-NEG Ethanol-121* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG . [2135-2-10] CT Head: IMPRESSION: 1. No acute intracranial process. 2. Mild sinus mucosal disease. . [2135-2-10] CXR: IMPRESSION: No acute cardiopulmonary abnormality. . [2135-2-11] TTE: The left atrium is mildly dilated. No thrombus/mass is seen in the body of the left atrium. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . Discharge labs: [2135-2-14] 05:40AM BLOOD WBC-4.1 RBC-3.26* Hgb-10.5* Hct-29.5* MCV-91 MCH-32.1* MCHC-35.5* RDW-14.5 Plt Ct-198 [2135-2-14] 05:40AM BLOOD Plt Ct-198 [2135-2-14] 05:40AM BLOOD Glucose-108* UreaN-10 Creat-0.8 Na-143 K-3.5 Cl-105 HCO3-31 AnGap-11 [2135-2-14] 05:40AM BLOOD Calcium-8.8 Phos-4.3# Mg-1.6 Brief Hospital Course: This is a 68 yo M with history of HTN, depression, chronic back pain and HIV/hep C who is admitted with AMS following a possible vicodin ingestion. . # Altered mental status: Likely secondary to ingestion per report. The patient reportedly told EMS that he had taken an entire bottle of hydrocodone/acetaminophen. Urine and serum tox screens positive for opiates, benzos and etoh. Head CT negative and no evidence of infiltrate on CXR. No leukocytosis or other evidence of current infection that might be contributing. Of note, patient reports vicodin overdose, but has a negative acetaminophen screen. Pt was monitored overnight in the ICU then transferred to the floors where he was initially somnolent but began to wake up with time. He remained oriented x3 while on the floor. Psych was consulted and agreed with d/c of all sedating medications. The exception to this is that the pt was put on a CIWA scale for possible EtOH withdrawl during his first 48 hr on the floor. Prior to discharge, they evaluated the pt and recommended he have an inpt psychiatric stay. Social work was also consulted. . # Hypernatremia: Likely from volume depletion/decreased free water intake as patient had not likely been able to drink while intoxicated. Also, appears to have been down for some time leading to elevated CK as below. Na quickly normalized with IVF. . # Rhabdomyalysis: CK elevated to 3000 with normal renal function on admission in the setting of intoxication, immobilization. Consistent with this diagnosis, initialy UA had large blood but no RBCS. Pt was hydrated with IVF initially and Cr was trended and remained stable at 0.8. . # Depression: Followed by psych at [Hospital1 18] prior to [2123] for recurrent major depression and etoh abuse. There is some question of whether this was a suicidal gesture according to signout from EMS. He is followed by Dr. [Last Name (STitle) ] (?sp) as an outpatient. Psychiatric meds were held initially in house with concern for oversedation. Psych evaluated pt in house and he is being discharged to inpatient psych bed. . # ECG changes: Last available ECG is from [2124]. RBBB this admission appears to be new as is TWI in III, avF. Also had elevated CK with mildly incr. trop. No complaints of chest pain or SOB. CE were repeated and pt was ruled out for MI. Echo was done and results are as above. . # Prophylaxis: Subcutaneous heparin, bowel regimen, no indication for ppi . # Communication: Patient. No contact information available for family members. [Name (NI) ] contact PCP in am for further information about patient, current medication regimen and chronic disease status. Medications on Admission: Vicodin 7.5-500 100 pills filled on [1-25] pills filled [1-17] Ambien 10 mg daily Methylphenidate SA 20 mg Finasteride 5 mg Paxil CR 37.5 mg HCTZ 12.5 - last filled on [10-22] Diazepam - last filled [10-22] Discharge Medications: 1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed. 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Discharge Disposition: Extended Care Discharge Diagnosis: Primary diagnosis: Alcohol intoxication and opiate overdose Altered Mental Status Secondary diagnoses: HIV Depression Hypernatremia Rhabdomyalysis Discharge Condition: Good. VSS. No O2 requirement. Hct stable Discharge Instructions: You were admitted with intoxication and medication overdose. While you were here, we monitored you for signs of toxic side effects of this overdose. Other than sleepiness, you did not have any of these side effects. You were also evaluated by psychiatry while you were here who determined you need to have an inpatient psychiatric stay before going home. . Please continue your medications as prescribed. . Please follow up with your PCP at [Name9 (PRE) 778] within 1-2 weeks. . Please call your doctor or return to the ED if you have fever, chest pain, shortness of breath, thoughts of wanting to hurt yourself, headaches, lightheadedness, sleepiness or any other concerning symptoms. Followup Instructions: Please follow up with your PCP, [Last Name (NamePattern4) ]. [First Name (STitle) 6164] within [11-26] wks after discharge from the hospital. The office number is [Telephone/Fax (1) 98861]. Completed by:[2135-2-15] ICD9 Codes: 2760, 2762, 4019, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9054 }	Medical Text: Admission Date: [2133-7-30] Discharge Date: [2133-8-4] Date of Birth: [2075-7-12] Sex: M Service: MEDICINE Allergies: Percodan Attending:[First Name3 (LF) 11495] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: s/p cardiac cath x 2 History of Present Illness: 58 y/o male with PMH significant for hyperlipidemia and atrial fibrillation was driving near [Hospital3 ] when he experienced [9-21] substernal crushing chest pain, shortness of breath associated with profuse sweating. He says the pain persisted, unabated, for 15 minutes, wherein he pulled off the road to the nearest emergency room at [Hospital6 33]. He states he has never had a pain like this before. At [Hospital1 34], he was given MSO4, NTG SL X3, NTG gtt, ASA and hep gtt without relief. His vitals at the time were 131/97 HR 68, no murmur or extra heart sounds were appreciated on exam there. . His swan was pulled after cath, and he has no CP/SOB currently. No palpitations/N/V. No diaphoresis. Only complaint is persistent cough. . He says that his cardiologist, Dr. [Last Name (STitle) 62285], at [Location (un) 511] Med Center, did a stress MIBI one month ago, which was WNL. The pt has h/o Afib, rate controlled with toprol and rhythmol, no anticoagulation, although he says his cardiologist was going to start anti-coag. He reports being started on digoxin in the past, without benefit. He intermittently feels palpitations with his Afib, usually occurring 2x/month. He has never been cardioverted. He sleeps on 1 pillow. No PND. No peripheral edema per pt. Past Medical History: 1. Hyperlipidemia 2. Atrial fibrillation Social History: From [Hospital3 ] area. Works as a project manager at a shipyard. Never smoked cigarettes, admits to smoking cigars for less than 1 year over 30 years ago. No alcohol. No IVDA. Married. Family History: Parents are alive, father with CA (unsure of what type). No h/o heart ds/MI. Physical Exam: General: 58 y/o Caucasian man. NAD. WNWD. Breathing comfortably. HEENT: PERRL, MMM. Neck: JVD difficult to assess/lying flat Lungs: With crackles bilaterally half way up the lung fields CV: RRR, S1 and S2 audible, pos S3 Abd: Soft, NT, ND, NABS, No masses Peripheral ext: 2+ peripheral pulses bilaterally, cool ext. Neuro: No focal deficits. Pertinent Results: Coronary Cath ([2133-7-30]). Selective coronary angiography in the co-dominant circulation revealed two vessel disease. The LMCA is without angiographically apparent flow limiting disease. The proximal LAD is without flow limiting disease, but the mid LAD has an 80% stenosis after the take-off of the D1. The distal LAD has a 30-40% stenosis. The D1 has mild luminal irregularities. The LCx was totally occluded with thrombus proximally before any branches. The RCA was without flow limiting disease throughout its course. The R-PDA and R-PL were also without significant flow limiting disease. There was back filling of the L-PDA and LCx via collaterals from the distal RCA, however, the OM was not filled. 2. Resting hemodynamics from right and left catheterization demonstrated moderate pulmonary arterial hypertension (59/30mmHg) and elevated right and left heart filling pressures (RVEDP=22mmHg, mean PCWP=34mmHg). Very large v waves (53mmHg) were noted on the PCWP tracing indicating severe mitral regurgitation. The calculated cardiac output by the Fick method was 4.2 L/min with a cardiac index of 1.8. 3. Successful thrombectomy and PTCA of the LCX and OM1. Final angiography revealed the LCX and all of its branch vessels except for the lPDA to be widely patent with no residual stenosis, no apparent dissection and normal flow (see PTCA comments). FINAL DIAGNOSIS: 1. Two vessel coronary artery disease with co-dominant circulation. 2. Severe mitral regurgitation given large v waves on PCWP tracings. 3. Depressed cardiac output (CI=1.8) 4. Elevated right and left heart filling pressures. 5. Moderate pulmonary arterial hypertension. 6. Succesful thrombectomy and PTCA of the LCX and OM1. Coronary Cath ([2133-8-3]): 1. Selective angiography of the left coronary circulation revealed 2 vessel disease. The LMCA had mild luminal irregularities. The LAD had a 70% stenosis just after D1. The LCX was free of significant angiographic disease until the distal vessel where the site of occlusion at the completion of the procedure on [2133-7-30] had recanalized and was now subtotally occluded. 2. Limited resting hemodynamics revealed normal systemic arterial pressures. 3. Successful direct stenting of the LAd witha 3.5 x 18 mm Cypher DES which was postdilated proximally to 4.0 mm. Final angiography revealed no residual stenosis, no apparent dissection, and normal flow (see PTCA comments). 4. Successful PTCA of the distal LCX. Final angiography revealed a 30% residula stenosis, no apparent dissection and normal flow (see PTCA comments). 5. Successful closure of the left common femoral arteriotomy with an 8 French Angioseal device. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Successful placement of a drug-eluting stent in the LAD. 3. Successful PTCA of the LCX. INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Moderate regional LV systolic dysfunction. LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior - akinetic; mid inferior - akinetic; basal inferolateral - akinetic; mid inferolateral - akinetic; septal apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Mildly dilated aortic arch. No 2D or Doppler evidence of distal arch coarctation. AORTIC VALVE: Normal aortic valve leaflets (3). Trace AR. MITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: Based on [2124] AHA endocarditis prophylaxis recommendations, the echo findings indicate a low risk (prophylaxis not recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Conclusions: The left atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with severe hypokinesis of the basal half of the inferior and inferolateral walls and distal septum. The remaining segments are mildly hypokinetic. Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. The aortic leaflets (3) are thin and mobile. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. PEAK CK [2133-7-30] 2153, MB 96, TnI 6.64 Brief Hospital Course: 58 y/o man with h/o hyperlipidemia, atrial fibrillation, admitted for chest pain, thrombectomy in cath for LCX lesion with 80% LAD lesion not stented, complicated by elevated PCWP and V waves, with concern for papillary dysfunction. 1. Cardiac: A. Coronary: Pt underwent thrombectomy of LCX artery, which showed the presence of thrombus, but no underlying coronary lesion. Thrombectomy was performed, with embolization into distal LCX and OM1, with occlusion of the LPDA. The patient was also noted to have an 80% LAD lesion, which was not believed to be contributing to the patient's symptoms. He was continued on Aspirin, integrillin x 18hours, and plavix. Upon resolution of the problems below, he was taken back to the cath lab on [8-3], with cypher stents placed in the LAD and LCX into the LPDA. He tolerated both procedures well and is discharged on plavix, aspirin, statin, as well as toprol XL. B. Pump: In the cath lab on [7-30], the patient was noted to have elevated PCWP with a large v wave, which given the evidence of LPDA occlusion was concerning for papillary muscle dysfunction. He was admitted to the CCU, where he was diuresed with lasix, started on an ACE inhibitor, and observed overnight. At no time was a murmur heard on physical exam, but he was noted to have an S3, which resolved with diuresis. Echo the following day showed LVEF 35%, with mild MR [First Name (Titles) ] [Last Name (Titles) ]-, basal-, posterior akinesis, with apical septal hypokinesis. His CHF resolved during the next few days, and he was without evidence of failure on discharge. C. Rhythm: Pt developed Aflutter post catheterization and an amiodarone drip was started. Electrophysiology was consulted. For anticoagulation, he was also on a heparin drip. He reverted to normal sinus rhythm, and remained on telemetry throughout his stay. He was transitioned to po amiodarone 400 [Hospital1 ] for one week, then po amiodarone 400mg po qd for 3 weeks per EP recommendations. If he should develop an Atrial flutter recurrence, consider Atrial flutter ablation or PVI. EP did not feel a procedure was indicated at this time. He will be discharged on [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of Hearts monitor as well, and follow up with his cardiologist, Dr. [Last Name (STitle) ]. 2. Hyperlipidemia We continued his statin. Medications on Admission: 1. Lipitor 2. Toprol 3. Rhythmol (propafenone) Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:3 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 30 days. Disp:30 Tablet(s) Refills:3 3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:30 Tablet Sustained Release 24HR(s) Refills:2 5. Outpatient Lab Work Please check PT/INR. Please call results to Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 62286], and Dr. [First Name4 (NamePattern1) 1193] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 43120]. 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO See Schedule below: Take 2 tabs twice a day for 5 days, then 2 tabs once a day for 4 weeks. . Disp:80 Tablet(s) Refills:0 7. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 8. Enoxaparin Sodium 120 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours). Disp:60 injection Refills:2 9. [Doctor Last Name ] of Hearts Monitor Please wear [Doctor Last Name ] of Hearts monitor for 2 weeks, and call results to Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 62286] Discharge Disposition: Home Discharge Diagnosis: Atrial flutter now conversion to sinus rhythm on amiodarone Myocardial infarction s/p pci to circumflex and later LAD Discharge Condition: good Discharge Instructions: please return to ed or [Name8 (MD) 138] md for development of chest pain, shortness of breath, palpitations, bleeding, lightheadedness, loss of consciousness. Please take amiodarone as written: 2 tabs twice a day for 5 days, then 2 tabs once a day for 4 weeks. Please have your INR drawn in 2 days, and follow up the results with your Primary care physician. Continue lovenox injections until instructed to stop by your PCP. Followup Instructions: Please call the holter lab at [Telephone/Fax (1) 3104] to arrange for [Doctor Last Name ] of Hearts monitor to be worn for 2 weeks Please call Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 62286] for appt in [12-14] weeks. Please follow up INR results with Dr. [First Name (STitle) 1193]. Completed by:[2133-8-4] ICD9 Codes: 4280, 4240, 4168, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9055 }	Medical Text: Admission Date: [2159-2-10] Discharge Date: [2159-2-22] Date of Birth: [2110-4-24] Sex: F Service: TRANSPLANT SURGERY CHIEF COMPLAINT: Need for kidney and pancreas transplant. HISTORY OF THE PRESENT ILLNESS: The patient is a 48-year-old Korean female with a history of hypertension and insulin-dependent diabetes mellitus who has end-stage renal disease requiring peritoneal dialysis for approximately the past two years. The patient denied fevers, chills, nausea, vomiting, chest pain, shortness of breath, or dysuria. The patient has some constipation that has been improved with stool softener. No diarrhea. No blood in the stool. The patient states that she noticed that the stools were dark due to taking iron pills. The patient denied any sick contacts. PAST MEDICAL HISTORY: 1. Hypertension. 2. Insulin-dependent diabetes mellitus. 3. Neuropathy. 4. End-stage renal disease requiring peritoneal dialysis. PAST SURGICAL HISTORY: 1. Status post bilateral cataracts. 2. Two cesarean sections. ALLERGIES: The patient has no known drug allergies. FAMILY HISTORY: Diabetes on the mother's side. ADMISSION MEDICATIONS: 1. Insulin pump six to seven years. 2. E-Vista 60 p.o. q.d. 3. Iron one tablet b.i.d. 4. Calcitriol 0.25 micrograms q.d. 5. Lipitor 10 mg p.o. q.d. 6. Norvasc 20 mg p.o. q.d. 7. Amitriptyline 10 mg p.o. q.d. 8. Metoprolol 50 mg q.a.m., 25 mg q.p.m. 9. PhosLo 667 mg capsule t.i.d. with meals. 10. Sliding scale insulin. 11. Bactroban 2% ointment. SOCIAL HISTORY: The patient moved to the United States in [2154] from South [Country 10181] and lives in [Location 10059] with husband, daughter, and son. She denied alcohol, tobacco, and illicit drug use. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 98.6, pulse 90, blood pressure 140/70, heart rate 90, respiratory rate 20, saturating 92% on room air, blood sugar 159. The patient weighs 127 pounds. General: The patient was lying comfortably in bed in no apparent distress. The patient was alert and oriented. HEENT: No lymphadenopathy. Extraocular muscles were intact. Heart: Regular rate and rhythm. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nondistended, nontender. The abdomen revealed a midline surgical scar below the umbilicus and right-sided PD catheter and a left-sided insulin pump. No erythema was noticed. Extremities: Warm 1+ edema with palpable pulse. PT and DP without any carotid pulses. HOSPITAL COURSE: The patient was admitted to the Transplant Surgery Service for pancreas and kidney transplant. The patient underwent the procedure on hospital day number two, postoperative day number one. The patient was continued on 1:1 replacement and continued on the immunosuppressive Solu-Medrol, MMF, ATG. The patient continued to have a good urine output without any difficulties. The patient had a NG tube placed, kept n.p.o. The patient's laboratories revealed that her creatinine was down to 1.0. On postoperative day number two, the patient complained of soreness in the throat with having the NG tube. The patient remained afebrile with stable vital signs and her blood sugars were between 103 and 112 and under excellent control. The patient continued to make good urine. The patient's immunosuppressives included ATG, Solu-Medrol. The patient was continued on a heparin drip. The patient's IV fluids were switched to 0.5 cc per 1 cc output replacement. The patient was continued on n.p.o. with NG tube placed. On postoperative day number three, the patient had a Guaiac positive diarrhea. The patient continued to be afebrile with stable vital signs. The patient was kept n.p.o. with a NG tube in place. The patient's heparin drip was stopped and IV fluids changed to 150 cc per hour. The patient had a crit drop to 27 from 39. The patient was transferred to the ICU for closer monitoring for acute GI bleeding. The patient also received 2 units of packed red blood cells, 2 units of FFP, and 1 unit of cryo. The patient was stabilized in the ICU. On postoperative day number four, the patient did well in the ICU setting and was stable with a hematocrit of 29. The patient's pain was well controlled with morphine PCA and good stable creatinine. On postoperative day number five, the patient continued to do well in the ICU setting. The patient's creatinine was 0.3. The patient's hematocrit was stabilized at 32.3. The NG tube was removed and the patient was transferred to the floor. On postoperative day number six, the patient had a bowel movement without any blood. The patient remained afebrile with stable vital signs. The patient continued to do well and was Hep-Locked and advanced to a regular diet. On postoperative day number seven, the patient complained of having a hard time sleeping. The patient remained afebrile with stable vital signs. On examination, the patient had some serous fluid draining from the wound without any signs of dehiscence. The patient was put on Dulcolax and placed on magnesia to help with her bowel movements. Also, she was put on some Ambien p.r.n. to help with sleep. On postoperative day number eight, the patient continued to have good urine output. We obtained a CT of the abdomen to assess the wound edge and it confirmed that there were no signs of dehiscence. The patient had an ultrasound-guided paracentesis of the fluid which improved her symptoms dramatically and decreased the amount of serous fluid production from the abdomen. On postoperative day number nine, the patient complained of a sore throat and remained afebrile with stable vital signs with good blood sugar control. We put the patient on Cepacol for a sore throat. The patient was started on some IV fluids for low blood pressure. On postoperative day number ten, we obtained a consult from ENT to evaluate a sore throat. They stated that the sore throat was due to the presence of some irritation due to the presence of NG tube. There was no need for treatment and would improve in approximately a week. On postoperative day number 11, the patient remained afebrile with stable vital signs except for perhaps a low blood pressure without any symptoms. The patient had no serous fluid draining from the abdomen. The patient was doing well. The patient was put on Augmentin for 14 days to rule out any causes for wound infection. The patient's CBI was removed and was discharged home. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Home. DISCHARGE MEDICATIONS: 1. Bactrim one tablet p.o. q.d. 2. Protonix 40 mg p.o. q.d. 3. Fluconazole 20 mg p.o. q.d. 4. CellCept [Pager number ] mg p.o. q.d. 5. MMF 500 mg p.o. b.i.d. 6. Tacrolimus 4 mg p.o. b.i.d. 7. Bisacodyl 10 mg p.o. q.d. 8. Augmentin 500 mg t.i.d. for 14 days. 9. Percocet one tablet p.o. q. four to six hours p.r.n. pain. DISCHARGE DIAGNOSIS: 1. Status post kidney and pancreas transplant on [2159-2-11]. 2. End-stage renal disease. 3. Hypertension. 4. Diabetes. 5. Status post bilateral cataract repair. 6. Status post cesarean section. 7. Neuropathy. RECOMMENDED FOLLOW-UP: Please follow-up with Dr. .................... on [2159-3-2]. Please follow-up with Dr. [Last Name (STitle) ] on [2159-3-5]. [Name6 (MD) 1344] [Name8 (MD) 1345], M.D. [MD Number(1) 1346] Dictated By:[Last Name (NamePattern1) 3118] MEDQUIST36 D: [2159-3-2] 01:54 T: [2159-3-3] 08:39 JOB#: [Job Number 40321] ICD9 Codes: 4280, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9056 }	Medical Text: Admission Date: [2141-3-18] Discharge Date: Service: ACOVE CHIEF COMPLAINT: Hemoptysis. HISTORY OF THE PRESENT ILLNESS: The patient is an 80-year-old male with history of tuberculosis, status post left thoracoplasty in the 60s; history of gastric cancer, to [Hospital 191] Clinic on [3-17] with the complaint of blood-tinged sputum for the past five to six days. Of note, he notes fevers to 99 degrees and malaise including left-sided pleuritic chest pain for the past five to six weeks. He was seen at [Company 191] two weeks ago. Chest x-ray was done at that time, which was negative for any infiltrate. He was treated with a seven day course of Levaquin for presumed this and presented again to [Company 191] on the day of admission. He occasionally feels shortness of breath at rest and he has been having an increased cough recently, especially when he talks. He also notes increasing bilateral lower extremity edema for the past one to two weeks. He has been having difficulty walking secondary to this. PAST MEDICAL HISTORY: 1. History of tuberculosis status post left thoracoplasty at the age of 28. 2. Gastric cancer, adenosea status post total gastrectomy and Roux-en-Y in [2131-3-4]. 3. Mitral valve prolapse. 4. Coronary artery disease. 5. Vertigo. 6. Nephrolithiasis. 7. B 12 deficient anemia. 8. Dyspnea secondary to restrictive lung disease. 9. Gastroesophageal reflux disease. MEDICATIONS ON ADMISSION: 1. Levaquin 250 q.d. 2. Halcion .25 q.h.s. ALLERGIES: The patient is allergic to QUININE, WHICH CAUSES A RASH. SOCIAL HISTORY: The patient is a former mechanic from [Country 532]. The patient takes no tobacco, no alcohol, lives with is wife. PHYSICAL EXAMINATION: Examination revealed the following: GENERAL: Temperature 98.6, heart rate 70, respirations 20, blood pressure 140/78, saturating 97% on room air. GENERAL: The patient is in no acute distress, sitting up in bed. Pupils equally round, reactive to light, no scleral icterus, oropharynx clear, no mucosal lesions. NECK: Neck was supple, no JVD, no lymphadenopathy. CHEST: Clear to auscultation on the right. There were minimal breath sounds with some bronchial breath sounds at the left upper lobe. HEART: Examination regular rate, S1 and S2 normal, no murmurs. ABDOMEN: Benign, midline scar, no masses. EXTREMITIES: There was 2+ pitting edema to the knees, no clubbing or cyanosis. LABS ON ADMISSION: The patient had a white count of 13.2, hematocrit 27.1, platelet count 359,000, INR 1.3. The patient had 79% polys, 12% lymphs, 6 monos. SMA 7 revealed the sodium of 141, potassium 3.9, chloride 108, bicarbonate 23, BUN 33, creatinine 1.6, which was his baseline; glucose 181, calcium 8.5, phosphatase 3.2, magnesium 1.9. The patient's urinalysis was negative. The patient's chest x-ray revealed a new opacification in the left upper lobe with a questionable effusion. ASSESSMENT: This is an 80-year-old male with history of TB status post thoracoplasty, status post gastrectomy for gastric cancer, presenting with low-grade fevers, malaise, blood-tinged sputum consistent with a left upper lobe pneumonia. INFECTIOUS DISEASE: The patient was admitted with presumed left upper lobe pneumonia. However, the patient was recently treated with Levaquin. The patient was doing well initially, however, started to spike fevers to 101 and 102. The patient continued to have hemoptysis causing a blood-tinged sputum. Infectious Disease was consulted, who felt the patient most likely had a community-acquired pneumonia and was to continue taking Levaquin. However, they also felt that a bronchoscopy may be warranted. The Pulmonary Department was consulted, who also felt that this was most likely left upper lobe pneumonia. However, they would like a chest CT, which chest CT was performed which showed again that there was more of a pneumonia than a collapse. There were no masses to suggest any post-obstructive pattern. The patient continued to have hemoptysis and high temperatures despite the Levaquin. It was decided for bronchoscopy to be performed, which was done on the 18th. Bronchoscopy showed some blood streaking and some edema from the left upper lobe consistent with pneumonia. Cultures were sent, which eventually came back negative for AFB, but showed some rare E. coli, which was Levaquin sensitive. Again, the patient is presumed to have an E. coli pneumonia, which was Levaquin sensitive and continued on the Levaquin. The patient completed a 14-day course of Levaquin while in the house. Eventually, the patient became afebrile. The patient's oxygen saturations remained stable on room air. The patient was ruled out with AFB negative times three and no AFB grew out from either the bronchial or the pericardial fluid. CARDIOVASCULAR: The patient was admitted with increasing dyspnea on exertion and bilateral edema. Initial echocardiogram revealed a large pericardial effusion, question as to whether it was secondary to pneumonia versus tuberculosis versus history of gastric malignancy. Department of Cardiology was consulted, who felt that although the infusion was large, there was no evidence of tamponade, and pericardiocentesis was not warranted at that time. Given the patient's continued spiking fevers and not responding appropriately to Levaquin and bronchoscopy, which was negative for TB and negative for malignant cells, the patient went on to have pericardiocentesis on the [3-27]. Due to the patient's anatomy, it was very difficult to get directly into the pericardial space, which resulted in right ventricular perforation. Initially, however, the patient eventually had 300 cc of blood removed from the pericardial sac. The patient was admitted to the Coronary Care Unit for observation while pericardial drain was in place. The pericardial drain initially returned 100 cc of bloody fluid, however, eventually stopped. The pericardial drain was pulled on the [3-28]. The patient had a repeat echocardiogram, which showed a small effusion with no evidence of reaccumulation. The patient was admitted from the Coronary Care Unit to the floor on [Hospital Ward Name 517], where the patient continued to do well. Pericardial fluid cultures eventually came back negative for any organisms, negative for AFB, negative for malignant cells, did show some white cells, which were consistent with reactive infusion secondary to pneumonia. The patient is to have a final echocardiogram on the [3-31] to assess for reaccumulation of fluid. If the echocardiogram is normal, the patient will most likely be discharged to rehabilitation. DISPOSITION: The patient had the Department of Physical Therapy evaluate the patient who felt that the patient was able to walk on his own. However, given the fact that he has care of his wife and is very weak, the patient is being screened for rehabilitation and will eventually be discharged to rehabilitation. The patient has completed his course of Levaquin and will be discharged mainly on cough depressants. CARDIAC: The patient was also started on Lopressor 12.5 b.i.d. and Lasix 20 q.d. in house to help with his tachycardia and to help with his diuresis. DISCHARGE DIAGNOSIS: 1. Left upper lobe pneumonia with reactive pericardial effusion. 2. History of tuberculosis status post left thoracoplasty. 3. Gastric cancer, status post total gastrectomy. 4. Mitral valve prolapse. 5. Coronary artery disease. 6. Vertigo. 7. Nephrolithiasis. 8. B12 deficiency anemia. 9. Restrictive lung disease. 10. Gastroesophageal reflux disease. DISCHARGE MEDICATIONS: 1. Robitussin AC cough suppressant 10 cc q.4h. 2. Tessalon Perles 100 mg t.i.d.p.r.n. 3. Colace 100 mg t.i.d. 4. Dulcolax 10 mg p.o.q.d.p.r.n. 5. Magnesium citrate 30 cc p.o.q.6.p.r.n. The patient will be discharged to acute rehabilitation physical therapy prior to being discharged home. Discharge date is pending echocardiogram results by [3-31], [2141]. The patient will followup with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Street Address(1) 16922], [Company 191]. [Initials (NamePattern4) ] [Last Name (NamePattern4) 5004] [Last Name (NamePattern1) ], M.D. [MD Number(1) 4987] Dictated By:[Name8 (MD) 2439] MEDQUIST36 D: [2141-3-31] 11:01 T: [2141-3-31] 11:15 JOB#: [Job Number 16923] ICD9 Codes: 2761, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9057 }	Medical Text: Unit No: [Numeric Identifier 70726] Admission Date: [2153-12-24] Discharge Date: [2153-12-24] Date of Birth: [2153-12-24] Sex: M Service: Neonatology HISTORY: Baby [Name (NI) ] [Known lastname 49485]-[Known lastname ] delivered at 30 weeks gestation, weighing 1485 grams and was admitted to the newborn intensive care unit for management of prematurity. Due to a high census at [Hospital1 69], he was stabilized and then transferred to [Hospital6 15291] by the [Hospital3 1810] transport team. Mother is a 41-year-old gravida VII, para II, now III, woman with estimated date of delivery [2154-3-4]. Prenatal screens included blood type O positive, antibody screen negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, and group B strep unknown. Past OB history remarkable for a term infant born in [2138], by cesarean section and then a 29 week female born by cesarean section in [2147], who was hospitalized at [Hospital1 346] and is currently well. This pregnancy was complicated by multiple evaluations for rupture membranes during the past 2 weeks, all with negative testing. She presented on day of delivery, [2153-12-24], with ruptured membranes and unstoppable preterm labor. She was delivered by repeat cesarean section under spinal anesthesia. She received antibiotics about a half hour prior to delivery. The infant emerged with a good cry, vigorous, received blow by oxygen and was bulb suctioned. Apgar scores were 9 and 9 at one and five minutes, respectively. PHYSICAL EXAMINATION: On admission, a vigorous premature male infant, pink, comfortable in room air, weight 1485 grams (50-75th percentile), length 38 cm (25-50th percentile), head circumference 28 cm (50th percentile). The anterior fontanelle was soft, flat, nondysmorphic, intact palate, normal red reflex both eyes, adequate aeration, clear breath sounds, no murmur, normal pulses, soft abdomen, 3 vessel cord, no hepatosplenomegaly, normal male genitalia, testes in canal bilaterally, no hip clicks, patent anus, no sacral dimple, mongolian spot on buttocks, pink and well perfused, moves all extremities equally, active with normal tone for age. HOSPITAL COURSE: Respiratory: Comfortable in room air. Cardiovascular: Blood pressure on admission 52/31 with a mean of 38. Fluids, electrolytes and nutrition: An umbilical venous catheter was placed for fluid management. The first blood glucose was 33 and received 2 ml/kg bolus of D10W and then IV fluids of 80 ml/kg/day was started. GI: No issues. Hematology: The patient's blood type is A positive. Direct Coombs is negative. Hematocrit on admission 45.6%. Infectious disease: CBC and blood culture was drawn on admission and was started on ampicillin and gentamicin. The CBC showed a white count of 9.2 with 19 polys, 1 band, platelets 240,000. Neurology: Will need a head ultrasound on day [8-20] of life. Sensory: Will need ROP exam around 4 weeks of age. CONDITION ON DISCHARGE: Stable preterm infant. DISCHARGE DISPOSITION: Transferred to [Hospital6 15291]. PRIMARY PEDIATRICIAN: [First Name8 (NamePattern2) 3551] [Last Name (NamePattern1) 56424], M.D. CARE RECOMMENDATIONS: 1. IV fluids, NPO. 2. Medications: Received vitamin K and erythromycin on admission. Received 1 dose of ampicillin 225 mg IV and gentamicin 4.5 mg IV. 3. State newborn screen was drawn prior to transfer to [Hospital6 ]. 4. Immunizations: Did not receive any immunizations. DISCHARGE DIAGNOSES: 1. Appropriate for gestational age 30 week preterm male. 2. Rule out sepsis. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 55780] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2154-1-2] 17:12:19 T: [2154-1-2] 17:52:32 Job#: [Job Number 70727] ICD9 Codes: V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9058 }	Medical Text: Admission Date: [2106-3-17] Discharge Date: [2106-3-18] Date of Birth: [2063-3-10] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 281] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Placement of tracheal stent [2106-3-17] History of Present Illness: Pt. is a 43 yr. old female with extensive cardiac history with tracheal stenosis thought to be caused by long-term intubation, and a tracheal mass. Past Medical History: - CAD: h/o MI; s/p cath w/ stents x [Hospital3 71312] - CHF - DM type 2 - HTN - hyperlipidemia - asthma - tracheal stenosis Social History: lives w/ daughter; smoked but quit in [4-16]; no alcohol, cocaine, or IVDU. Family History: NC Physical Exam: V/S: T96.9 P109 BP102/54 R18 sat100%NRB Gen - morbidly obese female in R lateral decubitus position, moderate distress CV - RRR without audible m/g/r Lungs - limited air movement, CTA bilat. [Last Name (un) ] - +BS, soft, NT, ND Ext - warm feet, no edema, no clubbing/cyanosis Brief Hospital Course: Pt. presented in the ED after being transferred from an outside hospital for shortness of breath. She underwent uncomplicated placement of tracheal stent on [2106-3-17]. Later that evening, she began complaining of angina. A cardiology consult was obtained given her extensive cardiac history. Several ECGs were obtained, including a lateral and posterior ECG, and all were negative for acute ST changes/signs of new ischemia/infarct. She was given ASA, clopidogrel, nitroglycerin, metoprolol, and morphine. She felt better thereafter. She is to see her cardiologist within 1 week after discharge. She is to follow up with Dr. [Last Name (STitle) ] on [2106-4-2]. Medications on Admission: ASA 81mg QD carvedilol 6.25mg [Hospital1 ] furosemide 40mg [Hospital1 ] spironolactone 25mg QD metolazone 2.5mg [Hospital1 ] digoxin 0.125mg QD atorvastatin 40mg QD glargine 40u QHS captopril 12.5mg TID Combivent nebs Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 3. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Metolazone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:45 Tablet(s) Refills:2 8. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for chf. Disp:30 Tablet(s) Refills:0 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. Disp:100 ML(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Tracheal mass, tracheal stenosis, angina Discharge Condition: Stable Discharge Instructions: You may resume your pre-hospital medications. Call Dr. [Last Name (STitle) ] or come to the emergency room if you have: * fever above 100.5 * nausea, vomiting or diarrhea that doesn't stop * chest pain, shortness of breath, or dizziness See your cardiologist in ONE WEEK. Followup Instructions: Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2106-4-2] 2:00 Provider: [Name10 (NameIs) ] [Name8 (MD) ], M.D. Phone:[Telephone/Fax (1) 3020] Date/Time:[2106-4-2] 3:00 Provider: [Name10 (NameIs) ],ROOM FOUR IP ROOMS Date/Time:[2106-4-2] 3:00 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 286] Completed by:[2106-3-18] ICD9 Codes: 4280, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9059 }	Medical Text: Admission Date: [2164-10-11] Discharge Date: [2164-10-16] Date of Birth: [2099-6-13] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4358] Chief Complaint: Chief Complaint: EtOH withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 90779] is a 65 yo man with history of alcohol dependence transferred from outside hospital for concern of first identified atrial fibrillation in the setting of alcohol withdrawal. . Per pt, he was in his usual state of health until 2 days prior to presentation when he drank [11-27] a pint of vodka, and he tripped over a vacuum and fell on his left shoulder. Pt is unsure of LOC, but denies any head trauma. He presented to an outside hospital with left shoulder pain two nights ago, and was found to have a left proximal clavicle fracture. While at the OSH, he subsequently began feeling shaky, was nauseous (+emesis) and had "hot flashes." Patient has a long-standing history of alcoholism, drinking [11-27] pint of brandy and "sip of beer" each day. He reports that he has previously detoxed from EtOH four times, most recently 3 mos ago. He does not have a history of seizures, delerium tremens, or need for intubation with prior EtOH detoxes. Patient started withdrawing at the outside hospital and was about to be discharged to detox program per his wishes when he went into new onset A. fib w/RVR with HR in the 120s. Patient was transferred to [Hospital1 18] for further evaluation. . In the ED, initial VS were: 98.2 125 132/79 18 94% RA. Labs were notable for anion gap of 11, negative serum tox (including EtOH), electrolytes WNL, INR 1.1. Patient received lorazepam 4 mg, diazepam 20 mg, oxycodone 5 mg. Of note, EtOH at presentation to OSH was 300. Pt was given diltiazem 20 mg IV at OSH @1544. . On arrival to the MICU VS are notable for HR 120s-130s, irregularly irregular and BP 146/79. Pt afebrile with O2 sat 96% RA. He appears restless. He is A&Ox3. Currently, pt feels "shaky," diaphoretic and nauseous. He reports [9-3] left shoulder pain. He reports feeling like his heart is racing and the sensation of skipped beats, but says that this has been intermittent for the past year. He denies any known cardiac problems. . He denies chest pain/pressure, pleuritic pain, cough or shortness of breath. He currently denies any headaches, blurry vision, double vision, paresthesias, weakness or numbness of his extremities. He reports chronic right-sided neck pain. Pt denies any recent fevers or night sweats, though currently reports chills. . Review of systems: (+) Per HPI Otherwise denies rhinorrhea or congestion. Reports diarrhea. Denies dysuria, polyuria, hematuria. Denies rashes or skin changes. Past Medical History: -EtOH dependence: 4 prior withdrawals (most recently 3 mos ago); no h/o seizures, delerium tremens, need for intubation -Depression: tx w/fluoxetine -Anxiety: tx w/propranolol -s/p back surgery ([7-/2164]): herniated disk repair -s/p cholecystectomy ([2160]) -s/p left knee replacement ([2160]) Social History: Pt lives in [Location 9188], MA with his wife and 43 y.o. daughter. [Name (NI) ] previously worked at a newspaper, but was laid off years ago and has been out of work since. He reports [11-27] pint brandy daily with "taste of beer." Denies any tobacco or illicits, though per OSH records, h/o oxycodone use. Family History: No known FH of early MI, arrhythmias or DM. Physical Exam: On Admission: Vitals: T 97.9, HR 126, BP 146/79, O2 sat 96% RA General: A&O x3, though inattentive at times throughout interview; redirectable HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, no LAD CV: Tachycardic with irregularly irregular 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 hepatosplenomegaly GU: deferred Ext: Noted ecchymosis on lateral left clavicle and posterior left scapula; full active and passive ROM in LUE; no noted stepoff on left lateral clavicle, extremely tender to palpation; warm, well perfused, 2+ DP pulses, no clubbing, cyanosis or edema Neuro: EOMI w/o nystagmus, PERRL (5mm-->3mm); CNII-X and XII intact (unable to shrug shoulders [12-28] pain), able to move all 4 limbs; 5/5 strength in BL lower extremities; grossly normal sensation, gait deferred, finger-to-nose intact with tremor Pertinent Results: Admission labs: [2164-10-11] 08:00PM BLOOD WBC-5.8 RBC-4.35* Hgb-13.6* Hct-39.5* MCV-91 MCH-31.2 MCHC-34.4 RDW-15.5 Plt Ct-111* [2164-10-11] 08:00PM BLOOD Neuts-78.1* Lymphs-13.7* Monos-7.3 Eos-0.5 Baso-0.3 [2164-10-11] 08:00PM BLOOD PT-12.6 PTT-27.0 INR(PT)-1.1 [2164-10-11] 08:00PM BLOOD Glucose-108* UreaN-11 Creat-0.7 Na-141 K-4.3 Cl-102 HCO3-28 AnGap-15 [2164-10-11] 08:00PM BLOOD ALT-52* AST-74* CK(CPK)-265 AlkPhos-94 TotBili-1.1 [2164-10-11] 08:00PM BLOOD Calcium-8.4 Phos-3.3 Mg-2.3 [2164-10-11] 08:00PM BLOOD TSH-1.2 [2164-10-12] 04:34AM BLOOD Free T4-1.0 [2164-10-11] 08:00PM BLOOD T4-3.7* [2164-10-11] 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG CT HEAD WITHOUT CONTRAST: FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect, or acute territorial infarction. The ventricles and sulci are normal in size and configuration. There is no large subgaleal hematoma. No calvarial or skull base fracture. The paranasal sinuses and mastoids are clear. IMPRESSION: No acute intracranial process. ECHO: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 50 %). Right ventricular chamber size and free wall motion are normal. Right ventricular chamber size is normal. Tricuspid annular plane systolic excursion is depressed (1.0 cm) consistent with right ventricular systolic dysfunction. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is no pericardial effusion. . CXR IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Elevation of the right lung base is pronounced, reflected in atelectasis. Left lung is low in volume but clear of any significant focal abnormality. There is no appreciable pleural effusion. Heart size is normal. Azygos vein is distended. Clinical service caring for this patient was telephoned to discuss differential diagnosis including the possibility of acute pulmonary embolism. Widely separated fracture, distal clavicle. . CTA Chest IMPRESSION: 1. No evidence of pulmonary embolism or acute aortic pathology. 2. Streaky right lower lobe atelectasis. 3. Healed left rib fractures. 4. Fatty liver. . [2164-10-15] 06:33AM BLOOD WBC-4.0 RBC-3.89* Hgb-12.0* Hct-35.6* MCV-92 MCH-30.9 MCHC-33.7 RDW-15.1 Plt Ct-104* [2164-10-15] 06:33AM BLOOD Plt Ct-104* [2164-10-15] 06:33AM BLOOD Glucose-90 UreaN-8 Creat-0.7 Na-139 K-3.9 Cl-102 HCO3-29 AnGap-12 [2164-10-12] 04:34AM BLOOD ALT-41* AST-56* AlkPhos-84 TotBili-1.2 [2164-10-15] 06:33AM BLOOD Calcium-8.9 Phos-4.5 Mg-1.9 [2164-10-11] 08:00PM BLOOD TSH-1.2 [2164-10-12] 04:34AM BLOOD Free T4-1.0 [2164-10-11] 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: Mr. [Known lastname 90779] is a 65 yo man with history of alcohol dependence transferred from outside hospital for concern of alcohol withdrawal in setting of new onset atrial fibrillation. #Atrial Fibrillation: Pt without known/documented history of cardiac disease, including afib, however, he reported feeling like his heart is racing and the sensation of skipped beats intermittently for the past year. Likely exacerbated by chronic EtOH use. No hyperthyroidism as evidenced by normal TSH and free T4. Pt's EKG was unremarkable and echo revealed mildly depressed LV function but no RH strain. CTA was performed and ruled out for PE. His CHADS2 score is zero so pt was not initiated on coumadin. In the MICU, patient was started on metoprolol 25 mg TID with control of heart rate. On the floor he continued to be tachycardic, and metoprolol was uptitrated to 50mg [Hospital1 ]. At time of discharge, pt was started on ASA 81 for prophylaxis. . #EtOH withdrawal: Pt presented to OSH with serum EtOH 300, resolved at presentation to [Hospital1 18]. No h/o seizures, DT or need for intubation with prior detox. No evidence of metabolic abnormality on admission labs. Throughout hospitalization, pt scored on subjective measures of CIWA scale. Benzodiazepines were weaned and on day prior to discharge benzos were stopped. At this point he was out of the window for DTs and seizures. He was discharged on thiamine, folate and MVI. He was evaluated by social work and found to be in contemplative phase of rehab. He did show some interest in returning to [Location (un) 22870] for treatment but wanted to arrange this on his own. . #Clavicular fx: Fx [12-28] mechanical fall. Fracture is nondisplaced. Pt was instructed to immobilize should with sling although he frequently removed this throughout hospitalization. He was informed of the importance of keeping his arm immobilized with sling for proper healing and pain control. His pain was treated with oxycodone PRN. A follow up with orthopedic surgeon in [Hospital1 1562] was arranged. Pt was instructed to call to schedule a follow up in two weeks time. . #Depression/anxiety: Pt was continued on home prozac dose. He had reportedly been taking propanolol at home for anxiety. This was discontinued given initiation of metoprolol for afib. He reported that he also takes diazepam at home, however, he could not verify who prescribes this for him or what pharmacy he uses to fill this prescription so this medication was stopped once there was no longer a concern for etoh withdrawal. . CODE: Full . Transitional: - follow up with PCP after discharge - ortho follow up for two weeks Medications on Admission: Fluoxetine 80 mg PO daily Neurontin 600 mg PO daily Propranolol 20 mg PO daily Trazadone 100 mg qhs Discharge Medications: 1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY (Daily). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 6. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 7. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain for 7 days. Disp:20 Tablet(s) Refills:0 8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] Discharge Diagnosis: atrial fibrillation with rapid ventricular rate EtOH withdrawal Left clavicular fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 90779], You were admitted to [Hospital1 18] from an outside hospital for atrial fibrillation and alcohol withdrawal. We treated your atrial fibrillation with a medication called metoprolol. This controls your heart rate so that it does not get too fast. Some patients with atrial fibrillation are treated with blood thinners because this condition increases one's risk for stroke. We started low dose aspirin to reduce your risk for stroke. We treated your alcohol withdrawal with diazepam. You are no longer withdrawing and we urge you to join a support group such as AA and continue to avoid alcohol in the future. In terms of your clavicle fracture, it is important to continue to wear your brace for six weeks. You should try to keep your arm in this sling to prevent overuse, which will cause you pain. We have made the following changes to your home medications: 1. START metoprolol tartrate 50mg by mouth twice daily 2. START Oxycodone 10mg every 4hrs as needed for pain. You should not drink alcohol or drive while on this sedating medication. 3. STOP propanolol Followup Instructions: Name: [Last Name (LF) 89697],[First Name3 (LF) ] L. Location: [Hospital3 ] FAMILY MEDICINE Address: 5 INDUSTRIAL DR [Last Name (STitle) ], [Location (un) ],[Numeric Identifier 88844] Phone: [Telephone/Fax (1) 89698] Appointment: TUESDAY [10-23] AT 9AM You need to see an orthopedic doctor to follow-up your broken clavicle. We have arranged for you to see Dr. [Last Name (STitle) 46850] in [Hospital1 1562]. Please call his office at [Telephone/Fax (1) 88160] to schedule an appointment in 2 weeks. Office: [Hospital1 90780], [Numeric Identifier 19665] ICD9 Codes: 2875, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9060 }	Medical Text: Admission Date: [2102-5-30] Discharge Date: [2102-6-3] Date of Birth: [2047-7-17] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 603] Chief Complaint: Seizure Major Surgical or Invasive Procedure: intubation. History of Present Illness: 45-yo man with known EtOH abuse, found by EMS to with tonic-clonic seizures, brought in to ED. Pt has reportedly been trying to stop drinking over the last few days, with his last drink being a few days ago. He appears to have received 2mg IM Ativan en route by EMS for seizures. In the ED, VS: HR 150s-160s, BP 180s-230s / 110s-130s, satting 93% RA --> 98% 4L NC --> NRB, Temp spiked to 102.4F. Continued with seizures in the ED, at which point he was oriented x0, unable to give any history, lost bowel and bladder control, and was noted to be looking to the left during his seizure, although had an otherwise non-focal neuro exam. He received an additional 7mg IV Ativan over 3 hours. He also received Tylenol PR for fevers, banana bag, and another 2L NS IVF. Labs were significant for WBC 10.3, Hct 36.5, Plt 140, Cr 1.3, INR 1.2, negative serum tox including EtOH level of 0 and urine tox, lactate 11.5, and ABG 7.07/54/116. ECG showed ST without ischemic changes, CXR appeared clear, and NCHCT showed no ICH. Given his high fevers, UA/Cx was sent and pt underwent LP, although Blood Cx were never sent. He received empiric 2g IV Ceftriaxone, and 1g IV Vancomycin. He is admitted to the MICU given his persistent post-ictal state and high risk of seizure. Past Medical History: Unable to obtain. Per prior D/C summary: HTN Previous crack cocaine use EtOH abuse (with multiple hospitalizations for withdrawal) History of stab wound to abdomen with abdominal exploration Inguinal hernia repair Social History: Homeless. Drinks [12-17] gallon vodka daily. +occasional marijuana. Denies other substances. Family History: Diabetes (brother) Alcohol abuse (brother) Physical Exam: VS: Temp 100.4F, HR 127, BP 153/100, HR 113, R 15, SaO2 96% NRB General: intubated. somnolent, withdraws to pain, MAE, o/w unable to cooperate HEENT: PERRL, sclera anicteric, dry MM, poor dentition Neck: supple, no LAD Lungs: CTA anteriorly, no r/rh/wh Heart: RRR, nl S1-S2, no MRG Abdomen: +BS, soft/NT/ND, no HSM Extrem: WWP, no c/c/e, fragile toenails Pertinent Results: [2102-5-30] 05:09PM GLUCOSE-77 UREA N-8 CREAT-0.8 SODIUM-136 POTASSIUM-3.3 CHLORIDE-96 TOTAL CO2-21* ANION GAP-22* [2102-5-30] 05:09PM ALT(SGPT)-29 AST(SGOT)-113* ALK PHOS-62 TOT BILI-1.4 [2102-5-30] 05:09PM CALCIUM-7.5* PHOSPHATE-3.3 MAGNESIUM-2.1 [2102-5-30] 05:09PM WBC-4.3 RBC-3.23* HGB-10.9* HCT-33.2* MCV-103* MCH-33.8* MCHC-32.9 RDW-14.6 [2102-5-30] 05:09PM PLT COUNT-103* [2102-5-30] 05:09PM PT-13.0 PTT-24.5 INR(PT)-1.1 [2102-5-30] 09:45AM TYPE-ART RATES-16/ TIDAL VOL-500 PEEP-5 O2-60 PO2-270* PCO2-39 PH-7.38 TOTAL CO2-24 BASE XS--1 -ASSIST/CON INTUBATED-INTUBATED [2102-5-30] 09:45AM LACTATE-1.0 [2102-5-30] 05:47AM GLUCOSE-116* UREA N-9 CREAT-0.9 SODIUM-132* POTASSIUM-4.5 CHLORIDE-93* TOTAL CO2-27 ANION GAP-17 [2102-5-30] 05:47AM ALT(SGPT)-39 AST(SGOT)-226* LD(LDH)-585* ALK PHOS-66 AMYLASE-177* TOT BILI-1.5 [2102-5-30] 05:47AM LIPASE-46 [2102-5-30] 05:47AM ALBUMIN-4.5 CALCIUM-6.9* PHOSPHATE-4.1 MAGNESIUM-1.0* [2102-5-30] 05:47AM WBC-7.7 RBC-3.21* HGB-10.7* HCT-32.0* MCV-100* MCH-33.3* MCHC-33.5 RDW-14.4 [2102-5-30] 05:47AM NEUTS-85* BANDS-0 LYMPHS-4* MONOS-11 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2102-5-30] 05:47AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [2102-5-30] 05:47AM PLT SMR-LOW PLT COUNT-120* [2102-5-30] 05:40AM TYPE-ART PO2-62* PCO2-70* PH-7.17* TOTAL CO2-27 BASE XS--4 [2102-5-30] 05:40AM LACTATE-1.2 [2102-5-30] 05:40AM O2 SAT-84 [2102-5-30] 05:40AM freeCa-0.95* [2102-5-30] 04:20AM CEREBROSPINAL FLUID (CSF) PROTEIN-34 GLUCOSE-104 [2102-5-30] 04:20AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-2* POLYS-0 LYMPHS-71 MONOS-29 [2102-5-30] 03:30AM URINE HOURS-RANDOM [2102-5-30] 03:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2102-5-30] 03:30AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.010 [2102-5-30] 03:30AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-75 GLUCOSE-100 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2102-5-30] 03:30AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 [2102-5-30] 01:17AM PO2-116* PCO2-54* PH-7.07* TOTAL CO2-17* BASE XS--15 COMMENTS-GREEN TOP [2102-5-30] 04:20AM CEREBROSPINAL FLUID (CSF) PROTEIN-34 GLUCOSE-104 [2102-5-30] 04:20AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-2* POLYS-0 LYMPHS-71 MONOS-29 [2102-5-30] 03:30AM URINE HOURS-RANDOM [2102-5-30] 03:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2102-5-30] 03:30AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.010 [2102-5-30] 03:30AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-75 GLUCOSE-100 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2102-5-30] 03:30AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 [2102-5-30] 01:17AM PO2-116* PCO2-54* PH-7.07* TOTAL CO2-17* BASE XS--15 COMMENTS-GREEN TOP [2102-5-30] 01:17AM GLUCOSE-224* LACTATE-11.5* NA+-138 K+-4.0 CL--94* [2102-5-30] 01:17AM freeCa-1.04* [2102-5-30] 01:11AM UREA N-12 CREAT-1.3* [2102-5-30] 01:11AM estGFR-Using this [2102-5-30] 01:11AM LIPASE-41 [2102-5-30] 01:11AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2102-5-30] 01:11AM WBC-10.3 RBC-3.59* HGB-12.0* HCT-36.5* MCV-102* MCH-33.5* MCHC-32.9 RDW-14.2 [2102-5-30] 01:11AM PT-13.9* PTT-21.7* INR(PT)-1.2* [2102-5-30] 01:11AM PLT COUNT-140* [2102-5-30] 01:11AM FIBRINOGE-318 . CT head-IMPRESSION: 1. No intracranial hemorrhage or evidence of other acute intracranial abnormalities. MRI is more sensitive for detecting sources of new or worsening seizures. 2. Prominent ventricles and sulci for age, which may be seen in patients on chronic anticonvulsant medications. . CXR FINDINGS: As compared to the previous radiograph, the patient is still intubated. The tip of the endotracheal tube projects 2.3 cm above the carina. Normal course of the nasogastric tube. Unchanged appearance of the cardiac silhouette and of the lung parenchyma. No relevant interval changes. . EKG-Sinus tachycardia. Baseline artifact. Consider ST-T wave abnormalities. No previous tracing available for comparison. Brief Hospital Course: Assessment and Plan: 45-yo man with h/o EtOH abuse, p/w AMS, and found to have seizures. . #. AMS/Seizures - Seizing on admission. Required at least 9mg IV/IM ativan in ED. He was given standing ativan during his ICU stay. Thought to be toxic-metabolic due to ETOH withdrawal. (Drinks [12-17] gallon of vodka daily-ETOH level 0 on admission). Infectious w/u unremarkable, including CSF. Pt did not have any seizures after ED stay. He was placed on seizure precautions and CIWA scale. . #ETOH abuse-Pt presented with ETOH level of zero. He was placed on a CIWA scale, but did not show signs of withdrawal. He was given thiamine, folate, and social work was consulted. . #fever-unclear etiology. Presented with fever in the ED and upon admission to the floor from the ICU. LP, Bcx and UCX, and CXR, and CSF negative. No leukocytosis or localizing symptoms. . #HTN-started on lisinopril 5mg while in ICU. This will likely be difficult to control long term given recurrent ETOH abuse and poor compliance. Pt was discharged on this medication. . #. Hypercarbia - resolved. . #. Sinus tachycardia - resolved. . #. Renal insufficiency - resolved. . #. FEN: regular diet, replete lytes prn #. PPx: SQ heparin, H2 blocker Medications on Admission: none Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: tonic clonic seizures alcohol withdrawal fever Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted after being found to have severe seizures. You were confused on admission and therefore were intubated (had a tube in your airwary to breath) and had a stay in the ICU given your seizures. You should avoid drinking alcohol as this is very dangerous to your health and could result in death, liver disease, heart disease, and recurrent seizures. . Your blood pressure was also elevated on admission. For this you were started on a new blood pressure medication called Lisinopril. We will give you a prescription for this. . Please follow up with appointments below. Followup Instructions: Please contact your PCP at Family Health Center in [Hospital1 1559] at [Telephone/Fax (1) 70592] to schedule a follow up appointment within 2 weeks of discharge. ICD9 Codes: 5849, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9061 }	Medical Text: Admission Date: [2173-10-4] Discharge Date: [2173-10-16] Date of Birth: [2109-5-24] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 12174] Chief Complaint: Hydrothorax Major Surgical or Invasive Procedure: TIPS Placement (Failed x2) History of Present Illness: [Known firstname 85376] [Known lastname 174] is a 64 year old male with alcoholic cirrhosis c/b portal hypertension, ascites, and varices who presented as a transfer from [Hospital1 ] for TIPS evaluation. Of note, he has Guillain-[Location (un) ] syndrome and is currently wheelchair bound due to lower extremity weakness. . He was diagnosed with cirrhosis in [4-/2173] and was unaware of his liver disease prior to then. Per patient report, he has had paracentesis about twice monthly since then with volumes of [7-16] L. He reports failing diuretic therapy due to symptomatic hypotension. He also reports that he has had endoscopy showing mild varices and denies ever having upper or lower GI bleeding. . Per the patient, he has needed recurrent paracentesis over the past few months despite being on Furosemide and Spironolactone. His hepatologist suggested a TIPS procedure to relieve the recurrent ascites and hepatic hydrothorax which he has had over the past year. The patient states that he initially went to [Hospital1 ] to have the TIPS procedure done, but later requested a transfer since he wanted one of the [Hospital1 18] IR physicians to do the procedure. . Per the transfer summary he was admitted to [Hospital3 ] on [2173-9-18] for increasing ascites and hypotension. The transfer summary is confusing but it appears as if there was a concern for SBP. He was given an albumin infusion which was later discontinued due to pleural effusion. He was then seen by Pulmonary who noted his cirrhosis, ascites, and a large pleural effusion. They decided to observe him, and offered thoracentesis for to help with dyspnea. The patient declined thoracentesis. According to the patient, he received [4-12] large volume paracentesis taps ranging from 8-9 L a tap. He states that during his hospitalization his diuretic therapy was stopped because he was hypotensive and required albumin infusions. . ROS was otherwise essentially negative. The patient denied recent fevers, night sweats, chills, hematemesis, coffee-ground emesis, nausea, vomiting, melena, hematochezia. He does have significant lower extremity weakness due to his ongoing Guillain-[Location (un) ] syndrome. . Past Medical History: Guillain-[Location (un) ] Syndrome Alcoholic Cirrhosis Portal Hypertension Postural Hypotension Anemia Anxiety Gait disorder Social History: He previously worked as a dentist. He is married and his wife is supportive. # Smoking: Quit over 15 years ago # Alcohol: Stopped drinking over 10 years ago # Drugs: No recreational drug use Family History: Noncontributory Physical Exam: VS: T 97.4(96.9-97.4), BP 106/65(100-115/58-71), HR 81(77-88) ....RR 22(20-22), SpO2 96(96-100) on RA Gen: NAD. Alert and oriented x3. Mood and affect appropriate. Pleasant and cooperative. Resting in bed. HEENT: NCAT. PERRL, EOMI, anicteric sclera. MMM, OP benign. Neck: Supple. JVP not elevated. No cervical lymphadenopathy. CV: RRR. Normal S1, S2. No M/R/G appreciated. Chest: Respiration unlabored. Decreased breath sounds on right. No wheezes, rhonchi, or rales. Abd: BS present. Soft, NT, ND. Ascites present but not tense. Ext: WWP, no cyanosis or clubbing. No LE edema. Digital cap refill <2 sec. Distal pulses radial 2+, DP 2+, PT 2+. Neuro: CN II-XII grossly intact. LE strength hip flexion [4-12], knee flexion and extension [4-12], dorsiflexion and plantarflexion [3-12]. UE strength intact. Pertinent Results: Labs on Admission: [2173-10-5] 12:50AM BLOOD WBC-2.4* RBC-3.10* Hgb-10.3* Hct-30.4* MCV-98 MCH-33.2* MCHC-33.8 RDW-14.6 Plt Ct-136* [2173-10-5] 12:50AM BLOOD PT-16.2* PTT-28.7 INR(PT)-1.4* [2173-10-5] 12:50AM BLOOD Glucose-107* UreaN-22* Creat-0.9 Na-136 K-5.2* Cl-103 HCO3-29 AnGap-9 [2173-10-5] 12:50AM BLOOD ALT-15 AST-22 AlkPhos-82 TotBili-1.2 [2173-10-5] 12:50AM BLOOD Albumin-3.1* Calcium-8.5 Phos-3.4 Mg-2.3 . Thoracentesis: [2173-10-6] 11:48AM PLEURAL WBC-23* RBC-428* Polys-11* Lymphs-51* Monos-10* Meso-4* Macro-24* [2173-10-6] 11:48AM PLEURAL TotProt-2.3 LD(LDH)-68 Albumin-1.6 . Other Relevant Labs: [2173-10-6] 05:25AM BLOOD VitB12-761 Folate-18.9 [2173-10-5] 05:35PM BLOOD calTIBC-114* Ferritn-558* TRF-88* [2173-10-5] 05:35PM BLOOD Iron-35* . [2173-10-14] 05:05AM BLOOD Triglyc-63 HDL-25 CHOL/HD-3.0 LDLcalc-37 [2173-10-5] 06:10AM BLOOD TSH-7.8* [2173-10-5] 06:10AM BLOOD Cortsol-8.3 . [2173-10-14] 05:05AM BLOOD HAV Ab-POSITIVE [2173-10-5] 05:35PM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE HBcAb-NEGATIVE [2173-10-5] 05:35PM BLOOD HCV Ab-NEGATIVE [2173-10-5] 05:35PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE [2173-10-5] 05:35PM BLOOD [Doctor First Name ]-NEGATIVE [2173-10-14] 05:05AM BLOOD CEA-4.2* PSA-0.4 AFP-1.5 [2173-10-5] 05:35PM BLOOD IgG-898 IgA-422* IgM-33* . . [2173-10-5] 17:35 Test Result Reference Range/Units ALPHA-1-ANTITRYPSIN QN 177 83-199 mg/dL . . [2173-10-5] 17:35 Test Result Reference Range/Units CERULOPLASMIN 18 18-36 mg/dL . . [2173-10-6] 11:48 am PLEURAL FLUID GRAM STAIN (Final [2173-10-6]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [2173-10-9]): NO GROWTH. ANAEROBIC CULTURE (Final [2173-10-12]): NO GROWTH. ACID FAST SMEAR (Final [2173-10-7]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. . . [2173-10-14] 5:05 am Blood (Toxo) TOXOPLASMA IgG ANTIBODY (Final [2173-10-15]): NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA. 0.0 IU/ML. . [2173-10-14] 5:05 am SEROLOGY/BLOOD VARICELLA-ZOSTER IgG SEROLOGY (Final [2173-10-15]): POSITIVE BY EIA. A positive IgG result generally indicates past exposure and/or immunity. . [2173-10-14] 5:05 am SEROLOGY/BLOOD Rubella IgG/IgM Antibody (Final [2173-10-14]): NEGATIVE by Latex Agglutination. A negative result generally indicates lack of immunity. . [2173-10-5] 5:35 pm Blood (EBV) [Doctor Last Name ]-[Doctor Last Name ] VIRUS VCA-IgG AB (Final [2173-10-7]): POSITIVE BY EIA. [Doctor Last Name ]-[Doctor Last Name ] VIRUS EBNA IgG AB (Final [2173-10-7]): POSITIVE BY EIA. [Doctor Last Name ]-[Doctor Last Name ] VIRUS VCA-IgM AB (Final [2173-10-7]): NEGATIVE <1:10 BY IFA. INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION. . [2173-10-5] 5:35 pm Blood (CMV AB) CMV IgG ANTIBODY (Final [2173-10-8]): NEGATIVE FOR CMV IgG ANTIBODY BY EIA. < 4 AU/ML. . [2173-10-5] 5:35 pm SEROLOGY/BLOOD CONSENT RECEIVED. RAPID PLASMA REAGIN TEST (Final [2173-10-6]): NONREACTIVE. . . TTE (Complete) Done [2173-10-5] at 3:50:26 PM The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). There is no left ventricular outflow obstruction at rest or with Valsalva. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 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. . . ABDOMEN U.S. (COMPLETE STUDY) Study Date of [2173-10-5] 10:22 AM FINDINGS: The liver is nodular and shrunken in appearance but no solid liver lesion is identified. A simple cyst is seen at the dome of the right lobe measuring 1.0 cm and a simple cyst is seen at the dome of the left lobe also measuring 1.0 cm. No biliary dilatation is seen and the common duct measures 0.4 cm. Several shadowing gallstones are seen within the lumen of the gallbladder. The pancreas and midline structures are obscured from view by overlying bowel. The spleen is enlarged measuring 19.7 cm. No hydronephrosis is seen. The right kidney measures 9.4 cm and the left kidney measures 10.8 cm. A moderate amount of ascites is seen within the abdomen. A large right pleural effusion is identified. DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images were obtained. The main, right and left portal veins are patent with hepatopetal flow. Appropriate flow is seen in the IVC, the hepatic veins, and the hepatic arteries. IMPRESSION: 1. Nodular shrunken liver with two small simple cysts but no solid liver lesion identified. 2. Large right pleural effusion and ascites. 3. Splenomegaly. 4. Cholelithiasis. . . CHEST (PA & LAT) Study Date of [2173-10-5] 2:52 PM FINDINGS: A large right pleural effusion causes collapse of the right lung. The left lung and cardiac size are normal. IMPRESSION: Extensive right pleural effusion with associated right pulmonary collapse. . . CHEST (PORTABLE AP) Study Date of [2173-10-6] 11:58 AM FINDINGS: In comparison with the study of [10-5], there has been removal of a substantial amount of fluid from the right hemithorax. However, a large amount of pleural fluid remains. The left lung is clear and there is no evidence of pneumothorax. . . Cytology Report PLEURAL FLUID Procedure Date of [2173-10-6] REPORT APPROVED DATE: [2173-10-8] SPECIMEN RECEIVED: [2173-10-7] [-1/3452] PLEURAL FLUID SPECIMEN DESCRIPTION: Received 2000ml cloudy yellow fluid. Prepared 1 ThinPrep slide. DIAGNOSIS: Pleural Fluid: NEGATIVE FOR MALIGNANT CELLS. Macrophages, mesothelial cells, and inflammatory cells. . . Radiology Report TIPS Study Date of [2173-10-8] 8:26 AM PROCEDURE: 1. Abdominal paracentesis. 2. Right pleural thoracocentesis. 3. Hepatic venography via right internal jugular vein approach. 4. Unsuccessful transhepatic cannulation of the portal vein. HISTORY: 64-year-old man with cirrhosis and intractable ascites, requires TIPS for control of ascites and recurrent right-sided hydrothorax. ANESTHESIA: General anesthesia was provided by the anesthesiology service. In addition, 1% lidocaine was administered to the skin around the internal jugular vein puncture, thoracocentesis and paracentesis site. RADIOLOGIST: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4401], Dr. [First Name8 (NamePattern2) ] [Name (STitle) ], Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 12166] performed the procedure. Dr. [Last Name (STitle) 12166], the attending radiologist, was present throughout the procedure. PROCEDURE: Informed consent was obtained outlining the risks and benefits of the procedure involved. Following this, the patient was brought to the angiography suite where general anesthesia was induced. The right neck and right-sided chest and upper abdomen were prepped and draped in the usual sterile fashion. A preprocedure huddle and timeout were performed as per [Hospital1 18] protocol. Ultrasound of the right side demonstrates a large right-sided pleural effusion and a large volume of ascites. Under ultrasound guidance, [Initials (NamePattern4) ] [Last Name (NamePattern4) 11097] centesis needle was positioned within the peritoneal space and [Initials (NamePattern4) ] [Last Name (NamePattern4) 7648] wire advanced under fluoroscopic guidance. A 5 French OmniFlush catheter was then advanced over the wire and attached to a suction drainage device. Again under ultrasound guidance and following administration of 1% lidocaine, a 7 French all purpose drainage catheter was advanced into the right pleural space and again attached to a underwater seal on suction drainage. Both drainage catheters were secured. Attention was then turned to access the right internal jugular vein. 1% lidocaine was administered to the skin overlying the internal jugular vein and under direct ultrasound guidance, a micropuncture needle advanced into the right internal jugular vein. A 4.5 French micropuncture sheath was advanced over an 018 nitinol wire. The 018 wire and inner dilator were removed and an 035 [Last Name (un) 7648] wire advanced into the IVC. The micropuncture sheath was removed and the venotomy site dilated with an 8 French dilator. The sheath was then advanced to the level of the origin of the hepatic veins and a 035 Glidewire advanced into the right hepatic vein. The sheath was advanced over the wire to lie in the mid portion of the right hepatic vein. Pressure gradients were obtained at this time. Following this, a 5 French 035 occlusive balloon was advanced into the distal right hepatic vein branch and CO2 portography was performed to evaluate the position of the right and left main portal vein. AP and lateral projections were obtained. Following this, the Roshida needle was used to attempt to access the portal vein from the right hepatic vein approach. Despite multiple needle passes in multiple orientations, it was not possible to enter the portal vein and advance a wire. In addition, an attempt was made to by the portal vein via a right flank percutaneous transhepatic approach. Again despite multiple wire passes, we were unable to sufficiently opacify the portal vein. Following a total procedure time of 6 hours and a fluoroscopic time of 80 minutes, a decision was made to abort the procedure. The internal jugular vein access sheath was removed and manual pressure was applied for 10 minutes, ensuring good hemostasis. The peritoneal drainage catheter was removed over a wire and a sterile dressing applied. A 7 French right pleural drain was left in situ to continue pleural drainage and lung expansion. The catheter was attached to an underwater seal. The referring clinician, Dr. [Last Name (STitle) ], was contact[Name (NI) ] at the time of procedure. There were no early complications and the patient was extubated in the angiography suite and transferred to the anesthesia care unit. FINDINGS: Ultrasound demonstrated large volume right-sided pleural effusion and ascites. There was uncomplicated placement of right pleural and right peritoneal drainage catheter. Portal venography demonstrated a markedly narrowed right hepatic vein. In addition, CO2 portography demonstrated a small right portal vein branch. Given the overall anatomy and severe background ascites added to the difficulty in accessing the portal vein transhepatically. CONCLUSION: Successful right-sided thoracocentesis and abdominal paracentesis. Hepatic venography and pressure measurements. The right atrial pressure was measured at 8 mmHg. The hepatic wedge pressure was measured at 20 mmHg. The staff radiologist, Dr. [Last Name (STitle) 12166], has reviewed the report. . . CT PELVIS W/O CONTRAST Study Date of [2173-10-12] 1:03 PM HISTORY: Alcoholic cirrhosis with known portal hypertension, status post attempted TIPS procedure x2, most recent complicated by hepatic venous arterial fistula and subsequent embolization. Evaluate for subcapsular or retroperitoneal bleed. COMPARISON: Outside CT [2173-9-22], as well as angiogram images from [2173-10-11]. CT ABDOMEN WITHOUT CONTRAST Limited evaluation of the included lung bases displays normal-appearing left lung. The right lung displays significant interval decrease in size to a now slightly high-attenuation small-to-moderate pleural effusion with persistent adjacent compressive atelectasis involving portions of the right lower lobe as well as the small locule of air noted posterior to the sternum and a small anterior pneumothorax present. Unenhanced images of the abdomen display no large retroperitoneal or subcapsular hematoma. There has been interval decrease in the amount of ascites when compared to the prior outside imaging; however, the fluid is now more mixed density with Hounsfield values measuring 20-30, suggestive of a mixture of underlying ascites hemorrhage likely related to some oozing after capsular puncture on TIPS attempt. Contrast is noted within the gallbladder and there is streak artifact from the indwelling coils and Amplatz occluder devices in the right hepatic artery. Distal to these devices, the hepatic parenchyma displays abnormal low attenuation, which may suggest underlying infarction given the poor flow noted on the post-embolization angiogram images to this region. Some residual air is noted within the liver parenchyma likely related to a recent procedure. Multiple small hypoattenuating lesions in the liver are again seen, likely hepatic cysts and there is unchanged configuration to known underlying cirrhosis with sequelae of portal hypertension including splenomegaly, massive esophageal/paraesophageal varices, and intra-abdominal collateral vessels. Limited unenhanced evaluation of the remaining solid organs within the abdomen including the pancreas and adrenal glands are normal. Kidneys displays persistent corticomedullary differentiation involving the kidneys suggestive of underlying renal dysfunction from prior contrast administration one day prior. There are some prominent air-filled loops of small and large bowel with the small bowel measuring up to 3.4 cm, which may suggest some mild underlying ileus with no findings of obstruction. Scattered mesenteric and retroperitoneal lymph nodes are better appreciated on prior contrast-enhanced CT. CT OF THE PELVIS WITHOUT INTRAVENOUS OR ORAL CONTRAST: Significant interval decrease in amount of free fluid within the pelvis is identified, although the fluid is noted to be slightly higher in attenuation as compared to the prior outside exam with Hounsfield value of approximately 20. A large fecal ball is noted within the rectal vault, with the intrapelvic bowel appearing otherwise unremarkable. Contrast is noted within the bladder from prior procedure. BONE WINDOWS: No malignant-appearing osseous lesions are identified. IMPRESSION: 1. No significant retroperitoneal or subcapsular hematoma identified. While the amount of intra-abdominal/pelvic ascites has significantly decreased from prior [2173-9-22] exam the fluid is of slightly higher density suggesting that it is a mixture of underlying ascites and blood likely related to oozing from capsular puncture during TIPS attempt. 2. Abnormal appearance to the inferior right hepatic lobe parenchyma distal to site of known embolization. This may reflect underlying parenchyma infarction. 3. Persistent corticomedullary differentiation of the kidneys with contrast within the collecting systems. This suggests underlying contrast-induced nephropathy/ATN and should be correlated with serial creatinine values. 4. Interval decrease in size to now moderate right pleural effusion which is also of slightly higher density than before and may have a component of blood within it. A very small anterior right pneumothorax is also noted, not unexpected given the recent pleural catheter removal. . . Brief Hospital Course: The patient is a 64 year old male with alcoholic cirrhosis c/b portal hypertension, ascites, and varices who presented as a transfer from OSH for TIPS evaluation. He has had two failed TIPS placement attempts with hepatic artery puncture on the second attempt. . # TIPS Placement Attempts: He was sent from OSH for TIPS evaluation and placement. CXR, echocardiogram, and duplex US of liver were completed and no contraindication to the procedure was identified on this imaging. Viral and autoimmune hepatitis assays were negative. Imaging from the OSH was uploaded and reviewed by IR. TIPS placement was attempted on [2173-10-8], but the shunt could not be passed through his liver tissue. He had a second attempt on [2173-10-11], which was also not successful. The hepatic artery was punctured during the procedure and repaired without blood loss or significant hemodynamic instability. He had a brief stay in the MICU and returned to the floor. His transaminases were significantly elevated after the second procedure, but were trending down rapidly at the time of discharge. Per IR, further TIPS placement attempts would be technically possible, but will be deferred until a later time. . # Creatinine Elevation: His Cr increased to 1.3 after his second TIPS attempt. CT scan on [2173-10-12] showed findings concerning for contrast-induced nephropathy/ATN. His Cr remained stable at 1.3 for the last three days. A prerenal etiology may also have been contributing given his limited PO intake and recent fluid losses. He will likely need aggressive hydration and Acetylcysteine with any future contrast loads. . # Pain Control: He has significant pain from immobility due to [Last Name (un) 4584]-[Location (un) ] Syndrome, which was made worse by chest tube placement during his first TIPS attempt. He was much more comfortable after the chest tube was removed. He was started on Oxycodone 5 mg PO with close monitoring. He did not show any signs of hepatic encephalopathy or sedation. He was switched to Q6H PRN dosing on [2173-10-13], which worked well for the patient. . # Hydrothorax: He has a history of recurrent hepatic hydrothorax. His CXR on admission showed a large pleural effusion / hydrothorax with complete whiteout of the right hemithorax. He was asymptomatic and maintaining good oxygen saturation. He had thoracentesis with removal of 2 L of fluid. He tolerated the procedure well, with only some mild coughing. The fluid was transudative based on Light's criteria, with no evidence of infection. During his TIPS procedure on [2173-10-8], he had 3.5 L of fluid drained and a chest tube was placed. The chest tube drained large amounts of fluid over the days following its placement. The chest tube was removed at the time of his repeat TIPS attempt on [2173-10-11]. Patient has oxygen saturation 98% on room air at time of discharge. . # Ascites: His outpatient hepatologist was contact[Name (NI) ] for more information regarding his prior diuresis, recurrent ascites, and hydrothorax. He was previously taking Furosemide and Spironolactone, but developed hypotension with use of the diuretics and continued to have significant hydrothorax and recurrent ascites requiring large volume paracentesis. During his stay at [Hospital1 18], he was kept on a low sodium diet and fluid restriction of 1500 ml. Strict I/Os and daily weights were monitored. He did not require additional paracentesis after 4 L of fluid were removed during his first TIPS attempt. . # Alcholic Cirrhosis: The indications for TIPS include recurrent ascites, hepatic hydrothorax, or variceal bleeding. His MELD score on admission was 11, so TIPS was not contraindicated. He denied any prior episodes of hepatic encephalopathy or GI bleeding. He was continued on a regimen of Lactulose and Rifaximin. His Rifaximin dosing was changed to 400 mg TID so that he could take smaller pills. MELD labs were checked daily and his score remained stable around 11, but acutely increased to 15 after his second TIPS attempt. . # Nutrition: On admission he appeared cachectic and chronically ill, reporting a significant weight loss over the last few months. His PO intake was poor during his admission. Nutrition consult felt that he would clearly benefit from additional nutrition through tube feeds. A Dobhoff tube was placed on [2173-10-15] and tube feeds were initiated. Nutrition recommended Nutren 2.0 at 70 ml/hr. Continued PO intake was encouraged and he was provided Ensure and Beneprotein supplements with each meal. . # Hypotension: He has a history of symptomatic hypotension. His TSH was mildly elevated at 7.8 and his morning cortisol was 8.3, which is WNL but on the low side. He will need followup of his TSH as an outpatient. Further workup of his cortisol level is probably not necessary at this time. He remained hemodynamically stable with SBP in the 90s to 100s after admission mild diuretic treatments, paracentesis, and thoracentesis. Diuretic treatment was discontinued pending TIPS. He was given Albumin (5%) 25 g on several occasions for volume repletion. . # [Last Name (un) 4584]-[Location (un) ] Syndrome: He had an episode of GBS in [2169] which resolved and a second episode which started several months ago. He is currently wheelchair bound due to LE weakness. He was seen by PT and was able to stand with a walker but not ambulate. He will require additional PT after discharge. . # Anemia: He has a slightly macrocytic anemia with a hematocrit stable around 30. His WBC count and platelets are also low, suggesting a component of marrow suppression. Iron studies show an moderately elevated ferritin, low TIBC, and low serum iron consistent with chronic inflammation. His B12 and folate levels were normal. His hematocrit was monitored closely, and he showed no signs of GI bleeding. . # DVT Prophylaxis: Provided with Heparin 5000 units SC TID. . # MICU Course [2173-4-8]: Patient was admitted to the MICU after puncture of hepatic artery during TIPS procedure for hemodynamic monitoring. Patient remained stable and serial hematocrits were stable. A CT scan was completed showing: No significant hematoma, with decreased ascites, with some blood mixed in (likely oozing from the TIPS procedure attempts). It also demonstrated possible kidney damage secondary to contrast nephropathy so patient's creatinine needs to be monitored clinically. Patient was transferred back to the floor after 24 hour monitoring. . # Followup: -- Appointment scheduled in 2 weeks with Dr [Name (NI) ] to begin transplant evaluation process -- Pending results: CA [82]-9 and Vitamin D assays Medications on Admission: Home Medications: Heparin 5,000 units daily Lactinex 1 packet [Hospital1 ] Lactulose 30 ml TID Lorazepam 1 mg QHS Lorazepam PRN Colace 100 mg [Hospital1 ] Senna Lactobacillus MVI daily . Discharge Medications: Morphine Sulfate 2 mg Q6H PRN Heparin SC 5,000 units [Hospital1 ] Lactulose 30 ml TID Rifaxamin 400 mg [Hospital1 ] Nasal Spray 1 spray each nostril TID Lorazepam 2 mg Q6H PRN Lorazepam 1 mg QHS Colace 100 mg [Hospital1 ] Senna 2 tabs QHS Lactobacillus 1 mg PO BID MVI daily . Discharge Medications: 1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): Titrate to [3-11] bowel movements per day. 2. rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hours on, 12 hours off. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: Hold for sedation, RR<12, or signs of encephalopathy. 8. Tube feeds Nutren 2.0 Full strength; Starting rate:10 ml/hr; Advance rate by 10 ml Q4H; Goal rate:70 ml/hr; Flush with 50 ml water Q6H 9. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection three times a day. Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 1110] Discharge Diagnosis: Primary: Alcoholic cirrhosis complicated by ascites Right hepatohydrothorax Ascites Secondary: Guillain-[Location (un) ] Syndrome 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 [Hospital1 69] on [2173-10-4] to have an evaluation for a TIPS procedure. Two attempts were made and unsuccessful. You also had a chest tube placed temporarily for fluid in your right lungs; this was removed several days prior to your discharge. During this hospitalization we discussed undergoing evaluation for a liver transplant; many tests were done in the hospital, and the workup will continue on an outpatient basis. You are scheduled to see Dr. [Name (NI) ], a liver specialist, for this and further management of your liver disease. A feeding tube was also placed to aid with your nutrition. During the hospitalization you also worked with physical therapy; improvement in your strength was noted. Your medication regimen has changed. Please review the medication list closely. Followup Instructions: Please be sure to keep the following appointment with the liver center. Department: TRANSPLANT When: FRIDAY [2173-10-29] at 8:40 AM With: [Name6 (MD) 1382] [Name8 (MD) 1383], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: TRANSPLANT SOCIAL WORK When: FRIDAY [2173-10-29] at 10:00 AM [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Please also schedule an appointment to see your primary care doctor within 1-2 weeks of discharge from the rehabilitation facility. During this hospital course you were noted to have a slightly elevated TSH, which is a marker of thyroid function. This should be rechecked as an outpatient, particularly after you start feeling better. Please discuss this with your primary care doctor. ICD9 Codes: 5845, 4589, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9062 }	Medical Text: Admission Date: [2162-10-11] Discharge Date: [2162-10-26] Date of Birth: [2087-10-20] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2901] Chief Complaint: S/P out of hospital cardiac arrest Major Surgical or Invasive Procedure: pulmonary intubation History of Present Illness: 55M with hx of multiple prior MI's including hx of silent MI, remote CABG, recent AAA repair [6-/2161], afib previously on coumadin (off for ~3 months), and DM c/b toe amputation admitted to the CCU s/p initation of post-arrest cooling protocol. The patient was in the passenger seat of his car with his girlfriend and had just left a VA appt for lab work. Per his girlfriend he slumped over towards her and then became unresponsive. He did not complain of any pain or abnl sxs prior to becoming unresponsive. He was removed from the car to the sidewalk and a code was called. He was initally shocked by [Location (un) 86] PD for vfib and CPR started. He was shocked again x 1 for vfib and intubated PTA. He arrived in the ED in PEA and CPR was begun. He received epi 1mg with ROSC, however he coded again in the ED requiring a 2nd epi 1mg. He was started on a Levophed and Dopamine gtt and a left subclavian was placed. Total down time prior to arrival to the emergency department was approximately 12 minutes. BS ECHO in ED showed inferior wall hypokinesis (possibly old) and global hypokinesia. . ROS: Unable to obtain review of systems as he is sedated, intubated, paralyzed and cooled. Per his partner, he was not complaining of any symptoms such as fevers, chills, cough, chest pain, SOB, DOE, Abd pain, N/V/D, Bleeding from stools or urine, numbness, weakness, or tingling. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: S/P multiple MI, one "large" remote MI and multiple other small silent MI's - CABG: Per report, remote - PERCUTANEOUS CORONARY INTERVENTIONS: Unknown - PACING/ICD: Unknown 3. OTHER PAST MEDICAL HISTORY: - AAA repair [6-/2161] - IDDM with complications - pAfib - "forgetfulness" Social History: Has girlfriend [Name (NI) 2894] who has lived with him for 35 years. She is his constant companion and does not leave him alone. Pt was confused but functional at home, able to go on vacation, out to dinner and shopping with [Doctor First Name 2894]. Was independent in ADL's before. Family History: Unable to obtain as patient intubated and sedated Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: GENERAL: Intubated, sedated, paralyzed with meds. HEENT: Pinpoint pupils NECK: Supple with JVP difficult to appreciate. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . DISCHARGE PHYSICAL EXAM GENERAL: 74 yo M NAD, sitting in chair HEENT: PERRLA, no pharyngeal erythema, no lymphadenopathy, JVP non elevated. CHEST: LS clear post, [Month (only) ] BS left base. CV: S1 S2 Normal in quality and intensity irreg/irreg no murmurs rubs or gallops ABD: soft, non-tender, non-distended, BS normoactive. no rebound/guarding. Foley in place EXT: wwp, no edema. NEURO: Disoriented, oriented to person only, Recognizes girlfriend and has intact distant memories. MAE, strenghts strong ([3-25]) and equal. Overall improving SKIN: no rash, feet with right great toe amputation, intact calluses on left lateral plantar area. PSYCH: improving, poor memory but much less agitated. Pertinent Results: ADMISSION LABS: [2162-10-11] 04:00PM BLOOD WBC-13.0* RBC-4.65 Hgb-13.5* Hct-41.0 MCV-88 MCH-29.1 MCHC-33.0 RDW-12.5 Plt Ct-186 [2162-10-12] 02:05AM BLOOD Neuts-87.3* Lymphs-8.4* Monos-3.9 Eos-0.1 Baso-0.2 [2162-10-11] 04:00PM BLOOD PT-14.1* PTT-24.5 INR(PT)-1.2* [2162-10-11] 04:00PM BLOOD UreaN-18 Creat-1.5* [2162-10-11] 08:10PM BLOOD Glucose-300* UreaN-21* Creat-1.4* Na-135 K-5.4* Cl-103 HCO3-23 AnGap-14 [2162-10-11] 08:10PM BLOOD ALT-120* AST-175* LD(LDH)-431* AlkPhos-55 TotBili-0.5 [2162-10-11] 04:00PM BLOOD cTropnT-0.01 [2162-10-11] 10:54PM BLOOD CK-MB-25* cTropnT-0.20* [2162-10-12] 02:05AM BLOOD CK-MB-28* MB Indx-5.3 cTropnT-0.17* [2162-10-13] 03:05AM BLOOD CK-MB-17* MB Indx-8.3* cTropnT-0.08* [2162-10-11] 08:10PM BLOOD Albumin-3.9 Calcium-8.0* Phos-3.1 Mg-1.2* PERTINENT LABS AND STUDIES [2162-10-18] 06:40AM BLOOD VitB12-794 Folate-13.9 [2162-10-18] 06:40AM BLOOD TSH-2.9 [2162-10-11] 04:00PM BLOOD Digoxin-<0.2* [2162-10-11] 04:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2162-10-11] 04:14PM BLOOD Glucose-193* Lactate-4.8* Na-138 K-4.1 Cl-101 calHCO3-22 C.diff negative x2 [10-23] urine culture [10-11] neg blood culture [10-11] neg sputum gram stain GNR [10-12] legionella antigen urine negative [10-13] urine culture [10-19] negative echo [10-11] The left ventricular cavity is moderately dilated. There is mild to moderate regional left ventricular systolic dysfunction with akinesis/thinning of the basal half of the inferolateral and severe hypokinesis of the inferior wall. The remaining segments contract normally (LVEF = 35 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Left ventricular cavity enlargement with regional systolic dysfunction c/w CAD. Mild mitral regurgitation. No pericardial effusion. . CT head [10-11] There is no evidence of acute hemorrhage or mass effect. A hypodensity in the right frontal lobe along the anterior [Doctor Last Name 534] of the right lateral ventricle could represent subacute area of ischemia (2:20). Prominence of the ventricles and sulci reflects generalized atrophy. Subtle areas of periventricular white matter hypodensity may reflect sequela of chronic small vessel ischemic disease. No concerning osseous lesion or fracture is identified. Aerosolized secretions and fluid are seen within the ethmoid air cells and sphenoid sinus as well as within the nasopharynx, consistent with intubation. The maxillary sinuses and mastoid air cells are clear. There are calcifications of the carotid siphons. IMPRESSION: Hypodensity in the right frontal lobe could represent an area of subacute ischemia. . CT chest abd pelvis [10-11] CT CHEST: No pulmonary arterial filling defect to suggest pulmonary embolism is seen. The aorta is normal in caliber and configuration without evidence of acute aortic syndrome. There are extensive vascular calcifications involving the coronary arteries and aortic valve. There is moderate cardiomegaly. No pericardial effusion is seen. The lungs demonstrate bilateral dependent opacities, which could represent aspiration. Septal thickening is suggestive of pulmonary edema. There is a background of emphysema with upper lobe predominance. No endobronchial lesion is seen. A small amount of secretion/aspiration is seen within the distal trachea extending to the right mainstem bronchus. No lymphadenopathy is identified. An endotracheal tube is in standard position. An esophageal catheter courses into the stomach. A left-sided subclavian central venous catheter is in place with tip in the distal brachiocephalic vein on the left. . CT ABDOMEN AND PELVIS: There is mild periportal edema. No focal liver lesion is seen. The gallbladder is contracted with small amount of pericholecystic fluid. There is wedge-shaped hypodensity in the lower pole of the leftkidney concerning for renal infarction (3B:158). Additionally, in the anteroinferior pole of the right kidney, there is a hypodensity with cortical thinning (3B:160). Bilateral rounded renal hypodensities are consistent with simple cysts. The spleen, pancreas and adrenal glands appear unremarkable. Loops of small and large bowel are normal in size and caliber. There are dense vascular calcifications. The patient is status post endovascular repair of abdominal aortic aneurysm. Hyperdensity external to within the aneurysm sac could represent chronic calcification though endoleak is not entirely excluded (3B:171). Distal loops of large bowel and rectum are normal in size and caliber. The bladder is collapsed around a Foley catheter. The prostate gland contains punctate calcification, otherwise unremarkable. No free air or abnormal fluid collection is seen. The patient is status post femoral-femoral bypass grafting. A left inguinal testis is partially imaged with adjacent fluid superior to the testis Bone windows demonstrate anterior rib fractures involving the second through seventh ribs on the left and the third through seventh ribs on the right. Additionally, there is a minimally displaced sternal fracture IMPRESSION: 1. No evidence of pulmonary embolism or acute aortic syndrome. Bilateral dependent opacities could represent aspiration. Mild pulmonary edema. 2. Hypodensity in the inferior pole of the left kidney concerning for renal infarction. Additional ill-defined hypodensity in the anterior inferior pole of the right kidney could represent additional area of infarction of unclear chronicity or chronic scarring. Suboptimnal evaluation of the renal vasculature since the abdomen was not imaged with CTA technique. 3. Bilateral anterior rib fractures and sternal fracture. 4. Emphysema. 5. Cardiomegaly. No pericardial effusion. 6. Status post repair of abdominal aortic aneurysm. High-density material within the aneurysmal sac most likely represents chronic calcification though endoleak is not entirely excluded given lack of non-contrast images. 7. Periportal edema and small amount of pericholecystic fluid may be related to fluid resuscitation. 8. Left inguinal testis, partially imaged. Bilateral LE dupplex [10-20] REASON: Status post aortobifemoral repair of abdominal aortic aneurysm. Evaluate anatomy prior to cardiac catheterization. FINDINGS: A Duplex was performed of the aortobifemoral graft. There are triphasic common femoral waveforms bilaterally with velocities of 223 on the right and 137 on the left. IMPRESSION: Patent aortobifemoral graft with bilateral anastomosis to the common femoral arteries. Normal waveforms. . Labs at discharge: [2162-10-26] 06:05AM BLOOD WBC-6.8 RBC-3.43* Hgb-10.1* Hct-30.6* MCV-89 MCH-29.4 MCHC-33.0 RDW-13.7 Plt Ct-372 [2162-10-26] 06:05AM BLOOD Glucose-110* UreaN-12 Creat-1.1 Na-138 K-4.5 Cl-104 HCO3-27 AnGap-12 [2162-10-26] 06:05AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.8 Brief Hospital Course: 74M with hx of multiple prior MI's including hx of silent MI, remote CABG, recent AAA repair [6-/2161], afib previously on coumadin (off for ~3 months), and DM c/b toe amputation admitted to the CCU s/p initation of post-arrest cooling protocol. . #VFIB ARREST: Pt had OOH Vfib arrest without clear precipitating cause. Most likely old ischemia leading to scar and VT/VF. CE elevation at admission was thought to be from shocks. Upon arrival to the [Hospital1 18] ER, he was in PEA and received epinephrine with ROSC. He was started on levophed and dopamine and hypothermia protocol was initiated for 24 hours with the Arctic Sun. He was admitted to the CCU for further monitoring. Pressors were weaned during the course of his CCU stay and he was extubated. Gerontology team and primary CCU team discussed goals of care and appropriate treatment with [Doctor First Name 2894], his HCP. His Outpatient NP was also updated on plan. They decided that an ICD would not be in his best interest and that continuing to aggressively treat would not be consistent with his goals of care. Plan for now is to discharge to rehabilitation, then home when he is able. He will f/u with EP cardiologist Dr. [Last Name (STitle) ] in 2 weeks to discuss possible catheterization and ongoing management. He will follow-up with the NP who cares for him at the VA after he leaves rehabilitation. . # Aspiration pneumonia: Patient was intubated in the field, findings suggestive of aspiration noted on CXR. He was initially treated with vancomycin and Zosyn which he received for 10 days. At discharge, he is off antibiotics and afebrile with normal WBC. . # Delerium/dementia: Likely occurred in the setting of multiple new medications and severe illness. This has happened during past hospitalizations per his partner [Name (NI) 2894]. [Name2 (NI) ] has moderate dementia per geronotology at baseline. Was started on seroquel that has helped agitation, the goal is to wean this medication over the next 4 days after discharge as his mental status has been improving. His girlfriend feels that pt is about 90% recovered from his delerium. Unclear how much anoxia during his cardiac arrest is contributing to the mental status changes. At discharge, the patient is confused but cooperative, gets frustrated with care but easily redirected. No restraints needed for 4 days. Gerontology feels that his prognosis with moderate dementia is 2-3 years. He was continued on his home memantine and donepezil during this admission. . # CAD: He has been ruled out for acute ischemia as EKG??????s are not c/w ischemia and elevated cardiac enzymes were likely related to being resuscitated with chest compressions and defibrillation. No new Wall motion abnormality on ECHO. On ASA, metoprolol and atorvastatin. [Month (only) 116] benefit from cardiac catheterization in the future if his mental status improves enough to proceed. This will be discussed at his next outpatient appt with Dr. [Last Name (STitle) ]. . # Acute systolic dysfunction: LVEF of 35%. Thought [12-23] VF arrest. No clinical evidence of CHF at present time and without known history. He should have daily weights and follow a low sodium diet. At discharge, he is on lisinopril and long acting beta blocker. Weight at dsicharge is 89.5 kg. . # RHYTHM: Possible atrial fibrillation at admission with recent hx of pAfib off of coumadin for 3 months. AT the time of discharge, he is in NSR with freq APC's and PVC's. Coumadin was not restarted. QTc at discharge was 0.46 sec. . # Cerebral Infarct/Renal Infarct: These appear to be subacute given the radiographic appearance. Unclear what the cause is but concern for embolic phenomena from Afib. Apical thrombus seen on echo [10-18] (improved from [10-9]). Also comlicated by possible endovascular leak from AAA repair site seen on CT which vascular has commented on as likely being calcification and not an acute event. Neuro has weighed in on brain imaging and agrees it is subacute stroke and recommends no intervention. Currently not anticoagulated at discharge. . # Sternal/Rib Fx's: Likely secondary to compressions during CPR. Occasional complaints of pain, improved with tylenol during admission. . # Transaminitis: Likely due to cardiac arrest and shock. Improved at the time of discharge. . #Urinary retention - Required a Foley catheter during part of his hospitalization for urinary retention. He was able to void at the time of discharge. He also received tamsulosin during this admission which will not be continued at discharge as his urinary retention had resolved. . # HTN: BP was elevated during agitation. On metoprolol and lisinopril and BP well controlled at discharge. . # HLD: Stable. On atrovastatin at discharge. . # Insulin dependent diabetes: Normally takes 70/30 insulin at home. Now on decreased dose because of persistently low fingersticks. At rehab, he should have fingersticks checked before breakfast and dinner and titrate 70/30 dosing as needed. . Transitions of care: 1. F/U with Dr. [Last Name (STitle) ] at [Hospital1 18] on [11-12] to re-assess mental status and decide whether pt can undergo further testing for ischemia. Health care Proxy has refused ICD for now 2. Fingersticks [Hospital1 ] as above and titrate 70/30 insulin as needed. 3. Please schedule appt with [First Name8 (NamePattern2) 4457] [Last Name (NamePattern1) 91730], NP from VA [Location 10050] once pt is ready to be discharged from rehab. 4. Please consider scheduling appt with [Name6 (MD) ] [Name8 (MD) ], MD ([Telephone/Fax (1) 17518] home. 5. Please discuss code status in the next few days, [Doctor First Name 2894] would like pt to be full code at present. 6. Wean off seroquel in the next 4 days. Medications on Admission: - Amlodipine 10mg PO daily - Ascorbic Acid 500mg PO daily - Aspirin 81mg PO daily - Donepezil 10mg PO daily - Insulin 70/30 (NPH/REg) 40U QAM 20U QPM - Lisinopril 5mg PO daily - Metoprolol succinate 200mg PO daily - Niaspan 1000mg PO daily - Omeprazole 20mg PO daily - Pravastatin 40mg PO daily - Metformin 1000mg [Hospital1 ] - Vitamin E 500IU PO daily study drug (could be placebo) - Memantine 5mg PO daily study drug (could be placebo) Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: Thirty Six (36) units Subcutaneous once a day: 36 units before breakfast, 15 units before dinner. 4. lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. metoprolol succinate 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day: HOLD SBP < 90, HR < 55. 6. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 7. memantine 5 mg Tablet Sig: One (1) Tablet PO Daily (). 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 10. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO 2200 (). 12. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): in am. 13. Outpatient Lab Work Please check chem-7 and CBC on Friday [2162-10-29] Discharge Disposition: Extended Care Facility: [Hospital3 78668] and Rehabilitation Center - [Location (un) 4047] Discharge Diagnosis: Sudden cardiac death from ventricular fibrillation Delirium Urinary retention Aspiration pneumonia Acute systolic dysfunction Subacute cerebral infact Sternal and rib fracture Insulin dependent Diabetes Mellitus Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You collapsed and your heart was in a dangerous rhythm called ventricular fibrillation. You were shocked out of this rhythm. Your body temperatuve was cooled to prevent damage to your brain and you are recovering well. You were treated for a pneumonia and you do not need oxygen anymore. We don't know exactly why your heart went into this rhythm but you are too confused to undergo any further testing at this time. You will see Dr. [Last Name (STitle) ] in a few weeks to evaluate your ability to undergo testing. You will also be seen By Dr. [Last Name (STitle) ] [Name (STitle) ] to evaluate your thinking and memory after you are home. Your heart is weak after the event, please weigh yourself every morning, call Dr. [First Name (STitle) ] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. . We made the following changes to your medicines: 1. STOP taking amlodipine, Vitamin C, Niaspan, Vitamin E 2. Increase aspirin to 325 mg daily 3. Increase lisinopril to 30 mg daily 4. Change prevastatin to atorvastatin to lower your cholesterol 5. START taking Seroquel to help you stay calm 6. DECREASE insulin 70/30 to 36 units in the am and 15 untis in the pm Followup Instructions: Department: CARDIAC SERVICES When: FRIDAY [2162-11-12] at 1:40 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 . Department: Behavioral Neurology When: please call after you are home to make an appt With: [Name6 (MD) ] [Name8 (MD) ], MD ([Telephone/Fax (1) 1703] Campus: EAST Best Parking: [Hospital Ward Name ] garage [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909] ICD9 Codes: 5070, 2762, 5180, 412, 2724, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9063 }	Medical Text: Admission Date: [2197-8-1] Discharge Date: [2197-8-10] Date of Birth: [2121-5-5] Sex: M Service: NEUROSURGERY Allergies: Morphine / Augmentin / lisinopril / Aldactone Attending:[First Name3 (LF) 1835] Chief Complaint: Hyperglycemia after starting dexamethasone Major Surgical or Invasive Procedure: [2197-8-4]: LEFT FRONTAL CRANIOTOMY FOR MENIGIOMA RESECTION History of Present Illness: Mr. [Known lastname 60843] is a 76 year old man with a history of CAD s/p MI in [2188] (subsequent normal cath in [2193]), CVA w/o residual defecits, sCHF, DMII, OSA (nonadherant with bipap), who is admitted for preoperative hyperglycemia management prior to meningioma removal scheduled for [2197-8-4]. Per the patient and patient's family, he was in his usual state of health until this spring when he and his family noticed headaches and generalized cognitive decline. He began forgetting dates and mixing up his medications. He then went to [Hospital3 ] on [2197-6-15] where an MRI revealed a large frontal meningioma. He was then seen by neurosurgery there who recommended surgery, however, he decided to come to [Hospital1 18] for a second opinion. He then established care here with neurooncology who noted RLE edema and obtained an U/S which revealed a DVT. He was started on lovenox. It is unclear if this is provoked or not. He was started on dexamethasone and Keppra for his meningioma but he has developed hyperglycemia as a result. His neurosurgeons therefore decided the patient should be admitted to medicine for hyperglycemia management prior to the operation. Of note, his aspirin and plavix were discontinued on [7-24] in preparation of surgery. 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. Also denies focal weakness, visual problems. [Name (NI) ] DOES report unsteady gate and memory difficulties. Past Medical History: 1. Meningioma 2. CAD s/p MI in [2188]. Repeat cath here in [2193] revealed patent coronaries 3. sCHF (no echo in our system but [2194] admission at OSH for CHF) 4. Diabetes 5. Hypertension 6. Dyslipidemia 7. Left ear infection, hearing loss, had surgery 8. Colon polyps removed 9. Bilateral LE blood clots 10. Sleep apnea, does not tolerate CPAP 11. Prostatism 12. Cognitive decline Social History: He is married and lives with his wife. [Name (NI) ] is a retired sheet metal worker, and had asbestos exposure in the shipyard. He is retired. He smoked [1-8] ppd for 60 years Family History: No family history of brain cancer, otherwise non-contributory Physical Exam: Admission exam: VS: 97.8 124/74 88 18 95%RA FS 240 GENERAL: Well-appearing man in NAD, comfortable, appropriate. HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear. NECK: Supple, no thyromegaly, no JVD, no carotid bruits. HEART: RRR, no MRG, nl S1-S2. LUNGS: CTA bilat, no rh/wh, good air movement, resp unlabored. Bibasilar crackles. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. Scar from colectomy for polyps (precancerous). EXTREMITIES: WWP, no c/c, 2+ peripheral pulses. 1+ edema on RLE. SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength [5-11] throughout UE/LE flexion/extension with subtle RLE weakness on knee flexion and extension, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait but with limp favoring right and + rhomberg sign. States days of week backward correctly without delay and states he is in hospital for meningioma to be removed. Discharge exam: Unchanged Pertinent Results: Admission labs: [2197-8-1] 09:45AM BLOOD WBC-9.7 RBC-4.59* Hgb-14.8 Hct-43.4 MCV-95 MCH-32.4* MCHC-34.2 RDW-12.7 Plt Ct-199 [2197-8-1] 09:45AM BLOOD Neuts-78.8* Lymphs-14.6* Monos-4.8 Eos-1.2 Baso-0.6 [2197-8-1] 09:45AM BLOOD Plt Ct-199 [2197-8-1] 09:45AM BLOOD PT-12.1 PTT-26.3 INR(PT)-1.0 [2197-8-1] 09:45AM BLOOD UreaN-14 Creat-0.6 Na-143 K-4.3 Cl-103 HCO3-29 AnGap-15 [2197-8-1] 09:45AM BLOOD Calcium-10.0 [2197-8-1] 09:45AM BLOOD %HbA1c-8.2* eAG-189* [2197-8-1] 09:45AM BLOOD CRP-14.1* [2197-8-4] ct brain FINDINGS: The patient is status post post-left frontal craniotomy, with changes related to excision of the previously described left frontal mass. A moderate amount of pneumocephalus is noted in the left frontal region. Trace amount of dense material is seen layering in the resection cavity, compatible with subarachnoid blood. The sulci of the left frontal lobe are mildly effaced as is the frontal [Doctor Last Name 534] of the left lateral ventricle. Subtle left-to-right shift of midline structures is seen, with the maximum displacement measuring 3 mm in the transverse plane (2; 15). Otherwise, there is no large subdural collection, hydrocephalus, or intraventricular hemorrhage. Small amount of subcutaneous gas is seen along the left aspect of the scalp in the region of the surgical intervention. The visualized paranasal sinuses and mastoid air cells are clear. Incidental note is made of a hearing aid on the left ear. IMPRESSION: Immediately status post resection of left frontovertex extra-axial mass, with moderate post-procedural pneumocephalus and trace subarachnoid blood at the operative bed; mild effacement of sulci and the left frontal [Doctor Last Name 534], with 3 mm rightward shift of midline structures, is unchanged from the pre-operative studies. [2197-8-5] MRI FINDINGS: The patient is status post left frontal craniotomy, with post-surgical changes in the left frontal region as well as the adjacent parenchyma of the left frontal lobe. Pneumocephalus and blood products and fluid are noted. There is moderate surrounding FLAIR hyperintense signal that is not significantly changed from the preop study. Areas of increased signal intensity are noted on the DWI sequence in the periphery of the resection cavity with decreased signal on the ADC sequence, which may relate to blood products/areas of ischemia or infarction in the adjacent tissue. Attention on followup can be considered (series 502, image 20). Evaluation for enhancing areas is limited, given the pre-contrast T1 hyperintense areas. However, there is slightly vague enhancement surrounding the surgical resection cavity. No areas of abnormal enhancement are noted elsewhere in the brain. Small fluid collection is noted in the left subdural space, in the frontal region. There is also soft tissue swelling with fluid collection in the soft tissues overlying the left frontal and the parietal bones (series 6, image 21) along with blood products. Mild enhancement of the overlying dura in the left side. Multiple FLAIR hyperintense foci are also noted in the cerebral white matter, likely related to small vessel ischemic changes. There is mass effect on the frontal [Doctor Last Name 534] of the left lateral ventricle, with mild rightward shift of the midline structures and subfalcine herniation measuring approximately 5 mm. The major intracranial arterial flow voids are noted, with a diminutive distal vertebral and Basilar artery with a fetal PCA pattern. There is increased signal intensity in the mastoid air cells on both sides and in the petrous apices from fluid/mucosal thickening. IMPRESSION: 1. Surgical changes in the left frontal region and in the left frontal lobe parenchyma with presence of blood products as described above. Unchanged appearance of the surrounding FLAIR hyperintense signal in the left frontal lobe. Interval development of an area of decreased diffusion surrounding the blood products, which may relate to infarction/ischemic changes in the parenchyma. Assessment for infarction is limited given the presence of blood products adjacent. Consider followup as clinically indicated for better assessment. 2. While there is no significant abnormal enhancement to suggest an obvious residual tumor, followup evaluation can be considered to assess residual tumor, after resolution of the post-surgical changes. 3. Mucosal thickening/fluid, in the mastoid air cells on both sides and in the petrous apices. Persistent mass effect on the left frontal [Doctor Last Name 534] and mild rightward shift of midline structures not significantly changed. Brief Hospital Course: 76M with CAD s/p MI, chronic diastolic CHF (EF 50%), T2DM, h/o CVA and recently diagnosed DVT who was admitted for pre-operative glycemic control in the setting of dexamethasone. #Meningioma - Patient noted having gait instability and difficulty with his memory, was diagnosed with a left frontal meningioma by MRI at an OSH. Was started on dexamethasone and Keppra for seizure prophylaxis. He had resection of the meningioma on [2197-8-4] by neurosurgery. This was done without complication. Post op head CT was without hematoma. Post op MRI revealed good resection. #T2DM - Patient reports that his diabetes had not been well controlled prior to starting dexamethasone, was reporting sugars in the 200s previously. Since starting dex, his glycemic control even worsened and was reporting glucose in the 400s. He was admitted for pre-operative glycemic control. We held his home glipizide and started him on insulin. By the day of surgery, his sugars remained elevated but were improved from prior to admission. His insulin regimen was Lantus 15 units and sliding scale Humalog. During his post-operative course he was on dexamethazone and his sugars were difficult to control. He was placed on an insulin drip for > 24 hours. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Diabetes consult was obtained. He was transferred to a sliding scale and PO meds were discontinued. His sliding scale insulin and Morning Lantus doses were adjusted and weaned [First Name8 (NamePattern2) ] [Last Name (un) ] consult in the setting of steroid taper. #DVT - He reports having a history of at least 2 prior DVTs. Was diagnosed with DVT prior to admission, had been on Lovenox. Was placed on a heparin gtt during this admission given his pending surgery. Heparin was turned off approximately 6 hours prior to his surgery. Post operative day #1 he was asa was restarted and on post-operative day #2 his plavix was restarted. On [8-10] he was started on Coumadin. #CAD s/p MI - Had cardiac cath in [2193] which did not show any significant lesions. He was continued on his home metoprolol, valsartan and amlodipine. He was continued on his cardiac meds on the day of the operation. #Diastolic CHF - TTE from OSH showed an EF of 50%. There were no clinical signs of volume overload, was given gentle fluids on the day of surgery while he was NPO. #OSA - Was continued on CPAP while he was an inpatient. On [2197-8-10] he was cleared for discharge home after being seen by PT. Pain was well controlled, tolerating a PO diet, voiding without difficulty and ambulating independently. He received Insulin training prior to discharge and will have VNA at home for furhter training. Family was in agreement with this plan. Medications on Admission: 1. Simvastatin 80 mg qday 2. Glipizide 10 mg po bid 3. Irbesartan 300 mg daily 4. Amlodipine 5 mg daily 5. Furosemide 20 mg daily 6. Dexamethasone 4 mg daily 7. Phenytoin 100 mg tid 8. Aspirin 81 mg daily 9. Clopidogrel 75 mg daily 10. Metoprolol XR 100 mg 11. Omeprazole 20 mg po daily 12. Aspirin 81 mg daily 13. Keppra 1000mg PO BID 14. Lovenox 120 SC BID Discharge Medications: 1. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. furosemide 20 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). [Date Range ]:30 Capsule, Delayed Release(E.C.)(s) Refills:2 4. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). [Date Range ]:120 Tablet(s) Refills:2 5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. valsartan 80 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Check INR on [8-12] or [8-13]. Further dosing by PCP. [Name Initial (NameIs) ]:30 Tablet(s) Refills:2 11. dexamethasone 1 mg Tablet Sig: taper Tablet PO taper for 4 days: 1mg PO Qday on [8-10] & [8-11]. 0.5mg PO Qday on [8-17] then d/c. [Month/Day (4) ]:qs Tablet(s) Refills:0 12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 13. insulin glargine 100 unit/mL Solution Sig: Fifty Five (55) units Subcutaneous once a day: Decrease to 35 units daily when taking 1mg Dexamethasone daily and decrease to 25 units daily when taking 0.5mg Dexamethasone daily. [Month/Day (4) ]:1 vial Refills:3 14. Humalog 100 unit/mL Solution Sig: per sliding scale units Subcutaneous before meals. [Month/Day (4) ]:1 vial Refills:2 15. diabetic supplies, miscellan. Kit Sig: One (1) kit Miscellaneous as directed. [Month/Day (4) ]:1 kit Refills:2 16. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). [Month/Day (4) ]:30 Patch 24 hr(s) Refills:2 17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Primary diagnoses: Meningioma s/p resection Hyperglycemia Secondary diagnoses: CAD Diastolic CHF OSA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions ?????? Have a friend/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, or excessive bending. ?????? Your wound closure uses dissolvable sutures, you may shower after 3 days. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. 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, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [7-16] days(from your date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [Telephone/Fax (1) 1669]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????You have an appointment in the Brain [Hospital 341] Clinic on [2197-9-4] at 1PM. The Brain [Hospital 341] Clinic is located on the [Hospital Ward Name 516] of [Hospital1 18], in the [Hospital Ward Name 23] Building, [Location (un) ]. Their phone number is [Telephone/Fax (1) 1844]. Please call if you need to change your appointment, or require additional directions. ?????? You need to follow up with your primary care physican early next week (mon or tues) to check on coumadin dosing/INR and blood sugars. You were seen in house by [Last Name (un) ] Diabetes. You should follow up with Dr. [Last Name (STitle) 818] for titration of the insulin as you stop the steroids (decadron). The timing and need for this can be discussed with your PCP. [Name10 (NameIs) ] phone number at [Last Name (un) ] Diabetes is [Telephone/Fax (1) 47802]. Completed by:[2197-8-10] ICD9 Codes: 4280, 3051, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9064 }	Medical Text: Admission Date: [2170-11-19] Discharge Date: [2170-11-23] Date of Birth: [2088-8-22] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Doctor First Name 1402] Chief Complaint: Dyspnea and PEA arrest Major Surgical or Invasive Procedure: [2170-11-19] to [2170-11-22] - Mechanical ventilation and intubation [2170-11-19] to [2170-11-20] - Post-arrest hypothermia protocol [2170-11-19] - Central venous line placement History of Present Illness: The patient is an 82 y/o F with unknown PMHx who is being admitted to the CCU after a witnessed cardiac arrest in an OSH ED. Per report, the patient called 911 this morning after developing acute-onset SOB at home this morning. She was noted to be hypoxic (O2 sat 70's to 80's on CPAP) and was brought to [Hospital3 ] ED. Shortly after arriving in the [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], she had a witnessed cardiac arrest. Initial rhythm was PEA; immediately prior to arrest, rhythm had been SR with prolonged PR followed by slow Afib. During the arrest, she received 2 of epi and 1 of atropine, with change of rhythm to Vfib. She then received 2 more of epi, 1 of bicarb, 10 units IV insulin, and 2 shocks, with ROSC. Rhythm at that time was Afib with RVR. She was intubated and therapeutic hypothermia was initiated. She was then transferred to the [Hospital1 18] ED for further management. Of note, she was also started on a diltiazem gtt for afib/rvr, which was stopped on arrival to [Hospital1 18]. Prior to transfer, she did exhibit some agitation and attempted to pull her ETT, for which she was given 3 mg ativan. In the [Hospital1 18] ED, ECG showed sinus tachycardia at a rate of 110's, no evidence of acute ischemia. The patient was placed on fentanyl and versed for sedation. She was evaluated by cardiology and bedside echo was performed. Given ? evidence of right heart strain on echo, there was high suspicion for PE as the etiology of the patient's arrest. She was empirically started on heparin gtt. Given concern for potential infiltrate on CXR, she was also empirically started on CTX/azithro. She was difficult to ventilate [12-27] dyssynchrony. CVL was placed and the patient was started on levophed to allow for increased sedation. She underwent CTA chest prior to transfer to the CCU. On arrival to the CCU, the patient was intubated and sedated, making further history unable to be obtained. Review of systems was unable to be obtained. Past Medical History: PAST MEDICAL HISTORY (discussed with the patient's son, will need to be confirmed in the morning with the patient's PCP): 1. CARDIAC RISK FACTORS: Dyslipidemia 2. CARDIAC HISTORY: - CABG: none - PERCUTANEOUS CORONARY INTERVENTIONS: none - PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - Dementia (small vessel disease) - worsening, getting lost prior - Provoked DVT prior due to injury to her leg, no known PE Social History: No tobacco or illicit drug use. Further social history was unable to be obtained [12-27] patient being intubated. Family History: No family history of bleeding or clotting disorders. Further family history was unable to be obtained [12-27] patient being intubated. Physical Exam: Admission exam: VS: T=90.3 (on arctic sun) BP=72/56 HR=115 RR=15 SaO2=100% on AC 500x26 FiO2 100% PEEP 5 GENERAL: Intubated, sedated. HEENT: NCAT. ETT in place. Sclera non-icteric. Pupils symmetric, minimally reactive. NECK: JVD difficult to assess. CARDIAC: Irregular rhythm, tachycardic. No m/r/g. LUNGS: No chest wall deformities, scoliosis or kyphosis. Rhonchorous breath sounds anteriorly. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Dopplerable pedal pulses. Pertinent Results: Admission labs: [2170-11-19] 10:45AM BLOOD WBC-31.7* RBC-4.12* Hgb-13.0 Hct-40.7 MCV-99* MCH-31.6 MCHC-32.1 RDW-13.1 Plt Ct-189 [2170-11-19] 11:00AM BLOOD PT-12.4 PTT-32.1 INR(PT)-1.1 [2170-11-19] 10:45AM BLOOD Glucose-220* UreaN-28* Creat-1.3* Na-146* K-3.5 Cl-113* HCO3-16* AnGap-21* [2170-11-19] 10:45AM BLOOD CK(CPK)-226* [2170-11-19] 04:14PM BLOOD Calcium-6.2* Phos-6.1* Mg-1.9 [2170-11-19] 11:16AM BLOOD Type-ART Rates-20/8 Tidal V-500 PEEP-5 FiO2-100 pO2-127* pCO2-60* pH-7.11* calTCO2-20* Base XS--11 AADO2-529 REQ O2-88 -ASSIST/CON Intubat-INTUBATED Comment-33.5 RECTA [2170-11-19] 11:16AM BLOOD Lactate-4.5* . Cardiac biomarkers: [2170-11-19] 10:45AM BLOOD CK-MB-10 MB Indx-4.4 cTropnT-0.37* proBNP-126 [2170-11-19] 04:14PM BLOOD CK-MB-15* MB Indx-4.6 cTropnT-0.67* [2170-11-19] 11:33PM BLOOD CK-MB-34* MB Indx-4.9 cTropnT-0.53* [2170-11-19] 10:45AM BLOOD CK(CPK)-226* [2170-11-19] 04:14PM BLOOD CK(CPK)-323* [2170-11-19] 11:33PM BLOOD CK(CPK)-696* . Imaging: -CXR ([2170-11-19]): 1. Endotracheal tube in standard position. No pneumothorax. 2. Multifocal opacities, most severe in the right upper lung, concerning for multifocal pneumonia. . -CTA chest ([2170-11-19]): Emboli within both right and left pulmonary arteries at the segemental level. Associated scattered peripheral airspace opacities likely reflect pulmonary infarction in the setting of PE, however, infection cannot be excluded. . -TTE ([2170-11-19]): The estimated right atrial pressure is at least 15 mmHg. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular free wall thickness is normal. The right ventricular cavity is moderately dilated with severe global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Dilated right ventricle with severe systolic dysfunction. Small left ventricle with normal global and regional systolic dysfunction. Unable to estimate pulmonary pressures on this study. . -LENIs ([2170-11-20]): No DVT; bilateral [Hospital Ward Name 4675] cyst. . - CT head noncontrast ([11-22]) IMPRESSION: 1. No acute intracranial process with no evidence of hemorrhage or mass. 2. No CT evidence of global hypoperfusion, though MRI would have increased sensitivity for early associated changes and can be obtained as clinically indicated. 3. Dilation of the bilateral right greater than left superior ophthalmic veins, which can be seen in the setting of carotid cavernous fistula. Brief Hospital Course: 82 y/o F with dementia and h/o VTE (not on anticoagulation at admission) who was admitted to the CCU after a witnessed PEA arrest in an OSH ED, with ROSC, now found to have bilateral PE's on CT imaging. . ACTIVE ISSUES # PEA ARREST: The patient is s/p witnessed cardiac arrest in OSH ED (PEA -> Vfib) with ROSC. She was intubated, paralyzed, sedated and therapeutic hypothermia protocol was initiated at 11AM on [2170-11-19] prior to transfer to [Hospital1 18]. The etiology of the patient's arrest is most likely bilateral PE's, which were seen on CTA imaging. She was started on a heparin gtt. Other etiologies which were considered include ischemia, electrolyte abnormalities. Trop peaked at 0.67, however she received chest compression and defibrillation prior to transfer, which could elevate her biomarkers. There were no EKG changes to suggest ischemia and ACS was not though to be the cause of her arrest. She was initially started on norepinephrine and phenylepherine to maintain her MAP >60, phenylepherine was subsequently changed to vasopressin. Initially, she was noted to have a significant metabolic acidosis with arterial pH <7.2. She received 1amp of bicarb followed by 1L of normal bicarbonate with improvement in her acidemia. Her lactate peaked at 5.3 and subsequently trended down. . # Bilateral PE's: She has a history of DVT according to her PCP who was [Name (NI) 653] during this admission. She was not on anticoagulation at the time of admission, prior DVT was in the setting of leg injury. As above, this is the likely etiology of the patient's PEA arrest. She did not receive thrombolysis because she was stable on 2 pressors at the time of arrival to [Hospital1 18], the risk was thought to outweigh the potential benefit. LENIs showed no DVT in her legs. . # Atrial Fibrillation: Her initial rhythm after ROSC was atrial fibrillation with RVR. She was briefly started on a dilt gtt, which was stopped when she became increasingly hypotensive. Upon arrival to [Hospital1 18], she was intermittently between sinus rhythm and Afib. She does not have a known history of Afib and this was likely related to myocardial strain in the setting of acute PE. . # Elevated Cr: Cr was 1.3 on presentation to [Hospital1 18]. Unclear baseline, but her creatinine improved to 1.0 after fluid resuscitation. Likely pre-renal from volume depletion and poor forward flow during her PEA arrest. . # Dementia: On Aricept and Namenda at home, these were held in the setting of sedation during intubation and hypothermia. . # Goal of care: Pt has code status of DNR/DNI as confirmed with family after she was resuscitated and intubated at the OSH. The family did not want to escalate care should her condition worsen. The discussion around goal of care was continued throughout the hospitalization. On [11-22], pt's family decided that comfort measure only was in compliance with pt's best interest given her current condition and prior wishes. . # End of life: At 04:33 Am on [2170-11-23], the housestaff was paged to come to the bedside of this patient who was found unresponsive and not breathing. She was unresponsive to voice, sternal pressure or supraorbital pressure. Breath sounds were absent. Heart sounds and pulses were absent. Pupillary reflexes were absent. She was pronounced dead at 4:35 AM. Patient's next [Doctor First Name ] and son, [Name (NI) 2855] [Name (NI) 10269] and other family members present at the bedside. Immediate cause of death was cardiorespiratory arrest. Chief cause of death was pulmonary embolism. Other antecedent causes include atrial fibrillation and dementia. Medications on Admission: - simvastatin 20 mg daily - namenda 10 mg daily - donepezil 10 mg HS - aspirin 325 mg daily Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: pulseless electric activity cardiac arrest Massive pulmonary embolism Discharge Condition: Expired Discharge Instructions: none Followup Instructions: none ICD9 Codes: 2762, 4275, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9065 }	Medical Text: Admission Date: [2140-9-27] Discharge Date: [2140-10-10] Date of Birth: [2080-1-30] Sex: M Service: MEDICINE Allergies: lisinopril Attending:[First Name3 (LF) 86897] Chief Complaint: hypoxemic respiratory failure Major Surgical or Invasive Procedure: Endotracheal intubation Central line A-line History of Present Illness: 60M with newly diagnosed small cell lung cancer, s/p 1st cycle of chemo (cisplation/etoposide [2060-9-11]) 2 weeks ago presenting with fever to 101.7 and dyspnea. Endorses mild cough and chest pain. . In the ED inital vitals were, 99.6 108/53 82%. ECG showed sinus tach. CXR showed large pneumonia. He was given vanc, zosyn and tylenol. Requiring NRB. 96%. had been maintaining pressures but then dropped to 80s. Patient did not want central line. He was given a total of 4L NS and BP was in 90s on transfer. On arrival to ICU, pt is comfortable. He states that symptoms of fever, dyspnea and pleuritic chest pain came on relatively suddenly yesterday. He lives alone and has no sick contacts. [Name (NI) ] has no other symptoms. Past Medical History: Past Medical History: 1. small cell lung cancer: presented with R arm and shoulder pain x 3 weeks and weight loss 15lbs in 4 months. CT on [2140-9-1] showed a 11CM RUL mass with mediastinal involvement. Biopsy of Right supraclavicular LN showed small cell lung cancer. MRI brain and PET scan no distant metastasis and his disease is consistent with limited stage small cell lung cancer. Current treatment: concurrent chemoXRT with Cisplatin 80mg/m2 iv day 1 + etoposide 100mg/m2 iv days [1-18] every 4 weeks for total 4 cycles with neulasta support. XRT is planned to start on [2140-9-29]. 2. Hypertension. 3. History of two colonic polyps removed in [2137], and an additional polyp removed in [2140]. 4. Multiple oral surgeries, currently with upper and lower dentures. Social History: He smokes 1ppd x40yrs. He was a heavy drinker but has been only drinking ETOH occasionally since 4 months ago. Widower, 4 children. Family History: His father has a history of hypertension and died in his 60s. His mother died in her 70s of unknown causes. There is no known family history of cancer. Physical Exam: Tmax: 37.3 ??????C (99.1 ??????F) Tcurrent: 37.2 ??????C (98.9 ??????F) HR: 84 (81 - 92) bpm BP: 147/65(86) {119/55(74) - 147/70(86)} mmHg RR: 21 (20 - 26) insp/min SpO2: 92% Heart rhythm: SR (Sinus Rhythm) Wgt (current): 64.2 kg (admission): 50.2 kg General Appearance: No acute distress Eyes / Conjunctiva: right sided ptosis, miosis, o/p clear Cardiovascular: (S1: Normal), (S2: Normal) no m/g/r Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Breath Sounds: Rhonchorous: ) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: absent, Left lower extremity edema: asent, No(t) Cyanosis, No(t) Clubbing Skin: Warm Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Discharge Exam: Vitals - Tm:99.7 Tc:99.7 BP: 120/50 HR:87 RR:18 02 sat: 95%RA, I/O: 744/500 GENERAL: Pleasant, thin man. Sitting up comfortably.AAOx3. HEENT: EOMI, PERRLA, anicteric sclera, pink conjunctiva, MMM, OP clear CARDIAC: rapid rate, reg rhythm, S1/S2, no mrg LUNG: Nonlabored on RA. coarse crackles in left lung diffusely ABDOMEN: Thin. nondistended, nontender in all quadrants, no rebound/guarding EXTREMITIES: no cyanosis or clubbing, 1+ edema bilaterally in LE NEURO: CN II-XII intact. No gross motor or sensory loss. Pertinent Results: ADMISSION LABS: [2140-9-27] 09:35PM BLOOD WBC-26.0# RBC-3.83 Hgb-10.4* Hct-29.5* MCV-77* MCH-27.3 MCHC-35.3* RDW-14.6 Plt Ct-609* [2140-9-27] 09:35PM BLOOD Neuts-87* Bands-3 Lymphs-4* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-2* [2140-9-27] 09:35PM BLOOD Glucose-130* UreaN-37* Creat-1.5* Na-127* K-4.5 Cl-85* HCO3-27 AnGap-20 [2140-9-27] 09:44PM BLOOD Lactate-1.9 [2140-9-27] 11:13PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.011 [2140-9-27] 11:13PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [2140-9-27] 11:13PM URINE RBC-5* WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1 [2140-9-27] 11:13PM URINE CastHy-60* OTHER PERTINENT LABS: JAK2: pending MICROBIOLOGY: [2140-9-27] BCx: negative [2140-9-28] Legionella Ag: positive [2140-9-28] BAL: GNRs, Legionella culture pending [2140-9-29] BCx: negative [2140-9-30] SputumCx: sparse yeast [2140-9-30] BCx: negative [2140-9-30] Cdiff: negative [2140-10-3] Cdiff: negative STUDIES: [2140-9-27] CXR: IMPRESSION: New left mid and lower lung field consolidation highly concerning for pneumonia. Known right apical mass appears slightly decreased in size compared to the prior exam. Trace left pleural effusion. [2140-9-28] CT CHEST W/O CONTRAST IMPRESSION: 1. Extensive consolidation involving the majority of the left lung. This is new from [2140-9-9] and consistent with extensive pneumonia. Trace left pleural effusion. The majority of opacification is related to consolidation as opposed to effusion. No endobronchial lesion identified. 2. Interval cavitation of known right upper lobe mass. Two additional right lower lobe lesions with cavitation concerning for metastatic deposits. Peripheral to the right upper lobe lesion, additional areas of post-obstructive inflammation/infection or possible lymphangitic carcinomatosis are seen. [2140-10-3] LIVER OR GALLBLADDER US (SINGLE ORGAN) IMPRESSION: 1. Normal liver echotexture. No intrahepatic bile duct dilation. 2. New mild abdominal ascites and a small right pleural effusion. DISCHARGE LABS: [2140-10-10] 07:00AM BLOOD WBC-12.3* RBC-3.33* Hgb-9.0* Hct-27.6* MCV-83 MCH-27.2 MCHC-32.7 RDW-17.4* Plt Ct-1424* [2140-10-10] 07:00AM BLOOD Glucose-104* UreaN-8 Creat-0.6 Na-137 K-4.4 Cl-100 HCO3-29 AnGap-12 [2140-10-10] 07:00AM BLOOD ALT-57* AST-44* LD(LDH)-403* AlkPhos-134* TotBili-0.4 [2140-10-10] 07:00AM BLOOD Calcium-9.0 Phos-4.0 Mg-1.6 Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION Mr. [Known lastname ] is a 60 year old man with h/o recently diagnosed SCLC, s/p C1 Cis/Etoposide, who was admitted to the [Hospital Unit Name 153] with fever and hypoxemic respiratory failure requiring intubation, found to have Legionella PNA. #. Legionella PNA: Patient was admitted to [Hospital Unit Name 153] after presenting to ER with hypoxia hypotension. Patient required intubation and levophed for respiratory and circulatory support. Chest Xray and CT showed extensive pneumonia. Patient was empirically started on vancomycin, zosyn and levofloxacin. Patient was also trreated with flagyl and cefepime during ICU stay. Antiobiotics were narrowed to levofloxacin after bronchial washings and urine were positive for legionella. Patient was successfully extubated and transferred to the OMED floor on standing albuterol and ipratropium. Oxygen was weaned as tolerated and patient was discharged satting mid90s on RA with plan to complete 21 day course of levofloxacin on [2140-10-19]. #. Leukocytosis: Patient with impressive leukocytosis during admission, peaking at 53.7 on [10-3]. Suspect due to infection and effect of neulasta following chemotherapy. Trended down and was 12.3 at discharge. #. Thrombocytosis: Plt count steadily increased during stay, up to 1449 on [10-9]. Etiology was originally attributed to acute phase reactant due to PNA and malignancy. To evaluate for myeloproliferative effect, JAK2 level was measured, and pending at time of discharge. Patient was started on ASA 81 daily. #. SCLC: Patient presented during C1 Cis/Etoposide. Patient underwent 3 fractions XRT as previously planned after transfer to the floor and is to continue follow up with radiaton oncology as outpatient. #. Anemia: HCT trended down after admission to 25.8, and patient was provided 1 unit pRBC in the [Hospital Unit Name 153] with appropriate increase. After transfusion, HCT again declined and stabilized around 25. Iron studies were suggestive of anemia of chronic inflammation. However, due to suspicion of iron deficiency driving thrombocytosis, patient was treated with IV iron and transfused another unit pRBCs. Patient noted to have a rash the day prior to discharge, c/w with drug rash, unclear if related to prior [Name (NI) ] or iron. PO supplementation was discontinued - can be re-evaluated as an outpatient. # LE Edema: Following aggressive fluid ressucitation in the [Hospital Unit Name 153], patient developed impressive bilateral LE edema. Patient was treated with IV lasix and compression stockings with good effect. He was discharged on Lasix PO. #. HTN: Home BP medications were held during hospitalization due to sepsis and hypotension. Upon transfer to floor, patient remained normotensive without treatment. On discharge, he was not restarted on his home medications of dyazide and amlodipine. TRANSITIONAL ISSUES - f/u JAK2 - f/u BAL Legionella Culture (sent to state lab) - monitor HCT, consider restarting iron supplementation - f/u LE edema, d/c Lasix prn Medications on Admission: allopurinol 300 mg Tab 1 Tablet(s) by mouth twice a day lorazepam 0.5 mg Tab 1 Tablet(s) by mouth every 6 hours as needed OxyContin 10 mg 12 hr Tab one Tablet(s) by mouth twice a day oxycodone 5 mg Cap 1 to 2 Capsule(s) every 4 to 6 hours as needed zofran 8mg q8 prn compazine 10 q4-6h prn magic mouthwash 15cc q4-6h prn triamterene-hctz 37.5/25 daily amlodipine 10mg daily Discharge Medications: 1. allopurinol 300 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for Pain. 4. ondansetron HCl 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 5. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 6. magic mouthwash Sig: One (1) treatment every 4-6 hours as needed for mucositis. 7. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 9 days: Take through [10-19]. Disp:9 Tablet(s) Refills:0 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:0 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:0 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. Disp:60 Tablet(s) Refills:0 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 12. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours). Disp:60 Tablet Extended Release 12 hr(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary: Legionella Pneumonia Secondary: Small cell lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname ], You were admitted to the hospital because you had a bad pneumonia called legionella. You went to the ICU where a tube was placed in your throat to help you breathe and medicines to keep your blood pressures up were used. We started antibiotics and soon you started to feel better. While you were here, your platelets (part of your blood that cause clotting) became very high, so we started you on an baby aspirin. This was likely caused by your infection, but low amounts of iron could also cause it, so we gave you extra iron and a transfusion of blood. Please note the following changes to your medications: START Levaquin 750mg daily through [10-19] START Aspirin 81mg daily START Lasix 40mg daily INCREASE Oxycontin to 20mg twice daily START Colace and Senna for constipation STOP Amlodipine and Dyazide. Followup Instructions: Please attend your Radiation Oncology Treatments as previously scheduled [Hospital Ward Name 332] Basement Radiation Oncology; [Hospital1 18]; [Hospital Ward Name 516]; [Location (un) ]; [Location (un) 86]. Please call the oncology office to follow up with Dr. [First Name (STitle) ] the week of [2140-10-17] Phone: [Telephone/Fax (1) 17667] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 86898] ICD9 Codes: 5180, 2761, 5849, 4019, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9066 }	Medical Text: Admission Date: [2126-5-7] Discharge Date: [2126-5-22] Date of Birth: [2072-2-25] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 30] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: intubation central line placement arterial line placement History of Present Illness: 54 yo F with unknown PMH presenting with respiratory failure s/p intubation on the field. . In the ED, CXR was c/w moderate pulmonary edema. BNP was elevated to 1687. EKG did not show any acute ischemic changes. CE x 1 was negative. Lasix 40 mg IV was given. Pt was administered Propofol for sedation. Past Medical History: HTN Social History: Pt lives with husband in [Name (NI) 392]. Her husband has a short-term [Last Name ] problem, that may be a significant stressor. +tob hx (1.5 packs per day), drinks 6 [Last Name 17963] daily, no drug use. Family History: nc Physical Exam: VS 98.2 BP 172/82 HR 77 99% RA on AC 550 X 14 P5 FiO2 100% GEN: intubated, sedated, responds to commands HEENT: EOMI, PERRL CV: RRR Nl S1 s2 no mrg appreciated LUNGS: crackles at bases ABD: obese, soft, NT, ND + BS EXT: no edema, no rash NEURO: responds to commands, moves all 4 Pertinent Results: EKG: [5-6] NSR 70 bpm, nl axis, nl int, no ST-T changes . CXR [5-7]: Comparison is made to a CT of the chest acquired one hour after the chest radiograph. The endotracheal tube is located with the tip approximately 4.4 cm above the carina. There are bilateral hazy opacities predominantly in the mid and lower lung zones, which are consistent with atelectasis/pleural effusions on the CT scan. The heart size is at the upper border of normal. An NG tube is seen with the tip projecting over the gastroesophageal junction. This should be advanced further. There is a mild amount of interstitial edema. There is also prominence of the hilar vessels. IMPRESSION: Moderate CHF with bilateral pleural effusion/atelectasis. NG tube with tip at the gastroesophageal junction. No evidence for pneumonia. . CTA Chest [5-7]: 1. No evidence of PE. 2. Multiple ulcerated atherosclerotic plaques in the descending aorta. 3. Bilateral atelectasis and small pleural effusions. 4. Multiple mediastinal lymph nodes, some of which meet size criteria for pathologic enlargement. . TTE [5-8]: The LA is mildly dilated. The LV cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. RV chamber size is normal. Biventricular systolic function appears grossly preserved but views are technically suboptimal. The aortic valve leaflets appear structurally normal with good leaflet excursion. The aortic valve is not well seen. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen in suboptimal views. There may be a trivial/physiologic pericardial effusion. . CXR [2126-5-18] - The heart is normal in size and the lungs are clear. There is no evidence of failure. Position of the right subclavian catheter, ETT, and NGT are unchanged since [2126-5-16]. There is no pneumothorax. There are no focal infiltrates. The heart is normal in size. Brief Hospital Course: 54 yo F with no known history, intubated on the field for respiratory distress found to be in acute pulmonary edema, failure to wean most likely [3-7] to underlying COPD and EtOH withdrawal. Reintubated [5-10]. . # Respiratory failure: Likely secondary to pulmonary edema given increased pulmonary vasculature and bilateral pleural effusions on CXR, CT with bilateral diffuse ground glass opacities/effusions. Elevated BNP on labs. Patient also with severe smoking history and radiologic changes c/w COPD. Unknown precipitant except for severe HTN requiring nitroglycerin gtt. No evidence of acute ischemic event. Patient also subsequently found to have LLL consolidation and underwent a 9 day course of Zosyn for gram negative rods that were sparse on sputum culture. There was no evidence of PE on CTA. Patient further work up in CHF was done with a TTE [5-8], which showed grossly preserved EF with suggestion of diastolic dysfunction but poor windows. Patient was initially extubated on [5-10] however due to increasing aggitation she required large amounts of valium and due to increased somnolence she was reintubated for protection of her airway. She was successfully extubated on [5-18] and quickly titrated down to 3L and transferred to the floor. She was on steroids in the ICU and they were discontinued on [5-17]. On the floor she was slowly weaned off oxygen and maintained O2 sats 92-93% on room air. On discharge will need continued management of heartfailure with afterload reduction and rate control. . # EtOH use/agitation - [Name (NI) ] husband reported 3 [Name2 (NI) 17963] per day, however the amount remains uncertain. Patient admits to daily drinking herself and has been a drinker for last [3-8] years. Patient peri-extubation required high doses of Valium up to 100 mg a day and also standing Haldol for presumed ICU delirium. Her symptoms were much improved by day 7 of hospitalization. Standing haldol was weaned off and she was placed on CIWA scale where she did not require much valium and this was weaned off aswell. Addiction consult spoke with the patient on the floor as well. . # Leukocytosis: WBC count upto 16K however no evidence of infection after treatment of PNA. This was likely due to actue stress reaction or secondary to steroids. WBC trended down to 11 off steroids. . # HTN: Found to be hypertensive on the field, started on nitro gtt. Currently normotensive. Patient became more hypertensive throughout her stay and her captopril and metoprolol were titrated up. They were subsequently changed to atenolol and lisinopril for improved compliance and doses were titrated. . # FEN: PO diet, Evaluated by S&S here who recommended a PO diet with chin tuck. # PPX: maintained on SC heparin and nicotine patch. Medications on Admission: Naproxen 500 mg Furesomide 20 mg QD Metoprolol 100 mg [Hospital1 ] Pravachol 20 mg QD Pletal Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [Hospital1 ] (2 times a day) as needed. 7. Lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO once a day. 10. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 11. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1) Inhalation every 4-6 hours. 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Doctor First Name 391] Bay Discharge Diagnosis: Principal: Diastolic Heart Failure Pulmonary Edema Aspiration Pneumonia Alcohol Withdrawal Secondary Alcohol Abuse Continuous COPD Obesity Hypertension Diabetes Mellitus Type II Respiratory Failure COPD Discharge Condition: Good Discharge Instructions: Please conitnue to take all your medications and follow up with your appointments as below. You should weigh yourself everyday and if you notice a weight gain, increased shortness of breath, chest pain, fevers, chills or shortness of breath with walking you should seek speak to your primary care doctor or return to the emergency room. Followup Instructions: Please follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 30384] in [2-4] weeks after discharge from rehab. Please follow up with pulmonary clinic as below: Provider: [Name10 (NameIs) 1571] BREATHING TESTS Phone:[Telephone/Fax (1) 612] Date/Time:[2126-6-20] 12:10 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 612] Date/Time:[2126-6-20] 12:30 Completed by:[2126-5-23] ICD9 Codes: 5070, 496, 5990, 2760, 4280, 3051, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9067 }	Medical Text: Admission Date: [2156-6-21] Discharge Date: [2156-6-26] Date of Birth: [2090-8-20] Sex: M Service: CSU CHIEF COMPLAINT: The patient was admitted for a cardiac catheterization as part of his preoperative workup. HISTORY OF PRESENT ILLNESS: The patient is a 65 year old male who had a cardiac catheterization eight years prior at [Hospital3 2358], which reported three vessel disease. The patient was recommended to have bypass surgery at that time but the patient had a second opinion at the [Hospital1 346] and has since been treated medically. The patient has been doing well since then. The patient swims three times a week and does not have any symptoms. The patient does report that he has developed exertional dyspnea and fatigue with activity like mowing his lawn or after climbing two to three flights of stairs. All these symptoms resolve with rest, and the patient denies having any symptoms at rest and denies any chest discomfort. The patient was scheduled for back surgery at [Hospital6 11896] and a stress echocardiogram was done as part of the workup. He exercised for roughly three minutes and had diffuse ST-T wave abnormalities that were nondiagnostic due to left bundle branch block. The patient's echocardiogram revealed dilated left ventricle with markedly decreased contractility globally, and his ejection fraction was 35 to 40 percent. There was concentric left ventricular hypertrophy and dilated left atrium. There was normal right ventricular size and contractility and mildly dilated aortic root. With exercise, there was no augmentation of contractility, and ejection fraction remained to be 35 to 40 percent. The patient denied claudication, orthopnea, lightheadedness. The patient had a cardiac catheterization which showed the patient had an ejection fraction of 20 to 25 percent without any mitral regurgitation with three vessel disease. PAST MEDICAL HISTORY: Hypertension. Hyperlipidemia. Right ankle/patellar syndrome. Back pain. Right carpal tunnel syndrome. Right C7 radiculopathy. PAST SURGICAL HISTORY: Knee replacement two years ago. Spinal surgery. Hernia repair. Ankle surgery. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Zocor 20 mg p.o. once daily. 2. Cartia 240 mg p.o. once daily. 3. Vioxx 50 mg p.o. once daily. 4. Aspirin 325 mg p.o. once daily. 5. Hydrochlorothiazide 25 mg p.o. once daily. 6. Multivitamin p.o. once daily. SOCIAL HISTORY: The patient is married and retired. The patient denies history of emotional, physical, sexual or threats of abuse in his home environment. FAMILY HISTORY: The patient's father died at age of 49 of a myocardial infarction. The patient's mother has angina in her 70s. PHYSICAL EXAMINATION: On examination, the patient was alert and oriented. The patient's chest was clear to auscultation bilaterally. The patient, however, was regular rate and rhythm. The patient's abdomen was soft, nontender, nondistended. No edema was noted. LABORATORY DATA: Hematocrit was 45.0 percent. Potassium was 4.2. Blood urea nitrogen was 21, creatinine was 1.1. HOSPITAL COURSE: The patient was admitted to the Cardiac Surgery service to undergo cardiac surgery. The patient on hospital day number two underwent a coronary artery bypass graft times four, left internal mammary artery to left anterior descending coronary artery, saphenous vein graft to posterior descending coronary artery, saphenous vein graft to obtuse marginal and saphenous vein graft to ramus intermedius. Please see the dictated operative note for details. Postoperatively, the patient had pain issues associated with the right carpal tunnel and back pain. Otherwise, the patient was doing well. The patient was extubated without any difficulties and was on some Neo-Synephrine in the Intensive Care Unit for a low blood pressure. Otherwise, the patient was stable postoperatively. On postoperative day number one, the patient continues to need some Neo-Synephrine for blood pressure support. Otherwise, he remained afebrile with stable vital signs. The patient's wound looked good and he had stable hematocrit and creatinine was 0.9. The patient was advanced to cardiac diet. On postoperative day number two, the patient stayed in the Intensive Care Unit due to continuing need for Neo-Synephrine. The patient's Neo- Synephrine was continued. The patient remained afebrile with stable vital signs and stable hematocrit and stable creatinine. The patient was continued on p.o. pain medication and was put on cardiac diet and was started on Lasix. The patient was transferred to the floor. On postoperative day number three, the patient remained afebrile with stable vital signs. The patient's heart rate was normal sinus. The patient's wires were removed and the patient's ambulation was increased. The patient's Lasix was stopped and the patient worked with physical therapy. On postoperative day number four, the patient remained afebrile with stable vital signs. The patient had a bout of heart rate up to 90s overnight and the patient's Metoprolol was increased to 25 mg and the patient was discharged home. MEDICATIONS ON DISCHARGE: 1. Colace 100 mg p.o. twice a day. 2. Zantac 150 mg p.o. twice a day. 3. Aspirin 325 mg p.o. once daily. 4. Percocet one to two tablets q4-6hours p.r.n. pain. 5. Plavix 75 mg p.o. once daily for three months. 6. Zocor 10 mg p.o. once daily. 7. Lopressor 25 mg p.o. twice a day. FOLLOW UP: Please follow-up with Dr. [Last Name (STitle) ] in three to four weeks. Please follow-up with Dr. [Last Name (STitle) ] in two to three weeks and please follow-up with Dr. [First Name (STitle) 1557] in two to three weeks. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: The patient was discharged to home with services. DISCHARGE DIAGNOSES: Hypertension. Hyperlipidemia. Right hand carpal tunnel syndrome. Back pain. Right C7 radiculopathy. Status post knee replacement surgery two years ago. Status post spinal surgery. Status post hernia repair. Status post ankle surgery. Status post coronary artery bypass graft times four. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1714], [MD Number(1) 1715] Dictated By:[Doctor Last Name 6052] MEDQUIST36 D: [2156-6-26] 09:32:04 T: [2156-6-26] 10:36:03 Job#: [Job Number 11897] ICD9 Codes: 2724, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9068 }	Medical Text: Admission Date: [2160-8-21] Discharge Date: [2160-9-3] Date of Birth: [2085-10-31] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: Cardiac Catheterization [2160-8-22] Aortic Valve Replacement with 25mm CE pericardial tissue valve and Excision of LA Mass [2160-8-25] History of Present Illness: 74M with DM, HTN, experiencing several months of increasing DOE, sometimes with interscapular pain, presented to OSH with dyspnea [8-20]. He denied CP, orthopnea, or PND. EKG revealed a fib, apparently new, and echo showed basically preserved LVEF but aortic stenosis with valve area 0.6cm2. He was transferred to [Hospital1 18] for further evaluation. Past Medical History: Hypertension, Diabetes Mellitus Social History: Lives with wife. [Name (NI) ] is retired. Quit smoking two years ago but smoked 1 ppd prior to that. Occ/social Etoh. Family History: Noncontributory Physical Exam: T96.7 BP160/90 HR70 RR16 Sat97%RA GEN: caucasian male, sitting up in bed, NAD NECK: Jugular veins 3-4cm above sternal angle, no carotid bruits CHEST: CTA B CV: irregularly irreg, s1, III/VI late peaking systolic m, no s2 ABD: obese, soft, flat, nontender, normoactive bowel sounds EXT: cool, dry, no cyanosis, clubbing, edema. PULSES: 2+ radial, 1+ DP/PT bilaterally Pertinent Results: CXR [9-1]: 1. Worsening left lower lobe consolidation and increasing small left pleural effusion. 2. Improved aeration in the right lower lobe with minimal residual atelectasis and decreased size of small left pleural effusion. Cath [8-22]: 1. Coronary arteries are normal. 2. Severe aortic stenosis. 3. Normal ventricular function. Echo [8-25]: PRE-BYPASS: The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. Overall left ventricular systolic function is low normal (LVEF 50-55%). There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis. Trace aortic regurgitation is seen. There is moderate thickening of the mitral valve chordae. Mild to moderate ([1-28]+) mitral regurgitation is seen. POST CPB: Preserved [Hospital1 ]-ventricular systolic function. On the [Last Name (un) 27185] attempt at separation form CPB a 1.5 cm echo dense mass was seen in the LA in the region of LAA. It was pedunculated and feeely mobile. CPB was reinstituded and a large clot was removed via left atriotomy. 2nd attempt: Preserved biventricular systolic function. LAA was not visualized secondary to surgical exclusiun. A bioprosthesis is seen in the aortic posiiton, well seated and mecahnically stable. Trace AI. CXR [8-27]: Comparison is made with a prior chest radiograph dated [2160-8-25]. The patient is status post median sternotomy. Previously noted endotracheal tube, Swan-Ganz catheter, chest tubes, and mediastinal drainage tubes have been removed. There is right IJ line terminating in upper SVC. There is no definite pneumothorax. Again note is made of cardiomegaly and prominent mediastinal contours. There is bibasilar atelectasis and small effusion, unchanged since prior study. Left upper old rib fracture. [2160-8-22] 05:05AM BLOOD WBC-7.4 RBC-3.71* Hgb-12.9* Hct-35.9* MCV-97 MCH-34.9* MCHC-36.0* RDW-13.0 Plt Ct-124* [2160-8-25] 01:35PM BLOOD WBC-11.2* RBC-3.00* Hgb-10.5* Hct-30.0* MCV-100* MCH-34.9* MCHC-34.9 RDW-12.9 Plt Ct-74* [2160-8-29] 07:20AM BLOOD WBC-9.8 RBC-3.32* Hgb-11.0* Hct-32.1* MCV-97 MCH-33.2* MCHC-34.3 RDW-14.0 Plt Ct-174 [2160-8-22] 05:05AM BLOOD PT-13.0 PTT-150* INR(PT)-1.1 [2160-8-29] 07:20AM BLOOD PT-13.0 PTT-30.2 INR(PT)-1.1 [2160-8-22] 05:05AM BLOOD Glucose-168* UreaN-17 Creat-1.1 Na-137 K-4.1 Cl-100 HCO3-28 AnGap-13 [2160-8-29] 07:20AM BLOOD Glucose-159* UreaN-31* Creat-1.3* Na-136 K-4.7 Cl-102 HCO3-28 AnGap-11 [2160-8-29] 07:20AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.5 [2160-8-22] 10:24PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.010 [2160-8-22] 10:24PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-1 pH-7.0 Leuks-NEG [2160-8-30] 09:33AM BLOOD WBC-10.3 RBC-3.19* Hgb-10.7* Hct-31.5* MCV-99* MCH-33.6* MCHC-34.1 RDW-13.8 Plt Ct-249 [2160-9-1] 08:00AM BLOOD PT-14.9* PTT-55.2* INR(PT)-1.3* [2160-9-1] 08:00AM BLOOD PT-14.9* PTT-55.2* INR(PT)-1.3* [2160-8-30] 09:33AM BLOOD UreaN-28* Creat-1.3* Na-138 [2160-9-3] 07:30AM BLOOD Hct-28.9* [2160-8-30] 09:33AM BLOOD WBC-10.3 RBC-3.19* Hgb-10.7* Hct-31.5* MCV-99* MCH-33.6* MCHC-34.1 RDW-13.8 Plt Ct-249 [2160-9-3] 07:30AM BLOOD PT-22.5* PTT-90.3* INR(PT)-2.2* [2160-9-2] 07:00AM BLOOD PT-18.5* PTT-65.8* INR(PT)-1.7* [2160-9-3] 07:30AM BLOOD Glucose-102 UreaN-14 Creat-1.2 Na-135 K-4.5 Cl-100 HCO3-24 AnGap-16 Brief Hospital Course: Ms. [Known lastname 69468] was transferred from OSH to [Hospital1 18] for presumed valve surgery. She underwent a cardiac cath on [8-22] which revealed severe aortic stenosis and normal coronaries. She then underwent all pre-operative work-up. On [8-25] she was brought to the operating room where she underwent an aortic valve replacement and removal of a mass from left atrium. Please see operative report for surgical details. Following surgery she was transferred to the CSRU for invasive monitoring in stable condition. Later on op day she was weaned from sedation, awoke neurologically intact and extubated. She received blood transfusion on op day and heart rhythm converted into atrial fibrillation. Amiodarone was initiated. Heparin was started on post-op day two and continued until his INR was therapeutic on Coumadin. Also on this day his chest tubes were removed. Beta blockers and diuretics were started and he was gently diuresed towards his pre-op weight. On post-op day three he was transferred to the SDU. He remained stable over the next several days waiting for his INR to increase and become therapeutic. On post-op day seven he was found to have some sternal drainage and antibiotics were initiated. The sternal drainage resolved. His INR was 2.2 and he was ready for discharge on [2160-9-3]. Medications on Admission: lasix 20 daily, diovan 80 daily, HCTZ 25 daily, glyburide 5 daily, metoprolol 25 tid, flonase Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: 400 mg (2 tablets) daily x 1 weeks, then 200 mg (1 tablet) daily, ongoing. Disp:50 Tablet(s) Refills:0 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. Disp:14 Tablet(s) Refills:0 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 1 weeks. Disp:28 Capsule, Sustained Release(s) Refills:0 10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:4 Tablet(s) Refills:0 11. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): 4 mg x 2 days, then check INR [9-5] with results to Dr. [Last Name (STitle) ]. Disp:120 Tablet(s) Refills:0 12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: Gentiva Discharge Diagnosis: Aortic stenosis s/p Aortic Valve Replacement Post-operative Atrial Fibrillation Congestive Heart Failure PMH: Hypertension, Diabetes Mellitus Discharge Condition: good Discharge Instructions: [Month (only) 116] take shower. Wash incision and gently pat dry. Do not take bath. Do not apply lotions, creams, ointments or powders to incision. Do not drive for 1 month. Do not lift greater than 10 pounds for 2 months. Please call office if you develop a fever or drainage from sternal incision. Please call to arrange all follow-up appointments. [Last Name (NamePattern4) 2138]p Instructions: Dr. [Last Name (Prefixes) ] in 4 weeks Dr. [Last Name (STitle) ] (Cardiologist) in [2-29] weeks and for coumadin follow up. Dr. [Last Name (STitle) 69469] (PCP) in [1-28] weeks Completed by:[2160-9-3] ICD9 Codes: 9971, 5180, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9069 }	Medical Text: Unit No: [Numeric Identifier 63292] Admission Date: [2197-11-29] Discharge Date: [2197-12-13] Sex: F Service: VSU CHIEF COMPLAINT: Epigastric pain. HISTORY OF PRESENT ILLNESS: An 82-year-old, with a 2-month history of epigastric pain with a known thoracoabdominal aneurysm of 11-cm status post rupture--she is now without complaints of pain of shortness of breath, who was admitted to the emergency room and then transferred to the vascular service for definitive care. ALLERGIES: No known drug allergies. MEDICATIONS: Include hydrochlorothiazide 12.5 mg once daily, Norvasc once daily, Lopressor, ferrous and Prilosec. ILLNESSES: Include hypertension. PAST SURGICAL HISTORY: Cholecystectomy. PHYSICAL EXAM: VITAL SIGNS: 97.1, 72, 121/78, 18, 99% O2 sat on room air. GENERAL APPEARANCE: This is a [Location 7972] speaking female, oriented x3 in no acute distress. Heart is a regular rate and rhythm. Chest is clear to auscultation bilaterally. Abdomen is soft, nontender with a palpable, pulsatile epigastric mass. Pulse exam shows palpable femorals, popliteals, DPs and PTs 2+ bilaterally. HOSPITAL COURSE: The patient was initially evaluated in the emergency room. She underwent a CT scan which showed a large saccular aneurysm from the aortic root 5-cm through the celiac and renal arteries with a large superceliac thrombus with a contrast extravasation with multiple liver and kidney cysts. The patient's admitting white count was 8.3, hematocrit 32, platelet count 190. Coags were normal. BUN 40, creatinine 1.7, K 4.3. Patient was begun on antihypertensives to maintain her systolic blood pressure at less than 130. After a long discussion with the family, the risks and benefits of undergoing repair, it was the decision of the patient and family to proceed with anticipated necessary surgery. The patient was evaluated by cardiology for perioperative risk assessment. The patient underwent a P-MIBI. The stress portion of the P-MIBI was absent for EKG changes or symptoms. The patient had a moderate reversible defect involving the left circumflex territory. Left ventricular cavity size and function was normal with an ejection fraction of 64%. An echo was obtained which demonstrated that the left atrium was elongated. There was mild symmetric left ventricular hypertrophy with normal cavity and systolic function. The right ventricular chamber size, freewall motion were normal. The aortic root is moderately dilated. The ascending aorta is markedly dilated. The abdominal aorta was markedly dilated. The aortic valves are 3 or mildly thickened, but aortic stenosis is not present. There is no aortic valve stenosis. There is mild to moderate aortic regurgitation of 2+. The left ventricular inflow pattern suggests impaired relaxation. The tricuspids are mildly thickened. There is moderate 2+ TR, and there is mild pulmonary artery systolic hypertension with significant pulmonic regurgitation. The main pulmonary artery is dilated. There is no pericardial effusion. Cardiology felt that the patient's cardiac function would be improved with planned surgery, in addition to blood pressure control, and effective beta blockade, and nitroglycerin afterload to improve coronary perfusion. The patient proceeded on [12-5] and underwent a repair of a thoracoabdominal aortic aneurysm (descending thoracic aorta to renals) with a beveled anastomosis. The patient tolerated the procedure well and was transferred to the PACU in stable condition. Postoperatively, the patient was transferred to the ICU for continued care. Postoperative day 1, there were no acute events. The patient was afebrile. Hematocrit was 31.2, BUN 32, creatinine 1.3. Physical exam was unremarkable. Postoperative day 2, there were no overnight events. The patient was begun on respiratory weaning to extubate. From a cardiac standpoint, she did well, although she had a right bundle branch block change on her EKG on postoperative day 2. Her hematocrit was 27.7. Recommendations were to maintain a hematocrit greater than 30, increase her beta blockade, and repeat an EKG to see if there was resolution of her right bundle branch block. Her cardiac enzymes were unremarkable. Postoperative day 3, the patient was extubated overnight, was satting well on 4 liters nasal prongs at 98%, remained afebrile. Epidural remained in place. Patient's chest tubes remained in place, and Foley remained in place. Chest tubes were discontinued. Beta blockade was increased. Her hydralazine was increased for rate and systolic blood pressure control. She was transfused platelets prior to epidural being discontinued. Her diet was advanced as tolerated, and she was transferred to the VICU for continued monitoring and care. Postoperative day 4, she remained afebrile. White count was 11.6, hematocrit 33.1, BUN 60, creatinine 2.4 down from 2.5, lactate 1.3. Fasting glucoses were 58-127. Exam showed 1+ edema in the lower extremities. The patient was begun on Percocet for analgesic control, incentive spirometry and pulmonary toiletry. She was continued on Lopressor, Norvasc and hydralazine. Aspirin was added to her diet. She continued to be diuresed. She was started on insulin regular sliding scale as needed. She remained in the VICU. Patient's blood pressure improved by postoperative day 4 with a systolic of 125. Her A-line was discontinued. Her electrolytes were repleted. Ambulation was begun. Physical therapy was requested to see the patient and felt that she would be able to be discharged to home when medically stable. Renal function continued to be monitored. The remaining hospital course was unremarkable. The patient was afebrile on postoperative day #5. The patient did have a significant amount of pleural drainage from the chest tube site. Repeat chest x-ray showed significant improvement in her pleural effusion. The chest tube site continued to drain. She was placed on Keflex 250 q. 24 h for a total fo 2 weeks until she is seen in follow-up with Dr. [Last Name (STitle) ]. The patient will be instructed to change her chest dressing as needed to keep the site dry. She will continue on the Keflex until seen in follow-up. At the time of discharge, wounds were clean, dry and intact. Chest site was without erythema. The drainage was serosanguineous. They have been instructed to call his office if she develops fever greater than 101.5, develops shortness of breath, if she develops change in character in her pleural fluid drainage. The patient has also been instructed to continue her antihypertensive medications as prescribed and to follow-up with her primary care physician for continued blood pressure management. DISCHARGE DIAGNOSES: 1. Thoracoabdominal aortic aneurysm--ruptured. 2. Hypertension, uncontrolled. 3. Postoperative pleural effusion, resolving. 4. Blood loss anemia--transfused. 5. Positive P-MIBI for moderate lateral wall reversible defect and an echo ejection fraction of 55%. Patient should follow-up with Dr. [Last Name (STitle) ] in 2 week's time. She should call for an appointment at [Telephone/Fax (1) 2625]. SURGICAL PROCEDURE: Repair of thoracoabdominal aneurysm on [2197-12-5]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(2) 6039] Dictated By:[Last Name (NamePattern1) 2382] MEDQUIST36 D: [2197-12-13] 11:32:36 T: [2197-12-13] 12:21:44 Job#: [Job Number 63293] ICD9 Codes: 5119, 2851, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9070 }	Medical Text: Admission Date: [2199-7-8] Discharge Date: [2199-7-11] Date of Birth: Sex: M Service: HISTORY OF PRESENT ILLNESS: Patient is a 51-year-old gentleman transferred from an outside hospital with subarachnoid hemorrhage by head CT scan, blood in the superior sagittal plane. He describes the onset of the worst headache of his life six days prior to admission. Had difficulty sleeping. Patient describes dry heaves with headache. PAST MEDICAL HISTORY: 1. Hypertension. 2. Noninsulin-dependent diabetes. PAST SURGICAL HISTORY: None. ALLERGIES: No known allergies. MEDICATIONS: 1. Elavil. 2. Inderal. PHYSICAL EXAMINATION: On physical exam, the patient is awake, alert, and oriented times three. Strength is [4-22] in the upper extremities and lower extremities. Reflexes are intact. Cranial nerves II through XII intact. Pupils are equal, round, and reactive to light. CT scan at the outside hospital shows blood in the superior sagittal sinus. CT angiogram showed no evidence of aneurysm. Patient was neurologically stable with a nonfocal exam, admitted to the Intensive Care Unit for close observation. On [2199-7-10], patient underwent arteriogram, which showed no evidence of aneurysm, AVM, or any vascular malformation. Postprocedure, the patient was awake, alert, and oriented times three, moving all extremities with good peripheral pulses and no hematoma in the groin. His vital signs remained stable, and he was discharged on [2198-5-11] with followup with his PCP as needed. [Name6 (MD) 6911] [Last Name (NamePattern4) 6912], MD [MD Number(1) 6913] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2199-7-15] 11:24 T: [2199-7-25] 11:49 JOB#: [Job Number 43765] ICD9 Codes: 431, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9071 }	Medical Text: Admission Date: [2193-3-8] Discharge Date: [2192-3-19] Date of Birth: [2124-5-30] Sex: M Service: NME ADDENDUM The patient complained of a headache and DICTATION ENDED [Name6 (MD) 4667] [Name8 (MD) ], M.D. [MD Number(2) 39921] Dictated By:[Last Name (NamePattern1) 15009] MEDQUIST36 D: [2193-3-19] 09:32:22 T: [2193-3-19] 09:38:45 Job#: [Job Number 50518] ICD9 Codes: 431, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9072 }	Medical Text: Admission Date: [2202-3-3] Discharge Date: [2202-3-13] Date of Birth: [2142-10-12] Sex: F Service: SURGERY Allergies: Keflex / Cephalosporins Attending:[First Name3 (LF) 668] Chief Complaint: Abd pain, nausea/vomiting. Major Surgical or Invasive Procedure: umbilical hernia repair History of Present Illness: 59F w/ h/o HCV cirrhosis c/b GI bleed, s/p tips, now w/ recurrent umbilical hernia. The patient states that she had a previous umbilical herniorrhaphy by Dr. [First Name (STitle) ] in [2199]. She has had no recurrence, and has not noticed any mass until yesterday. Since yesterday AM she has noticed a new palpable mass at her umbilicis. She has had worsening abdominal pain, nausea and vomiting, that she states was feculant. She has not had any fevers or chills. No jaundice. She has not been able to tolerate any POs, and has not noticed worsening distension. Past Medical History: Hepatitis C, dx [2184], genotype 1, multiple attempts at ribavirin/interferon Splenomegaly Varices s/p banding x3 Biliary pancreatitis [2193] -> cholecystectomy Rectal abscess Uveitis Gout Mild pulmonary hypertension Recurrent cellulitis/phlebitis Bilateral DVT - on warfarin outpatient, d/c'ed in hospital LLE MSSA abscess with fasciotomy/debridement, [2194] LLE cellulitis, abscess (pan-sensitive pseudomonas), tx with Zosyn, [1-/2200] Social History: Worked as nurse, then nurse administrator. Close to daughter. Nonsmoker (quit [2193], 7 cigs/d x15y), little EtOH, no IVDU. Family History: Her mother had pancreatic cancer, and her father brain cancer (NOS). There is no history of clots or phlebitis in the family, to her knowledge. Physical Exam: PEX: 97.1 82 95/57 18 100 RA NAD/A&O CTAB RRR Abd Soft, tender around umbilicus. ~3cm mass palpable, reducible in ER, ~2cm hernia defect palpable. Labs: CBC: Pending [Age over 90 ]\|92\|55 ---------<127 4.0\|23\|1.8 ALT ALT 68 AST 56 AP 112 TBIli 0.3 Lipase 979 INR 1.0 PT 10.8 PTT25.6 Pertinent Results: [2202-3-3] 01:45PM BLOOD WBC-9.8 RBC-3.74* Hgb-13.5 Hct-38.8 MCV-104* MCH-36.1* MCHC-34.7 RDW-15.0 Plt Ct-101* [2202-3-12] 04:20AM BLOOD WBC-20.4* RBC-3.49* Hgb-11.8* Hct-35.5* MCV-102* MCH-33.9* MCHC-33.3 RDW-15.7* Plt Ct-103* [2202-3-12] 04:20AM BLOOD PT-25.7* PTT-48.6* INR(PT)-2.5* [2202-3-12] 04:20AM BLOOD Glucose-107* UreaN-40* Creat-1.6* Na-126* K-3.6 Cl-94* HCO3-24 AnGap-12 [2202-3-11] 06:30AM BLOOD ALT-30 AST-52* AlkPhos-40 TotBili-2.4* [2202-3-9] 04:59AM BLOOD Albumin-2.9* Calcium-8.4 Phos-3.2 Mg-2.0 [2202-3-11] 10:04 am BLOOD CULTURE Source: Line-POC. Blood Culture, Routine (Pending): [2202-3-11] 10:05 am URINE Source: Catheter. URINE CULTURE (Pending): [2202-3-11] 2:16 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT [2202-3-12] C. difficile DNA amplification assay (Final [2202-3-12]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). Brief Hospital Course: Ms. [Known lastname 54488] presented to ED on [2202-3-3] with a new palpable mass at her umbilicus which she had noted the day prior. She then began to have worsening abdominal pain and nausea and vomiting. Initially the umbilical hernia was reduced in the ER, however overnight on [2202-3-4] the patient again vomitted. A KUB was obtained which revealed continued signs of obstruction. It was then decided to proceed to the OR for repair of the umbilical hernia. Postoperatively her mental status deteriorated and she was transferred to the ICU for monitoring. She was started on PR lactulose via enema with fentanyl 50 mcg IV x 1, her PO meds were held overnight. On [3-5], she continued to have AMS overnight and was only intermittently following commands, responded to tactile stimulation, and PR lactulose was attempted. She was also started on PO rifaxamin. Hepatology c/s. On [2202-3-6] her mental status improved and by [3-7] she was AAO x 3. Her NGT was discontinued while she was still in the ICU as she had started to pass flatus and her NGT output had decreased. She was transferred to the floor on [2202-3-8] and was advanced to a clear liquid diet which she tolerated without issue. On [2202-3-9] her coumadin was restarted and her flexiseal was discontinued. Diet was slowly advanced. Lactulose was resumed and she was passing stool. WBC count increased to 20 on [3-10]. UA was positive. Urine and blood cultures were sent and were pending at time of discharge. Ciprofloxacin was started for positive UA on [3-11]. Stool for cdiff was negative. Incision was intact with staples without redness or draiange. PT worked with her and recommended PT at home. Coumadin was resumed on [3-9] (h/o DVTs). Given potential for Cipro interaction, Coumadin dose was decreased. Medications on Admission: Ropinirole 0.5', Xifaxan 550'', Allopurinol 150', , Lasix 80qpm 40qam, Calcium daily, KCl 10', Spironolactone 200'', , Synthroid 100', Albumin, Oxycodone prn, Coumadin 3', Gabapentin 200', MgOxide 250'', Metolazone 5'. Discharge Medications: 1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): Titrate to 3 - 4 BMs daily. 2. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. furosemide 20 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). 8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:10 Tablet(s) Refills:0 9. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day. 10. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 6687] VNA Discharge Diagnosis: HCV cirrhosis umbilical hernia h/o DVTs UTI 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 Dr.[Name (NI) 670] office [Telephone/Fax (1) 673] if you have any of the following: temperature of 101 or greater, chills, nausea, vomiting, increased incision/abdominal pain, incision redness/bleeding/drainage, constipation or diarrhea -you may shower with soap and water. do not apply powder or ointment to incision -do not lift anything heavier than 10 pounds. no straining Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 2422] Date/Time:[2202-4-6] 1:00 Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 2424], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2202-4-20] 10:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2202-3-22] 11:00 Completed by:[2202-3-13] ICD9 Codes: 5990, 5715, 4019, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9073 }	Medical Text: Admission Date: [2160-1-8] Discharge Date: [2160-1-24] Date of Birth: [2115-10-23] Sex: M Service: ORTHOPAEDICS Allergies: Codeine / Celebrex / Ibuprofen Attending:[First Name3 (LF) 3645] Chief Complaint: Dysphagia Major Surgical or Invasive Procedure: I&D surgical incision Tracheostomy History of Present Illness: I had the pleasure of seeing Mr. [Known lastname 19205] back in followup today. As you know, he is a pleasant 44-year-old gentleman, who underwent C3 with C4 partial corpectomy with fusion by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1352] on [2159-12-18]. He was admitted to the [Hospital1 771] after a fall resulted in bilateral upper extremity radiculitis, numbness and tingling bilaterally. MRI showed a large central disc herniation at C3-C4 and he did have progressive neurologic symptoms. At that time, he underwent a surgical procedure. He tolerated the procedure well. He is now approximately three weeks postoperative. He comes in today stating that over the last week, he has experienced symptoms of vomiting. In addition, he has had some thick white drainage from his anterior cervical incision. He states that two or three days ago this broke open and a lot of fluid came out. In addition, he feels hotter than normal, though he does not have objective documented fever. Secondary to all of this, he has also had an increase in his dysphagia. He states that he did have some mild dysphagia during his surgical procedure; however, four days afterwards he was doing well and eating all types of food both solid and liquid. Since that time, approximately day eight he has shown intolerance towards soft and solid foods. Overall, he feels that this is worsening. Temperature measured today in clinic was 98.8. We asked that Mr. [Known lastname 19205] go to the emergency department for urgent MRI of his cervical spine. He was admitted from the emergency department Past Medical History: Chronic Pain, HTN Social History: NC Family History: NC Physical Exam: On discharge, Upper extremity strength is [6-11] throughout, he is sensory intact to light touch. Incision appears well healed throughout, sutures were removed. Cervical spine is still tender in and around the incision area. He does show some difficulty swallowing and he coughs numerous times during the exam. Trach is in place, he is able to clear trach without difficulty. No evidence of infection. Pertinent Results: [2160-1-9] 4:25 pm TISSUE CONTENT CERVICAL SPINE. GRAM STAIN (Final [2160-1-9]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [2160-1-17]): REPORTED BY PHONE TO DR.[First Name (STitle) ] ON [2160-1-10] AT 13:45. STAPH AUREUS COAG +. SPARSE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH. SENSITIVITIES REQUESTED BY DR. [First Name (STitle) ] #[Numeric Identifier 95354]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CORYNEBACTERIUM SPECIES (DIPHTHEROIDS) \| \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S 4 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S PENICILLIN G---------- =>0.5 R 1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [2160-1-13]): NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final [2160-1-10]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. FUNGAL CULTURE (Final [2160-1-22]): NO FUNGUS ISOLATED. ACID FAST CULTURE (Preliminary): POTASSIUM HYDROXIDE PREPARATION (Final [2160-1-9]): NO FUNGAL ELEMENTS SEEN. [2160-1-9] 4:18 pm SWAB RETROPHANGNX. GRAM STAIN (Final [2160-1-9]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2160-1-13]): 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. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S PENICILLIN G---------- =>0.5 R TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Final [2160-1-13]): NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final [2160-1-10]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. POTASSIUM HYDROXIDE PREPARATION (Final [2160-1-10]): TEST CANCELLED, PATIENT CREDITED. Inappropriate specimen collection (swab) for Fungal Smear (KOH). [2160-1-16] 1:35 am SPUTUM Site: ENDOTRACHEAL FINAL REPORT [2160-1-18] GRAM STAIN (Final [2160-1-16]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2160-1-18]): SPARSE GROWTH OROPHARYNGEAL FLORA. CITROBACTER KOSERI. MODERATE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. GRAM NEGATIVE ROD #2. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER KOSERI \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- 8 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S MRI C-Spine [2160-1-9] FINDINGS: Since the prior study, a metallic anterior cervical fusion complex, consisting of two pairs of pedicle screws and an anterior connecting plate span the C3-4 interspace. There is substantial prevertebral soft tissue swelling at this level, encroaching upon the oropharynx and proximal hypopharynx. This area has slightly elevated T2 signal, best shown on the STIR images, as well as a diffuse enhancement pattern, moderate in extent. Within the posterior half of the C3-4 interspace is a rectangular-shaped area of enhancement, which causes mild impression upon the ventral cord margin, which is at the level of the stated cord edema. This region could represent granulation tissue, but it is impossible to determine on the basis of the imaging study whether this or the prevertebral soft tissue swelling is either sterile or infected. The spinal cord compression noted preoperatively appears to be unaltered. More over, as was discussed with Dr. [Last Name (STitle) 1352] today, there is diffuse spinal stenosis, congenital in origin involving the C3-4 through C6-7 levels, aggravated by small posterior disc protrusions at the C5-6 and C6-7 levels, and to a minimal degree at C4-5. There is no malalignment of the component vertebrae. There is a somewhat heterogeneous signal pattern within slightly prominent posterior-superior nasopharyngeal soft tissues. This finding could represent a complex Tornwaldt cyst, which could be further evaluated by transaxial MR imaging of this region. Finally, it is to be noted that the present axial gradient-echo scans are grossly compromised by patient motion, precluding precise analysis on the basis of these images. CONCLUSION: Interval development of extensive prevertebral soft tissue swelling as well as some impingement upon the spinal cord by enhancing soft tissue posterior to the C3-4 bone cage. On the basis of imaging, it is not possible to determine whether these findings are sterile or infected (phlegmon). CT Scan C-Spine [2160-1-9] IMPRESSION: 1. Extensive increased attenuation in the prevertebral and retropharyngeal soft tissues, with possible fluid, with thin linear enhancement anteriorly which can represent inflammation/infection/ phlegmon/ evolving abscess. This is seen extending from above the level of the dens to the upper thoracic region. The fat plane is not clearly visualized in prevertebral soft tissues. No definite focal well- formed thick-walled abscess. However, close followup is necessary. Pl.s ee above details. Multilevel mild degenerative changes in the C-spine are not adequately assessed on the present study. Pl. see the report on MR C spine performed earlier for additional details. Brief Hospital Course: Mr. [Known lastname 19205] was directly admitted from the emergency department here at [Hospital1 18] after follow up visit in clinic on [2160-1-8]. He was approximatly 3 weeks from his anterior cervical decompression and fusion when he noted significant increase in dysphagia. He had no dysphagia after his discarge from his surgical procedure on [2159-12-18]. On his MRI from the ED he was noted to have significant interval retropharangeal soft tissue swelling. Mr. [Known lastname 19205] was brought to the OR for I&D of his anterior cervical spine. He tolerated the procedure well, but was left intubated and transfered to the SICU to allow for decrease in tissue swelling from his I&D. Once Mr. [Known lastname 19205] was taken off sedation, he recieved a tracheostomy and the intubation tube was removed. Cultures were sent. Tissue and swab cultures grew out MSSA and Corynebacterium. Infectious disease was consulted and he was placed on Nafcillin till [2160-1-23]. He was also started on TPN for his nutrition requirements. Mr. [Known lastname 19205] has tolerated the tracheostomy well. He was brought to the general floor and was re-evaluated by speech and swallow. He was advanced to nectar soft liquids and soft solids. Nutrition was reconsulted for removal of TPN. Medications on Admission: [Known lastname 101433] [Known lastname ] nexium lipitor singulair advair oxycontin lisinopril Discharge Medications: 1. Gabapentin 250 mg/5 mL Solution Sig: [2-7] PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): contiune untill pt is abulatory. 8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheeze. 9. Docusate Sodium 50 mg/5 mL Liquid Sig: [2-7] PO BID (2 times a day). 10. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for prn constipation. 11. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Diphenhydramine HCl 25 mg Capsule Sig: [2-7] Capsules PO TID PRN (). 14. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 17. Diazepam 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 19. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed: please crush and serve with applesauce. 20. Oxycodone 20 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day): please crush and serve with applesauce. 21. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital1 ] Sattelite Discharge Diagnosis: Wound Infection Discharge Condition: Stable to rehab Discharge Instructions: Please keep incision clean and dry. You may shower in 48 hours, but please do not soak the incision. Change the dressing daily with clean dry gauze. If you notice drainage or redness around the incision, or if you have a fever greater than 100.5, please call the office at [Telephone/Fax (1) ]. Please resume all home mediciation as prescribed by your primary care physician. [Name10 (NameIs) ] have been given additional medication to control pain. Please allow 72 hours for refills of this medication. Please plan accordingly. You can either have this prescription mailed to your home or you may pick this up at the clinic located on [Hospital Ward Name 23] 2. We are not allowed to call in prescriptions for narcotics to the pharmacy. If you have questions concerning activity, please refer to the activity sheet. Physical Therapy: Activity as tolerated Treatments Frequency: No staples or sutures to remove. Please monitor for signs of infection. Followup Instructions: Please follow up with [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3648] PA-C at two weeks from the date of discharge. You will need to call [Telephone/Fax (1) ] for this appointment. Please follow up with Dr. [Last Name (STitle) ] for your tracheostomy in [2-7] weeks. Please call [Telephone/Fax (1) ] to make this appointment. Completed by:[2160-1-24] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9074 }	Medical Text: Admission Date: [2103-10-6] Discharge Date: [2103-10-8] Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 695] Chief Complaint: Bile duct injury. Major Surgical or Invasive Procedure: [2103-10-7]: Exploratory laparotomy. History of Present Illness: 86-y.o. male underwent laparoscopic cholecystectomy for acute cholecystitis at [Hospital6 204] on [2103-10-1]. Post-operatively, he had an increase in WBC (peak 18.5 on [2103-10-6] at 06:00) and t-bili (max 2.4 on [2103-10-6] at 06:00) and developed ileus. CT abd/pelvis was performed on [2103-10-5], which demonstrated "ascites." HIDA scan on [2103-10-6] demonstrated a bile leak. Pt was transferred to [Hospital1 18] for ERCP. Past Medical History: COPD, DMII, GERD, hyperlipidemia, h/o Meniere's disease. Past Surgical History: Laparoscopic cholecystectomy [2103-10-1]. Social History: Has been married 65 years. Lives with wife. Completely independent ADLs. Smokes 1 pack/day. No EtOH. WWII veteran. Family History: Father died of tooth infection at age 42. Mother died of unknown causes at age 68. Sister, age [Age over 90 ], alive and well. Physical Exam: On [2103-10-6] at time of surgical consult: PE: (on fentanyl gtt at 50, midazolam gtt [Company 91426] 98.2 P 103 BP 83/40 RR 17 O2sat 93% CMV 0.7/450x24/12 bladder pressure 27 Gen: intubated, sedated, jaundiced CVS: slightly tachy, reg rhythm Pulm: CTA b/l, intubated Abd: very distended, tympanitic, diffusely tender, no BS; OGT in place - ~150cc feculent fluid in canister, suction not functioning Ext: no c/c/e Pertinent Results: [2103-10-6] 07:24PM WBC-2.3* RBC-4.44* HGB-14.1 HCT-41.7 MCV-94 MCH-31.7 MCHC-33.7 RDW-13.5 [2103-10-6] 07:24PM PLT COUNT-438 [2103-10-6] 07:24PM GLUCOSE-162* UREA N-61* CREAT-1.1 SODIUM-133 POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-20* ANION GAP-18 [2103-10-6] 07:24PM CALCIUM-8.0* PHOSPHATE-3.5 MAGNESIUM-2.9* [2103-10-6] 07:24PM ALT(SGPT)-39 AST(SGOT)-44* LD(LDH)-297* CK(CPK)-97 ALK PHOS-148* TOT BILI-2.8* CT abd/pelvis ([10-5], reviewed with radiology resident): [2-22] intraparenchymal R hepatic abscesses (not noted on OSH read), non-organized fluid collections in LUQ, R abd, pelvis. ERCP ([10-6]): extravasation at cystic duct c/w large bile leak; filling defect in bile duct c/w sludge; sphincterotomy, sludge extraction, and biliary stenting performed. Reviewed cholangiogram images with Dr. [First Name (STitle) ]: given location of clips (and abscesses), R hepatic artery was likely taken in lap chole instead of cystic artery. Brief Hospital Course: On [2103-10-6], the patient was transferred to [Hospital1 18] for ERCP. Extravasation at cystic duct was noted. Sphincterotomy, sludge extraction, and biliary stenting were performed. [Name (NI) 1917], pt was unable to be extubated and was transferred to the [Hospital Unit Name 153]. He became hypotensive and is currently being resuscitated with NS (also hyponatremic). OGT was placed, 150cc feculent material drained. After surgical consultation, the patient was transferred to the TISCU on the hepatobiliary surgery service. He rapidly deteriorated - despite 4-5L IVF in and 4 pressors at max dose, SBP in mid-80s. Increasing vent requirements. Bladder pressure 14 on arrival, increased to 21. Increasing lactate (~5), acidosis (pH<7.2, bicarb 15), Cr (1.5). Duplex US of liver failed to demonstrate R hepatic arterial flow. TEE performed by TSICU team demonstrated minimal cardiac function, EF~20%. Case discussed with Dr. [Last Name (STitle) ] and IR. Pt was too unstable for operative intervention. IR did not believe his liver lesions are organized enough to drain at this time. Supportive management w/ bicarb gtt (BP is responsive to this - SBP 90s-115), pressors, antibiotics (vancomycin, zosyn, meropenem). Both TSICU and Hepatobiliary Surgery teams have discussed critical nature of situation with family. On [2103-10-7], family consented to bedside exploratory laparotomy, where 3 liters of bilious fluid wer drained from the peritoneal space. The attempt at abdominal decompression did not significantly improve ventilation or cardiovascular function. By [2103-10-8], the patient remained in critical condition with no interval improvement. After discussion with the family, the patient was rendered CMO and he expired. Medications on Admission: Reglan 10', NPH 4U qAM/12U qhs, simvastatin 80', Combivent 2puffs prn, Prilosec 20' Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Bile peritonitis Cholangitis Sepsis Multi-organ system failure Discharge Condition: Expired. Discharge Instructions: He who has gone, so we but cherish his memory. Followup Instructions: None. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2103-10-8] ICD9 Codes: 0389, 5845, 2761, 2762, 496, 2724, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9075 }	Medical Text: Admission Date: [2180-9-24] Discharge Date: [2180-9-28] Service: UROLOGY Allergies: Penicillins Attending:[First Name3 (LF) 5724] Chief Complaint: Hematuria Major Surgical or Invasive Procedure: Cystoscopy, clot evacuation, prostatic urethra fulguration, Dr. [Last Name (STitle) 986], [2180-9-26]. History of Present Illness: 86 y/o male with hx of BPH and indwelling foley catheter presenting to the ED with 3 days of hematuria. He came to the ED on [9-23] with hematuria and was discharged to his nursing home with instructions to irrigate the catheter as needed and follow up with Dr. [Last Name (STitle) 986] as an outpatient. Last night, the nursing home was unable to irrigate his catheter. They removed his catheter and were unable to replace the catheter. He failed to void and had suprapubic discomfort. He was taken to the ED and an 18F 3 way foley was placed with gross hematuria drainage. CBI was started but the catheter stopped draining. He finished 5 doses of levaquin on [2180-9-23]. He was recently admitted to [Hospital1 2025] s/p fall/failure to thrive. Of note, he had a voiding trial on [2180-9-12], which he failed. History is obtained from the patient's wife and through [Name (NI) ] translator/ ED resident. Past Medical History: PMH: BPH Indwelling foley catheter HTN CAD s/p MI [2170] Hx orthostatic hypotension Hx of falls Vit D deficiency PSH: None Social History: Normally lives with his wife at home. Admitted to [Hospital3 ] on [2180-9-6] after discharge from [Hospital1 2025]. No tobacco/EtOH. Physical Exam: VS: Afebrile HR 83 BP 146/81 RR 20 97%RA NAD, A&Ox3 No respiratory distress Abd: Soft, nondistended, nontender GU: 18F 3 way foley in place (placed by ED), no CBI running with dark red drainage in bag, +clots. Ext: No cyanosis/clubbing/edema. Pertinent Results: [2180-9-24] 12:40PM WBC-7.2 RBC-3.61* HGB-11.5* HCT-34.3* MCV-95 MCH-31.8 MCHC-33.5 RDW-14.6 [2180-9-28] 07:45AM BLOOD WBC-5.5 RBC-3.26* Hgb-10.3* Hct-28.8* MCV-88 MCH-31.4 MCHC-35.6* RDW-15.9* Plt Ct-137* [2180-9-28] 07:45AM BLOOD PT-14.4* PTT-31.2 INR(PT)-1.2* [2180-9-28] 07:45AM BLOOD Glucose-99 UreaN-21* Creat-0.7 Na-141 K-3.5 Cl-109* HCO3-25 AnGap-11 Brief Hospital Course: The patient was admitted to Dr.[Name (NI) 5725] Urology service on [2180-9-24] from the ED with hematuria. He was transferred to the floor in stable condition. He received 1 unit pRBC's and vitamin K on HD 2, and his urine cleared with CBI on HD 2. On HD 3, the patient's hematuria returned, and he received 2 units of pRBC's and vitamin K for Hct of 23.3/INR 1.3. On the evening of HD 3, the patient was taken to the OR for cystoscopy, clot evacuation, prostatic urethra fulguration. The patient received 1 unit FFP and 2 units pRBC during the procedue. Please see dictated operative note for details. He patient received peri-operative antibiotic prophylaxis with IV ciprofloxacin. The patient was taken to the ICU intubated from the OR in stable condition. He was given 1 more unit of FFP and The patient remained intubated overnight, and was extubated the morning on POD 1 without difficulty. On POD 1, the patient was transferred from the ICU to the floor in stable condition. His urine was clear yellow without clots. He remained afebrile throughout his hospital stay. Patient's postoperative course was uncomplicated. At discharge, patient's pain well controlled without pain medications, tolerating regular diet. He is given oral pain medications on discharge, without antibiotics. He is given explicit instructions to call Dr. [Last Name (STitle) 986] for follow-up/ to change foley catheter to a smaller catheter in 2 weeks. Medications on Admission: Finasteride 5mg Flomax 0.4mg qhs Remeron 15mg qhs Colace Senna Tylenol Vit D weekly MVI Lactulose Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain/Fever. 2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Bacitracin 500 unit/g Ointment Sig: One (1) 500unit/gm Topical three times a day: apply to tip of penis 3 x daily . Disp:1 500unit/gm Refills:2 8. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for constipation. 10. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Hematuria status post cystoscopy, clot evacuation, prostatic urethra fulguration Discharge Condition: Stable Discharge Instructions: - You have been discharged with a foley in place, apply bacitracin to tip of penis 3x daily to prevent foley irritation. The nursing facility with assist you with care of the foley and leg bag. -If you note increased blood in your urine or the urine flow into the bag decreases or stops please return to the Emergency Department (ED). -If you develop fevers >101.7, abdominal pain, nausea or vomiting, return to the ED -Please contact Dr.[Name (NI) 5725] office upon discharge to arrange a follow up appointment - [Telephone/Fax (1) 5726] Followup Instructions: Please contact Dr.[Name (NI) 5725] office upon discharge to arrange a follow up appointment for foley catheter change to a smaller sized catheter in 2 weeks. [Telephone/Fax (1) 5726] Please contact Dr.[Name2 (NI) 825] office to discuss future operative planning. [Telephone/Fax (1) 5727]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 5728] Completed by:[2180-9-28] ICD9 Codes: 4019, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9076 }	Medical Text: Admission Date: [2157-1-21] Discharge Date: [2157-1-24] Date of Birth: [2094-1-13] Sex: M Service: CARDIOTHORACIC Allergies: Ace Inhibitors / Lisinopril / Adhesive Tape Attending:[First Name3 (LF) 922] Chief Complaint: Worsening fatigue. Major Surgical or Invasive Procedure: Left mini thoracotomy, placement of 2 epicardial LV leads and repositioning of biventricular pacer/defibrillator. History of Present Illness: This is a 62yo male with ischemic cardiomyopathy who is followed closely at the heart failure clinic @ [Hospital1 18]. Over the last year, patient has noticed progressive fatigue and lack of energy, which is beginning to interfere with his day-to-day activities. He has no shortness of breath or problems with peripheral edema, orthopnea, or PND. His weights are pretty stable at 202 pounds. His appetite is good and he remains completely independent with his routine ADL's. He has no stamina and feels that this has definitely gotten worse. In [2156-12-4], he underwent failed attempt for biventricular lead placement due to anatomy. He is now referred for surgical placment of epicardial LV lead. Past Medical History: Coronary Artery Disease, prior MI, Ischemic cardiomyopathy, Moderate mitral and tricuspid regurgitation, Hypertension, Dyslipidemia, Sleep apnea on CPAP, Tracheobronchomalacia, GERD, Stable lung nodule, hx of pleural effusions s/p R thoracentesis x 4 in the past, and hx of Acute renal failure in [2152]. Social History: Lives with: Wife Occupation: Engineer Tobacco: Quit in [2139] ETOH: Rare Family History: non-contributory Physical Exam: Pulse: 68 Resp: 18 O2 sat: 99% B/P Right: 124/71 Left: 123/65 Height: 5'8" Weight: 204 lbs General: No acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear with bilateral wheezes, Well-healed MSI, right thoracotomy and PPM/AICD incision sites on left upper chest. Heart: RRR [X] Irregular [] Murmur-soft systolic Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Ventral hernia at lower sternal incision Extremities: Warm [X], well-perfused [X] Edema/Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: - Left: - Pertinent Results: [2157-1-23] 07:25PM BLOOD WBC-10.1 RBC-4.00* Hgb-12.6* Hct-36.1* MCV-90 MCH-31.5 MCHC-34.9 RDW-12.8 Plt Ct-251 [2157-1-23] 07:25PM BLOOD Glucose-111* UreaN-18 Creat-1.0 Na-137 K-4.2 Cl-99 HCO3-28 AnGap-14 [2157-1-23] 07:25PM BLOOD Mg-2.3 UricAcd-8.0* [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 58051] (Complete) Done [2157-1-21] at 2:16:43 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) 177] C. [Hospital Unit Name 927] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2094-1-13] Age (years): 63 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Thoracotomy for ventricular lead placement. ICD-9 Codes: 786.05, 424.0 Test Information Date/Time: [2157-1-21] at 14:16 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3318], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 3318], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2011AW1-: Machine: us2 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 7.0 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 10% to 15% >= 55% TR Gradient (+ RA = PASP): >= 23 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Severely depressed LVEF. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Normal ascending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate (2+) MR. TRICUSPID VALVE: Moderate [2+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions The patient is having a limited left thoracotomy to place a venticulary pacing lead s/p CABG. No spontaneous echo contrast is seen in the left atrial appendage. There is a dilated cardiomyopathy. Overall left ventricular systolic function is severely depressed (LVEF= 10 - 15 %). with mild global free wall hypokinesis. There are complex (>4mm) atheroma in the descending thoracic aorta. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. Brief Hospital Course: The patient was brought to the operating room on [2157-1-21] where the patient underwent a left mini thoracotomy, placement of 2 epicardial LV leads and repositioning of biventricular pacer/defibrillator. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. On POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery on POD 2. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. He was started on colchicine and given a cane for a complaint of left knee pain and a uric acid level of 8. His pain improved with this regimen. By the time of discharge on POD three the patient was ambulating with cane assistance, the wound was healing and pain was controlled with oral analgesics and colchicine. The patient was discharged to home with VNA services in good condition with appropriate follow up instructions. Medications on Admission: Candesartan 16 mg daily Carvedilol 25 mg twice a day Vytorin 10-40 mg daily,Digoxin 125mg daily Furosemide 40 mg twice a day Imdur 30 mg daily Lorazepam as needed at bedtime Pantoprazole 40 mg twice a day Aspirin 81 mg daily Discharge Medications: 1. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s)* Refills:2 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 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 5. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 8. isosorbide mononitrate 30 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 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 10. candesartan 16 mg Tablet Sig: One (1) Tablet PO daily (). Disp:30 Tablet(s) Refills:2 11. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a day. 12. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:10 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 ] VNA Discharge Diagnosis: Coronary Artery Disease, prior MI,Ischemic cardiomyopathy, Moderate mitral and tricuspid regurgitation,HTN, Dyslipidemia, Sleep apnea on CPAP,Tracheobronchomalacia,GERD,stable lung nodule,Hx of pleural effusions s/p right thoracentesis x 4 in the past,History of Acute renal failure in [2152]. Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: Please call to schedule the following: Surgeon Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 914] [Telephone/Fax (1) 170] in 1-2weeks Cardiologist Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 437] [Telephone/Fax (1) 62] in [12-5] weeks Primary Care Dr. [Last Name (STitle) 58052],[First Name3 (LF) ] [Telephone/Fax (1) 28724] in [3-8] 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:[2157-1-24] ICD9 Codes: 4280, 4240, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9077 }	Medical Text: Admission Date: [2186-1-7] Discharge Date: [2186-1-9] Date of Birth: [2110-12-6] Sex: F Service: MEDICINE Allergies: Penicillins / Enalapril / Ace Inhibitors / Iodine / Codeine / Advair HFA / Combivent / Losartan / Levofloxacin Attending:[First Name3 (LF) 3565] Chief Complaint: Face Swelling Major Surgical or Invasive Procedure: None History of Present Illness: 75 yo F h/o COPD on 3 liters, chronic dCHF, dementia, HTN on [First Name8 (NamePattern2) ] [Last Name (un) ], recently admitted [Date range (1) 97410] for COPD exacerbation treated with high dose levofloxacin and prednisone who was discharged home without incident who is admitted due to uvula swelling. This morning her granddaughter noticed facial swelling and called EMS. She states she noticed increased lip redness Friday evening, but no swelling. No new foods changes or insect bites. Other than levofloxacin and 40 mg prednisone, no other new medications. Notably, did not get her presciptions filled yesterday and has not taken levofloxacin or prednisone Friday or Saturday. Notably has had levofloxacin in [2177] and no obvious reaction per her daughter and records. . In the ED, initial VS were: 80 140/88 24 92% 3L Nasal Cannula. She was noted to have hives and a large uvula, no angioedema, no stridor or changes in voice. She was given an epi pen, diphenhydrAMINE 25mg x 2, Famotidine 20mg IV, MethylPREDNISolone Succ 125mg x 1, Albuterol and Ipratropium nebulizers. She was also given 200 cc of NS. Last vitals: 80 140/68 23 100% on 3 liters, . On arrival to the MICU, she states she is breathing well, however is using accessory muscles to breath. She has no complaints at present. She states she is in the hospital because she broker her arm. Notably admitted for a mechanical fall [0-0-]/12 and developed a non-displaced ulnar styloid fracture and was splinted by orthopedics. . Review of systems: Patient denies any symptoms, but unable to obtain accurate history due to dementia Past Medical History: - Oxygen-dependent COPD (3LPM), status post respiratory arrest in [2184-7-11] for which she was intubated, had a prolonged hospital and rehab stay, and was also treated for pneumonia - Hypertension - Diabetes - Hyperlipidemia - osteoporosis with compression fractures - Dementia - Chronic MGUS - Tobacco abuse - Schizoaffective disorder - Tardive dyskinesia - Chronic uritcaria - Depression - Colonic adenoma - s/p tonsillectomy - s/p prophylactic appendectomy at time of hysterectomy - s/p total abdominal hysterectomy (pt has ovaries) - mechanical fall resulting in fractured left wrist and discharged on [2185-12-11] . Social History: She lives at her daughter [Name (NI) 97409] house. Both [Doctor First Name 4944] and Divine are sharing time serving as her caregiver. One of them is with her all the time. ALCOHOL: none in > 2 yrs, + alcohol abuse for >40 yrs CIGARETTES/DAY: smokes 1.5 ppd, for >50 yrs. DRUGS: none Family History: Family History:Mother: Stroke, heart disease, hypertension, diabetes, anemia Sister: Uterine cancer Father: [Name (NI) ], TB, passed away in 90s Daughter: Hypertension Physical Exam: ADMISSION PE: Vitals: T: 97.1 BP: 162/71 P: 76 R: 23 O2: 100% on 3 L General: Alert, oriented to person, place, time, but not situation, no acute distress HEENT: Sclera anicteric, MMM, uvula enlarged, however not compromising airway, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: rhonchi bilatearlly, no wheezes, rales, Abdomen: soft, non-tender, non-distended, bowel sounds present, however diminisehd, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred, no focal deficits DISCHARGE PE: General: Alert, oriented to person, place, time, no acute distress HEENT: Sclera anicteric, MMM, uvula improved, no throat swelling, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: rhonchi bilatearlly- clearing with cough, no wheezes, rales, Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: Foley d/ced, pt voiding without difficulty Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: 5/5 strength upper/lower extremities, grossly normal sensation, pt with Tardive dyskinesia (central unintentional movements which family states to be her baseline) Pertinent Results: ADMISSION LAB: [2186-1-7] 12:15PM BLOOD WBC-8.3# RBC-4.62 Hgb-12.2 Hct-37.7 MCV-82 MCH-26.4* MCHC-32.3 RDW-15.2 Plt Ct-252 [2186-1-7] 12:15PM BLOOD Neuts-80.7* Lymphs-16.1* Monos-1.4* Eos-1.6 Baso-0.3 [2186-1-7] 12:15PM BLOOD PT-11.1 PTT-24.1* INR(PT)-1.0 [2186-1-7] 12:15PM BLOOD Glucose-291* UreaN-12 Creat-0.7 Na-135 K-4.9 Cl-99 HCO3-28 AnGap-13 DISCHARGE LABS: [2186-1-8] 04:28AM BLOOD WBC-7.8 RBC-4.54 Hgb-12.1 Hct-37.1 MCV-82 MCH-26.6* MCHC-32.6 RDW-15.1 Plt Ct-261 [2186-1-9] 11:11AM BLOOD WBC-15.5# RBC-4.43 Hgb-11.8 Hct-36.4 MCV-82 MCH-26.5* MCHC-32.3 RDW-14.8 Plt Ct-250 [2186-1-9] 11:11AM BLOOD Neuts-91.0* Lymphs-6.5* Monos-2.1 Eos-0.3 Baso-0.1 [2186-1-9] 11:11AM BLOOD Plt Ct-250 [2186-1-9] 11:11AM BLOOD Glucose-310* UreaN-22* Creat-0.8 Na-135 K-4.1 Cl-96 HCO3-27 AnGap-16 [2186-1-8] 04:28AM BLOOD Calcium-9.6 Phos-3.6 Mg-2.0 CXR: COMPARISON: Comparison is made to chest x-ray performed [2186-1-3]. There is stable flattening of the bilateral hemidiaphragms with a relative paucity of vasculature in the left upper lung, consistent with reported history of COPD. Stable mild bilateral blunting of the costophrenic angles may represent a small pleural effusion. No focal opacification concerning for pneumonia identified. Mediastinal, hilar, and cardiac contours are unremarkable. IMPRESSION: Overall unchanged exam. Stable minimal blunting of bilateral costophrenic angles may represent small effusions versus scarring. . EKG: [1-4]: Sinus rhythm. Consider left atrial abnormality. Somewhat late R wave progression. ST-T wave abnormalities. Since the previous tracing the rate is slower. QRS voltage is less prominent in the precordial leads. . Brief Hospital Course: Assessment and Plan: 75 yo F h/o COPD on 3L with recent COPD exacerbation, HTN on [Last Name (un) ] presenting with uvula swelling and urticaria which was concerning for allergic reaction to levofloxacin or Losartan. . # Uvula Swelling: Only new exposures include levofloxacin and prednisone. Levofloxacin renally cleared and patient does have mildly decreased GFR, so the timing of this new medication may coincide with her reaction. Another possibility includes the [Initials (NamePattern4) 228] [Last Name (NamePattern4) ]. Both medications can cause an allergic reaction in less than 1 % of all noted reactions. Airway did not appear compromised. Patient had no dysphagia, odynophagia, dyspnea, stridor and is managing secretions without difficulty. On home O2. Was initially using accessory muscles, however improved after nebulizers. We emailed Dr. [First Name (STitle) ], allergist and the recommendation was to continue to hold levofloxacin and losartan, while was okay to start on HCTZ. ENT was also consulted and recommended tx with steroids. She was given an dose of epinephrine in the ED and then started on methaPred than transitioned to prednisone 40mg with recs to take it for 5 days. Her uvula slight less swollen at time of discharge. As noted above, it was only mildly swollen by the time she arrived to the MICU. she was instructed to stop taking levofloxacin and possible losartan. I gave granddaughter verbal instructions over the phone since they could not come to pick up the patients. - Prednisone 40mg for 5 days - Famotidine and hydroxy as needed for symptomatic relief - Hold levofloxacin and losartan - [Month (only) 116] consider allergist referral . # COPD: On 3 liters at baseline, however did appear in mild to moderate distress on presentation which improved with neb treatments. She appears to have increase WOB due to her movement disorder and as per the family she was on her baseline. She denies having any SOB prior to her discharge. We also sent Dr. [Last Name (STitle) ] an email to discuss possible starting on Azithromycin ppx for her recurrent COPD flares, although her resp appears to be at baseline. He will discuss this with patient during her upcoming visit. - Continue steroids as above - Continue dulera, albuterol and ipratropium - Continue 3 liters NC - F/u with Dr. [Last Name (STitle) ] . # small Pleural Effusion: Pt appears to have a small pleural effusion on Cxray. Her LVEF on [5-22] showed normal EF and normal E/E', so does not appear to have diastolic dysfunction. Given mild respiratory distress on presentation and pleural effusion, she was given only one dose of lasix 10mg IV with good response. She was breathing comfortable during the rest of her stay, so further doses of lasix were given. . # Chronic Urticaria: Has been a problem for several years per daughter. Is seen by allergy (Dr. [Last Name (STitle) 2603] and feels possibly related to chronic MGUS. Managed with ranitidine and Aveeno - Treat as above plus Sarna prn . # Diabetes: Her glucose was elevated since she was placed on steroids and her insulin sliding scale was increased while on steroids. She was continued on her home dose of lantus. I reviewed this information with her granddaughter and asked that her [Name (NI) 31567] be checked at home 4 times per day (before meals and at bed time). I also recommended that she continues with her sliding scale and call her PCP if her glucose remains elevated >300. Metformin was held while she was inpatient and restarted once she was d/ced. -Continue home lantus and HISS . # Hypertension: Mildly hypertensive on presentation. We continued her diltiazem, and given concern for possible allergic reaction to the losartan we then started on HCTZ. Her SBP was in the 140s-150s at time of discharge with the plans for her to follow-up with her PCP [Last Name (NamePattern4) ] 1 week. - Hold losartan as above - Started on HCTZ 25mg daily - Asked VNA to check daily BPS - F/u with her PCP office in 1 week . # Hyperlipidemia: Continue pravastatin . # Tardive dyskinesia: She was off her medication while inpatient since the pharmacy does not carry it and her own pharmacy was out of stock. She has increase unintentional truncal movements consistent with her hx of tardive dyskinesia. - Continue tetrabenazine 25 mg q.h.s . # Mild to moderate dementia: Noted on NeuroPsych testing in the past - Continue olanzapine and perphenazine . # FEN: No IVF, replete electrolytes, eating a regular- soft diet with no difficulty # Prophylaxis: Subcutaneous heparin, pneumoboots # Access: peripherals # Communication: Patient and daughter, [Name (NI) 4944]: H: [Telephone/Fax (1) 97411], C: [Telephone/Fax (1) 97412] # Code: Full (confirmed) # Disposition: home to daughter and granddaughter. She was taken by ambulance. Medications on Admission: diltiazem HCl 180 mg ER DAILY (Daily). clonazepam 1 mg PO QHS as needed for insomnia. fexofenadine 60 mg PO BID omeprazole 20 mg PO DAILY losartan 50 mg Tablet PO DAILY pravastatin 20 mg daily Insulin glargine 20 units QHS metformin 1,000 mg Tablet Extended Rel 24 hr daily. olanzapine 5 mg PO HS ranitidine HCl 300 mg PO HS Lispro sliding scale TID perphenazine 8 mg Tablet PO HS prednisone 40 mg Tablet DAILY for 3 days. (last dose 1/26) levofloxacin 750 mg Tablet PO DAILY 3 days. (last dose 1/26) Dulera 100-5 mcg/Actuation HFA Aerosol Inhaler Two puffs twice a day. ipratropium-albuterol 18-103 mcg/Actuation 1-2 puffs every six hours as needed for shortness of breath or wheezing. fluticasone 50 mcg/Actuation Spray, One (1) spray Nasal once a day. albuterol sulfate Nebulization every six (6) hours as needed for shortness of breath or wheezing. tetrabenazine 25 mg PO hs camphor-menthol 0.5-0.5 % Lotion One (1) application Topical three times a day as needed for itching. ipratropium bromide 0.02 % Solution every six hours as needed for shortness of breath or wheezing. Discharge Medications: 1. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 2. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 3. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [12-12] Inhalation every six (6) hours as needed for shortness of breath or wheezing. 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every 4-6 hours as needed for sob/wheeze. 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 6. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Dulera 100-5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every twelve (12) hours. 10. tetrabenazine 25 mg Tablet Sig: One (1) Tablet PO qhs (). 11. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 13. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 4 days. Disp:10 Tablet(s) Refills:0 14. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:0 15. diphenhydramine HCl 50 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed for hives/dyspnea: As needed for hives and itching. 16. insulin glargine 100 unit/mL Cartridge Sig: Twenty (20) units Subcutaneous at bedtime. 17. insulin lispro 100 unit/mL Solution Sig: One (1) injection Subcutaneous Before meals: Please follow current sliding scale since may need more insulin due to prednisone. 18. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 19. fluticasone 50 mcg/Actuation Spray, Suspension Sig: [12-12] spray to each nostril Nasal once a day. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Face and throat swelling Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid ([Location (un) ] or cane). Discharge Instructions: You were admitted to the hospital for concern for swelling of your face and throat. You were given an epinephrine injection, steroids and your medications, Levofloxacin and Losartan, were stopped as these sometimes may cause an allergic reaction and swelling of the face. You did not have any evidence of airway compromise or obstruction, and you were continued on steroids and an anti-histamine, to be continued for 5 days total. The following changes were made to your home medications: - Prednisone was STARTED to be taken for FOUR additional days - Famotidine was STARTED to be taken for FOUR additional days - Start Hydrochlorozide 25mg once daily for your blood pressure - STOP LOSARTAN since this is a concern that may have caused your allergic reaction. YOU SHOULD AVOID TAKING A CLASS OF BLOOD PRESSURE MEDICATIONS CALLED ACE-I, [Last Name (un) ] - STOP LEVOFLOXACIN since we are uncertain if this could had caused your allergic reaction. Followup Instructions: Please CALL DR. [Last Name (STitle) 6210] office to schedule an appointment within 1 week to discuss further pulmonary care. Phone # is [Telephone/Fax (1) 612] You will need to follow-up on Monday, [1-16] at 10:00 at the post discharge clinic. Same clinic as Dr. [Last Name (STitle) ], [First Name3 (LF) ] Location: [Hospital3 249] [Hospital1 ]/EAST Address: [Location (un) ], E/CC-6, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 250] Department: ORTHOPEDICS When: THURSDAY [2186-1-12] at 1:40 PM With: ORTHO XRAY (SCC 2) [Telephone/Fax (1) 1228] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: THURSDAY [2186-1-12] at 2:00 PM With: [First Name11 (Name Pattern1) 2191] [Last Name (NamePattern4) 2192], NP [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 1935] CENTER When: WEDNESDAY [2186-1-18] at 9:30 AM With: [First Name11 (Name Pattern1) 354] [Last Name (NamePattern4) 3013], 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 ICD9 Codes: 496, 4019, 4280, 3051, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9078 }	Medical Text: Admission Date: [2164-5-13] [Month/Day/Year ] Date: [2164-6-5] Date of Birth: [2110-11-6] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 371] Chief Complaint: S/p fall with Sternal Fx/Left Rib Fx/Pneumothorax Major Surgical or Invasive Procedure: Tracheostomy PEG tube placement History of Present Illness: 53 yo male fell off a bridge whlle intoxicated(ETOH). Swam to shore after the fall, fall from [9-9] feet. Questionable LOC. + Head Lac and chest pain. Pt. reportedly dove into water b/c he thought he saw a baby in the river. Reportedly drank 6 beers, [11-28] pint of Vodka. Past Medical History: None Social History: + ETOH, has been to rehab, drinks qod Family History: NC Physical Exam: 92, 130/P 20 Gen: NAD Resp: CTA B CV: RRR + S1/S2 Abd: NT/ND Ext- Bilateral knee abrasions Rectal- good tone, guiac - Left shoulder abrasion + C-Spine tenderness Pertinent Results: [2164-5-13] 09:13PM GLUCOSE-93 LACTATE-4.8* NA+-151* K+-4.7 CL--108 TCO2-24 [2164-5-13] 09:05PM UREA N-17 CREAT-1.0 [2164-5-13] 09:05PM CK(CPK)-2103* AMYLASE-91 [2164-5-13] 09:05PM CK-MB-64* MB INDX-3.0 cTropnT-<0.01 [2164-5-13] 09:05PM WBC-22.4* RBC-4.10* HGB-13.9* HCT-40.2 MCV-98 MCH-33.9* MCHC-34.7 RDW-14.7 [2164-5-13] 09:05PM PT-11.6 PTT-23.9 INR(PT)-1.0 [2164-5-13] 09:05PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG Brief Hospital Course: Pt was originally admitted to floor bed, but developed a tension PTX on the floor, [12-29] + mediatinal shift. Pt was intubated, chest tube was placed and he was transferred to TSICU on HD#2. Remained in the ICU Intubated for 10 days. Pt. received tracheostomy on HD #10. He progressively regained neurological function. On HD#9 it was determined that [Name (NI) 1094] PTX was resolved and his chest tube was removed without difficulty. Pt. received PEG tube placement on HD# 10 and tolerated TF well throughout hospital course. At d/c patient was to goal at 80cc/hr. Pt. received multiple courses of Abx during his hospitalization for presumed pneumonia. Abx included 8 day course of Levofloxacin, Vancomycin and a short course of Zosyn. On [Name (NI) ] Pt. was afebrile without increased WBC for 7 days. Pt. Cervical spine remained immobilized until he was conscious enough for clinical clearance. On HD # 20 Pt. received Flex/Ex C-spine X-rays which were WNL and with clinical C-spine clearance, C-collar was D/C. Pt c/o sternal Chest pain throughout his floor stay, Multiple CXR were WNL and Cardiac enzymes were WNL with no EKG changes. The pain is attributed to his sternal fracture and has been controlled on his pain medication. Upon [Name (NI) ] patient was highly functional, walking, grooming, dressing on his own. Medications on Admission: None [Name (NI) ] Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:30 Tablet(s) Refills:0 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Three [Age over 90 ]y Five (325) mg PO DAILY (Daily). Disp:qs one month Refills:0 4. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:0 6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). Disp:qs one month Refills:0 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). Disp:30 nebulizer Refills:0 8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain: NG. Disp:500 ML(s) Refills:0 9. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:30 Patch 24HR(s) Refills:0 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Neb Inhalation Q6H (every 6 hours) as needed for SOB. Disp:20 Neb Refills:0 [Age over 90 ] Disposition: Extended Care Facility: [Hospital6 2222] - [Location (un) 538] [Location (un) ] Diagnosis: Left [1-28] Rib Fracture/Sternal Fracture/Resolved Left Hemopneumothorax [Month/Day (3) ] Condition: Good [Month/Day (3) ] Instructions: Return to Emergency Room For: Fever > 101.5 Difficulty Breathing Severe Chest Pain Dizziness Loss of Consciousness Followup Instructions: Folow up in Trauma Clinic in [11-28] weeks. Please call ([Telephone/Fax (1) 9946] to schedule an appointment. Follow up with your primary care doctor [First Name (Titles) ] [Last Name (Titles) ] Completed by:[2164-6-5] ICD9 Codes: 5070, 4589, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9079 }	Medical Text: Admission Date: [2191-11-6] Discharge Date: [2191-11-21] Date of Birth: [2114-4-7] Sex: M Service: Medicine HISTORY OF PRESENT ILLNESS: Mr. [Known lastname ] is a 77 year old male with a history of diabetes mellitus, coronary artery disease, congestive heart failure, peripheral vascular disease, status post left below the knee amputation and status post right first and second toe amputations, chronic kidney disease, history of Methicillin resistant Staphylococcus aureus and vancomycin resistant enterococcus, who presented with left lower extremity swelling, erythema and a "green drainage" from the right heel per VNA, who had seen the patient on [2191-11-5]. The patient complains of right lower extremity pain extending from the knee down to the foot. He also noted increased fingersticks at home in the 400 to 500 range for two days prior to admission. Review of systems at presentation was significant for no fevers, chills, nausea, vomiting, shortness of breath, chest pain, abdominal pain, diarrhea, constipation, dysuria or bright red blood per rectum. In the Emergency Room, the patient was given Vicodin, morphine, Ancef and oral Levaquin. PAST MEDICAL HISTORY: 1. Coronary artery disease: The patient had a recent cardiac catheterization in [2191-3-23] which demonstrated diffuse three vessel disease. The patient received stents to the left marginal for a 70% stenosis and the obtuse marginal one for a 90% stenosis. The patient has a known left bundle branch block. Persantine thallium in [2191-4-23] demonstrated defects inferiorly (moderate partially reversible), apical (moderate to severe reversible) and anteroseptal (mild, fixed) walls. The left ventricular ejection fraction was noted to be 31% at that time with global hypokinesis and enlargement. 2. Diabetes mellitus type 2 complicated by chronic kidney disease (several episodes of acute renal failure, receiving dialysis at that time), neuropathy and retinopathy. 3. Intermittent left bundle branch block. 4. Peripheral vascular disease. 5. Recurrent right lower extremity cellulitis, last admission [2191-6-23] with piperacillin/tazobactam therapy. Magnetic resonance imaging scan at that time was negative for osteomyelitis. 6. Left renal artery stenosis, stented in [2191-3-23]. 7. Anemia. 8. History of Methicillin resistant Staphylococcus aureus and vancomycin resistant enterococcus infections. 9. Cataracts/blindness. PAST SURGICAL HISTORY: 1. Left thyroid lobectomy. 2. Amputation of right first toe in [2181]. 3. Amputation of right second toe in [2183]. 4. Right popliteal-dorsalis pedis bypass in [2183]. 5. Left below the knee amputation in [2185]. ALLERGIES: The patient has an unclear allergy to codeine. MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o.q.d., Lipitor 40 mg p.o.q.d., metoprolol 100 mg p.o.b.i.d., NPH insulin 36 units q.a.m., isosorbide mononitrate 60 mg p.o.q.d., Plavix 75 mg p.o.q.d., Lasix 40 mg p.o.q.d., Colace 100 mg p.o.b.i.d., Neurontin. SOCIAL HISTORY: The patient lives in [Hospital3 4634]. He has VNA visits twice weekly and his children are actively involved in his care. He has not been ambulatory for the last year. PHYSICAL EXAMINATION: On physical examination on admission, the patient had a temperature of 97.9, blood pressure 132/66, heart rate 86, respiratory rate 20 and oxygen saturation 98% in room air. General: Alert, in no acute distress. Head, eyes, ears, nose and throat: Left eye shut, extraocular movements full, oropharynx clear. Neck: Supple without lymphadenopathy, no jugular venous distention. Lungs: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Extremities: Left lower extremity below the knee amputation, no erythema or edema, right lower extremity with erythema and edema extending above the knee, status post right number one and number two toe amputations, heel ulcer healing with no drainage, beginning of skin breakdown on right shin and right foot but no drainage and no cuts/ulcers/lesions. LABORATORY DATA: Admission sodium was 142, BUN 73, creatinine 2.3, white blood cell count 5.9, hematocrit 30, platelet count 233,000, prothrombin time 12, partial thromboplastin time 29.8, and INR 1. On the day prior to discharge, BUN 29, creatinine 1.2, white blood cell count 4.7, hematocrit 33.1, and platelet count 328,000. IMPRESSION: Mr. [Known lastname ] is a 77 year old male with vasculopathy, peripheral vascular disease, status post left below the knee amputation, coronary artery bypass grafting, who was admitted with right lower extremity cellulitis complicated by Methicillin resistant Staphylococcus aureus bacteremia and aspiration pneumonia. The patient had a non-ST elevation myocardial infarction, likely in the setting of demand ischemia and acute renal failure, now improved. He has remained afebrile while on levofloxacin and clindamycin. HOSPITAL COURSE: Mr. [Known lastname ] presented to the [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] Emergency Room on [2191-11-6] with Methicillin resistant Staphylococcus aureus right lower extremity cellulitis. A chest x-ray was clear and venous ultrasound was negative for thrombosis at that time. He received hydrocodone 5 mg orally, cefazolin 1 gram, levofloxacin 500 mg, and intravenous morphine 2 mg. The patient was admitted to the Medicine Service, where intravenous metronidazole was added, cefazolin was changed to vancomycin pending the MRSA screen. BUN and creatinine were noted to be elevated and he received one liter of half normal saline. Early in the morning on [2191-11-7], the patient developed five out of ten chest pain. An electrocardiogram showed 1 mm inferior and lateral ST depressions and his chest pain resolved with one sublingual nitroglycerin. That day, antibiotics were changed to intravenous ampicillin/sulbactam 3 grams every eight hours and intravenous vancomycin 1,000 mg every 24 hours. Both of these antibiotics were continued through [11-8]. He had received a total of three units of packed red blood cells for a hematocrit less than 30. His stool remained occult blood negative. Mr. [Known lastname ] developed an episode of nonsustained ventricular tachycardia on [2191-11-10] and consideration of repeat vascularization may be undertaken after the acute process resolves. On [2191-11-11], the patient developed a cough and shortness of breath with mild desaturation. Secondary to increasing serum creatinine, Captopril was also discontinued on that day. On [2191-11-12], the patient was noted to be somnolent, with nausea and vomiting. Narcotics were withheld and he did not respond to Neurontin. The patient had received Kayexalate per rectum for a potassium of 5.6. The patient became febrile and had a temperature that peaked at 102.9. The Nephrology Service was consulted for a rising creatinine (4.4) and oliguria. The Renal Service suspected acute tubular necrosis and Lasix boluses and isosorbide mononitrate were discontinued. Throughout the evening of [2191-11-12], the patient continued to have rigors and soaking sweats. He experienced several episodes of transient hypotension to the 80s and 90s systolic. He rapidly became hypoxic around 2:00 p.m. and eventually required a 10 liter face mask. He was noted to have poor secretion management, with a weak cough and persistent rattle without frequent suctioning. He was noted to have cardiac enzymes that were positive and his metoprolol was decreased to 25 mg twice a day rather than discontinuing it altogether secondary to his hypotension. He was totally anuric at that time. The patient was transferred to the Intensive Care Unit for suctioning and blood pressure monitoring. He was diagnosed with aspiration pneumonia at that time and was treated with renally dosed levofloxacin and clindamycin. He was continued on aspiration precautions with the head of bed greater than 45 degrees with frequent tracheal suctioning. A nasogastric tube was continued to low intermittent wall suction to minimize gastric aspiration, although this is of unclear benefit. The patient's repeat chest x-ray on [2191-11-13] was stable. His oxygenation continued to improve as well as the patient's blood pressure control. Mr. [Known lastname ] was transferred to the medical floor in good condition on [2191-11-15]. His cardiac enzymes continued to trend down, his peak CK was 422 on [2191-11-13] and trended thereafter to 51 on [2191-11-17]. The cardiology service was contact[Name (NI) ] and the patient was felt not to be a candidate for cardiac catheterization as his renal dysfunction was prohibitive. Vascular Surgery was re-consulted to assess the patient's right lower extremity for possible revascularization or amputation. They evaluated the patient and felt there was no indication for amputation or revascularization acutely. He will be followed in the vascular surgery clinic for continued evaluation. The patient's renal function continued to improve, with a creatinine of 1.2 on the day prior to discharge. As the renal function improved, cardiology was re-contact[Name (NI) ] and they felt that medical management would be indicated at this time. He will be followed up by cardiology as an outpatient. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient is being discharged to [Hospital3 ] in [Location (un) 246]. DISCHARGE DIAGNOSES: 1. Non-ST elevation myocardial infarction. 2. Diabetes mellitus type 2. 3. Chronic kidney disease with an episode of acute renal failure, which resolved. 4. Peripheral vascular disease complicated by right lower extremity ulcers. 5. Anemia. 6. Cellulitis. 7. Renal artery stenosis. 8. Cataracts. 9. Neuropathy. 10. Retinopathy. 11. Methicillin resistant Staphylococcus aureus bacteremia. DISCHARGE MEDICATIONS: Levaquin 500 mg p.o.q.d. until [2191-12-3]. Amlodipine 5 mg p.o.q.d. Lipitor 40 mg p.o.q.h.s. Clindamycin 450 mg p.o.q.6h. until [2191-12-3]. Isosorbide mononitrate 120 mg p.o.q.d. Acetaminophen 650 mg p.o.q.4-6h.p.r.n. Sarna lotion applied p.r.n. Eucerin cream applied to right lower extremity b.i.d. Ipratropium bromide meter dose inhaler two puffs q.i.d. Risperidone 0.5 mg p.o.q.h.s. Olanzapine (disintegrating tablets) 5 mg p.o.q.d.p.r.n. agitation. Protonix 40 mg p.o.q.d. Enteric coated aspirin 325 mg p.o.q.d. Metoprolol 100 mg p.o.t.i.d. Plavix 75 mg p.o.q.d. Epogen 3,000 units s.c.q. Friday. Atrovent nebulizer q.6h.p.r.n. Heparin 5,000 units s.c.q.12h. Albuterol nebulizer q.6h. Sublingual nitroglycerin 0.3 mg p.r.n. NPH 20 units s.c.q. breakfast, NPH 10 units s.c.q. dinner. Sliding scale insulin. PHYSICIAN [Last Name (NamePattern4) ]: 1. The patient will follow up with his primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], at [Hospital 22849] Medical Center ([Telephone/Fax (1) 22850] on [2191-12-15] at 2:00 p.m. The address is [Doctor Last Name 22851], [Location (un) 14663], [Numeric Identifier 22852]. 2. Mr. [Known lastname ] needs follow-up with cardiology, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 22853], at [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] on [2191-12-29] at 11:00 a.m., telephone number [Telephone/Fax (1) 2207]. 3. He has a follow-up appointment with vascular surgery, Dr. [Last Name (STitle) ], on [2191-12-6] at 2:00 p.m. at [Hospital Unit Name 22854]. DISCHARGE INSTRUCTIONS: 1. Fingersticks q.i.d. 2. Wound care-right foot and leg, apply Bacitracin ointment to ulcers on heel then wrap with dry Kerlix, then wrap with an Ace compression wrap; elevate the leg. 3. Left stump, wrap and dry Kerlix/gauze then wrap with an Ace wrap. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-986 Dictated By:[Last Name (NamePattern1) 20054] MEDQUIST36 D: [2191-12-9] 05:19 T: [2191-12-12] 11:18 JOB#: [Job Number ] ICD9 Codes: 5070, 7907, 5845, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9080 }	Medical Text: Admission Date: [2159-12-24] Discharge Date: [2159-12-29] Date of Birth: [2112-3-15] Sex: M Service: [Hospital1 212] HISTORY OF THE PRESENT ILLNESS: The patient is a 47-year-old male with minimal past medical history admitted status post in which he was an unrestrained passenger, ran into a pole, and was found unconscious in the passenger seat. There was a witnessed seizure in the field and again at [Hospital6 48708] where he was loaded with Dilantin. His GCS at [Hospital3 ] was 5. No history could be obtained by the patient but per his sister in-law, he had been complaining of a headache, photophobia and was somnolent for two days prior to his motor vehicle accident. PAST MEDICAL HISTORY: 1. Irritable bowel syndrome. 2. Hypercholesterolemia. 3. Seasonal allergies. 4. No history of heart or lung disease. ADMISSION MEDICATIONS: 1. Lipitor. 2. Prevacid. 3. Viagra. 4. Amoxicillin. 5. Nasal decongestant, suspect for a recent sinusitis. ALLERGIES: The patient has no known drug allergies. FAMILY HISTORY: Father and paternal grandfather with coronary artery disease, first MI in their 70s. SOCIAL HISTORY: The patient denied tobacco, alcohol, or drug use. He states that he lives with his wife, has no children, and works as an apartment manager. Of note, this admission, his wife has learned of his infidelity. Social work was consulted. PHYSICAL EXAMINATION ON ADMISSION: On initial presentation, he was intubated on propofol. The pupils were 2 mm with trace reactivity, 4 mm reduced to 2 mm when aroused. Corneals were intact bilaterally. Oculocephalic examination was unable to be done as the patient was in a C-spine collar. He was arousable to painful stimuli, withdrew all extremities to painful stimuli, and with arousal, there was spontaneous movement of all extremities. His lungs were clear. On cardiovascular examination, he had an S1 and S2 with no murmurs noted. The abdomen was soft with no hepatosplenomegaly. The extremities revealed no edema. LABORATORIES AND DIAGNOSTICS: The admission white count was 17.0, decreased to within normal limits prior to discharge, initial hematocrit 43.5, stabilized in the range of 34-35. The Chem-10 was within normal limits. The most recent Dilantin level was 8.7 on [2159-12-28]. PT 13.0, INR 1.1, PTT 26.8. CT of the L-spine revealed a fracture of the right L1 transverse process. No other fracture or subluxation. The chest x-ray revealed no pneumonia or CHF. CT of the head revealed no intracranial or extracranial hemorrhage, mass affect, or shift. No evidence of infarction. Ventricle cistern and sulci are unremarkable. Partial opacification of all paranasal sinuses. The RPR was nonreactive. The EEG revealed predominance of excessively drowsy and sleepy activity consistent with encephalopathic pattern versus sleep depravation. Left ankle x-ray revealed medial and malleolar fracture with mild surrounding soft tissue swelling. Left knee x-ray revealed no fracture or joint effusion. No fracture of the proximal left fibular head. Blood cultures from [2159-12-23] revealed no growth until the time of this dictation. ALT 61 on presentation, decreased to 33, AST 71, decreased to 26, alkaline phosphatase 60, LDH 551 on presentation, deceased to 396, total bilirubin 0.5. Drug screen negative including alcohol but positive for opiates. The U/A revealed negative nitrate leukocyte esterase, [5-15] red blood cells, [2-8] white blood cells, occasional bacteria. CSF from lumbar puncture on [2159-12-23] revealed bottle one 62 white blood cells, 525 red blood cells, 89% polys, 8% lymphocytes, 3% monocytes. Bottle number four revealed 73 white blood cells, 460 red blood cells, 33% polys, 65% lymphocytes, 2% monocytes. CSF lumbar puncture on [2159-12-29] bottle number one revealed 2 white blood cells, 1,250 red blood cells, 12 polys, 43 lymphocytes, 40 monocytes, 1 eosinophils, 4 mac. Bottle number four revealed 1 white blood cell, 2,250 red blood cells, 36 polys, 24 lymphocytes, 36 monocytes, 4% eosinophils. Enterovirus PCR is pending. HSV PCR is pending. Total protein from CSF tap 47, glucose 74, LDH 34. Viral cultures from the CSF revealed no growth to date. Gram's stain negative. Culture negative. Fungal negative. Cryptococcal antigen negative. Acid-fast pending. Head MRI with neck MRA to rule out vertebral dissection pending. HOSPITAL COURSE: This is a 47-year-old male with no significant past medical history admitted status post MVA with left medial malleolar fracture and L1 transverse process fracture noted to have 60-70 white blood cells on initial LP concerning for meningitis managed with IV antibiotics. 1. MENINGITIS: The patient was noted to have 60-70 white blood cells on initial lumbar puncture with a confusing differential, unclear whether this is due to bacterial or viral origin. Thus, the patient was started on ceftriaxone, vancomycin, and acyclovir. Plan to continue ceftriaxone and vancomycin for a total of two weeks. The acyclovir will be continued pending results of the HSV PCR. The patient is being covered for possible HSV infection due to note of high-risk sexual activity in addition to RBCs in the CSF consistent with an HSV infection but may be due to traumatic brain injury with diffuse axonal injury. 2. SEIZURE: The patient was noted to have a witnessed seizure in the field and again at [Hospital6 302]. Likely this has occurred in the context of traumatic brain injury. An EEG was done and showed predominance of an excessively drowsy and sleepy activity consistent with an encephalopathic versus sleep-deprived state. No seizure activity was noted. The patient was loaded with Dilantin and is currently taking Dilantin p.o. 300 mg t.i.d. We will follow his Dilantin level with a goal Dilantin level of [9-24] for seizure prophylaxis. The patient was maintained on seizure precautions; however, no seizure activity has been noted this admission. 3. FRACTURE OF THE TRANSVERSE PROCESS OF L1: The patient was fitted with a lumbar corset and has been seen by Physical Therapy. Recommendation for physical therapy two to four times per week for mobility and balance training, gait training, and patient education. The patient's pain from this fracture has been managed with p.r.n. Tylenol and Percocet. 4. LEFT MEDIAL MALLEOLAR FRACTURE: The patient's left lower extremity was casted. We managed his pain with p.r.n. Percocet and Tylenol. X-rays were done to rule out proximal fibular fracture which commonly is associated with this type of malleolar fracture. These x-rays were found to be negative. As stated above, the patient will need continued physical therapy. 5. PULMONARY: The patient required intubation upon presentation for a hypoxia. He was extubated without difficulty on [2159-12-26]. Upon transfer to the floor, he was quickly weaned off 2 liters nasal cannula to room air which he is currently saturating 92% on room air. 6. PERSISTENT LOW-GRADE FEVER: The patient was with a temperature maximum of 100.6, continuing to run low-grade fevers. These are likely central fevers as the patient has no white count. Blood cultures have remained no growth from [2159-12-23]. He has been on the antibiotics since the 20th. His U/A was negative. His chest x-ray was negative. He showed no other signs or symptoms of infection. 7. PROPHYLAXIS: The patient was maintained on subcutaneous heparin b.i.d. while he was not ambulating. He was also maintained on a PPI and bowel regimen. 8. CODE: The patient is full code. CONDITION ON DISCHARGE: Good. Pain well controlled. The patient was ambulating but requires further physical therapy. Neurological examination stable. DISCHARGE STATUS: The patient is to be discharged to a rehabilitation facility yet to be identified for continued physical therapy. DISCHARGE MEDICATIONS: 1. Heparin 5,000 units subcutaneously b.i.d. until the patient is ambulating regularly. 2. Oxycodone acetaminophen 5/325 one to two tablets p.o. q. four to six hours p.r.n. pain. 3. Colace 100 mg p.o. b.i.d. 4. Protonix 40 mg p.o. q.d. 5. Tylenol 325 to 650 mg p.o. q. four to six hours p.r.n. 6. Dilantin 300 mg p.o. t.i.d. 7. Acyclovir 800 mg IV q. eight hours until HSV PCR negative. 8. Vancomycin 1 gram IV q. 12 hours times ten days. 9. Ceftriaxone 2 grams IV q. 24 hours times ten days. FOLLOW-UP: 1. The patient is to follow-up with his primary care physician in one to two weeks. 2. The patient is to follow-up with Orthopedics for removal of his cast as instructed. 3. The patient is to follow-up with Neurology for continued management of his Dilantin as instructed. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520], M.D. [MD Number(1) 521] Dictated By:[Name8 (MD) 14337] MEDQUIST36 D: [2159-12-28] 03:34 T: [2159-12-28] 17:24 JOB#: [Job Number 53099] ICD9 Codes: 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9081 }	Medical Text: Admission Date: [2173-6-30] Discharge Date: [2173-7-6] Service: Medicine CHIEF COMPLAINT: Chief complaint was increased swelling, change in mental status, and acute renal failure. HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old woman with congestive heart failure with an ejection fraction of 20%, atrial fibrillation, and anasarca who presented with acute renal failure, mental status changes, and swelling in the extremities. The patient is on a chronic diuresis for her anasarca. On [2173-6-21], her creatinine was noted to be 1.7 and had progressively increased to 4 on [2173-6-30]. During this period, the patient did not have a Foley catheter in place, raising the possibility of urinary retention. The change in mental status was reported by her primary care physician (Dr. [Last Name (STitle) ], but when the patient herself denied feeling confused. The patient denied chest pain. The patient admits to shortness of breath which was no different from her baseline. She normally sits upright in bed at all times, even at night when she sleeps. The patient denies fever, cough, chills, nausea, vomiting, diarrhea, dysuria, or abdominal pain. PAST MEDICAL HISTORY: 1. Congestive heart failure with an ejection fraction of 20%. 2. Atrial fibrillation. 3. Chronic hypotension. 4. Home oxygen of 2 liters via nasal cannula. 5. Status post left above-knee amputation for squamous cell carcinoma. 6. Peripheral vascular disease. 7. Status post hemicolectomy in [2165] secondary to bowel strangulation. 8. Guaiac-positive in [2168]. 9. Venous stasis disease. 10. Hypothyroidism. 11. Status post cholecystectomy in [2154]. 12. Status post ventral hernia repair in [2165] 13. Chronic constipation. 14. Osteoarthritis. 15. History of cellulitis. 16. History of [Last Name (un) ] syndrome. MEDICATIONS ON ADMISSION: Medications included Synthroid 25 mcg p.o. q.d., captopril 6.25 mg p.o. b.i.d., Lasix 120 mg p.o. q.d., enteric-coated aspirin 325 mg p.o. q.d., Aldactone 50 mg p.o. b.i.d., lactulose 30 cc p.o. q.d., Senokot two tablets p.o. q.h.s., Miconazole powder topically b.i.d., Protonix 40 mg p.o. q.d., Colace 100 mg p.o. b.i.d., K-Dur 20 mEq p.o. q.d. ALLERGIES: Allergy to CIPROFLOXACIN, BIAXIN, ERYTHROMYCIN, and DUODERM (reaction unknown). SOCIAL HISTORY: The patient is retired. She has a daughter in [Name (NI) 86]. Lived in [Hospital3 2558] for the last two weeks. She denies tobacco or drinking alcohol. FAMILY HISTORY: Family history is significant for coronary artery disease. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, temperature was 96.3, pulse was 80, blood pressure was 89/59, respiratory rate was 25, oxygen saturation was 94% on 2 liters. In general, the patient was an obese elderly Caucasian female in no acute distress; slightly tachypneic. Head, eyes, ears, nose, and throat revealed pupils were equal, round, and reactive to light. The fundi were unremarkable. Mucous membranes were slightly dry. The oropharynx was benign. The neck revealed no cervical lymphadenopathy. Jugular venous distention about 12 cm. No thyromegaly. No carotid bruits bilaterally. Heart was irregularly irregular rhythm. First heart sound and second heart sound were normal. Distant heart sounds. Lungs revealed bibasilar rales in the lower half of the lungs. No wheezes or rhonchi. Gastrointestinal revealed positive bowel sounds, soft, and obese. No masses. Extremities revealed left above-knee amputation, 2+ edema bilaterally in the lower extremities. The patient had a 3-cm X 3-cm ulcer on the anterior aspect of the distal right lower extremity. There was also a 2-cm X 2-cm on the medial aspect of the distal right lower extremity; this ulcer had a clean base, not erythematous, with no discharge or pus. The patient also had an ulcer on the left buttocks and the right thigh. Neurologically, alert and oriented times three. Cranial nerves II through XII were intact. No gross loss of tactile sensation. Deep tendon reflexes were 2+ throughout. Dermatologic examination revealed decreased skin turgor. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories revealed a white blood cell count of 10.1, hematocrit was 25.3, platelets were 100. Differential revealed 75 polys, 3 lymphocytes, and 10 bands. Sodium was 137, potassium was 4.7, chloride was 95, bicarbonate was 33, blood urea nitrogen was 56, creatinine was 4.1, blood glucose was 124. Arterial blood gas revealed pH of 7.43, PCO2 of 59, PO2 of 76. Urinalysis was negative except for large blood and trace leukocyte. Microbiology urinalysis showed red blood cells of greater than 50, white blood cells equaled 3. Negative for eosinophils. Urine sodium was 57. Urine creatinine was 72. FENa was approximately 2.2%. RADIOLOGY/IMAGING: A chest x-ray showed increased density in the left cardiac region; could represent atelectasis, effusion, or pneumonia. There was increased pulmonary bilaterally hilar opacity; represent pulmonary edema. Electrocardiogram was unchanged from previous electrocardiogram. There was atrial fibrillation with a heart rate of 121 beats per minute, QRS interval of 164. HOSPITAL COURSE: This is an 86-year-old female with a past medical history of congestive heart failure with an ejection fraction of 20%, atrial fibrillation, and anasarca who presented with worsening congestive heart failure and acute renal failure. The most likely cause of her acute renal failure was prerenal based on her physical examination and laboratories. Also, secondary to over-aggressive diuresis with Lasix and decompensated congestive heart failure. On the morning of [2173-7-2] at 4 a.m., the patient had hypotension with a blood pressure of 60/30 with decreased oxygen saturations to below 70% on 7 liters. With mask oxygenation, the patient's vital signs were back to normal range. Blood pressure was up to 85/43 and oxygen saturation of 100%. The patient went on to have a similar episode of hypotension. At this time, the medical team agreed to send the patient to Medical Intensive Care Unit for further evaluation. In the Medical Intensive Care Unit, the patient was treated with dobutamine, dopamine, an intravenous fluids; but the patient showed little improvement in terms of oxygenation and bilateral maintenance. After a long discussion with the patient's primary care doctor, and also her attending doctor, and the family members including her daughters and grandsons we decided to send her back to the floor for comfort measures on [2173-7-4]. It was a very difficult decision to make the patient do not resuscitate/do not intubate with the primary goal of comfort, but the family of the patient and the medical team also agreed that this was the appropriate step to take. When the patient was transferred back to the floor on [2173-7-4], she was kept on comfort measures which included only morphine intravenously and oxygenation through nasal cannula to keep the patient comfortable. It was a very difficult to make the patient do not resuscitate/do not intubate the patient without monitoring except for morphine and oxygenation. The patient passed away two days later, on the morning of [2173-7-6]. The family members and the attending were notified at 2:30 a.m. Our grievance and sympathy go out to the [Known lastname ] family. 1. CARDIOVASCULAR: The patient had decompensated congestive heart failure with an ejection fraction of 20% with reduced forward flow and pulmonary edema as evidenced by a chest x-ray and fistulogram. On the second day of hospitalization, the patient developed a dry cough but was afebrile. The cough was likely due to pulmonary edema. Reduced afterload was limited due to a history of hypotension. Anatrophic agents such as digoxin did not help her in the past, according to her primary care doctor. Diuresis is limited due to acute renal failure. Therefore, very minimal intravenous fluids were used throughout the hospital stay, and Lasix was withheld due to the acute renal failure. 2. RENAL: The patient acute renal failure with a creatinine of 4 and a fraction excretion of sodium of 2.2 which suggested prerenal secondary to third space and possible acute tubular necrosis in progression. The patient had negative urinary eosinophils, which suggests that renal interstitial disease was unlikely. The patient also had low urine output on [2173-7-1] of around 15 cc per hour. In the Medical Intensive Care Unit after the Medical Intensive Care Unit admission, the patient was anuric. The patient did not put out any urine. When the patient came back to the floor on [2173-7-4], transferred back from the Medical Intensive Care Unit, the patient anuric. Because the patient was on comfort measures only, no blood work or other monitoring was done. 3. PULMONARY: The patient had baseline shortness of breath. Her shortness of breath progressively worsened throughout her hospitalization. Although the patient was on high percentage of oxygen nasal cannula (up to 10 liters), the patient's oxygen saturation sometimes fell to the lower 70s. The most likely cause of her low oxygen saturation was due to worsening congestive heart failure. 4. INFECTIOUS DISEASE: The patient had a negative urinalysis with no fever or symptoms of dysuria. Thus, urinary tract infection was unlikely. The patient had a dry cough which was most likely caused by pulmonary edema due to worsening congestive heart failure. 5. HEMATOLOGY: The patient's hematocrit was in the low 20%; however, this was her baseline. Transfusion was limited due to the worsening congestive heart failure. Therefore, the decision was to withhold blood transfusion in her case. CONDITION AT DISCHARGE: The patient expired on [2173-7-6]. DIAGNOSES: The patient had worsening congestive heart failure and worsening acute renal failure. [First Name11 (Name Pattern1) 8207] [Last Name (NamePattern4) 8208], M.D. [MD Number(1) 8209] Dictated By:[Name8 (MD) 38662] MEDQUIST36 D: [2173-7-6] 19:18 T: [2173-7-10] 05:28 JOB#: [Job Number 103827] ICD9 Codes: 5849, 4280, 2765, 4439, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9082 }	Medical Text: Admission Date: [2171-11-14] Discharge Date: [2171-11-16] Date of Birth: [2115-10-14] Sex: M Service: MEDICINE Allergies: Beeswax Attending:[First Name3 (LF) 4654] Chief Complaint: Epistaxis Major Surgical or Invasive Procedure: nasal packing blood transfusion History of Present Illness: 54M CAD s/p MI, IDDM, [Hospital ] transferred from NVMC with epistaxis. Seen in ED originally Friday [11-8] for L sided epistaxis which spontaneously resolved. Seen again Sunday for recurrent episode, had anterior packing placed and removed on Tuesday given Clindamycin. Epistaxis resolved until [11-13] when had recurrent episode, seen again in ED, had anterior and posterior packing on L, anterior packing to R, given Ativan, Zofran Morphine prn, 2L NS boluswas tachy to 130s with Hct drop 3 points over 3 days and was trasnferred for ICU monitoring. In ED here SBP 130s, HR 110s, had 1 episode of bleeding from lacrimal duct resolved. Patient only on ASA, no other NSAID, COumadin, Plavix. No new meds. notes weakness, dizziness today with melena x 2 days, diarrhea. No BRBPR, hematochezia, or syncope. 1 episode coughing up blood assoc. with nausea during transfer from ED now resolved. Denies facial trauma, surgery, inhaled drug or nasal spray use, allergies. No prior history of epistaxis. Denies CP, palpitations or SOB. Past Medical History: PMH: CAD s/p MI [2157], reports multiple PCI, no stent placement IDDM: Since [2159] HTN Hypercholesterolemia . PSurgHx: Ulnar nerve surgery Social History: Social Hx: Cleans cross-country gas lines. Lives in [Location 1157] with wife. 4 kids. Denies ETOH tobacco, other drug use. Family History: Fam Hx: No h/o bleeding d/o Physical Exam: VS: T 97.3 HR 108 RR 12 BP 150/68 SaO2 94% RA Gen: NAD, obese, pleasant, appears somnolent but arousable, interactive Eyes: PERRL, 2-3 mm, EOMI HEENT: nc/at Nose with R sided Mercocel, packings on left. Has evidence of dried blood on beard, in posterior oropharynx. No bleeding from nares currently. No active bleeding. MM dry Neck: Supple, thick, no LAD, no mass. No JVD CV: Tachy. Reg. 1-2/6 systolic murmur LUSB Resp: CTA BL with diminished BS in bases Abd: Soft. Obese. NT/ND with umbilican hernia. + but hypoactive BS Ext: No c/c/e 2+ DP/PT BL Pertinent Results: [2171-11-14] 01:20AM BLOOD WBC-11.0 RBC-3.84* Hgb-11.6* Hct-33.4* MCV-87 MCH-30.3 MCHC-34.8 RDW-14.2 Plt Ct-286 [2171-11-14] 07:54AM BLOOD Hct-30.4* [2171-11-14] 12:12PM BLOOD Hct-31.4* [2171-11-14] 01:20AM BLOOD PT-13.0 PTT-20.8* INR(PT)-1.1 Brief Hospital Course: 54M CAD s/p MI, IDDM, [Hospital ] transferred from OSH with recurrent episodes epistaxis for MICU monitoring # Epistaxis: Epistaxis of unclear etiology. Contributing factors may include seasonal allergies, aspirin use, and hypertension. S/p anterior packing to both nares with achievement of hemostasis. ENT evaluated patient the morning after admission, confirmed R side anterior merocel nasal packing and L side (side of epistaxis) with an anterior rapid rhino nasal balloon. However, on the afternoon of [2171-11-14], pt developed recurrent epistaxis. He was seen by ENT and nares were repacked with achievement of hemostasis. ~30 min after packing, pt had a likely vagal event during which he became acutely bradycardic and somnolent. Anesthesia was called, but he was breathing and maintained his blood pressure throughout the event. Hemostasis was again achieved. He was given Narcan 0.4mg without significant reponse. ABG: 7.43/36/130/25. EKG without ischemic changes. Cardiac enzymes sent and were negative x 3. HCT decreased to 26.8 on [11-15] so 1 unit PRBCs transfused. He was continued on strict epistaxis precautions (No nose-blowing, no lifting/straining/bending, sneeze with mouth open, no alcohol consumption. Sleep with HOB elevated 30 degrees). Episodes of epistaxis were treated with Afrin sprays to nasal packing and pressure for at least 20 min. ASA was held. He was treated with course of Keflex while packing in place. He will return to ED for remaoval of packing. # CAD s/p MI: Patient has h/o CAD with MI in [2157]. Holding ASA given acute epistaxis, continuing beta blocker, statin # HTN: Goal SBP <150-160 to avoid further episodes of bleeding. We continued his home medications of metoprolol, amlodipine, lasix. He received prn lopressor to maintain SBP<160. # IDDM: Holding home hypoglycemics in house and using fixed lantus 20 units qhs and sliding scale humalog insulin with FS QID. # Hypercholesterolemia: Continued home Niaspan, statin # FEN: Regular Cardiac, diabetic # Code: Full, confirmed with patient and wife. . # Comm: With patient, wife [Name (NI) 803] [Telephone/Fax (1) 109218]. Medications on Admission: Lasix 40 Po daily Metoprolol 50 [Hospital1 ] ASA 81 daily Amlodipine 10 daily actos 30 Po daily metformin 1000 PO BID pravastatin 40 PO qhs clindamycin 300mg PO TID x 3 days niaspan ER 500 PO BID glipizide 10 mg PO BID lantus 20 units SQ qhs NTG SL prn Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. Disp:30 Capsule(s) Refills:0 6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. Disp:30 Tablet(s) Refills:0 7. Niacin 250 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day). 8. Cephalexin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 3 days. Disp:24 Capsule(s) Refills:0 9. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day. 10. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Lantus 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime. 12. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: primary: epistaxis hypertension coronary artery disease diabetes hypercholesterolemia Discharge Condition: epistaxis stable. nasal packing in place. Discharge Instructions: you were admitted for a severe nose bleed. The ear, nose and throat doctors saw [Name5 (PTitle) ] and placed a nasal packing in your left nostril. You were admitted to the intensive care unit for observation and were given 1 unit of blood. . very important please return to the [Hospital3 ] emergency room on Monday [11-18] to have your packing removed by the ENT doctors. They will also arrange follow up and instruct you on further antibiotics. please use [4-9] pillows to keep your head elevated while sleeping . it is critical that your blood pressure is well controlled. Please check your blood pressure daily and call your primary care doctor if your pressure is above 160/90. . do not take aspirin until you consult with your doctors. . do not strain, and when you cough or sneeze- do so with your mouth open so as to relieve pressure from your nose. you have been prescribed as bowel regimen which you should continue, this will help reduce straining during bowel movements. . continue keflex (antibiotic) as directed. . if you have nosebleeds that continue to bleed despite applying of pressure go to the emergency room. If you have chest pain, shortness of breath, fevers, chills or other worrisome symptoms please go to the emergency room. . restart your home diabetes regimen. Followup Instructions: ear, nose and throat follow up. [First Name8 (NamePattern2) ] [Name8 (MD) 474] MD [MD Number(2) 4658] ICD9 Codes: 2851, 412, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9083 }	Medical Text: Admission Date: [2139-1-19] Discharge Date: [2139-3-8] Date of Birth: [2066-7-24] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3918] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: Lumbar puncture ([2139-1-22]) History of Present Illness: Dr. [Known lastname ] is a 72M left handed psychiatrist with h/o ESRD s/p ECD renal transplant [2131] complicated by bx-proved BK nepropathy treated with cidofovir now with failing graft (Cr 3.5), diffuse large B cell lymphoma s/p 6 cycles of R-[Hospital1 ] ([Date range (1) 95198]) and 2xIT MTX and 2xIT ARA-C with bone mets, CAD and CABG x3 [2130], CHF with EF 30% and 2+ MR, DM, depression, and laryngeal ca who presents from [Hospital1 ] for evaluation of altered mental status. As recently as [2138-11-9], Dr. [Known lastname ] was seeing pts as a psychiatrist after finishing five months of chemotherapy for lymphoma. His wife notes some paraphasic errors in his speech and difficulties with abstraction over the past year, but not major cognitive deficits. He was able to walk with a cane, but had progressively worsening gait from neuropathy secondary to diabetes and vincristine. In late [Month (only) ], he fell four times in one week and felt significantly weaker so his PCP advised him to seek medical attention. He was hospitalized [Date range (2) 95199]. Recurrent falls thought to be multifactorial with a degree of spinal stenosis and neuropathy. He was readmitted [Date range (1) 95200] from rehab for AMS. Admission BUN 103 and Cr 4.4. Found to improve when sedating medications (lorazepam, oxycodone, modafinil, buproprion, gabapentin) removed and with HD. No infectious etiology identified. D/C'ed to [Hospital1 ]. Over the next two weeks, pt's wife continued to be concerned about his mental status. Per wife, he was disoriented and talking about "running marathons." Dr. [Known lastname ] was seen by his oncologist on [2139-1-6], who also noted disorientation. Thought possibly due to uremia, but no improvement with HD, so oncologist did LP. CSF with 8 WBC, 3 RBC, Protein unavailable, Glucose 105, HHV negative, culture negative, and "clonality not assessed due to insufficient B cells.: Dr. [Known lastname ] continued to stay at [Hospital1 ]. He improved slightly, at one point able to get OOB and walk 100ft with walker and PT. After this improvement, however, his mental status became progressively worse. Wife describes pt as disoriented to time and place. He once asked for peanuts when he was already holding some in his hands. Over the last several days, these confusional states have gone from intermittent (worse in early AM and then PM) to continuous. Per wife, today's hospitalization results from cumulative decline and was not precipitated by an acute event. Wife does not recall any recent medication changes or acute illnesses other than above. REVIEW OF SYSTEMS: Neurological: Denies HA, neck pain, visual change, difficulties in hearing, talking, swallowing. Wife notes some paraphasic errors and difficulty with abstract thought. Also pt seems to have difficulties with balance and weakness in R side. Pt also has remote hx of head trauma [2-10] MVC as child, possibly involving damage to ? temporal lobe, and had some seizures as a child. Some increased urinary urge and frequency but without incontinence and baseline per wife. [Name (NI) ] other changes in bowel/bladder habits. Gen: No fevers/chills/sweats, SOB, cough, CP, palpitations, abd pain, N/V/D, dysuria. 5lb weight loss over past year. Past Medical History: As per discharge summary [2138-12-19]: 1. Diffuse large B cell lymphoma s/p 6 cycles of R-[Hospital1 ] ([Date range (1) 95198]) and 2xIT MTX and 2xIT ARA-C with bone mets in lumbar spine 2. ESRD s/p ECD renal transplant [2131] complicated by bx-proved BK nepropathy treated with cidofovir now with failing graft (Cr 3.5) 3. CAD s/p NQWMI and CABG x3 [2130], now with CHF and EF 30% and moderate MR/mild AS 4. Stage 1 laryngeal ca 5. IDDM 6. Depression 7. Osteoarthritis status post R total knee replacement [2126] 8. light chain lambda gammopathy 9. Hypercalcemia of malignancy 10. HTN 11. BPH Social History: Dr. [Known lastname ] is a psychiatrist who worked part time until his recent illness. He lives in [Hospital1 8] with his wife. [Name (NI) ] wife died from breast ca. They have no recent travel hx. He used to smoke a pipe, but stopped 15 years ago. ETOH <5 drinks/wk. No illicit drug use. Family History: FAMILY HISTORY: Mom with stroke and breast ca. Paternal cousion with breast ca. Denies other hx of stroke, sz, mental/psych illness. Physical Exam: PE: Gen: Initially lying in bed with eyes closed, answering questions in whisper with eyes closed. Later opens eyes and becomes more alert. Skin: Many bruises, especially notable on the abdomen. Heent: Normocephalic, atraumatic. Mucous membranes moist, oropharynx clear. Resp: Clear to auscultation bilaterally CV: Regular rate and rhythm, 2/6 SEM Abd: Bowel sounds present, abdomen soft, non-tender, and non-distended. No hepatosplenomegaly or masses palpable. Extrem: Warm and well-perfused. No arthralgia. ROM full. NEUROLOGIC EXAM MS - Awake, alert, interactive. Initially lying in bed with eyes closed, answering questions in whisper with eyes closed. Later opens eyes and becomes more alert. MS varies significantly over the course of exam. Pt sometimes answers questions quickly and correctly, sometimes answers the same question (when repeated) quickly and incorrectly, and sometimes has prolonged processing times (10-15 seconds to answer the same question he had just answered). Oriented to person. When asked where he is at various points in the exam, answers include "[State 531], [Hospital Ward Name 23] Building," "[State 531], at the phone company," and "[Hospital3 ] Hospital." Intermittently gets the month and year correct, then reports it is [2136]. Reports the president is "[Last Name (un) 2450]." Naming intact. When asked to spell world backward, says "WD." 100-7=13. 9 quarters = $1.25. No signs of apraxia. No left-right confusion. Cranial Nerves ?????? Pupils equal and sluggishly reactive (2.5 to 2mm); no diplopia; no nystagmus. Saccadic pursuit on lateral gaze. Impairment of superior and inferior movement of eyes b/l, worse on inferior. Intact facial sensation, moderate flattening of R nasolabial fold, hearing grossly intact, palatal elevation greater on L, and tongue protrusion is slightly R deviated with full movement. Sternocleidomastoid and trapezius are strong and normal volume. Tone - Normal Strength - Delt [Hospital1 ] Tri WrEx FEx WrFl FFlx IP Quad Ham TA G [First Name9 (NamePattern2) ] [Last Name (un) 938] L 5 4+ 5- 5 5 5 5 5- 5- 5- 5- 4+ 5- 5- R 5 4+ 4+ 5- 5- 5 5 4 4+ 4+ 4+ 4+ 5- 5- Reflexes - Biceps Triceps Brachioradialis Patellar Ankle R 1 1 1 1 0 L 1 1 1 1 0 Extensor response on R and flexor on L. No ankle clonus. Sensation - LT, temp, vibration symmetric b/l over UEs. LT diminished on bottom of L foot. Decreased LT and vibration sense over dorsal aspect of R foot. LT, temp, vibration intact and b/l symmetric over remainder of LEs. PS intact in index fingers b/l, [2-11] in toes b/l. Coordination - Past-pointing on finger to nose. Pertinent Results: MR [Name13 (STitle) 430] with and without contrast- [2139-1-21]- Nodular subependymal enhancement corresponding to FLAIR and T2 abnormality. The main differential consideration is lymphomatous infiltration. Small vessel chronic ischemia may co-exist. EEG- [2139-1-20]- This is an abnormal routine EEG due to intermittent left temporal theta slowing and right temporal sharp waves. These findings suggest subcortical dysfunction on the left and cortical irritability on the right in the temporal regions. No electrographic seizures were noted during this recording. CSF - [2139-1-22] WBC 2, RBC 2, Protein 54, Glucose 98 LDH 87 Gram Stain Negative Culture negative Cytology: Rare atypical cells in a background of mature lymphocytes and monocytes. Protein electrophoresis (SPEP): No oligoclonal bands VZV PCR negative Cryptococcal Ag negative [Male First Name (un) 2326] Virus negative EKG ([2139-1-25]): Sinus tachycardia. Left atrial abnormality. Prominent QRS voltage suggests left ventricular hypertrophy, although it is non-diagnostic. ST-T wave abnormalities may be due to left ventricular hypertrophy but clinical correlation is suggested. Since the previous tracing of [2138-12-16] sinus tachycardia is now present and QRS voltage is less prominent. Renal US ([2139-1-27]): No hydronephrosis. Linear calcifications within the transplant kidney may represent non-obstructive calculi. CXR ([2139-1-19]): No acute intrathoracic abnormality. CXR ([2139-1-24]): Pending CXR ([2139-1-25]): In comparison with the study of [1-19], respiratory motion somewhat degrades the image. The heart is normal in size and there is no vascular congestion or pleural effusion. No definite acute focal pneumonia. Broken sternal wires are again seen. CXR ([2139-1-27]): Left lung is clear. There could be a small region of new opacification at the base of the right lung above the elevated right hemidiaphragm, probably mild atelectasis or superimposition of normal structures. There are no abnormalities convincing for pneumonia. Pleural effusion, if any, is minimal on the right. Heart size is normal. Incidental note is made of possible acute fracture of the left eighth rib more obvious on the chest radiograph from [1-25], and distortion of the right seventh rib posterolaterally that looks more like a healed fracture. CXR ([2139-1-27]): NG appropriately placed. . [2138-2-13] CXR-FINDINGS: Improvement in degree of pulmonary edema with residual perihilar haziness. An asymmetric area of alveolar consolidation in the right infrahilar region. The latter may be due to a resolving area of asymmetrical edema, but infection is also possible in the appropriate setting. Small pleural effusions are present bilaterally as well as atelectatic changes in the left retrocardiac area. . LENI [2-15]-IMPRESSION: No DVT identified within bilateral lower extremities. . CXR [2-17]-FINDINGS: As compared to the previous radiograph, the monitoring and support devices are in unchanged position. The pre-existing right basal opacity is less dense but slightly more extensive. The pre-existing left retrocardiac opacity has completely resolved. There is no evidence of interval occurrence of focal parenchymal opacities suggesting pneumonia. Unchanged size of the cardiac silhouette. . Brief Hospital Course: MICU Course: Dr.[Known lastname ] was admitted to the ICU for acute hypoxic respiratory failure. This was felt to be flash pulmonary edema secondary to hypertension with BPs 220s/130s. He was maintained on Bipap. Fluid was removed via HD. He was initially placed on nitro gtt for BP control. His BP regimen was changed by increasing his metoprolol to 50 TID, adding back his home amlodipine 10mg and adding hydral. He had been on an ACE and [Last Name (un) ] at home which were held for [Last Name (un) ]. His CEs were stable. Other chantges: Keppra redosed for HD. No MTX yet. LENIs negative. Renal and onc coordintating. Continues to be lethargic. Responds to questions by noding head yes or no. NEUROLOGY: Altered Mental Status - Upon presentation, Dr. [Known lastname ] had a waxing and [Doctor Last Name 688] level of orientation, frequently talking as if his daydreams were reality. Focal exam deficits included impairment of downward gaze, right facial droop, right arm and leg weakness. MRI with contrast was concerning for metastatic lymphoma. Infectious causes were also initially in the differential, especially CMV; however, the infectious work-up was negative. Toxic/Metabolic work-up was negative. Uremic encephalopathy not likely in setting or low-for-pt BUN and Cr as well as continued hemodialysis. Ultimately, the patient was transferred to the BMT service. He was given a cycle of intravenous methotrexate and Rituxan. After this treatment, his mental status was monitored and his mental status did not improve, and ultimately he was made comfort measures only and passed away in the hospital. Seizures - Given concern that the waxing and [Doctor Last Name 688] mental status could suggest seizures, EEG was initially obtained and revealed intermittent L temporal theta slowing and R temporal sharp waves, but no seizure activity on EEG. On [1-24], Dr. [Known lastname ] had several episodes of unresponsiveness to voice and reports of left leg and arm shaking, clinically concerning for seizure. He was started on Keppra for seizure prophylaxis, and the episodes appear to have resolved at the time of transfer to the BMT service. CNS Lymphoma - After the MRI with contrast raised concern for metastatic lymphoma, a follow-up LP was performed. This showed 2 WBC, insufficent for determination of clonality. Cytology demonstrated a few atypical lymphocytes. SPEP showed no oligoclonal bands. Beta-2 microglobulin was noted to be elevated in the CSF.. Intrathecal methotrexate was considered but neuro-oncology expressed concern that this would not adequately reach the subependymal region where the metastatses were seen. The option for IV methotrexate was discussed extensively with the family, and they expressed interest. He was ultimately transferred to the BMT service, where he was given a cycle of intravenous methotrexate. He subsequently received leucovorin and hemodialysis to minimize methotrexate toxicity. He had a transaminitis most likely from the methotrexate which resolved. He was given leucovorin until the methotrexate levels in his blood were undectable. Shingles - On [1-22], Dr. [Known lastname ] developed a rash in the right C3-C5 distribution ending midline. Derm was consulted and suspected Shingles; DFA which was positive for VZV in setting of immunosuppression. Dr. [Known lastname ] was then started on renal dose acyclovir, briefly switched to famciclovir and then ultimately ganciclovir per ID recommendations, to cover CMV as well as VZV. On [1-26], given concern for bacterial suprainfection, vancomycin was started per hemodialysis protocol, with all doses given during dialysis. He was continued on vancomycin until.... UTI - Initial urine culture showed mixed flora, and UA was negative. Dr. [Known lastname ] developed fevers during admission and repeat urine studies revealed E. Coli (>100,000 colonies, pan-sensitive except to Bactrim) and Enterococcus (10,000-100,000 colonies). This was initially treated with ceftriaxone ([1-26]), and then switched to cefepime ([1-27]) in the context of bacteremia (see below), per ID recs. ID also recommended a renal ultrasound to check for GU reflux in the context of oliguria; demonstrated no hydronephrosis. They also recommended considering abdominal CT to further evaluate the kidneys if renal ultrasound was unrevealing...... Bacteremia / Fevers - Blood culture [1-25] grew gram-negative rods, pan-sensitive. As noted above, Dr. [Known lastname ] had been started on Ceftriaxone ([1-26]) and later switched to Cefepime ([1-27]). On [1-30], he was noted to have a fever. CXR was performed but did not show evidence of an acute lung process. He was placed on cefepime/flagyl. Flagyl was eventually stopped on [2-4], per ID recommendations...... ESRD- Dr. [Known lastname ] has ESRD s/p transplant now with failing graft. He was started back on HD in [Month (only) 1096] for concern for uremic encephalopathy. We continued his hemodialysis regimen (Monday/Wednesday/Friday) as well as his Prednisone and Bactrim prophylaxis. He was dialyzed twice in 24 hours post-Gad administration for his MRI. After he received cycle 1 of methotrexate, he was dialyzed on several consecutive days to aid in methotrexate clearance.... NSVT - Dr. [Known lastname ] was noted to have 10-12 beat runs of VTach on telemetry, which seemed to coincide with seizure activity. CK was WNL and Troponin 0.08 in setting of renal failure. The episodes appeared to resolve once Keppra was on board...... Rib Fracture - CXR did show what appeared to be an acute rib fracture of the 8th rib and an older fracture of the 7th rib. There was no history of rib fractures, and the patient does not appear to be in pain from this...... Pressure Ulcers - Dr. [Known lastname ] has two sacral pressure ulcers which are being monitored by the wound consult nurse....... Medications on Admission: Acetaminophen 650 mg PO/NG Q6H:PRN Pain Metoprolol Succinate XL 100 mg PO DAILY Allopurinol 100 mg PO/NG MWF After dialysis Miconazole Powder 2% 1 Appl TP [Hospital1 ] Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO/NG QID:PRN Nausea Milk of Magnesia 30 mL PO/NG Q6H:PRN Nausea Amlodipine 10 mg PO/NG DAILY Nephrocaps 1 CAP PO DAILY Bisacodyl 10 mg PR HS:PRN Constipation Paricalcitol 1 mcg IV Give at dialysis only Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [Hospital1 ] Polyethylene Glycol 17 g PO/NG DAILY [Month (only) 116] hold for loose stools PredniSONE 4 mg PO/NG DAILY Docusate Sodium 100 mg PO BID [Month (only) 116] hold for loose stools Psyllium 1 PKT PO DAILY:PRN Constipation Famotidine 20 mg PO/NG Q24H Senna 1 TAB PO/NG [Hospital1 ] [Month (only) 116] hold for loose stools Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Sulfameth/Trimethoprim DS 1 TAB PO/NG MWF Prophylaxis on steroids Discharge Medications: Patient expired Discharge Disposition: Expired Discharge Diagnosis: Primary -CNS Lymphoma -Herpes zoster -Altered mental status Secondary -End-Stage Renal Disease on Hemodialysis -Diabetes Mellitus -Congestive Heart Failure -Coronary Artery Disease -Hypertension Discharge Condition: Patient Expired Discharge Instructions: Patient Expired Followup Instructions: Patient Expired [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 3922] Completed by:[2141-7-11] ICD9 Codes: 5856, 5990, 4280, 3572, 311, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9084 }	Medical Text: Admission Date: [2191-2-19] Discharge Date: [2191-2-23] Date of Birth: [2106-8-11] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 1] Chief Complaint: weakness Major Surgical or Invasive Procedure: [2191-2-19] ERCP and stent placement History of Present Illness: 84 y.o male with h.o CAD s/p CABG and stenting, pacemaker placement, seizure who presented to OSH with weakness, fatigue, epigastric tenderness, jaundice, and febrile to 101. Pt was given vanco and levaquin, U/S apparently showing CBD dilatation. [Doctor First Name ] called and wanted to admit to [Doctor First Name ] ICU on the east, with plans of ERCP in the am. Pt states his fatigue/chills started 1 wk ago and progressed to where he could not get out of bed today or move. Pt reports waxing/[Doctor Last Name 688] symptoms over the week. He also reports chills, difficulty in taking a deep breath, occasional "knot" in epigastric area, and severely decreased appetite. He also reports the sensation of falling when trying to sit upright. Pt denies fever, headache, dizziness, ST/URI/blurred vision/cough/cp/palp/abd pain/n/v/d/c/melena/brbpr/dysuria/hematuria/joint pain/skin rash paresthesias. He reportedly had and US at OSH without clear evidence of gallstones or CBD dilation. He then had a CT scan that suggested choledocholithiasis with mild dilation of the CBD but no significant intrahepatic duct dilation. . Currently, pt reports that his pain is gone. . In the ED, vital signs were initially: Time Pain Temp HR BP RR Pox -21:00 7 98.6 92 152/118 18 98 102.7T, 97, 157/58, 18, 97% on 3L He was given flagyl and morphine. -pt refusing tylenol in the ED stating it will make him bleed. Pt underwent RUQ u/s and surgery was consulted. Past Medical History: -cabg [2175] after ?blood clot in heart, ?silent MI. Stenting a few years later -pacemaker, 2 yrs ago after fainting spells -seizure, started after neck injury -neck fracture -l.hip fx. -kidney stones -gout. Social History: Lives by himself. Quit smoking 40 years ago. Denies ETOH. Family History: NC Physical Exam: VS:T. 98.2, HR 84, BP 109/55, RR 20 sat 93% on 2L GEN:The patient is in no distress and appears comfortable, jaundiced. SKIN:No rashes or skin changes noted HEENT:EOMI, unable to assess JVD, neck supple, No lymphadenopathy in cervical, posterior, or supraclavicular chains noted. CHEST:b/a ae, +faint crackles at bases. CARDIAC: Regular rhythm; no murmurs, rubs, or gallops. distant heart sounds. +midline sternal scar, well healed. ABDOMEN: +bs, soft, Nt, ND, no guarding or rebound. EXTREMITIES:no peripheral edema, warm without cyanosis NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE [5-18], and BLE [5-18] both proximally and distally. Pertinent Results: ULTRASOUND: 1. Echogenic liver consistent with fatty infiltration. Other forms of liver disease and mnore severe liver disease including significant hepatic cirrhosis/fibrosis is not excluded. 2. No intra- or extra-hepatic biliary dilatation. 3. Distended gallbladder with mild wall thickening and edema, which could be secondary to third spacing, though in the appropriate clinical setting cholecystitis is not excluded. ERCP: -A single periampullary diverticulum with large opening was found at the major papilla. -The diverticulum distorted the position of the major papilla making cannulation difficult. -Cannulation of the biliary duct was attempted with a sphincterotome as well as a 5-4-3 tapered cannula with a guidewire, and ultimately cannulation was successfully performed with a sphincterotome after a guidewire was placed. Contrast medium was injected resulting in complete opacification. -A moderate dilation was seen at the main duct with the CBD measuring 10-11 mm. Two 10 mm round stones that were causing partial obstruction were seen at the lower third of the common bile duct. A 7cm by 10FR plastic biliary stent was placed successfully. -After the stent was placed, pus and sludge were seen exiting from the stent and the ampulla. -A sphincterotomy was not performed due to the increased risk of bleeding on aspirin and Plavix. [2191-2-18] 09:10PM BLOOD WBC-11.0 RBC-5.07 Hgb-14.9 Hct-45.9 MCV-90 MCH-29.3 MCHC-32.4 RDW-14.5 Plt Ct-242 [2191-2-19] 04:16AM BLOOD WBC-12.9* RBC-4.18* Hgb-12.7* Hct-38.0* MCV-91 MCH-30.4 MCHC-33.5 RDW-14.4 Plt Ct-223 [2191-2-20] 03:38AM BLOOD WBC-8.4 RBC-4.32* Hgb-13.0* Hct-40.8 MCV-95 MCH-30.2 MCHC-31.9 RDW-14.7 Plt Ct-212 [2191-2-21] 06:54AM BLOOD WBC-8.3 RBC-4.24* Hgb-12.8* Hct-39.8* MCV-94 MCH-30.1 MCHC-32.1 RDW-14.7 Plt Ct-278 [2191-2-18] 09:10PM BLOOD PT-12.5 PTT-20.6* INR(PT)-1.1 [2191-2-19] 04:16AM BLOOD PT-14.4* PTT-22.4 INR(PT)-1.2* [2191-2-20] 09:38AM BLOOD PT-14.1* PTT-23.2 INR(PT)-1.2* [2191-2-18] 09:10PM BLOOD Glucose-124* UreaN-34* Creat-1.7* Na-135 K-3.6 Cl-98 HCO3-24 AnGap-17 [2191-2-19] 04:16AM BLOOD Glucose-153* UreaN-33* Creat-1.6* Na-136 K-3.1* Cl-104 HCO3-19* AnGap-16 [2191-2-19] 03:15PM BLOOD Glucose-87 UreaN-31* Creat-1.3* Na-139 K-3.8 Cl-109* HCO3-20* AnGap-14 [2191-2-20] 03:38AM BLOOD Glucose-82 UreaN-26* Creat-1.1 Na-139 K-3.7 Cl-110* HCO3-19* AnGap-14 [2191-2-21] 06:54AM BLOOD Glucose-119* UreaN-19 Creat-1.1 Na-138 K-3.9 Cl-104 HCO3-26 AnGap-12 [2191-2-18] 09:10PM BLOOD ALT-277* AST-246* AlkPhos-339* TotBili-8.6* DirBili-6.8* IndBili-1.8 [2191-2-19] 04:16AM BLOOD ALT-211* AST-190* LD(LDH)-221 AlkPhos-269* TotBili-8.0* [2191-2-20] 03:38AM BLOOD ALT-197* AST-161* LD(LDH)-184 AlkPhos-243* Amylase-18 TotBili-7.7* [2191-2-21] 06:54AM BLOOD ALT-164* AST-117* AlkPhos-275* TotBili-7.3* [2191-2-18] 09:10PM BLOOD Lipase-152* [2191-2-19] 04:16AM BLOOD Lipase-54 [2191-2-20] 03:38AM BLOOD Lipase-59 [2191-2-18] 09:10PM BLOOD Albumin-3.6 [2191-2-19] 04:16AM BLOOD Albumin-2.7* Calcium-7.7* Phos-3.5 Mg-2.0 [2191-2-19] 03:15PM BLOOD Calcium-7.8* Phos-3.5 Mg-2.1 [2191-2-20] 03:38AM BLOOD Calcium-8.2* Phos-2.6* Mg-2.1 [2191-2-21] 06:54AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.0 [2191-2-18] 09:30PM BLOOD Lactate-1.9 [2191-2-19] 03:15PM URINE Color-[Location (un) ] Appear-Hazy Sp [Last Name (un) ]-1.019 [2191-2-19] 03:15PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-4* pH-5.5 Leuks-TR [2191-2-19] 03:15PM URINE RBC-368* WBC-15* Bacteri-FEW Yeast-NONE Epi-<1 [2191-2-19] 03:15PM URINE CastHy-2* [2191-2-19] 03:15PM URINE Eos-POSITIVE [2191-2-20] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2191-2-20] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2191-2-19] URINE URINE CULTURE-FINAL INPATIENT [2191-2-18] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY {GRAM NEGATIVE ROD(S)}; Anaerobic Bottle Gram Stain-FINAL EMERGENCY [Hospital1 ] [2191-2-18] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY {GRAM NEGATIVE ROD(S)}; Anaerobic Bottle Gram Stain-FINAL EMERGENCY [Hospital1 ] Brief Hospital Course: MICU Course: Mr. [Known lastname 86463] was admitted with fever jaundice and RUQ pain. Labs and imaging consistent with cholangitis. He went for ERCP and a drain was placed. Sphincterotomy was not performed as he was on aspirin and Plavix. He was noted to have a wide-complex tachycardia with pacing spikes. Electrophysiology was consulted and this was determined to be an atrial tracking rhythm resulting from the settings on his pace-maker. Routine cardiology follow-up is recommended. He was on Cipro/Flagyl. After ERCP he was hypotensive, he responded very well to aggressive fluids resuscitation. IV Vancomycin was added to antibiotic regiment for empiric cover of Enterococcus. After procedure home dose of aspirin and Plavix was started. On PPD 1 we restarted regular diet, he tolerated very well and did not have any abdominal pain. Liver function tests, bilirubin, amylase and lipase were followed every day with marked improve in values. Blood cultures from ED were positive for BACTEROIDES FRAGILIS GROUP. BETA LACTAMASE POSITIVE. Further surveillance blood cultures were negatives, as well as urinary cultures. IV vancomycin was discontinued. Patient was transferred from MICU to the floor on the evening of [2191-2-20]. Physical therapy started working with him. They recommended the patient to go to the Rehab facility on discharge. On evening of [2191-2-21] patient had SOB, EKG showed no acute changed, cardiac enzymes times 3 showed no elevation, We started him on Pulmonary toilet and Albuterol Nebs which worked very well and patient had relieve from symptoms. Morning od [2191-2-22] patient has asymptomatic hypertensive episode with SBP 190, he was given IV Hydralazine 10mg blood pressure decreased properly. His blood pressure was stable the rest of his hospitalization. On [2-23]/ 10 : patient feeling fine, vital signs stable and no abdominal pain. Medications on Admission: Isosorbide Dinitrate 30 mg Tab Oral daily Allopurinol 100 mg Tab Oral daily Avapro 150 mg Tab Oral [Hospital1 ] coreg 6.25 [Hospital1 ] Protonix 40 mg Tab Oral [Hospital1 ] Zocor 20 mg Tab Oral daily Levetiracetam 500 mg Tab Oral [Hospital1 ] Plavix 75 mg Tab Oral daily Niacin 800 mg PO BID 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: One (1) PO BID (2 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: One (1) PO HS (at bedtime) as needed for insomnia. 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB, wheezing. 10. Carvedilol 12.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 11. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 12. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 13. Avapro 150 mg Tablet Sig: One (1) Tablet PO twice a day. 14. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day. 15. Niacin Oral 16. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 10 days. 17. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Discharge Disposition: Extended Care Facility: Liberty Commons Nursing & Rehab Center - [Location (un) 4979] Discharge Diagnosis: Primary: Cholangitis, choledocholithiasis Secondary: coronary artery disease, acute renal insufficiency Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Dear Mr. [Known lastname 86463], It was a pleasure caring for you. You were admitted for cholangitis, which is an infection in your biliary tract. You had a procedure called an ERCP. There were stones obstructing but they were not removed because of the risk of bleeding from your plavix and aspirin. A drain was placed to remove the infection and bile. You are on antibiotics for the infection which also spread to your blood. You had an abnormal heart rhythm that was not dangerous and resulted from the settings of your pace maker. It is called atrial tracking. You should discuss this with your cardiologist. 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 is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [5-23] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Followup Instructions: ERCP: Please call Dr.[Name (NI) 2798] office to schedule an appointment in 4 weeks. ([Telephone/Fax (1) 86464] Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 9011] Please schedule an appointment with Dr. [Last Name (STitle) ] after your appointment with ERCP. Dr [Last Name (STitle) ] will discuss Cholecystectomy surgery options (Remove of gallbladder) to prevent further episodes of gallstones complications. Completed by:[2191-2-23*] ICD9 Codes: 5849, 7907, 2749, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9085 }	Medical Text: Admission Date: [2170-4-9] Discharge Date: [2170-4-13] Date of Birth: [2109-10-21] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: [2170-4-9] Aortic Valve Replacement (23mm CE pericardial valve)/Asc. Aorta and Hemiarch Replacement (24mm Gelweave graft) History of Present Illness: 60 y/o male with known bicuspid aortic valve and aortic stenosis. Most recent edho revealed severe AS with moderate AI. Also had a dilated aorta. Referred for surgical intervention. Past Medical History: Bicuspid Aortic Valve, Aortic Stenosis, Chronic Obstructive Pulmonary Disease, Hypertension, s/p Tonsillectomy Social History: + Current Tobacco use (1ppd x 40 yrs). 1 ETOH drink/month. Denies recreational drug use. Family History: Mother with CAD in 70s. Father died from MI at 60. Physical Exam: VS: 62 145/69 5'9" 79.5kg Gen: WDWN male in NAD Skin: W/D -lesions HEENT: NC/AT, EOMI, PERRL Neck: Supple, FROM, -JVD Lungs: CTAB -w/r/r Heart: RRR w/ 5/6 SEM Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, -c/c/e Neuro: A&O x 3, MAE, non-focal, 2+ pulses throughout Pertinent Results: [2170-4-9] Echo: PRE-BYPASS: Overall left ventricular systolic function is normal (LVEF>55%). Regional left ventricular wall motion is normal. There is mild symmetric left ventricular hypertrophy. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis (area 0.8 cm2). Severe (4+) aortic regurgitation is seen. No atrial septal defect is seen by 2D or color Doppler. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. POST-BYPASS: On infusion of phenylephrine. Preserved left ventricular systolic function. Bioprosthetic aortic valve is seen in good position. No perivalvular leak. Trivial aortic insufficiency. Peak gradient of 21 mm Hg, mean gradient of 11. Rest of the study is unchanged from baseline. [2170-4-9] 10:49AM BLOOD WBC-4.2 RBC-2.88# Hgb-9.2# Hct-25.0# MCV-87 MCH-31.8 MCHC-36.6 RDW-13.0 Plt Ct-97* [2170-4-9] 10:49AM BLOOD PT-15.7* PTT-46.5* INR(PT)-1.4* [2170-4-9] 11:44AM BLOOD UreaN-15 Creat-0.7 Cl-109* HCO3-23 [2170-4-13] 06:55AM BLOOD WBC-10.8 RBC-3.27* Hgb-10.4* Hct-28.7* MCV-88 MCH-31.7 MCHC-36.2* RDW-13.4 Plt Ct-170 [2170-4-13] 06:55AM BLOOD Plt Ct-170 [2170-4-13] 06:55AM BLOOD Glucose-114* UreaN-16 Creat-0.9 Na-132* K-4.6 Cl-97 HCO3-28 AnGap-12 Brief Hospital Course: Mr. [Known lastname 64344] was a same day admit after undergoing all pre-operative work-up as an outpatient. On [4-9] he was brought to the operating room where he underwent an aortic valve replacement and ascending aorta and hemiarch replacement. Please see operative report for details. Following surgery he was transferred to the CSRU for invasive monitoring. Later on op day he was weaned from sedation, awoke neurologically intact and extubated. Chest tubes were removed on post-op day one and he was transferred to the telemetry floor for further care. Beta blockers and diuretics were initiated and he was gently diuresed towards his pre-op weight. Pacing wires removed on POD #3. He made excellent progress and was cleared for discharge to home with VNA services on POD #4. Pt. is to make all follow-up appts. as per discharge instructions. Medications on Admission: Accuretic 20/12.5mg qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:1 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:1 3. 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 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 5. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed. Disp:100 Tablet(s) Refills:0 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:20 Tablet(s) Refills:0 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 10 days. Disp:20 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: Aortic Stenosis/Bicuspid Aortic Valve/ Ascending Aortic Aneurysm s/p Aortic Valve Replacement/Asc. Aorta and Hemiarch Replacement PMH: Chronic Obstructive Pulmonary Disease, Hypertension, s/p Tonsillectomy Discharge Condition: Good Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting greater than 10 pounds for 10 weeks. No driving for one month. [Last Name (NamePattern4) 2138]p Instructions: Dr. [Last Name (Prefixes) ] in 4 weeks Dr. [Last Name (STitle) 6254] in [2-3] weeks Dr. [First Name (STitle) ] in [1-2] weeks Completed by:[2170-4-13] ICD9 Codes: 4241
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9086 }	Medical Text: Admission Date: [2202-12-29] Discharge Date: [2202-12-30] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2291] Chief Complaint: Gastrointestinal bleed Major Surgical or Invasive Procedure: expired History of Present Illness: Mr. [Known lastname 40370] is a [Age over 90 ]-year-old man with dementia and a history of clostridium difficile who presented with a brisk upper GI bleed (hematemesis and melena) from [Hospital3 537]. He also had altered mental status. He continued to have hematemesis and melena on presentation. Initially he got 4units packed red blood cells, fresh frozen plasma and platelets. His code status was DNR/DNI so he was not intubated. He also has an abdominal aortic aneurysm that had increased in size on imaging. He was admitted to the MICU. A family discussion took place and the patient was transitioned to comfort-focused care. Past Medical History: 1. h/o Paroxysmal atrial fibrillation 2. HTN 3. h/o falls 4. BPH 5. L ear deafness 6. R eye cataracts s/p lens replacement 7. Arthritis bilateral knees and L hip 8. Mild dementia, unspecified type Social History: Mr. [Known lastname 40370] lives in the [Hospital3 15333] facility. Daughter [Name (NI) ] (work: [Telephone/Fax (1) 40371]) is his HCP. Smoked for 30 years, [1-23] pack/day. Denied EtOH use. No recent smoking or alcohol. Family History: Noncontributory. Physical Exam: Admission Exam: Vitals: HR 108-122 General: Nonverbal, NAD, appears comfortable HEENT: dry MM CV: deferred Lungs: deferred Abdomen: deferred GU: foley Ext: deferred Neuro: deferred Discharge Exam: patient expired Pertinent Results: [2202-12-29] 09:15AM PLT COUNT-222 [2202-12-29] 09:15AM WBC-11.1* RBC-3.25* HGB-10.4* HCT-32.5* MCV-100* MCH-32.0 MCHC-32.0 RDW-12.8 [2202-12-29] 09:15AM LIPASE-16 [2202-12-29] 09:15AM UREA N-27* CREAT-0.8 [2202-12-29] 09:22AM GLUCOSE-160* LACTATE-3.3* NA+-141 K+-3.8 CL--108 TCO2-24 [2202-12-29] 09:40AM FIBRINOGE-343 [2202-12-29] 09:40AM PT-12.6* PTT-26.6 INR(PT)-1.2* [2202-12-29] 11:24AM URINE RBC-8* WBC-2 BACTERIA-NONE YEAST-NONE EPI-<1 [2202-12-29] 11:24AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-NEG [2202-12-29] 11:24AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.043* [2202-12-29] 11:42AM PLT COUNT-141* [2202-12-29] 11:42AM NEUTS-86.1* LYMPHS-9.4* MONOS-3.9 EOS-0.4 BASOS-0.3 [2202-12-29] 11:42AM WBC-15.5* RBC-3.86* HGB-12.2* HCT-36.2* MCV-94 MCH-31.7 MCHC-33.8 RDW-15.2 [2202-12-29] 11:43AM freeCa-0.98* [2202-12-29] 11:43AM HGB-12.9* calcHCT-39 [2202-12-29] 11:43AM GLUCOSE-173* LACTATE-4.0* NA+-143 K+-4.0 CL--110* TCO2-20* . [2202-12-29] CT Abdomen 1. No acute intra- or retroperitoneal hemorrhage or hematoma. 2. Extensive atherosclerotic disease with interval enlargement of the AAA from [2197]. No evidence of current aneurysmal rupture or aortoenteric fistulization. 3. New pneumobilia. Suggest correlation with history of sphincterotomy. If none, findings can also be seen with biliary-enteric fistula. 4. Cholelithiasis without evidence of acute cholecystitis Brief Hospital Course: Mr. [Known lastname 40370] is a [Age over 90 ]-year-old man with dementia and a history of clostridium difficile who presented with a brisk upper GI bleed (hematemesis and melena) from [Hospital3 537]. A family discussion took place and the patient was transitioned to comfort-focused care. . His hospital course by problem is as follows: . # Pain/anxiety: He was placed on morphine gtt with lorazepam and acetaminophen as needed. Medications not geared towards comfort were discontinued. The Palliative Care team was aware of his admission and made recommendations for pain management. The patient was frequently assessed for pain and was kept clean and comfortable. The patient was placed in a single room and a quiet peaceful environment was maintained in order to maximize his comfort. His family was updated through phone calls. # GI Bleed: He had continued melena throughout the admission. Initially, this was aggressively treated, but when the goals of care changed patient was not given any further transfusions or attempts at intervention. . # 6.5cm abdominal aortic aneurysm (AAA): His AAA was noted but given his status as comfort-measures-only, surgery was not pursued. The patient expired on [2202-12-30]. Medications on Admission: brimonidine citalopram donepezil finasteride nystatin aspirin Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9087 }	Medical Text: Admission Date: [2120-12-30] Discharge Date: [2121-1-3] Date of Birth: [2040-2-23] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 618] Chief Complaint: Recurrent Intracranial hemorrhage Major Surgical or Invasive Procedure: NONE History of Present Illness: 80 year-old woman with a history of a recent right frontal hemorrhage with left hemiparesis (discharged from [Hospital1 18] [12-6]), hypertension, dyslipidemia, coronary artery disease s/p MI with stent placement, and hypothyroidism, who returns today as a transfer from an outside hospital for worsening left-sided weakness. The patient's nurse spoke at [Hospital 582] Rehabilitation spoke with Neurology attending Dr. [Last Name (STitle) ] at ~10 am today. According to her nurse, on Friday, the patient was able to sit in a chair, feed herself, say short phrases, and move her left arm and leg "to a limited extent." Today, the nurse noted the patient had a notable left-sided flaccid hemiplegia. She was not vocalizing. The time of onset is unclear from documentation, though she was noted to be sleeping from 11 pm to 7 am. A note from OT today states that she was able to follow a three-step command and move her left-side to command on [11-27]. However today, she was able to follow only a one-step command and was unable to move her left side to command. She was then brought to [Hospital3 3765]. There, documentation notes that her left side was flaccid with a left-upgoing toe. By report, a head CT there revealed a new right frontal bleed, more posterior than her prior. There was mild associated edema but no significant mass effect. WBC was 9.5 with neutrophilic predominance (81%). Chemistry was unremarkable. TSH was significantly elevated at 20.2. ESR was 41. Urinalysis was concerning for a urinary tract infection: turbid, large blood ([10-23] RBC), 30 protein, large leukocyte esterase, positive nitrites, many bacteria, and rare calcium oxalate crystals. EKG was sinus rhythm at a rate of 82. She was loaded with fosphenytoin and a dose of Rocephin for the presumed urinary tract infection. Of note, it appears that she was on Levaquin at her rehabilitation facility (per OSH note). Of note, she was admitted to the neurologic-ICU on [11-19] for a large, spontaneous right lobar hemorrhage with edema. (Of note, she was on a full daily Aspirin and Plavix at the time.) There was and mass effect on the right lateral ventricle and 4 mm shift to the left. A small amount of hydrocephalus as well as subarachnoid and intraventricular hemorrhage was noted. Her hemorrhage was stable with sequential imaging. Though there was concern for amyloid angiopathy as the underlying process, an MRI did not reveal microbleeds. A CTA did not reveal an underlying vascular malformation. On transfer to the floor, she developed hyponatremia to ~127 that improved after her hydrochlorothiazide was discontinued. She also developed a urinary tract infection with both enterococcus and E. coli which was treated with a week course of vancomycin and ceftriaxone respectively. She also developed soft stools, though C. diff was negative on two samples. This development was thought to be related to her tube feeding, which was adjusted. She received a PEG tube on [12-4]. On discharge, her examination was noted as follows: "stable LUE and LLE paresis. Stable eyelid apraxia. Minimally responsive to touch or voice. Rare vocalizations yes/no." Review of Systems: Given her somnolence and inattention, the patient was unable to reliably answer questions posed to her. Past Medical History: CAD s/p MI and proximal LAD taxus stent HTN HLD hypothyroidism left knee sx Social History: Lives at home with husband Family History: Noncontributory Physical Exam: General: elderly woman lying sprawled across stretcher, trying to remove her blankets HEENT: NC/AT, sclerae anicteric, dry MM, no noted exudates in oropharynx Neck: no nuchal rigidity, but moves neck actively reducing ability to assess on passive range of motion, no bruits Lungs: reduced breath sounds on poor effort, but clear to auscultation CV: regular rate and rhythm, no MMRG Abdomen: PEG in place, site C/D/I, soft, non-tender, non-distended Ext: cool, no edema, pedal pulses appreciated Skin: pale Neurologic Examination: Mental Status: Has eyes closed, though able to open on command at first. For much of the interview, she actually closes her eyes on request of opening as I attempt to assess them. She does not follow other commands and does appear somewhat inattentive and somnolent (even accounting for the previously reported eyelid apraxia). She seems to be moving around restlessly in the bed. Cranial Nerves: Could not assess fundi as patient actively closed eyes on attempts to examine; there is no clear deficit of visual fields on blink to threat. Pupils equally round and reactive to light, 4 to 3 mm bilaterally. Moves eyes to left and right spontaneously, but does not follow commands for assessment of vertical gaze, no nystagmus seen. Left facial weakness noted in lower face. Hearing intact to finger rub bilaterally. Palate elevates midline and tongue protrudes midline on yawn. Sensorimotor: Normal bulk and though tone seems increased in the left side, more so in the arm than in the leg. No tremor or adventitious movements seen. The patient is too inattentive to participate in full formal strength testing. She is moving the right side spontaneously and against gravity, and is able to demonstrate near full strength in the biceps and triceps on the right. On her left, she spontaneous is flexing her hip anti-gravity to raise her knee off the bed. She appears to have some minimal movement in the left arm, perhaps ~2-/5. She withdraws all extremities to noxious, right side more than left. Her left leg withdraws far more briskly than her left arm. Reflexes: B T Br Pa Pl Right 2 2 2 2 0 Left 3 2 3 3 0 Toes were upgoing bilaterally. Has grasp reflex on the right. The patient was unable to participate in coordination and gait testing. Pertinent Results: [2120-12-30] 03:54PM PT-14.9* PTT-26.4 INR(PT)-1.3* [2120-12-30] 03:54PM PLT COUNT-419 [2120-12-30] 03:54PM NEUTS-77.8* LYMPHS-16.4* MONOS-3.4 EOS-2.0 BASOS-0.4 [2120-12-30] 03:54PM WBC-9.9 RBC-4.11* HGB-12.4 HCT-36.7 MCV-89 MCH-30.2 MCHC-33.8 RDW-14.0 [2120-12-30] 03:54PM ASA-NEG ETHANOL-NEG ACETMNPHN-5.2 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2120-12-30] 03:54PM PHENYTOIN-19.4 [2120-12-30] 03:54PM T3-63* FREE T4-1.1 [2120-12-30] 03:54PM TSH-23* [2120-12-30] 03:54PM ALBUMIN-4.0 CALCIUM-9.4 PHOSPHATE-3.7 MAGNESIUM-1.9 [2120-12-30] 03:54PM CK-MB-7 [2120-12-30] 03:54PM CK-MB-7 [2120-12-30] 03:54PM UREA N-19 CREAT-0.6 SODIUM-138 POTASSIUM-3.2* CHLORIDE-97 TOTAL CO2-33* ANION GAP-11 [2120-12-30] 04:00PM URINE RBC-[11-28]* WBC->1000 BACTERIA-MANY YEAST-NONE EPI-0 [2120-12-30] 04:00PM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.013 [2120-12-30] 06:44PM LACTATE-1.2 [2120-12-30] 09:19PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2120-12-30] 09:19PM URINE HOURS-RANDOM [2120-12-30] 09:52PM CK-MB-8 cTropnT-<0.01 [2120-12-30] 09:52PM CK(CPK)-452* [2120-12-31] Head CT IMPRESSION: 1. Unchanged appearance of right parietooccipital parenchymal hematoma with an old evolving right parasagittal frontal hematoma; this overall appearance is suggestive of underlying amyloid angiopathy. Persistent mass effect. 2. Disproportionate temporal [Doctor Last Name 534] dilatation suggests more severe medial temporal atrophy, raising the concern for Alzheimer's disease (which may be associated with amyloid angiopathy). 3. No evidence of new hemorrhage. [2121-1-1] Head CT - IMPRESSION: 1. No new hemorrhage or fracture. 2. No significant interval changes, with the known intraparenchymal hemotomas, peri-hemorrhagic edema and mass effect as described above. Brief Hospital Course: Pt was admitted to the ICU for management of her ICH. Neuro: Serial Head CT were obtained to monitor progression of her ICH. Pt was initially started on dilantin for seizure prophylaxis then it was discontinued on [1-1]. ID: UTI She was noted to have a UTI. Ucx Enterococcus and 10K-100K E.coli. Pt initially started on Vanco and CTX IV Abx then switched to PO cephalosporin on the day of discharge for an additional 3 days to complete her course. ENDO: Hypothyroidism Hypothyroidism was known prior to admission yet TSH and free T4 values were obtained to show a need for additional thyroixine supplementation. Her levothyroxine was increased from 88mcg to 112mcg prior to d/c. Medications on Admission: Atorvastatin 80 mg po daily -Acetaminophen 325 mg tablet, 1-2 Tablets every 6 hours as needed for fever, pain -Memantine 10 mg daily -Levothyroxine 88 mcg daily -Amlodipine 2.5 mg daily -Lisinopril 20 mg daily -Senna 8.6 mg [Hospital1 ] as needed for constipation -Docusate Sodium 50 mg/5 mL 100 mg [Hospital1 ] Discharge Medications: 1. Pneumococcal 23-ValPS Vaccine 25 mcg/0.5 mL Injectable Sig: One (1) ML Injection ASDIR (AS DIRECTED). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain or fever. 3. Senna 8.8 mg/5 mL Syrup Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 4. Memantine 5 mg Tablet Sig: Two (2) Tablet PO daily (). 5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 6. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q 6 HOURS PRN FOR SYSTOLIC BLOOD PRESSURE GREATER THAN 160 (). 10. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. Discharge Disposition: Extended Care Facility: [Location (un) 582] Of [Location (un) 5176] Discharge Diagnosis: Right frontal hemorrhage Amyloid Angiopathy Hypothyroidism Right frontal hemorrhage, as discussed above -s/p PEG placement [12-4] -Coronary artery disease s/p MI with prox LAD taxus stent -Hypertension -Dyslipidemia -s/p left knee surgery Discharge Condition: Stable. Eyelid apraxia, Left hemiparesis (leg>arm), Left hyperreflexia, and upgoing toe. UTI. Discharge Instructions: You have come in for an intracranial hemorrhage/brain bleed. This was most likely due to amyloid angiopathy. For this reason you should not be placed on aspirin now or in the future without this being mentioned. You also have an UTI you will be sent out with 3 days of oral antibiotics. Also your thyroid medication has been increased from 88mcg to 112mcg. You TSH and Free T4 should be checked by your PCP [Last Name (NamePattern4) ] 4-6weeks and adjust accordingly. Return to the ER if your symptoms recur, you have persistent nausea and vomiting or any motor deficits. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 640] [Last Name (NamePattern4) 3445], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2121-1-22] 1:00 PCP [Name Initial (PRE) 176] 1-2 weeks [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] ICD9 Codes: 431, 5990, 412, 4019, 2724, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9088 }	Medical Text: Admission Date: [2137-3-3] Discharge Date: [2137-3-8] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4052] Chief Complaint: Chest Pain/Shortness of Breath CHF,demand ischemia Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 85 year old man recently admitted to [Hospital1 18] in [2137-1-20] for bilateral lower lobe pneumonia complicated by a NSTEMI. Patient has reported history of untreated multiple MIs in the [2111] and has diagnoses of HTN, CKD, CHF, DVT,and bipolar disorder. On last admission, the patient had an echocardiogram that revealed an EF 40-50% with global LV hypokinesis. The cardiology service was consulted at this time with recommendation that the patient was likely a poor cath candidate given his multiple comorbidities and CKD with creatinine of 2.5 The patient was discharged back to his home at Heathwood NH with decision to manage patient's cardiac disease medically. Per notes from E.D. the patient is reported to have experienced chest pain and dyspnea early this a.m. that was relieved at that time with SL-NTG x1. The patient's symptoms recurred and was treated again with nitropaste as well as lasix 120mg PO, without resolution of symptoms this time. Given his symptoms, the patient was trasnferred to [Hospital1 18] where he was found to be tachypnic and dyspneic on arrival. In the ED, the patient was treated with ASA 325mg, 80mg IV lasix, O2, NTG gtt and was started on non-invasive ventilation, with reported resolution of pain. The patient was treated with an additional 160mg IV lasix without good initial response. Upon transfer to the CCU, the patient had produced only 300cc urine. . Allergies: NKDA Past Medical History: 1. HTN 2. CKD: Cr from office visit last year w/ Cr 1.8 3. bipolar disorder - on lithium previously, recently experienced toxicity 4. hyperlipidemia 5. prostrate surgery many years ago - indication not specified 6. Patient reports hospitalization in [2111]'s for MI but does not know details. 7. Urinary incontinence 8. MI ([2111]) and a recent NSTEMI in [Month (only) ]/06 9. DVT 10. CHF Social History: Patient lives with his wife of > 60 years in an [Hospital3 ] senior facility in [Location (un) ]. The patient is reported to be independent of ADLs. He receives prepared meals twice daily via the home facility. He reports that at baseline he is able to ambulate although only with the aid of a walker on wheels. He denies any drinking history and has very remote tobacco use. Has 2 grown children, one is [State ] and one in [State 760]. Dr. [Last Name (STitle) 1266] is the patient's PCP and his wife his HCP. Dr. [Last Name (STitle) 1266] has been very involved with this patient regarding code status and goals of care. Currently, the patient is full code as was established on last admission and confirmed this admission. Given patient's overall prognosis and expectation that the patient will require more and more frequent hospitalization, conversation is ongoing with regards to overall management strategies. Full code. Wife is his health care proxy. . Family History: Non-contributory Physical Exam: Physical Exam: Vitals: BP: 118/59 HR: 77 (NSR) RR: 31-32 O2 Sat: 96% on 4L NC . Gen: Patient is an elderly male, sitting upright in bed in moderate respiratory distress, with use of accessory muscles when breathing and audible wheezes. HEENT: NC, patient with small dry blood over left lower lip. MM: dry Neck: prominent EJ, + JVD Chest: Noteable for use of sternocleidomastoids and intercostal muscles with breathing. Patient with audible expiratory wheezes from upper airway, asucultation of lung fields without significant wheezes. Rapid breathing with small tidal volume, poor airmovement throughout. Small crackles at left lower base Cor: RRR, no obvious M/R/G Abd: Obese, soft, NT. +NABS Ext: 2+ pedal edema, 1+ pitting edema to knees. Chronic hyperpigmentation of lower extremities bilaterally. Distal pulses 2+ bilaterally. Pertinent Results: Admission Labs: . [2137-3-3] 11:40AM URINE RBC-0-2 WBC->50 BACTERIA-MOD YEAST-NONE EPI-0-2 [2137-3-3] 11:40AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2137-3-3] 11:40AM URINE COLOR-Yellow APPEAR-Cloudy SP [Last Name (un) 155]-1.011 [2137-3-3] 11:40AM PT-43.1* PTT-31.8 INR(PT)-4.9* [2137-3-3] 11:40AM NEUTS-95.2* BANDS-0 LYMPHS-3.1* MONOS-1.5* EOS-0.2 BASOS-0 [2137-3-3] 11:40AM WBC-16.8* RBC-3.53* HGB-11.0* HCT-32.6* MCV-92 MCH-31.3 MCHC-33.9 RDW-14.7 [2137-3-3] 11:40AM VALPROATE-11* [2137-3-3] 11:40AM CALCIUM-8.9 PHOSPHATE-6.1# MAGNESIUM-2.4 [2137-3-3] 11:40AM CK-MB-4 [2137-3-3] 11:40AM cTropnT-0.13 [2137-3-3] 11:40AM CK(CPK)-170 [2137-3-3] 11:40AM GLUCOSE-121* UREA N-45* CREAT-2.5* SODIUM-138 POTASSIUM-7.0* CHLORIDE-107 TOTAL CO2-18* ANION GAP-20 [2137-3-3] 12:00PM ALBUMIN-4.0 [2137-3-3] 12:00PM POTASSIUM-4.4 [2137-3-3] 12:03PM LACTATE-1.7 [2137-3-3] 12:03PM COMMENTS-GREEN TOP [2137-3-3] 03:12PM %HbA1c-5.4 [Hgb]-DONE [A1c]-DONE [2137-3-3] 05:40PM CK-MB-22* MB INDX-10.4* cTropnT-0.48* [2137-3-3] 05:40PM CK(CPK)-212* [2137-3-3] 07:23PM O2 SAT-97 [2137-3-3] 07:23PM K+-4.0 [2137-3-3] 07:23PM TYPE-ART PO2-87 PCO2-33* PH-7.43 TOTAL CO2-23 BASE XS-0 [2137-3-3] 08:04PM CALCIUM-8.9 MAGNESIUM-2.1 [2137-3-3] 08:04PM POTASSIUM-4.0 Pertinent Labs/Studies . CK: 170 -> 212 -> 224 -> 138 CK-MB: 4 -> 22 -> 23 -> 13 Trop: < .01 -> .48 -> .13 . Creatinine: 2.5 -> 2.6 -> 2.7 -> 2.9 . [2137-3-3]: HbA1c - 5.4% [2137-3-3]: Valproate - 11 [2137-3-3]: CCU admission ABG: 7.43/33/87/23 . . Imaging: [2137-3-3]: Portable Chest - There is stable cardiomegaly. The left costophrenic angle is excluded from the radiograph. There is slight prominence of the pulmonary vasculature centrally but no overt edema. Again identified is bibasilar opacification persisting at the lung bases slightly increased in the left lower lobe compared to the prior study which could be residual edema or atelectasis. The possibility of mild volume overload or developing infection cannot be excluded. No pneumothorax is identified. The soft tissue and osseous structures are stable. IMPRESSION: Slight increase in opacification at the lung bases reflecting bibasilar atelectasis or possible developing infection/mild volume overload. . [2137-3-5]: Chest Pa/Lat - pending . . Microbiology: Urine Cultures: [2137-3-3]: UA: Leuks Mod, Nit neg, WBC > 50, Bact - mod [2137-3-5]: UA: Leuks Mod, Nit neg, WBC [3-24], Bact - few [2137-3-3]: Urine Cx: >100K Coag Pos Staph [2137-3-5]: Urine Cx: pending . Blood Cultures: [2137-3-3]: Blood Cultures x 4: NGTD [2137-3-5]: pending Discharge Labs: Brief Hospital Course: Assessment: Patient is an 85 year old male with past CAD hx who presents with CHF exacerbation and enzyme leak likely secondary to demand ischemia. . Cardiovascular: CHF: The patient presented to the hospital with symptoms of decompensated CHF including dyspnea, rales on exam and peripheral edema. The patient additionally reported chest pain on admission that was initially responsive to nitrate therapy, then refractory. In the ED the patient was assessed to be in CHF and was treated with lasix, 120mg IV in total, nitro gtt, and additionally given aspirin given chest pain and history of CAD. The patient was noted on admission to have an supratherapeutic INR of 5.1 on admission for which additional anticoagulation with Heparin gtt or Lovenox was held. The patient's ECG on admission was remarkable for an old LBBB with some non-specific TWI in I and aVL, poor R wave progression but no significant or acute ST changes. The patient was admitted to the CCU for ongoing diuresis with additional monitoring of enzymes for potential NSTEMI. Of note, in the ED the patient was initially treated with non-invasive mask ventilation with good effect. Attempted diuresis prior to admission only yielded an output of 300cc net negative. Despite this, the patient was transferred to the floor without need for non-invasive ventilation and was oxygenating well with 5L NC. The patient was placed on a lasix gtt with good effect with negative diuresis 2.5-3.0 liters since admission. The patient remains mildly fluid overloaded with goal additional diuresis of approximately one more liter, which will be performed now with lasix boluses. Further diuresis beyond one liter may be limited by the patient's renal function given rise in creatinine from 2.5 to 2.9 as well as blood pressure. The patient has had a steady oxygen requirement of 2.0 L NC with some improvement in subjective symptoms. It is thought that patient may do well on discharge with combination Hydralazine/Nitrate for afterload/preload reduction as his creatinine will not tolerate an ACE inhibitor. . CAD: As noted, on admission the patient was known to reportedly have had multiple MIs in the 80's without intervention. The patient's initial cardiac enzymes on admission were CK-170, MB-4, Trop- .13 with peak values of 224/23/.48. Rise in patient's enzymes were thought most likely to be secondary to demand ischemia in the setting of decompensated CHF although a small NSTEMI can not be [Month/Day/Year 20003] out. Trying to illicit the precipitating event was unsuccessful. The patient on admission was maintained on ASA and Plavix (which he was previously taking). Heparin was not started given patient's elevated INR on admission and coumadin was held. Patient was maintained on high dose Atorvastatin for secondary prevention. The patient remained chest pain free for the remainder of his admission. The patient had an echocardiogram performed in [Month (only) 404] during his last admission which demonstrated an EF of 40-50% with global LV hypokinesis. Given there was no evidence for large infarct, there was no expectation of any great change from previous, so a repeat echocardiogram was not performed. Pt in the past has not been able to tolerate an ACEi due to worsening renal function every time an ACE is started. . Rhythm: The patient on admission was in NSR without significant ectopy during his hospital course. The patient however was noted to develop afib on [2137-3-4] without clear precipitant. The patient was normotensive without ongoing evidence of ischemia at this time. The patient has no chart diagnosis of Afib but it is possible or likely that he has paroxysmal afib that has not previously been recognized. THe patient is currently already anticoagulated for an indication of DVT. Given his age and medical status, the patient is thought likely to be a poor candidate for cardioversion. Therefore, current strategy is to continue anticoagulation (INR goal 2.0-3.0) and rate control. Currently the patient has had fair rate control with HR ranging from 60-110. The patient's dose of hydralazine was decreased to 50mg po 6h to allow increase in metoprolol to 75mg po tid for increased rate control. His rate is now well controlled with a heart rate ranging from 60-80s. . #. ID - The patient remained afebrile without elevated white count on admission. On previous admission the patient was treated for PNA. On admission to CCU, patient was noted to have +UA as well as questionable left lower lobe consolidation worse than previous for which levo/Flagyl was started. Flagyl was discontinued the following day given no evidence for aspiration or PNA and the patient was continued on levofloxacin for pna to complete a ten day course. Urine culture from [2137-3-3] grew Coag + Staph, sensitivity pending. Given foley, it was thought this more likely represented contaminant or colonizer so abx regimen was not changed. The patient's foley catheter was changed and repeat UA/UCx ordered. The patient had one set of blood culture without growth and a repeat was ordered to ensure there was no seeding of urine from blood. The bacteria was later identified as MRSA and patient was treated with 2 days of IV Vancomycin, and transitioned to Linezolid PO to complete a 1 week course. . #. Heme: On admission the patient was noted to have a supratherapeutic INR of 5.1 for which coumadin was held. Despite this, the patient's INR continued to rise to 7.0 over two days. This was thought most likely to be nutritional and the patient was given 5mg PO Vitamin K on [2137-3-5]. Also of note the patient had a HCt drop from 32.6 on admission to 27.7. However, repeat Hct have been relatively stable and the patient is without any obvious source of bleeding (no bowel movements yet this admission). INR dropped to 1.4 after administration of Vit K and patient was restarted on his coumadin at a dose of 4mg po qhs. Pt is have his INR monitored by his PCP and dose will be titrated as needed to maintain goal of [2-22]. . #. CKD: Patient is noted to have baseline creatinine of 2.0-2.8. On admission the patient had a creatinine of 2.5 which has been rising, most recently 2.9 in the setting of diuresis. Patient's meds have been reneally dosed and current diuresis plans are to remove approximately one additional liter given rising creatinine and potential for hypotension. Pt's creatinine eventually peaked at 3.1, and with continued diuresis, pt's Cr dropped to 2.6 on day of discharge, which is patient's baseline. . #. FEN: Patient was maintained on a Cardiac Healthy/Low Na diet. Patient had a S+S eval which cleared his as appropriate for thin liquids and puree solids with appropriate aspiration precautions and assistance with feeding. Patient is being fluid restricted < 1200 given CHF. . #. Code: Full. # DISPO: Patient to be discharged to rehabilitation for short term rehab. Medications on Admission: Depakote: 250mg EC qhs, 125mg qam Lasix 60mg po qd Norvasc 10mg po qd Plavix 75mg po qd Hydralazine 75mg po qd Protonix 40mg po qd Lipitor 80mg po qd ASA 81mg po qd Coumadin 5mg po qhs Toprol XL 225mg po qd Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Divalproex 250 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO HS (at bedtime). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 weeks. Disp:7 Tablet(s) Refills:0 8. Divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QAM (once a day (in the morning)). 9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 10. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 11. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 16. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO three times a day: with meals. 17. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 18. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital1 2670] - [Location (un) ] Discharge Diagnosis: Primary: 1. Decompansated CHF 2. ? Demand ischemia vs. small NSTEMI 3. UTI (MRSA) Secondary: 4. Coronary artery disease 5. Hypertension 6. Chronic renal insufficency 7. Anemia 8. DVT Discharge Condition: Afebrile, pain free, stable to be discharged home Discharge Instructions: 1. Please report to the nearest emergency department if you have fever, shortness of breath, chest pain or loss of consciousness. 2. Please weigh yourself daily. Please call Dr. [Last Name (STitle) 1266] if you gain more than 3 lbs. 3. Please limit your fluid intake to 1200 ml daily 4. Please follow up with the following providers: A. Primary Care Please make an appointment to followup with Dr. [Last Name (STitle) 1266] within the next 2 weeks. You can reach his office at [Telephone/Fax (1) 608]. B. Cardiology: Please call to schedule an appointment to be seen within 1 month ([Telephone/Fax (1) 62]) for follow-up of congestive heart failure C. [Telephone/Fax (1) ] Surgery Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SURGERY (NHB) (see appointment time below) D. Podiatry Provider: [First Name11 (Name Pattern1) 3210] [Initial (NamePattern1) ] [Last Name (NamePattern4) ], DPM Phone:[Telephone/Fax (1) 543] Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8384], MD Phone:[Telephone/Fax (1) 1690] Date/Time:[2137-3-15] 10:00 Provider: [First Name11 (Name Pattern1) 3210] [Initial (NamePattern1) ] [Last Name (NamePattern4) ], DPM Phone:[Telephone/Fax (1) 543] Date/Time:[2137-4-26] 2:20 Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SURGERY (NHB) Date/Time:[2137-7-30] 10:30 [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 4055] Completed by:[2137-3-8] ICD9 Codes: 4280, 486, 5990, 5849, 5859, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9089 }	Medical Text: Admission Date: [2154-12-16] Discharge Date: [2154-12-24] Date of Birth: [2076-3-19] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Aspirin Attending:[First Name3 (LF) 7141] Chief Complaint: Pelvic mass Major Surgical or Invasive Procedure: Exploratory Laparotomy Pelvic washings Extensive lysis of adhesions Radical resection of pelvic mass Total abdominal hysterectomy Bilateral salpingo-oophorectomy History of Present Illness: The patient is a 78 y.o. female who was referred for a 12.3 X 9 cm pelvic mass seen on CT [2154-11-25]. She has a h/o small bowel obstruction in 8/99. At that time she underwent small bowel resection and was found to have a gastrointestinal stromal tumor of high malignant potential. She then developed liver recurrence in [2149]. She was treated with chemoembolization and radiofrequency ablation. She has currently been on Gleevac and has a generally stable tumor in the liver. She presented to the gynecology/oncology team for surgical management. Past Medical History: PMH: COPD, Bronchitis, SBO, gastrointestinal stroma tumor, gout, portal HTN PSH: Small bowel sarcoma s/p resection (99/01), mastecomy in [2152] (pathology benign), partial liver resection [2150]. Gyn History: Last pap smear unknown. Last mammogram was normal last year. OB History: Negative Social History: The patient does not smoke, but she is a former heavy smoker who quit in [2147]. She drinks occasionally. Family History: Brother with pancreatic cancer. Physical Exam: HEENT: sclerae anicteric, no LAD. Lungs: scattered expiratory wheezes and distant breath sounds. CV: RRR, no murmurs. Breasts: no masses. Abd: soft, NT, suggestion of a mass in the lower abdomen which was difficult to define. Pelvic exam: Normal vulva, vagina and cervix. Bimanual and rectovaginal examination revealed a suggestion of a large pelvic mass which again was difficult to define. This mass seemed to be more anterior and high up in the pelvis. The rectum was intrinsically normal and there was no cul-de-sac nodularity. The uterus and adnexa were not separately palpable. Extremities without edema. Pertinent Results: [2154-12-16] 11:57AM WBC-4.2 RBC-3.46* HGB-10.9* HCT-32.3* MCV-93# MCH-31.5 MCHC-33.8 RDW-15.1 [2154-12-16] 11:57AM NEUTS-85* BANDS-0 LYMPHS-9* MONOS-4 EOS-2 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2154-12-16] 11:57AM ALBUMIN-2.4* CALCIUM-8.6 PHOSPHATE-5.8# MAGNESIUM-1.1 [2154-12-16] 11:57AM CK-MB-5 cTropnT-0.02* [2154-12-16] 11:57AM CK(CPK)-116 [2154-12-16] 11:57AM GLUCOSE-184* UREA N-41* CREAT-1.6* SODIUM-137 POTASSIUM-4.5 CHLORIDE-109* TOTAL CO2-21* ANION GAP-12 [2154-12-16] 10:11PM FIBRINOGE-271 [2154-12-16] 10:11PM PLT COUNT-151 [2154-12-16] 10:11PM PTT-24.4 [2154-12-16] 10:11PM HCT-30.9* [2154-12-16] 10:11PM MAGNESIUM-2.6 [2154-12-16] 10:11PM CK-MB-10 MB INDX-3.2 cTropnT-0.02* [2154-12-16] 10:11PM CK(CPK)-312* [2154-12-16] 10:11PM UREA N-41* CREAT-1.6* SODIUM-139 POTASSIUM-5.1 Brief Hospital Course: On [2154-12-16] the patient underwent an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, radical resection of a pelvic mass, extensive lysis of adhesions, and RIJ placement. She received 4500 LR and 3 units PRBCs intraoperatively for a 1500ml blood loss. She also experienced three episodes of desaturation to 73%. Intraoperative findings included a large left adnexal mass with extensive adhesions. The mass was found to be sarcoma on frozen section. Final pathology is pending. Post-operative course: HEME: The patient had a pre-operative HCT of 27, she received 2u PRBC's intraoperatively for a ~1500 ml blood loss. On POD#1 she received an additional u PRBC for a HCT of 26.4. An additional 1 u PRBC (for a total of 5 units) was given on POD #2 for a HCT of 28.9. This raised her HCT to 35.5. It remained stable for the remainder of her hospital stay. Neuro: The patient became disoriented following the operation. On POD #1 she was put on soft restraints to prevent her from pulling out her lines. She was transferred to the unit on POD#1. She was treated with Haldol for agitation. Her pain continued to be controlled with Dilaudid. Her agitation was felt to be due to post-op delirium with pain medications from surgery and resolved on POD#2 with minimization of narcotics. She was transitioned to oral Oxycodone from Dilaudid on POD#3. Respiratory: The patient had three episodes of acute desaturation during the operation. She was maintained on supplemental O2 post-operatively and her respiratoy status remained stable. She had course breath sounds bilaterally and a chest X-ray performed on POD #1 showed fluid overload she was treated with Lasix. Incentive spirometry and aggressive pulmonary toilet were encouraged. She also received chest PT. The patient remained on home medications of Advair and Combivent for her history of COPD. Cardiovascular: Cardiac enzymes were checked post-operatively due to the intra-operative desaturations and she ruled out for a myocardial infarction. The patient had 2 episodes of rapid ectopic beats on POD #2; these were asymptomatic and electolytes were wnl. An echo showed likely normal LV systolic function, trace aortic regurgitation, slightly thickened mitral valve with mild mitral regurgitation and pulmonary artery hypertension. Renal: The patient had low urine output post-operatively. She was thought to have acute-on-chronic renal failure, with an FeNa of <1%. Her urine ouput increased on POD #2 with administration of fluids and Lasix. A urine analysis and culture were sent and found to be positive for yeast. The patient was started on fluconazole. Her foley was D/C'd on POD#5 and the patient experienced nocturia, similar to the symptoms she had prior to the operation. Gastrointestinal: The patient was started on a diet of clear fluids and it was advanced as tolerated. She began experiencing diarrhea over night on POD #3. Her C. Diff toxin was negative. The diarrhea resolved on POD #6. The patient was found to be slightly jaundiced with elevated LFT's on POD#4. These resolved over her hospital course. The LFT elevation was thought to be consistent with a brief hemolytic picture. The patient's incision remained clean, dry and intact. By the time of discharge the patient was tolerating a regular diet, ambulating with assistance, voiding spontaneously, passing flatus, and her pain was well-controlled. Medications on Admission: Gleevac, Inderal, Diovan HCT, Ranitidine, Quinine sulfate, Allopurinol, Iron pills, Combivant, Advair. Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:100 Tablet(s) Refills:0 2. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:100 Tablet(s) Refills:0 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [12-8] Puffs Inhalation [Hospital1 ] (2 times a day) as needed. 5. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 6. Albuterol Sulfate 0.083 % Solution Sig: [12-8] Inhalation Q4-6H (every 4 to 6 hours) as needed. 7. Imatinib Mesylate 100 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)) as needed for sarcoma. 8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: Two (2) Disk with Device Inhalation [Hospital1 ] (2 times a day). 9. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 14 days. Disp:14 Tablet(s) Refills:0 10. Propranolol HCl 80 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Valsartan 80 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Rehab & Nursing Center - [Location (un) 47] Discharge Diagnosis: Pelvic mass Discharge Condition: Good Discharge Instructions: 1) No heavy lifting, exercise or intercourse for 8 weeks. 2) No Driving for 2 weeks. 3) Please call your doctor if you experience fever/chills, nausea/vomiting, increasing abdominal pain, or other symptoms that are concerning to you. Followup Instructions: 1) Please call Dr.[Name (NI) 2989] office to have your staples removed in 1 week. 2) Provider: [Name10 (NameIs) ],[First Name3 (LF) ] B. GYN ONC PPS (SB) Where: GYN ONC PPS (SB) Date/Time:[2155-1-22] 2:00 3) Provider: [Name10 (NameIs) ] SCAN Where: [Hospital6 29] RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2155-3-24] 9:30 4) Provider: [First Name11 (Name Pattern1) 396] [Last Name (NamePattern4) 397], MD Where: [Hospital6 29] HEMATOLOGY/ONCOLOGY Phone:[Telephone/Fax (1) 22] Date/Time:[2155-3-24] 10:30 ICD9 Codes: 5849, 496, 2930
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9090 }	Medical Text: Admission Date: [2151-3-13] Discharge Date: [2151-3-16] Date of Birth: [2122-12-6] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1055] Chief Complaint: Polydipsia, polyphagia Major Surgical or Invasive Procedure: None History of Present Illness: 28 yo male with h/o seasonal allergies and alopecia admitted for DKA. Pt was in USOH until last week when he noticed increasing drinking and urination. He also noted a 20lb wt gain over the past weak and attempted to increase his food intake but was unable to do so due to drinking lots of fluids. He reported nocturia and generalized malaise, with blurred vision when looking at the scores on television. He denied frequent skin infections, abdominal pain. Pt scheduled appt with PCP but decided to go to the ED due to mention by a friend that his story was typical for diabetes. In the ED he had T 98.4 HR 114 BP 151/77 rr 20. Labs revealed an anion gap of 27 and he was hydrated with 5 liters of NS and started on insulin ggt and transferred to the MICU. Potassium was aggressively repleted with >150 mEq of K. In the MICU he was cont on insulin gtt until 11 am after anion gap closed. Past Medical History: Alopecia-undifferentiated followed by dermatology in past but not for the past year Seasonal allergies Social History: Pt lives roomates in [Location (un) ] but spends a lot of time with his family in [Location (un) ]. Currently works for [Company 34423] group. Drinks EtOH socially on weekends 6-8 beers, no smoking or illicit drug use. Family History: Cousin DMI at 15 yo, paternal great great grandmother with [Name (NI) 2320], maternal grandfather with liver CA, father with HTN, no hx of CVA or CAD Physical Exam: PE-T 98.1 HR 81 BP 109/53 RR 16 O2 sats 100% [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 4459]-PERRL, no icterus, no plaque on tongue, otherwise oropharynx clear, no ant or post cervical lymphadenopathy, thyroid nonpalp Hrt-RRR, nS1S2 no MRG Lungs-CTA bilat Abdomen-soft, nondistended, NABS, no tenderness, liver edge nonpalp, NABS Extrem-no [Location (un) ] erythema, 2+ rad and dp pulses, no LE edema Neuro-CN II-XII intact, 5/5 strength in UE and LE bilat, distal sensation intact, 2+ patellar and achilles reflexes bilat Skin-diaphoretic, diffuse alopecia Pertinent Results: [2151-3-13] 05:48PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2151-3-13] 05:48PM GLUCOSE-594* UREA N-28* CREAT-1.7* SODIUM-125* POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-8* ANION GAP-27* [2151-3-13] 11:00PM GLUCOSE-180* UREA N-18 CREAT-1.0 SODIUM-135 POTASSIUM-3.9 CHLORIDE-115* TOTAL CO2-9* ANION GAP-15 [2151-3-16] 05:00AM BLOOD Glucose-231* UreaN-8 Creat-1.2 Na-136 K-3.8 Cl-112* HCO3-20* AnGap-8 [2151-3-15] 11:20AM BLOOD Glucose-300* UreaN-8 Creat-1.1 Na-133 K-4.1 Cl-111* HCO3-15* AnGap-11 [2151-3-15] 04:45AM BLOOD Glucose-54* UreaN-8 Creat-1.1 Na-138 K-3.6 Cl-116* HCO3-14* AnGap-12 [2151-3-14] 09:00PM BLOOD Glucose-412* UreaN-10 Creat-1.1 Na-131* K-4.1 Cl-110* HCO3-11* AnGap-14 [2151-3-14] 05:15PM BLOOD Glucose-193* UreaN-8 Creat-1.0 Na-134 K-3.8 Cl-111* HCO3-8* AnGap-19 [2151-3-15] 04:45AM BLOOD WBC-7.0 RBC-5.39 Hgb-15.0 Hct-42.9 MCV-80* MCH-27.9 MCHC-35.0 RDW-12.9 Plt Ct-211 [2151-3-16] 05:00AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.1 [2151-3-15] 11:20AM BLOOD calTIBC-196* Ferritn-570* TRF-151* [2151-3-15] 11:20AM BLOOD TSH-1.3 [2151-3-15] 11:20AM BLOOD Free T4-1.5 [2151-3-15] 11:20AM BLOOD ALT-22 AST-19 AlkPhos-75 TotBili-0.8 [2151-3-15] 11:20AM BLOOD Calcium-8.3* Phos-2.6* Mg-2.0 Iron-64 Brief Hospital Course: Diabetes-suspectedly type I in this young male who presented in DKA with poor insulin production. Not African American so unlikely Bushman diabetes with insulin resistance. As he began taking better PO's finger sticks climbed to the 300's despite RISS so over his second night of admission he was put bakc on an insulin drip for only 1 hour with good response. He was also started on 10u of lantus at that time and RISS was changed to Humalog sliding scale the next afternoon. [Last Name (un) ] consulted and recommended new Humalog SS and glargine with uptitration of glargine to 12 U which we did. Nursing taught pt to use glucometer and administer insulin to himself. Nutrition consulted, social work consulted and plan was made for him to check his FS qid at home with plan for follow-up appointment with Dr. [Last Name (STitle) 34424] on [2151-3-23] at 3pm and JVN at 2:15 along with diabetic teaching classes on [2151-3-24] at 10:30 am and 1pm. He was monitored on his new insulin scale with FS in the 150's to low 200's upon discharge. Alopecia-Pt on steroid creams in the past with poor response. No need for intervention at this time. Also obtained TSH as screen in this pt with 2 autoimmune conditions, and both TSH and free T4 were normal. Low MCV-He had a borderline low MCV but no increased RDW. Fe studies revealed anemia of chronic disease, but Hct was within normal limits so no further workup completed. Medications on Admission: None Discharge Medications: 1. Insulin Glargine 100 unit/mL Solution Sig: .12 ml Subcutaneous at bedtime. Disp:qs ml Refills:2 2. One Touch Ultra Test Strip Sig: Five (5) Miscell. once a day. Disp:qs strips Refills:2 3. Humalog 100 unit/mL Solution Sig: Two (2) slid Subcutaneous four times a day. Disp:qs tid Refills:2 4. Lancets Misc Sig: One (1) lancet Miscell. four times a day. Disp:40 lancet Refills:2 5. Syringe Syringe Sig: One (1) syringe Miscell. four times a day: 1/3 cc syringe short need 31 gauge. Disp:qs needle Refills:2 6. Glucagon Emergency 1 mg Kit Sig: One (1) kit Injection once a day. Disp:1 kit Refills:2 Discharge Disposition: Home Discharge Diagnosis: Newly diagnosed type I diabetes Diabetic ketoacidosis Discharge Condition: Blood sugars stable Discharge Instructions: If you experience any recurrence of your large amounts of urination, shakiness, blood sugars greater than 350, inablility to use your diabetes supplies you should call Dr. [Last Name (STitle) 34424], but if he is not availalble you should go to the emergency room. You also need to establish a primary care physician through your insurance company. Followup Instructions: You are schedule for follow-up appointment with Dr. [Last Name (STitle) 34424] on [2151-3-23] at 3pm and a [Hospital1 ] vision exam at 2:15 prior to your appointment. You should also attend diabetic teaching classes on [2151-3-24] at 9:30, 10:30 am and 1pm at the [Hospital3 ] called First Steps, What you can eat, and teaching nurse meeting with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 9973]. ICD9 Codes: 2765
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9091 }	Medical Text: Admission Date: [2178-1-20] Discharge Date: [2178-2-7] Date of Birth: [2107-2-15] Sex: M Service: OME HISTORY OF PRESENT ILLNESS: This patient is a 70-year-old male with extensive locally recurrent melanoma involving his face, status post excision, neck dissection and radiation therapy. Initial staging was consistent with stage III C disease but now with mets to the lung, bone and soft tissue. He was due to be started on high-dose IL-2 but in clinic on [2178-1-12], he was noticed to have erythema in an area of recent lymph node dissection felt consistent with cellulitis, and was started on oral Keflex, and now is presenting with worsening erythema. The patient reports that in the week since he started antibiotics, the erythema has enlarged and become more red. In clinic today, his white blood cell count was up to 20,000 and he was admitted to OMED service. PAST MEDICAL HISTORY: Hypertension, metastatic melanoma with original diagnosis in [2177-6-5]. On [2177-8-21] he underwent wide local excision and sentinel lymph node biopsy, with melanoma present in 1 left intraparotid node. On [2177-8-28] he had re-excision of the left temple and cheek area and a left radical neck dissection, with melanoma in 7 of 69 total lymph nodes. He underwent radiation therapy to the forehead area, completing 20 fractions over 4 weeks. He then developed soft tissue nodule superior to the graft, that might have represented residual melanoma and appeared to have reduced in size with radiation. In late [2177-10-6] a PET CT showed increased glucose uptake at sites of surgery on his thigh and around the superior edge of the graft on his face. He was seen in follow-up one of three weeks after completion of radiation. Follow up head MRI and torso CT on [2178-1-7] revealed no metastatic brain lesions, but metastatic disease in his chest, left axilla, mediastinum and lung, as well as a T12 sclerotic focus felt consistent with melanoma. The BRCA mutation testing on his tumor was negative. He has passed screening tests to begin high-dose IL-2 therapy. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Enalapril 20 mg p.o. daily, pravastatin 20 mg p.o. daily, Keflex 500 mg p.o. b.i.d. PHYSICAL EXAMINATION ON ADMISSION: Reveals an elderly male in no apparent distress. HEENT: Pupils equal, round, reactive to light. Left temporal and buccal graft without erythema. NECK: Well-healed scar from posterior auricular area to the left upper chest. No signs of wound dehiscence. Broad area of erythema and corresponding area warm to touch. No palpable masses or fluid collections. No cervical, supraclavicular or axillary lymphadenopathy. HEART: Regular rate and rhythm, S1, S2. CHEST: No dullness to percussion and clear to auscultation bilaterally. ABDOMEN: Positive bowel sounds, soft, nontender. EXTREMITIES: Warm and well perfused, 1+ edema to [12-8] the way up shins bilaterally, 2+ DP and PT pulses. NEUROLOGIC EXAM: Nonfocal. ADMISSION LABS: WBC 20.9, hemoglobin 11.7, hematocrit 33.7, platelet count 206,000, BUN 20, creatinine 1.2, sodium 134, potassium 6.1, chloride 101, CO2 23, glucose 117. HOSPITAL COURSE: The patient was admitted with cellulitis and was placed on IV vancomycin. Doxycycline was added when he did not appear to be improving. Unasyn was added when the cellulitic area continued to worsen. He also became short of breath and was treated with Lasix. Transthoracic echo revealed diastolic heart failure and he was continued on enalapril and Lasix. He had an ID consult on [1-28] who suggested stopping the Unasyn, changing to cefepime and adding vancomycin back. Blood cultures remained negative and he was afebrile throughout this time. Derm consult on [1-28] was obtained due to persistent rash, and a biopsy was performed consistent with melanoma. He was subsequently transferred to the biologic service on [2178-1-30] to begin high-dose IL-2 therapy. During this week he received 7 of 14 doses with 7 doses held related to tachycardia and pulmonary edema. On treatment day #4, he was tachypneic with hypoxia to the mid 80s. Chest x- ray was consistent with bilateral pleural effusions. Throughout the day he became increasingly more tachypneic and fatigued, and was transferred to the ICU. He was treated with Lasix with improvement in his respiratory status. An echocardiogram on [2178-2-3] showed a small pericardial effusion with question tamponade physiology. Cardiology was consulted and felt they were not able to tap the effusion. He underwent a cardiac MRI on [2178-2-4] revealing no cardiac metastases and no tamponade physiology. He developed SVT to the 140s on [2178-2-4], which spontaneously improved with a fluid bolus. His respiratory status improved with continued diuresis, and he was transferred back to the floor on [2178-2-5]. Lasix and enalapril were continued and he was weaned to room air with O2 saturations in the mid 90s. Physical therapy consult was initiated and he was ambulating short distances with a steady gait. He was discharged to home on [2178-2-7] with a plan to follow up in clinic on [2178-2-10]. Other side effects related to IL-2 included rigors improved with Demerol; fatigue; and hypotension on treatment day 3, requiring fluid boluses. During this week he developed acute renal failure with a peak creatinine of 3.0 with associated oliguria. He developed metabolic acidosis with a minimum bicarb of 18, improved with bicarbonate boluses. Electrolytes were monitored and repleted per protocol. Strict I & Os and serum chemistries were maintained. IV fluids were continued given acute renal failure. During this week he had mild ST elevation to 54, which improved prior to discharge. He had no hyperbilirubinemia, myocarditis or coagulopathy noted. He was thrombocytopenic to a platelet count low of 68,000 without evidence of bleeding. He was anemic and was transfused with packed red blood cells with discharge hemoglobin of 9.1. By [2178-2-7] he had recovered from side effects to allow for discharge to home. CONDITION ON DISCHARGE: Alert, oriented and ambulatory. DISCHARGE STATUS: To home with his family. DISCHARGE DIAGNOSES: 1. Metastatic melanoma status post cycle 1, week 1, high- dose IL-2 therapy complicated by pulmonary edema, and bilateral pleural effusions from IL-2 induced capillary leak, with respiratory distress. 2. Acute renal failure related to IL-2 therapy. DISCHARGE MEDICATIONS: Enalapril 20 mg p.o. daily, Lasix 20 mg p.o. daily, lorazepam 0.5 mg q. 6 hours p.r.n. nausea, pravastatin 20 mg p.o. daily, Compazine 5 to 10 mg q.i.d. p.r.n. nausea. FOLLOW-UP PLANS: The patient will return to clinic on [2178-2-10] for assessment of his clinical status prior to consideration for treatment with week #2 of therapy. I have reviewed the discharge summary and agree with the hospital course and disposition as dictated by [First Name8 (NamePattern2) 622] [Last Name (NamePattern1) 17265]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], MD [MD Number(2) 66804] Dictated By:[Last Name (NamePattern1) 18853] MEDQUIST36 D: [2178-2-24] 12:32:55 T: [2178-2-25] 15:33:12 Job#: [Job Number 87177] cc:[Numeric Identifier 87178] ICD9 Codes: 5185, 5849, 2762, 5119, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9092 }	Medical Text: Admission Date: [2183-7-10] Discharge Date: [2183-7-15] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1115] Chief Complaint: SDH and tSAH after a Fall on Coumadin Major Surgical or Invasive Procedure: None History of Present Illness: 88 yo M w/ h/o dementia, Afib, s/p PPM, CHF (on Coumadin), CKD (baseline Cr 1.5-2.2) p/w fall and found to have SDH and traumatic SAH. Pt fell (trip and witnessed, ? LOC, felt to be mechanical) on his way to coumadin clinic, and went to OSH where his INR was 2.0, and CT head demonstrated small parafalcine SDH and bilat SAH. He received vitamin K then transferred to [Hospital1 18]. He was initially admitted to the NSG ICU then transfered to MICU for [Last Name (un) ] (at that time did not know baseline Cr), and increasing bilateral pulmonary infiltrates. He was placed on keppra ppx. He was placed on neuro checks and had an trauma survey revealed minimally displaced, extraarticular distal right radius and ulna fractures. On [7-11] he had repeat head CT that showed increased bifrontal SAH and right SDH. Though CT worse, exam clinically the same. Per NSG patient not surgical candidate, but wanted f/u head CT on [7-13]. All anti-coag being held. Ortho was c/s and his arm was splinted. On collaberation w/ family, patient was thought to be close to his baseline (brief conversation, walks w/ cane). Cards also c/s b/c trop leak 0.08, flat ck-mb, cardiology felt to be in setting of ckd not. CXR showed bilateral pleural effusions w/ ? focal consolidation. Felt to be all volume related, got 80mg iv lasix x1 w/ good diuresis, on room air, except for at night. He is -2L length of stay. Currently, denies any shortness of breath or chest pain. Review of systems: denies fevers, chills, nausea, vomiting, headache, shortness of breath, or chest pain. Past Medical History: Afib CAD status post CABG x3 MI 4 years ago CHF with EF 25%, status post AICD hyperlipidemia hypertension, rhabdomyolysis Right hip fracture CKD s/p hypothermic episode Social History: - Tobacco: denies - Alcohol: denies - Illicits: denies Family History: Sister w/ parkinsons, hypertension and CAD in family Physical Exam: At admission: T: 97 HR: 90 BP: 136/68 RR: 18 Sat: 97% ra Gen: cachectic, appears stated age, comfortable, NAD. HEENT: right eyebrow laceration and hematoma. Small laceration right posterior scalp Neck: Supple. C-collar in place Extrem: dorsum right hand with abrasions, abraisions right shoulder. Neuro: Mental status: Awake and alert, cooperative with exam Orientation: AOx2 (baseline) Oriented to person, place "hospital" but not date. 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, 3 to 2.5 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, but HOH on Right IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: decreased bulk throughout with normal tone bilaterally. No abnormal movements,tremors. Right UE weakness bis/tris [5-1], right grip full. Otherwise strength is symmetric with bilat Delt weakness. Otherwise strength is full [5-31] throughout. Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally At discharge: Vitals: 98.0 98.0 143/87 110s-140s/70s-80s 72 70s-90s (70s in AM) 95-100% RA I/Os: 340 / 0 \| 125 +large incont / 0 AM: 0/0\| large incont / 0 General: awake, follows commands, responsive HEENT: Sclera anicteric, oropharynx clear, EOMI, PERRL (3->2 bl). Eyelids pulsing with motion. Neck: No appreciable LAD. JVP non-elevated. CV: Irreg rhythm. 3/6SEM at base radiating b/l to neck and to apex, normal S1 + S2, without rubs, gallops Lungs: With quiet breathing, CTAB with ?crackles at bases. After deep breaths, tachypneic with suprasternal retractions. Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: White nails. Warm, well perfused, 2+ pulses, no clubbing or edema. Neuro: EOMI, PERRL, CNII-XII intact. Sensation grossly intact to light touch in upper/lower ext. 4+ strength in all extremities (testing of R arm limited by cast). MS: A&Ox1 (no 'hospital'). Pertinent Results: [2183-7-10] 07:20PM BLOOD WBC-7.0 RBC-3.88* Hgb-12.0* Hct-36.9* MCV-95 MCH-31.0 MCHC-32.6 RDW-15.4 Plt Ct-157 [2183-7-11] 03:43AM BLOOD WBC-7.8 RBC-3.73* Hgb-11.5* Hct-35.5* MCV-95 MCH-30.8 MCHC-32.4 RDW-15.5 Plt Ct-140* [2183-7-11] 03:04PM BLOOD WBC-7.1 RBC-3.63* Hgb-10.9* Hct-34.6* MCV-95 MCH-29.9 MCHC-31.4 RDW-15.5 Plt Ct-150 [2183-7-12] 02:13AM BLOOD WBC-6.0 RBC-3.54* Hgb-10.7* Hct-34.2* MCV-96 MCH-30.1 MCHC-31.2 RDW-15.3 Plt Ct-129* [2183-7-13] 06:15AM BLOOD WBC-5.4 RBC-3.86* Hgb-11.5* Hct-37.2* MCV-97 MCH-29.8 MCHC-30.9* RDW-15.1 Plt Ct-142* [2183-7-14] 05:53AM BLOOD WBC-5.3 RBC-3.95* Hgb-11.9* Hct-38.4* MCV-97 MCH-30.1 MCHC-31.0 RDW-15.2 Plt Ct-163 [2183-7-15] 05:12AM BLOOD WBC-4.8 RBC-3.63* Hgb-11.3* Hct-34.7* MCV-96 MCH-31.1 MCHC-32.6 RDW-15.6* Plt Ct-148* [2183-7-10] 07:20PM BLOOD PT-21.6* PTT-32.5 INR(PT)-2.1* [2183-7-11] 03:43AM BLOOD PT-16.6* PTT-31.5 INR(PT)-1.6* [2183-7-11] 09:17AM BLOOD PT-15.0* PTT-31.2 INR(PT)-1.4* [2183-7-11] 03:04PM BLOOD PT-13.5* PTT-32.4 INR(PT)-1.3* [2183-7-12] 02:13AM BLOOD PT-14.1* PTT-29.7 INR(PT)-1.3* [2183-7-13] 06:15AM BLOOD PT-12.8* INR(PT)-1.2* [2183-7-10] 07:20PM BLOOD Glucose-134* UreaN-57* Creat-1.8* Na-140 K-4.5 Cl-101 HCO3-26 AnGap-18 [2183-7-11] 03:43AM BLOOD Glucose-154* UreaN-57* Creat-1.8* Na-140 K-5.1 Cl-101 HCO3-28 AnGap-16 [2183-7-11] 03:04PM BLOOD Glucose-108* UreaN-57* Creat-1.9* Na-141 K-4.5 Cl-102 HCO3-29 AnGap-15 [2183-7-12] 02:13AM BLOOD Glucose-93 UreaN-60* Creat-1.9* Na-142 K-4.6 Cl-103 HCO3-30 AnGap-14 [2183-7-13] 06:15AM BLOOD Glucose-63* UreaN-64* Creat-1.9* Na-146* K-4.3 Cl-105 HCO3-26 AnGap-19 [2183-7-14] 05:53AM BLOOD Glucose-98 UreaN-65* Creat-1.9* Na-146* K-4.0 Cl-104 HCO3-30 AnGap-16 [2183-7-15] 05:12AM BLOOD Glucose-92 UreaN-59* Creat-1.8* Na-147* K-3.9 Cl-106 HCO3-30 AnGap-15 [2183-7-10] 07:20PM BLOOD CK(CPK)-61 [2183-7-11] 03:43AM BLOOD ALT-37 AST-45* CK(CPK)-99 AlkPhos-71 TotBili-1.4 [2183-7-13] 06:15AM BLOOD ALT-21 AST-21 AlkPhos-59 TotBili-1.9* [2183-7-14] 05:53AM BLOOD ALT-20 AST-20 AlkPhos-62 TotBili-1.5 [2183-7-10] 07:20PM BLOOD CK-MB-3 cTropnT-0.08* [2183-7-11] 03:43AM BLOOD CK-MB-3 cTropnT-0.08* [2183-7-10] 07:20PM BLOOD Calcium-9.2 Phos-3.6 Mg-2.5 [2183-7-11] 03:43AM BLOOD Albumin-4.1 Calcium-9.7 Phos-3.7 Mg-2.5 [2183-7-11] 03:04PM BLOOD Calcium-9.5 Phos-3.8 Mg-2.4 [2183-7-12] 02:13AM BLOOD Calcium-9.4 Phos-4.3 Mg-2.5 [2183-7-13] 06:15AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.4 [2183-7-14] 05:53AM BLOOD Calcium-9.8 Phos-3.5 Mg-2.5 Brief Hospital Course: The patient is an 88 year old gentleman with multiple medical problems who was admitted initially to the Neurosurgery service for SDH and SAH. He appeared at his neurological baseline (AOx [1-27]). INR was reversed at admission. . #SDH and SAH Neuro: Repeat HCT showed enlargement of right occipital SDH. Given his multiple medical problems (dementia, CHF with EF 25%, CRF), he is not a candidate for surgical intervention. No shift caused by SDH. INR was reversed and he was monitored clinically. Fall was likely mechanical in nature. On [7-13], a repeat head CT was stable without extension or new hemorrhage. His neuro exam remained stable throughout his stay. He was followed by neurosurgery. He was continued on Keppra for seizure prophylaxis. Per neurosurgery, it was confirmed that he could be restarted on aspirin 81mg. He should continue to hold coumadin until his outpatient appointment with neurosurgery. #SOB/tachypnea/sCHF Increasing bilateral pulmonary infiltrates on repeat cxr. Cardiology c/s was placed in ED who recommended diuresis. The patient was diuresed with IV lasix. A TTE on HD3 revealed significant global systolic dysfunction and dilated left ventricle consistent with multivessel coronary artery disease. He was restarted on his metoprolol and the dose was titrated up his home dose of 100mg daily. He was started lisinopril 2.5mg after discussion with outpatient provider, [Name10 (NameIs) ] was restarted on home lasix 40 mg PO daily. . #Renal Insufficiency: Baseline creatinine 1.5-1.8, although as been as high as 2.2 in [2181]. Mild [Last Name (un) ] in setting of SDH and traumatic SAH. I His creatinine continued to trend down and on discharge was 1.8. His foley was out and he was voiding well, but incontinent. He was started on lisinopril 2.5mg. Should have repeat Chem 7 within 3 days of discharge. . #Fall: Likely mechanical. No recollection of events related to fall or syncopal episode. No evidence by ICD of an arrhythmia (ie. VT or VF). Troponins were borderline elevated, likely due to renal insufficiency as his CK-MB was flat, and ECG was consistent with strain pattern not ischemia. Cards saw the pt in the ED. No infectious source. On telemetry, he had one run of 8 beats of NSVT. He had no evidence of infection or metabolic disease to explain his fall. No report of seizure activity. C-collar was cleared clinically and radiographically. PT recommended rehab. . # Distal radial/ulnar fractures: He was followed by the Ortho Trauma service. His right arm was initial spinted and later a short arm cast was placed. He should keep it elevated and non-weight bearing. . CAD: Pt with EF 25% s/p AICD placement and signficiant coronary disease and h/o MI and CABG. Elevated troponins and flat CK-MB, in setting of [Last Name (un) ]. ECG c/w strain pattern. Prior troponins at [Hospital6 ] 0.11. Likely exacerbated in setting of [Last Name (un) ]. Cardiology reviewed imaging on admission and recommended diuresis. A TTE was performed on HD3 and revealed significant global systolic dysfunction and dilated left ventricle consistent with multivessel coronary artery disease. He was restarted on aspirin and started on lisinopril 2.5mg. He was continued on pravastatin and metoprolol was titrated up to home dose. . # Afib: He appeared to be in sinus rhythm with multiple PVCs through his stay. His coumadin was held, in the setting of the head bleed. After the CT and exam were stable, he was restarted on aspirin. His beta-blocker was titrated up to his home dose. He should continue to hold coumadin until he is reevaluated by neurosurgery at his follow-up appointment. # Hypernatremia: He developed a mild hypernatremia (Na 147 - free water deficit 2L). It was thought to be due to limited PO intake and he was thirsty and has been reliant on assistance for all eating/drinking. He was given 500cc 1/2 NS. Should have repeat Chem 7 within 3 days of discharge. TRANSITIONAL ISSUES: - Start tylenol PRN for pain - Start calcium carbonate and vitamin D to help with low bone density - Start keppra for seizure prophylaxis and discuss with Neurosurgery - Start lisinopril 2.5 mg daily for heart failure, hold for SBP < 100 and discuss at cardiology follow-up - STOP coumadin. [Month (only) 116] restart if neurosurgery recommends at follow-up appointment. - Scheduled for a repeat X-ray and follow-up with Orthopedics - Scheduled for a repeat head CT and follow-up with Neurosurgery - Scheduled for follow-up with Cardiology - DNR/I Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver. 1. Metoprolol Succinate XL 100 mg PO DAILY 2. Pravastatin 10 mg PO DAILY 3. Warfarin 3.75 mg PO DAILY16 4. Aspirin 81 mg PO DAILY 5. Furosemide 40 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Furosemide 40 mg PO DAILY 3. Pravastatin 10 mg PO DAILY 4. Calcium Carbonate 500 mg PO TID 5. Acetaminophen 650 mg PO TID 6. LeVETiracetam 500 mg PO BID 7. Lisinopril 2.5 mg PO DAILY hold for sbp<100 8. Metoprolol Succinate XL 100 mg PO DAILY 9. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [Doctor Last Name ] Green Nursing & Rehab Center - [Hospital1 ] Discharge Diagnosis: Subdural hematoma Subarachnoid hemorrhage [Last Name (un) ] Right radial and ulnar distal fracture Systolic heart failure with pulmonary edema 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 112243], It was a pleasure participating in your care at [Hospital1 18]. You came into the hospital because you fell and had a head bleed. We reversed your anticoagulation and stopped your coumadin. You were in the ICU because of fluid in your lungs and kidney failure. Your repeat head CT showed that the bleeding your brain was stable and your mental thinking has appeared to stabilize. We restarted your home heart medications. goes up more than 3 lbs. Followup Instructions: Department: ORTHOPEDICS When: TUESDAY [2183-7-29] at 1:20 PM 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 [2183-7-29] at 1:40 PM With: [First Name11 (Name Pattern1) 2191] [Last Name (NamePattern4) 2192], NP [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: RADIOLOGY When: MONDAY [2183-8-4] at 11:30 AM With: CAT SCAN [Telephone/Fax (1) 590] Building: CC [Location (un) 591] [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Nothing to eat or drink 3 hours prior to the Cat Scan. Department: NEUROSURGERY When: MONDAY [2183-8-4] at 12:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 43708], MD [Telephone/Fax (1) 2731] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: CARDIAC SERVICES When: WEDNESDAY [2183-9-17] at 10:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2183-7-15*] ICD9 Codes: 5849, 2760, 4280, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9093 }	Medical Text: Admission Date: [2185-12-1] Discharge Date: [2186-1-10] Date of Birth: [2121-3-30] Sex: F Service: CARDIOTHORACIC Allergies: Percodan Attending:[First Name3 (LF) 4272] Chief Complaint: Right bronchopleural fistula, s/p right lower lobectomy Major Surgical or Invasive Procedure: [12-5] debridement of bronchopleural fistula History of Present Illness: Mrs. [Known lastname 59614] is a pleasant 64-year-old woman who underwent a right lower lobectomy at an outside hospital in [2185-7-21]. She has had a complicated hospital stay including the development of a bronchopleural fistula and attempts to control this twice with omental flaps. The fistula persists and she has been transferred to the [Hospital1 69] for our assistance in her care. She was admitted on [2185-12-1]. Past Medical History: RLL NSCLC T2N0M0 [8-9] RLL lobectomy plus LN dissection [9-13] readmission for hydropneumothorax [9-19] R chest exploration, debridement, closure of bronchus [10-19] Eloesser procedure, omental graft and bronchal closure [11-17] tracheostomy, thoracotomy, redo omental flap COPD h/o candica sepsis h/o MRSA tracheobronchitis c-section x3 Social History: 100PY h/o smoking Family History: N/c Physical Exam: VS 52kg 98.3 (99.1) 102/58 73 20 97%TM 97-99% 2LNC NAD, A&Ox3 trach size 6 fenestrated, capped RRR, B CTA R chest deep curving granulating cleen cavity, open bronchus exposed in depth Abd soft, NT/ND, BS + B LE WWP, no edema Pertinent Results: [2186-1-2] 09:35AM BLOOD WBC-10.1 RBC-3.64* Hgb-11.8* Hct-35.6* MCV-98 MCH-32.5* MCHC-33.3 RDW-18.5* Plt Ct-419 [2186-1-2] 09:35AM BLOOD Plt Ct-419 [2186-1-5] 10:00AM BLOOD Glucose-155* UreaN-10 Na-137 K-4.2 Cl-92* HCO3-34* AnGap-15 [2186-1-2] 09:35AM BLOOD Lipase-33 [2186-1-6] 05:30AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2186-1-5] 10:00AM BLOOD Calcium-9.1 Phos-5.4* CXR [2186-1-6] IMPRESSION 1. Progression of mild congestive heart failure. 2. Unchanged appearance of the chest, with a persistent small air collection communicating with the posterior chest wall on the right with small bilateral pleural effusions with possible loculation on the right. Brief Hospital Course: Pt was admitted on date of surgery for repair of bronchopleural fistula that developed after lobe resection in [Month (only) 205] of 04. She tolerated the procedure well and was transferred to the Surgical Intensive Care Unit for recovery. She was maintained on levofloxacin, metronidazole, and fluconazole for coverage of fistula. AGgressive wound packing was maintained along with mechanical ventilation. Based on culture data, the fluconazole was discontinued on [12-12]. Pt was tried on Passy-Muir valve on the 22nd, but was noted to have only weak voice with the valve. Remaining antibiotics were discontinued on [12-13]. Pt began trach mask trials on [12-14], with some success. Open wound debridements began on [12-21], with resection of a small amount of necrotic tissue, and visualization of the fistula. Per Infectious disease service pt was started on vanco based on culture data from wound. AS of [12-28], pt continued to have occasional runs of afib, and her metoprolol was increased in response to this. Began re-entering cholecystostomy output into J-tube to prevent excess loss of bile acids. Pt gradually recovered ability to take food by mouth, and began requiring less tube feed support. By [1-7] pt was doing well, with well-healing wound, and deemed a suitable candidate for a rehabilitation facility to optimize her functional status. She has excellent rehabilitation potential for speech, ambulation, and eventual closure of her bronchopleural fistula. Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: [1-21] Inhalation Q6H (every 6 hours) as needed. 2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [1-21] Puffs Inhalation Q6H (every 6 hours) as needed. 3. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 4. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 9. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 11. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed. 12. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 13. Vancomycin HCl 1000 mg IV Q24H 14. Lorazepam 0.5 mg IV Q12H:PRN Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Right broncho-pleural fistula. Discharge Condition: Good. Discharge Instructions: Dressing change [Hospital1 ]. Physical therapy to evaluate and treat. Followup Instructions: F/u with Dr. [Last Name (STitle) 175] in his clinic on [2186-1-19] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9094 }	Medical Text: Admission Date: [2131-5-26] Discharge Date: [2131-8-5] Date of Birth: [2131-5-26] Sex: M Service: Neonatology HISTORY: Baby [Name (NI) ] [Known lastname ] #1 is a former 1,070 g, 26-4/7 week twin #1 male admitted secondary to respiratory distress and prematurity. Mother is a 37-year-old gravida 3, para [12-14] white female. Prenatal screens AB-, antibody negative, RPR nonreactive, hepatitis B surface antigen negative, GBS unknown. This was an IVF achieved pregnancy with triplets spontaneously reduced to twins at 13 weeks, cervical incompetence treated with cerclage, spontaneous rupture of membranes on [5-14] days prior to admission. Cerclage was removed, betamethasone complete, antibiotics given. On the day of delivery mother was noted to have evidence of chorioamnionitis, therefore delivery was performed via cesarean section. This infant emerged vigorous, briefly received blow-by O2, was suctioned, had fair aeration with mild retractions, Apgar scores were 7 at one minute and 8 at five minutes. The infant was transferred to the newborn intensive care unit with blow-by O2. HOSPITAL COURSE: 1. Respiratory: The baby was intubated, received two doses of surfactant, transitioned to CPAP on day of life three, CPAP of 5, and room air. By day of life three he came off the CPAP and was on room air where he remained until day of life 10 when he had increased work of breathing, increased apnea and bradycardia and was again placed on continuous positive airway pressure, which he remained on from day 10 to day 30. He then transitioned to nasal cannula O2, but again required resumption of CPAP for increased work of breathing, apnea and bradycardia. He remained on CPAP until day of life 40 when he then transitioned to room air, where he currently remains without any further respiratory distress. Baseline respiratory rate is 30s to 50s. The baby was started on caffeine citrate on day of life two which he remained on until day of life 53 for apnea and bradycardia of prematurity. At the time of discharge he will be free of apnea and bradycardia for greater than five days. 2. Cardiovascular: The baby has not had any cardiovascular issues. He has had an intermittent murmur thought to be a flow murmur. Baseline heart rate is 140s to 160s. Baseline blood pressure is 60s/30s with the means in the 40s. 3. Fluids, electrolytes and nutrition: Birth weight 1,070, 70th percentile; discharge weight 2440 grams 25th percentile; admission length 35.5, 50th percentile, discharge length 46 cm, greater than 25th percentile; admission head circumference 25.5, 60th percentile; discharge head circumference 33 cm, greater than 50th percentile. The baby initially was n.p.o., had an umbilical artery catheter placed that remained in place until day of life four, when a PICC line was placed. He initially started on maintenance intravenous fluids and PN and Intralipid. Enteral feedings were started on day of life five. He achieved full enteral feedings by day of life 14 without incident, and then calories were increased to breast milk 30 with ProMod. As his weight gain was sufficient, calories have been decreased to breast milk 26, which is achieved by four calories per ounce of Enfamil powder and two calories per ounce of corn oil. He is ad lib feeding a minimum of 130 cc per kg per day. His last electrolytes and nutrition laboratory studies on [2131-7-9] were sodium 135, potassium 4.9, chloride 100, CO2 25, calcium 10.8, phosphorous 6.5, alkaline phosphatase 393. The baby is currently receiving [Male First Name (un) 48733] 1 cc p.o. q.d. and ferrous sulfate 4 mg per kg with 25 mg per cc, 0.4 cc p.o. q.d. He is voiding and stooling without issue. 4. GI: The baby had a peak bilirubin on day of life two of 3.4/0.3. He responded to phototherapy and had a rebound bilirubin on day of life nine of 2.4/0.3. 5. Hematology: He was blood type A+, Coombs negative. He received one blood transfusion on day of life four. His last hematocrit on [2131-7-9] was 25.2 with reticulocyte count of 6.2%. 6. Infectious disease: On admission the baby had a blood culture and a CBC drawn because of concern for chorioamnionitis and his prematurity and respiratory distress. Initial white count was 14.3 with 57 polys, two bands, platelet count of 527,000 and an hematocrit of 41. He had blood cultures sent, was started on ampicillin and gentamicin. He had a lumbar puncture on day of life six prior to discontinuing the antibiotics, with a white blood cell count of 3, red blood cell count of 1, 0 polys, 13 lymphocytes, 87 monocytes, protein 96, glucose 52. He had his ampicillin and gentamicin discontinued after seven days. Blood cultures remained negative. He had therapeutic gentamicin levels during that time of treatment. On day of life nine he had increased work of breathing and increase in apnea and bradycardia. He had another blood culture and CBC sent. CBC had a white count of 17 with 27 polys, one band, 37 lymphocytes, platelet count of 541,000, hematocrit of 44. Blood culture was also sent. He was started on vancomycin and gentamicin. He again had a lumbar puncture done which had 3 white blood cells, 23 red blood cells, 0 polys, 26 lymphocytes, 74 macros, protein of 80 and glucose 31. This course of antibiotics continued for seven days. Cultures remained negative. The baby was clinically well and they were discontinued. He also had therapeutic gentamicin levels during this time, as well as therapeutic vancomycin levels. He has had no further issues with infection. 7. Neurology: He has had serial head ultrasounds done and all have been within normal limits. No evidence of intraventricular hemorrhage or periventricular leukomalacia. The baby's physical examination is neurologically appropriate for gestational age. 8. Sensory: Hearing screen was performed with automated auditory brainstem response. The baby passed. He has had serial eye examinations done with the last one being on [2131-7-30] that showed stage I ROP, zone 3, two clock hours in the right eye, four clock hours in the left eye with a plan to follow up in one week. Follow-up appointment will be with Dr. [Last Name (STitle) 6955] on [2131-8-8] at the [Hospital3 1810]. 9. Psychosocial: The parents have been visiting [Known lastname ] and his brother [Name (NI) 48734] and look forward to transitioning home. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: Home with his family. PRIMARY PEDIATRICIAN: Dr. [Last Name (STitle) 34141], [Hospital ] Pediatrics, [Telephone/Fax (1) 40204]. CARE RECOMMENDATIONS: Continue ad lib feeding of breast milk 26, with Enfamil powder and corn oil. MEDICATIONS: 1. Ferrous sulfate 0.4 cc of 25 mg per cc, which equals 4 mg per kg per day. 2. Poly-Vi-[Male First Name (un) ] 1 cc p.o. q.d. CAR SEAT POSITION SCREENING: Pending at the time of dictation. STATE NEWBORN SCREEN: Serial screens were done and were within normal range. IMMUNIZATIONS RECEIVED: Hepatitis B vaccine on [2131-7-28]. DTaP [2131-7-28]. HIB [2131-7-28]. IPV [2131-7-28]. Pneumococcal 7 valent conjugate vaccine [2131-7-28]. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria: 1. Born at less than 32 weeks. 2. Born between 32 and 35 weeks with plans for daycare during RSV season with a smoker in the household or with preschool siblings. 3. With chronic lung disease. Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age; before this age the family and other caregivers should be considered for immunization against influenza to protect the infant. FOLLOW-UP APPOINTMENTS SCHEDULED/RECOMMENDED: 1. With Dr. [Last Name (STitle) 34141] of [Hospital ] Pediatrics several days after discharge; mother will call for appointment. 2. Enable, Inc. Early Intervention Program, [Telephone/Fax (1) 48735]. 3. [Hospital1 1474] VNA, [Telephone/Fax (1) 36133]. 4. Infant Follow-up Program, [Telephone/Fax (1) 36479]. 4. Ophthalmology, Dr. [Last Name (STitle) 6955], [Telephone/Fax (1) 38451] on [2131-8-8]. DISCHARGE DIAGNOSES: 1. Former 26-4/7 weeks twin #1 of two. 2. Status post respiratory distress syndrome. 3. Status post hyperbilirubinemia. 4. Status post apnea and bradycardia of prematurity. 5. Retinopathy of prematurity. 6. Anemia of prematurity. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 36142], M.D. [MD Number(1) 36143] Dictated By:[Last Name (NamePattern1) 38253] MEDQUIST36 D: [2131-8-3] 02:37 T: [2131-8-3] 07:42 JOB#: [Job Number 48736] ICD9 Codes: 769, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9095 }	Medical Text: Admission Date: [2128-8-24] Discharge Date: [2128-9-16] Date of Birth: [2054-5-13] Sex: F Service: ADMITTING DIAGNOSES: 1. Sarcoma DISCHARGE DIAGNOSIS: 1. Status post posterior pelvic exenteration for HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old woman G5, P1-0-1-4 who presented to the hospital for vaginal bleeding, initially presented to [Hospital3 1280] Hospital on [8-22] where she required multiple units of blood for vaginal bleeding. Her hematocrit was as low as 25 on admission there. Her CT scan was significant for a rectovaginal [Hospital1 ] [First Name (Titles) ] [Last Name (Titles) ] to the Gyn/Onc service for further. A needle biopsy performed demonstrated high grade sarcoma versus poorly differentiated carcinoma. During her hospital course up until the time she was operated upon, she had a lot of vaginal bleeding requiring pad changes at least every three hours. She was admitted and underwent a posterior pelvic exenteration on [2128-9-2]. She had received 6 units of packed red blood cells in the Operating Room. Postoperatively, patient was transferred to the Intensive Care Unit. Postoperatively, she was ruled out for an myocardial infarction. She was extubated on postoperative day #3 without any complications. While in the Intensive Care Unit, she was transfused 2 more units to a total of 8 units throughout, 6 units since being in the Operating Room. She had one episode of hypotension 77/40, but after a normal saline bolus, her blood pressure went to 123/52. While in the Intensive Care Unit, she was placed on dopamine and propofol which were weaned off. She was started on ampicillin, Flagyl and levofloxacin which she was on for seven days. For the first seven days postoperatively, she was continued on those antibiotics. Her white count was as high as 17.4, but it trended down daily and she was taken off the antibiotics on [9-11] and her Foley was also removed. She was NPO. For pain control, first she was on epidural which fell out and she was then placed on a Dilaudid PCA. When she was on the floor, she was given Demerol and Vistaril. The patient did have one episode of supraventricular tachycardia for 28 beats prior to being transferred from the Intensive Care Unit to the floor. She was therefore started on Lopressor 25 mg [Hospital1 ]. She was on telemetry and the telemetry was discontinued after the patient demonstrated normal sinus rhythm for several days. On [9-11], postoperative day #8, a nasogastric tube was placed. A PICC was also placed. The patient had over [2126] cc of bilious emesis, but once the nasogastric tube was placed, the patient felt much better. The nasogastric tube was left in place for four days. Once the nasogastric tube was removed, the patient was able to tolerate solid po's without any difficulty. Her last set of labs, her white count was 9.5, hemoglobin 10.7, hematocrit 32.2, platelets 584, sodium 141, potassium 3.7, chloride 105, bicarbonate 27, BUN 10, creatinine 0.4, glucose 104. Her electrolytes were monitored daily. She had been on TPN while she was NPO. First, she was on PPN and then she was on TPN. Her TPN was discontinued once she was able to tolerate po's. On exam, her stoma was pink. Her ostomy was putting out bilious drainage. Ostomy nurse came and taught the patient as well as her two daughters how to care for the stoma. The patient is to be transferred to [Hospital3 1280] for rehabilitation. She is to follow up with Dr. [First Name (STitle) 1022] in two weeks. She was sent home with all her ostomy care supplies, as well as Percocet and Motrin for pain relief and Lopressor. Her JP drain was removed as well as her staple prior to discharge. [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 4871] Dictated By:[Last Name (NamePattern1) 30184] MEDQUIST36 D: [2128-9-16] 07:54 T: [2128-9-16] 09:20 JOB#: [Job Number 44105] ICD9 Codes: 5990, 4271
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9096 }	Medical Text: Admission Date: [2177-4-25] Discharge Date: [2177-5-2] Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 6780] Chief Complaint: guiac + stool, weakness Major Surgical or Invasive Procedure: [2177-4-29] EGD History of Present Illness: This is a 89 y/o female with CRI (baseline Cr 2.8), h/o colon CA and DVT/PE s/p IVC filter and requiring anticoagulation, recently admitted at [Hospital1 18] from [Date range (1) 95216] for weakness and UTI, who now re-presents with CC of weakness. At [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] was found to be hypotensive to 79/54 and HR of 88. Also found to have guiac+ stool and melena this am in the setting of a supratherapeutic INR. Coumadin has been held since yesterday. Per reports, patient has had poor po intake for several days, but labs done yesterday on [4-24] revealed a Cr of 2.5 (baseline), BUN 55, WBC 10.6, Hct 35. . During her last admission, she was found to have ARF in the setting of poor po intake and a UTI. Cr improved rapidly with fluids and she was treated with ciprofloxacin for her UTI. As her BP was slightly low to normotensive during her last stay, her verapamil dose was decreased from 240 mg to 120 mg daily as well as her toprol dose, which was decreased from 100 mg to 25 mg daily. Of note, the patient had watery diarrhea during her last admission and was guiac positive, however Hct remained stable during that time. Stool cx were negative and there no concerning symptoms, including fevers or abdominal pain. . Per family, patient has been having decreased po intake for some time now and feel that she is very dehydrated and this is why her blood pressure was low. In addition, she has been having diarrhea x 1 week. No n/v. They are not aware of any BRBPR or melena. . In the ED, VS were T 99.8, BP 89/47, HR 70, RR 22, SaO2 96%/RA. BP at one point low as 74/48. Patient was given 3 L NS and a right IJ was placed for access under sterile conditions. Give 40 mg IV PPI. Her exam was significant for guiac + smear, but no stool in the vault. had one episode of liquid melena. Patient could not tolerate NG lavage with multiple attempts. She was also given 5 mg SC vitamin K and 1 U FFP for reversal of her coagulopathy (INR 4.0). . ROS - all negative per family Past Medical History: 1. Hypertension 2. cecal CA s/p R colecotmy 3. CAD + MI 4. recurrent PE and DVTs 5. GERD 6. pacemaker for refractory SVT 7. diverticulosis 8. arthritis 9. CRI, baseline Cr 1.8-2.9 10. Dementia Social History: Recently at [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ], h/o short-term memory deficits at baseline. No tobacco/EtOH/IVDU use. Has 7 children and multiple family memebers involved in her care. Family History: NC Physical Exam: VS: Tc 97.4, BP 125/81, HR 69, RR 14, SaO2 100%/2L NC General: Pleasant AAF in NAD, AO x 3 HEENT: NC/AT, PERRL, EOMI. MMM, OP clear Neck: supple, no LAD or JVD Chest: CTA-B, no w/r/r CV: paced, no m/g/r Abd: soft, NT/ND, NABS, +guiac in ED though no stool in vault Ext: no c/c/e, pulses 2+ b/l Neuro: AO x 2 (place, self). CN II-XII grossly intact. Moving all extremities, no focal deficits. Pertinent Results: [2177-4-25] 02:10PM PT-36.4* PTT-40.8* INR(PT)-4.0* [2177-4-25] 02:10PM WBC-9.9# RBC-4.18* HGB-12.8 HCT-39.1 MCV-94 MCH-30.6 MCHC-32.7 RDW-16.2* [2177-4-25] 02:10PM PLT COUNT-404# [2177-4-25] 02:10PM GLUCOSE-111* UREA N-84* CREAT-4.4# SODIUM-135 POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-16 ANION GAP-22 [2177-4-25] 02:10PM CALCIUM-9.7 PHOSPHATE-6.0# MAGNESIUM-2.4 . CXR Line placement [2177-4-25]: IJ line in lower SVC. . EKG: Extensive baseline artifact. A-V sequential pacing at a rate of 70 beats per minute. QRS axis is 0.60. P-R interval 0.18. Compared to the previous tracing of [2177-4-9] non-specific T wave changes in the anterolateral leads are more apparent. . CXR [2177-5-1]: Right pulmonary artery fullness, probably unchanged. No acute cardiopulmonary abnormality detected. Please note that chest radiograph is insensitive for presence of pulmonary embolism. . AXR [2177-5-1]: Non-specific air-fluid levels. No evidence of pneumoperitoneum. . Gastric Biopsies: Pending Brief Hospital Course: This is a 89 y/o female with CAD, h/o colon CA, recurrent DVTs and PE, now presenting with hypotension and guiac + stool on coumadin. . # GI bleed - in the setting of supratherapeutic INR 4.0. Patient initially had no active GIB after arrival to the MICU, but then developed melena overnight. Pt received 5mg sc vitamin K, 2 units of FFPs and 2 PRBC for INR reversal. Pt received aggressive fluids for rescuscitation and ongoing diarrhea. Pt was also continued on IV PPI [Hospital1 ]. GI was made aware and patient will need an EGD, but as melena as slowed down and hct is stable, EGD is deferred for now. After 2 more units of PRBC, Hct remained stable. She has not required any more PRBCs since admission. EGD performed on [4-29] demonstrated a small non-bleeding ulcer in the duodenal bulb, which was biopsied (the patient will be notified of the results of the biopsy within the next 2 weeks). . # Hypotension - LIkely from GI bleeding and dehydration from diarrhea and poor po intake. Pt was aggressively fluid resuscitated with LR and did not require any pressors. Later, her stool cx returned + for C. diff, explaining her ongoing diarrhea. Flagyl was started. Antihypertensives were held. - Antihypertensives (Toprol XL and verapamil) were held throughout the admission and can be added back as BP or HR permits. . # C. diff colitis: Stool culture was sent at admission which returned positive for c.diff the following day. Pt was started on Flagyl on [4-27], PO vancomycin was added on [5-1]. She should continue for a total 14 day course (10 days after discharge). . # AG Metabolic acidosis - likely secondary to diarrhea + acute on chronic renal failure. Pt was resuscitated with LR and lytes were repleted aggressively. . # Cardiac - AV-paced for refractory SVT. Held BB and CCB for hypotension and fluid resuscitated aggressively. . # Acute on CRF - likely pre-renal in the setting of hypotension and decreased po intake. Her renal failure resolved with fluid resuscitation. . # MS - pt at baseline per family in regards to her dementia . # Coagulopathy - held coumadin and reversed with vitamin K and FFPs. She was discharged home without coumadin, as she has an IVC filter in place and the risk associated with bleeding was thought to be worse than the benefit of anticoagulation. Medications on Admission: 1. Allopurinol 100 mg daily 2. Verapamil SR 120 mg daily 3. Toprol XL 100 mg daily 4. Coumadin 1 mg daily 5. Remeron 15-30 mg qhs Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 7 days: After 7 days, reduce frequency to daily. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once). 4. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 10 days. 5. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 10 days. Discharge Disposition: Extended Care Facility: [Hospital6 4657] - [Location 1268] Discharge Diagnosis: Duodenal ulcer Hypotension Upper GI bleeding Secondary: History of DVT's/PE on coumadin Discharge Condition: Stable blood pressure, stable hematocrit, no evidence of bleeding Discharge Instructions: You were admitted with low blood pressure and bleeding from your GI tract. You were given blood transfusions, and a procedure to look at your stomach and duodenum showed a small ulcer. You should continue to take pantoprazole twice daily for the next week and then take it once daily indefinitely. You will be notified of the results of the biopsies within the next few weeks. . You should follow up with Dr. [Last Name (STitle) ] within one week of leaving rehab. . Please take all of your medications as prescribed. Followup Instructions: Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2177-5-6] 1:30 Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 327] Date/Time:[2177-6-13] 8:40 Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 327] Date/Time:[2177-6-13*] 9:00 ICD9 Codes: 5849, 2762, 5859, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9097 }	Medical Text: Admission Date: [2196-2-14] Discharge Date: [2196-2-17] Date of Birth: [2134-3-20] Sex: M Service: CARDIAC Intensive Care Unit HISTORY OF PRESENT ILLNESS: This is a 61 year old male with a previous medical history significant for hypertension, dyslipidemia, who had intermittent episodes of chest pressure and pain over the past month that resolved spontaneously. The patient states that 24 hours prior to admission he developed increased chest pain intermittent while at rest. He notified EMS; the pain lasted one hour, seven out of ten and was dull. He did report diaphoresis; no nausea, vomiting, shortness of breath or palpitations. Initial blood pressure when patient arrived at outside hospital was 90/palpable. The patient was given two boluses of intravenous fluid and blood pressure improved to the 110s. EKG was remarkable for V5, V4 ST elevations. The patient was given two aspirin and Nitroglycerin was held secondary to decreased blood pressure. The patient was transferred to [Hospital1 69] for catheterization. Catheterization demonstrated a right dominant system. The LMCA was normal; left anterior descending with 90% occlusion after the first diagonal, left circumflex occluded after small high obtuse marginal. Right coronary artery was normal. The patient's left circumflex occlusion was across revealing a long severe lesion with marked tortuosity. It was dilated and stented with two overlapping Hepacoat stents with no residual and normal flow. The thrombotic occlusion resolved with wire manipulation with a final very distal occlusion. The patient's 90% ostial lesion of the small obtuse marginal 1 with normal flow was not treated at that time. Hemodynamic RA pressure mean of 9.0, PA pressure of 35/14 with a mean of 24, RV 35/6 and pressure of 11. TCW mean of 13. ......was 6.07 cardiac index 3.09. The patient received heparin and Integrilin during the catheterization and had one episode of bradycardia with heart rate to the 30s. Received 1 mg of Atropine and the heart rate increased to the 90s. Blood pressure was stable throughout the catheterization. Additional hemodynamics, SVR was 1082. PAST MEDICAL HISTORY: 1. Gastroesophageal reflux disease. 2. History of hypercholesterolemia. 3. History of hypertension. 4. History of appendectomy. 5. Hemorrhoidectomy. SOCIAL HISTORY: The patient is married; the patient is a former smoker who smoked 1.5 packs for 20 years but has quit. The patient reports moderate alcohol use. Denies any other drug use. FAMILY HISTORY: The patient's father had an myocardial infarction at the age of 57. REVIEW OF SYSTEMS: Review of systems positive only for chest pain. Negative for dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, shortness of breath, edema, palpitations, syncope or presyncope. HOME MEDICATIONS: 1. Hydrochlorothiazide. 2. Zestril. 3. Lovastatin. 4. Ranitidine. PHYSICAL EXAMINATION: On admission, blood pressure 119/79; pulse 50; saturation of 99 to 100%. In general, he is alert and oriented times three, in no acute distress. HEENT: Pink conjunctivae; no scleral icterus. Cardiovascular is S1, S2, regular, no murmurs or rubs. No jugular venous distention is noted. Pulmonary clear to auscultation with no rales or rhonchi. Abdominal examination with normal bowel sounds, obese, nontender. Extremities with no lower extremity edema. Dorsalis pedis two plus bilaterally. Neurologic is nonfocal. LABORATORY: EKG on admission is sinus bradycardia around a rate of 40. Normal PR-QRS, normal axis. No left ventricular hypertrophy is noted. NO Qs. There are ST elevations in V5 and V6 and ST depression in II. Labs are notable for a creatinine of 1.3 and a post catheterization CK of 102. HOSPITAL COURSE: 1. CARDIOVASCULAR: The patient was admitted to the Cardiac Intensive Care Unit post catheterization on Integrilin for 18 hours as well as Plavix. The patient developed a right arterial groin bleed at 08:30 a.m. on [2196-2-14]. Pressure was applied and held for an additional 30 minutes. A pressure dressing was applied. The patient's hematocrit remained stable after this small bleed. The patient's CKs were trended and peaked at 1860 with an MB of 206. Lipid panel was obtained demonstrating LDL of 107, HDL 44, triglycerides of 140, total cholesterol of 187. The patient was noted to have runs of ventricular tachycardia asymptomatic and was continued on Telemetry with resolution of these abnormalities. The patient had a post catheterization echocardiogram on [2196-2-15], which demonstrated an ejection fraction of 45 to 50% with overall left ventricular function mildly depressed in the basal and mid inferior lateral hypokinesis, lateral apex hypokinesis, two plus mitral regurgitation and moderate pulmonary artery hypertension. The patient returned to the catheterization laboratory on [2-16], for intervention of the left anterior descending lesion which was dilated and stented with a Cypher stent. No residual, normal flow. Angiomed used for anti-coagulation. No complications. The patient obtained Physical Therapy for cardiac rehabilitation recommendations as well as Nutritional consultation and was restarted on a beta blocker prior to his discharge. Cardiac follow-up is arranged with Dr. [Last Name (STitle) 52394], who works in association with patient's primary care physician. 2. PULMONARY: A chest x-ray was demonstrated as patient reportedly had a wide mediastinum on outside chest x-ray from outside hospital. The chest x-ray demonstrated marked tortuosity of the thoracic aorta; mediastinal width within normal limits. There is a left posterior pleural thickening versus loculated pleural fluid. This will be followed with patient's primary care physician as an outpatient with outpatient chest x-ray. 3. GASTROINTESTINAL: The patient was maintained on ranitidine for his history of gastroesophageal reflux disease. 4. HEMATOLOGIC: The patient's hematocrit remained stable after his right groin bleed status post catheterization. DISCHARGE DIAGNOSES: 1. ST elevation myocardial infarction. 2. Hypertension. 3. Hypercholesterolemia. 4. Gastroesophageal reflux disease. 5. Coronary artery disease. DISCHARGE INSTRUCTIONS: 1. Follow-up with Dr. [First Name (STitle) ] ......, number [Telephone/Fax (1) 52395], [2196-3-7], at 03:15 p.m., [Hospital1 52396], will need a referral from Dr. [Last Name (STitle) 52397]. 2. Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 52397], [Telephone/Fax (1) 52398] within the next month for follow-up of chest x-ray findings. MAJOR SURGICAL OR INVASIVE PROCEDURES: 1. Cardiac catheterization [2-14]. 2. Cardiac catheterization on [2-16]. CONDITION AT DISCHARGE: The patient is tolerating p.o. and ambulating well. Works with Physical Therapy and has had nutritional consultation. DISCHARGE MEDICATIONS: 1. Acetaminophen. 2. Docusate. 3. Senna. 4. Aspirin 325 mg q. day. 5. Plavix 75 mg q. day. 6. Atorvastatin 40 q. day. 7. Ranitidine 150 twice a day. 8. Toprol XL 25 q. day. In addition, the patient was given a letter for work to resume in two weeks, during which time he will pursue cardiac rehabilitation. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 15176], M.D. [MD Number(1) 15177] Dictated By:[Last Name (NamePattern1) 5713] MEDQUIST36 D: [2196-2-17] 13:06 T: [2196-2-17] 15:09 JOB#: [Job Number 52399] ICD9 Codes: 9971, 4271, 5119, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9098 }	Medical Text: Admission Date: [2182-8-31] Discharge Date: [2182-9-9] Date of Birth: [2154-11-25] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1390] Chief Complaint: right facial swelling Major Surgical or Invasive Procedure: [2182-8-31] S/P Extra-oral and Intra-oral drainage of the right submandibular/sublingual/submental and lateral pharyngeal space abscesses, extraction of tooth #30. [2182-9-6] PICC line placement right basilic vein History of Present Illness: HISTORY OF PRESENTING ILLNESS This patient is a 27 year old male who complains of RIGHT FACIAL SWELLING. 5 days ago had slight right submandibular swelling. Two days later noted pain right lower molar pain-did not go due to insurance concerns. Over past 24 hours markedly more swollen. No dyspnea or sensation of airway closure. Difficult swallowing due to pain but no trouble handling secretions. No fevers. Timing: Gradual Severity: Severe Duration: 5 Days Location: right face Associated Signs/Symptoms: odynophagia Past Medical History: PMH Upper extremity abscess Testicular varicose vein Social History: Social History: IVDA, positive for drugs Family History: NC Physical Exam: PHYSICAL EXAMINATION: upon admission Temp: 98.8 HR: 116 BP: 120/74 Resp: 18 O(2)Sat: 99 Normal Constitutional: Masses sign of the right lower cheek and submandibular region, severe trismus, unable to view oropharynx, unable to appreciate dentition 2 to limited mouth opening HEENT: No stridor, phonation full Chest: Normal Cardiovascular: Normal Abdominal: Normal Skin: Warm and dry Pertinent Results: [2182-9-7] 06:00AM BLOOD WBC-7.0# RBC-4.35* Hgb-12.8* Hct-36.1* MCV-83 MCH-29.4 MCHC-35.4* RDW-13.5 Plt Ct-440 [2182-9-3] 06:00AM BLOOD WBC-4.4 RBC-4.62 Hgb-13.3* Hct-40.8 MCV-88 MCH-28.8 MCHC-32.7 RDW-13.4 Plt Ct-470* [2182-8-31] 10:30AM BLOOD WBC-21.0* RBC-4.80 Hgb-13.7* Hct-39.8* MCV-83 MCH-28.6 MCHC-34.5 RDW-13.0 Plt Ct-520* [2182-8-31] 10:30AM BLOOD Neuts-81* Bands-0 Lymphs-10* Monos-9 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2182-9-7] 06:00AM BLOOD Plt Ct-440 [2182-9-2] 06:20AM BLOOD Glucose-130* UreaN-6 Creat-0.8 Na-141 K-3.7 Cl-102 HCO3-31 AnGap-12 [2182-9-1] 02:18AM BLOOD Glucose-107* UreaN-8 Creat-0.8 Na-134 K-4.2 Cl-101 HCO3-26 AnGap-11 [2182-9-2] 09:00PM BLOOD ALT-14 AST-24 AlkPhos-62 TotBili-0.3 [2182-9-2] 09:00PM BLOOD Albumin-3.3* [2182-9-4] 05:30PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [2182-9-3] 03:30PM BLOOD HIV Ab-NEGATIVE [2182-9-5] 04:10PM BLOOD Vanco-7.1* [2182-8-31]: neck cat scan: . Extensive soft tissue stranding and phlegmonous material/enlarged lymphnodes surrounding the right mandible, as described above. There is an associated defect in the medial cortex of the right body of the mandible, adjacent to the reported tooth #20 dental caries, likely representing the psuedopassage of infectious/inflammatory material. 2. Mild leftward displacement of the airway by the adjacent inflammatory/infectious phlegmonous region without present obstruction of the airway [2182-9-3]: Echo: Conclusions The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The 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 no pericardial effusion. No vegetation seen. [2182-9-6]: chest x-ray: FINDINGS: A new right-approach PICC tip terminates within the lower SVC several centimeters beyond the wire position. The lungs are clear. There are no pleural effusions or pneumothorax. The cardiomediastinal and hilar contours are normal. Pulmonary vascularity is not increased. IMPRESSION: Right PICC in standard position within the low SVC. Cultures: [2182-8-31] 3:15 pm SWAB Site: MANDIBLE RIGHT SUBMANDIBULAR WOUND. FINAL REPORT [2182-9-6] GRAM STAIN (Final [2182-8-31]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. PAIRS AND SHORT CHAINS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). WOUND CULTURE (Final [2182-9-6]): 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.. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 8021] [9-/3832] [2182-9-3] REQUESTED FURTHER WORKUP. STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. SPARSE GROWTH. NEISSERIA SPECIES. RARE GROWTH. PIGMENTED, NON-PATHOGENIC. NEISSERIA SPECIES. SPARSE GROWTH. SECOND MORPHOLOGY. PRESUMPTIVE STREPTOCOCCUS BOVIS. SPARSE GROWTH. GRAM POSITIVE RODS. RARE GROWTH. UNABLE TO FUTHER IDENTIFY. HAEMOPHILUS SP. RARE GROWTH. BETA LACTAMASE NEGATIVE. ANAEROBIC CULTURE (Final [2182-9-6]): Mixed bacterial flora-culture screened for B. fragilis, C. perfringens, and C. septicum. None isolated. Further workup requested by DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 8021]. FUSOBACTERIUM NUCLEATUM. HEAVY GROWTH. BETA LACTAMASE NEGATIVE. PREVOTELLA SPECIES. MODERATE GROWTH. BETA LACTAMASE NEGATIVE. [2182-8-31] 10:20 am BLOOD CULTURE #1. FINAL REPORT [2182-9-6] Blood Culture, Routine (Final [2182-9-6]): NO GROWTH. [2182-8-31] 10:28 am BLOOD CULTURE #2. Blood Culture, Routine (Preliminary): BETA STREPTOCOCCUS. NON-TYPABLE. STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. FINAL SENSITIVITIES. Sensitivity testing performed by Sensititre. CLINDAMYCIN <= 0.12 MCG/ML. Susceptibility results were obtained by a procedure that has not been standardized for this organism Results may not be reliable and must be interpreted with caution. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP \| CLINDAMYCIN----------- S ERYTHROMYCIN----------<=0.25 S PENICILLIN G----------<=0.06 S VANCOMYCIN------------ <=1 S Anaerobic Bottle Gram Stain (Final [2182-9-1]): GRAM POSITIVE COCCI IN PAIRS. [2182-9-1] 10:04 pm BLOOD CULTURE FINAL REPORT [2182-9-7] Blood Culture, Routine (Final [2182-9-7]): NO GROWTH. [2182-9-1] 10:03 pm BLOOD CULTURE FINAL REPORT [2182-9-7] Blood Culture, Routine (Final [2182-9-7]): NO GROWTH. [2182-9-2] 7:33 am URINE Source: CVS. FINAL REPORT [2182-9-3] URINE CULTURE (Final [2182-9-3]): NO GROWTH. /[11-5] 2:08 am STOOL CONSISTENCY: LOOSE Source: Stool. FINAL REPORT [2182-9-4] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2182-9-4]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [2182-9-4] 6:15 am IMMUNOLOGY FINAL REPORT [2182-9-6] HCV VIRAL LOAD (Final [2182-9-5]): HCV-RNA NOT DETECTED. Performed using the Cobas Ampliprep / Cobas Taqman HCV Test. Linear range of quantification: 43 IU/mL - 69 million IU/mL. Rare instances of underquantification of HCV genotype 4 samples by [Doctor Last Name ] COBAS Ampliprep/COBAS TaqMan HCV test method used in our laboratory may occur, generally in the range of 10 to 100 fold underquantitation. If your patient has HCV genotype 4 virus and if clinically appropriate, please contact the molecular diagnostics laboratory ([Telephone/Fax (1) 6182]) so that results can be confirmed by an alternate methodology. Limit of detection: 18 IU/mL. Brief Hospital Course: 27 year old gentleman admitted to the acute care service with right sided facial swelling. Upon admission, OMFS was consulted and he was started on antibiotiocs. He was taken to the operating room where he was found to have a right mandibular abscess. He underwent an incision and drainage of the abscess with placment of three penrose drains. He also had an extraction of the right submandibular molar. During his immediate post-operative course, he remained intubated and was transferred to the intensive care unit for further monitoring. He was extubated on POD #1. His foley and [Last Name (un) ]-gastric tube were also discontinued. He was started on a soft diet. Blood cultures drawn in the emergency room did grow GPC( beta strept) and polymicrobial GPC/GNRs from his wound culture. He initiallly was treated with vancomycin and zosyn. Throughout his hosptial course, infectious disease continued to follow him and recommendations were made for a 4 week course of ertapenem upon discharge. During his hospital stay, he continued on zosyn. His penrose drains were discontinued on POD #4. He had a PICC line placed into his right arm and was started on unasyn until his discharge with coversion over to ertapenem at discharge. Because of his culture findings, he underwent a echocardiogram to assess for vegetation on the valves. The echo was normal with no signs of vegetation. His vital signs are stable and he is afebrile. His white blood cell count is normal. He is tolerating a regular diet and ambulating. He is preparing for discharge to a rehabilitation facility where he can complete his course of antbiotic and have his electroyltes monitored during this time. He will follow up with Infectious disease and with OMFS. Of note: 1st dose of ertapenem was started prior to discharge on [9-9] Medications on Admission: none Discharge Medications: 1. 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. 2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc Injection TID (3 times a day). 3. ertapenem 1 gram Recon Soln Sig: One (1) Gm Injection once a day: thru [2182-9-28]. 4. oxycodone 5 mg/5 mL Solution Sig: 5-10 mg PO Q3H (every 3 hours) as needed for pain. 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever/pain. 6. Colace 60 mg/15 mL Syrup Sig: Twenty Five (25) ml PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital6 2222] - [Location (un) 538] Discharge Diagnosis: Right submandibular submental, sublingual and lateral pharyngeal space infections. 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 an abscess on your right jaw which required drainage in the Operating Room by the maxillofacial surgeons. * You tolerated the procedure well and currently have been afebrile. * You are able to eat soft foods and should continue to do so. * The Infectious Disease doctors [Name5 (PTitle) 6349] [Name5 (PTitle) ] and recommended intravenous antibiotics for 4 weeks as you had a blood infection along with thejaw infection. * These antibiotics will need to be given thru your PICC line. * You will need follow up with the Infectious Disease doctors along with the Maxillofacial surgeons. ( see below ) Followup Instructions: Please follow up with Dr [Last Name (STitle) ] on [9-10] at 10:00 am at [Hospital6 ], Yawkey Building ACC 5(Fifth floor)(#[Telephone/Fax (1) 90827]) Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4593], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2182-9-24] 10:30 ( Infectious Disease Clinic ) [2182-10-30] 09:00a ID,[Doctor Last Name 8021],[Doctor Last Name ] ( Infectious disease) LM [Hospital Ward Name ] BLDG ([Doctor First Name ]), BASEMENT ID WEST (SB) ( # [Telephone/Fax (1) 457]) Completed by:[2182-9-9] ICD9 Codes: 7907
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 9099 }	Medical Text: Admission Date: [2106-6-30] Discharge Date: [2106-7-5] Date of Birth: [2023-9-4] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2106-6-30] AVR(27mm Porcine)/CABGx4(left internal mammary artery to left anterior descending with vein grafts to diagonal, obtuse marginal and right coronary artery) History of Present Illness: This is an 82 yo male with known aortic stenosis and multivessel coronary artery disease. Has had increasing SOB and worsening fatigue. Referred for surgical intervention. Past Medical History: aortic stenosis, coronary artery disease carotid artery disease polymyalgia rheumatica hypertension hyperlipidemia gout prior trace rectal bleed s/p abdominal hernia repair [2043] s/p left 5th finger tendon release [2097] s/p appendectomy [2045] s/p tonsillectomy Social History: Lives with: wife Occupation: retired auto dealer Tobacco: quit [2061] ETOH: 5 drinks/week Family History: Father died of MI at 73. Mother with CVA at 62. Physical Exam: Pulse: 61 Resp: 16 O2 sat: 99%RA B/P Right: 151/80 Left: Height: 5'[07]" Weight: 200lb General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur 3/6 SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema- trace edema bilateral ankles Varicosities- moderate varicosities, left worse than right, numerous superficial spider veins, venous stasis changes bilaterally Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit none Pertinent Results: [2106-6-30] Intraop TEE: PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. There are complex (mobile) atheroma in the descending aorta. The aortic valve leaflets (3) are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is no pericardial effusion. POST-BYPASS: Preserved biventricular systolic function. Intact thoracic aorta. The aortic bioprosthesis is stable and functioning well with a residual mean gradient of 12mm of HG. Trivial MR [First Name (Titles) ] [Last Name (Titles) ]. [2106-7-4] 05:36AM BLOOD WBC-11.3* RBC-3.33* Hgb-10.6* Hct-30.5* MCV-92 MCH-31.8 MCHC-34.7 RDW-14.6 Plt Ct-145* [2106-6-30] 04:18PM BLOOD PT-15.2* PTT-41.7* INR(PT)-1.3* [2106-7-5] 04:07AM BLOOD Glucose-101* UreaN-32* Creat-1.2 Na-136 K-3.8 Cl-102 HCO3-27 AnGap-11 [2106-7-4] 05:36AM BLOOD UreaN-33* Creat-1.2 Na-137 K-4.1 Cl-104 Brief Hospital Course: Mr. [Known lastname 85644] was admitted and underwent an aortic valve replacement and coronary artery bypass grafting surgery by Dr. [Last Name (STitle) 914]. For surgical details, please see operative note. Following surgery, 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 otherwise uneventful. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. He had a brief episode of afib which converted to SR with beta blocker titration and amiodarone. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: HCTZ 25 mg daily Allopurinol 100 mg daily ASA 81 mg daily Lisinopril 20 mg daily Prednisone 5 mg [Hospital1 ] Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:65 Tablet(s) Refills:0 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Psyllium Packet Sig: One (1) Packet PO TID (3 times a day) as needed for constipation. 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 10. Outpatient Lab Work Serial PT/INR dx: atrial fibrillation goal INR [2-10] Please call results to Dr. [First Name (STitle) ] ([Telephone/Fax (1) 85645] 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: dose will change daily for goal INR [2-10], Dr. [First Name (STitle) ] to manage, first lab draw by VNA [2106-7-6]. Disp:30 Tablet(s) Refills:2 13. Lisinopril 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:45 Tablet(s) Refills:0 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:10 Tablet(s) Refills:0 15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. Disp:10 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1376] [Hospital3 635] Discharge Diagnosis: Coronary Artery Disease, Aortic Stenosis - s/p AVR (#27 tissue)/CABG x4 on [2106-6-27] Hypertension Dyslipidemia Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema [1-9]+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] 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 have been scheduled to see your surgeon Dr. [Last Name (STitle) 914] on [2106-8-3] at 1pm [Telephone/Fax (1) 170] Plaese call and schedule the following appointments Dr. [First Name8 (NamePattern2) 4115] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 85645] in [1-9] weeks Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10168] in [1-9] weeks 1-[Telephone/Fax (1) 70181] VNA to draw INR [7-6] and call results to Dr. [First Name (STitle) ] ([Telephone/Fax (1) 85646] for management of coumadin dosing Completed by:[2106-7-5] ICD9 Codes: 4241, 2749, 2724, 4019

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