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10,030,852
22,579,782
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: diabetic ketoacidosis with history of Type I dia...
[ "T85614A", "E1010", "O24013", "T85624A", "T383X6A", "Z3A34", "O99213", "E669", "Z6836", "Y929" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: diabetic ketoacidosis with history of Type I diabetes [MASKED] [MASKED] Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] G1 at [MASKED] with T1DM transferred for poorly controlled diabetes. She reports her finger stic...
[]
[ "E669", "Y929" ]
[ "T85614A: Breakdown (mechanical) of insulin pump, initial encounter", "E1010: Type 1 diabetes mellitus with ketoacidosis without coma", "O24013: Pre-existing type 1 diabetes mellitus, in pregnancy, third trimester", "T85624A: Displacement of insulin pump, initial encounter", "T383X6A: Underdosing of insulin...
10,030,852
22,871,136
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: poor diabetes control Major Surgical or Invasi...
[ "O24013", "E1065", "O99213", "O403XX0", "Z3A32", "Z794", "Z9641", "Z6836" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: poor diabetes control Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] G1 with T1DM at 32w3d who presents for admission due to poorly controlled diabetes. Pt has been followed by her endocrinologist (Dr [MASKED] but h...
[]
[ "Z794" ]
[ "O24013: Pre-existing type 1 diabetes mellitus, in pregnancy, third trimester", "E1065: Type 1 diabetes mellitus with hyperglycemia", "O99213: Obesity complicating pregnancy, third trimester", "O403XX0: Polyhydramnios, third trimester, not applicable or unspecified", "Z3A32: 32 weeks gestation of pregnancy"...
10,030,852
27,541,847
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Elevated BPs Major Surgical or Invasive Proced...
[ "O1414", "O2402", "Z6841", "E1065", "O631", "O99214", "O660", "O7581", "O701", "O691XX0", "Z370", "Z9641", "Z794", "Z3A37" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Elevated BPs Major Surgical or Invasive Procedure: Vacuum-assisted vaginal delivery History of Present Illness: [MASKED] G1P0 at 36w3d with poorly controlled [MASKED] transferred from [MASKED] with elevated BPs. She had BPs 172/101 and 164/80 at [M...
[]
[ "Z794" ]
[ "O1414: Severe pre-eclampsia complicating childbirth", "O2402: Pre-existing type 1 diabetes mellitus, in childbirth", "Z6841: Body mass index [BMI]40.0-44.9, adult", "E1065: Type 1 diabetes mellitus with hyperglycemia", "O631: Prolonged second stage (of labor)", "O99214: Obesity complicating childbirth", ...
10,030,863
22,221,453
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Multihance Attending: ___. Chief Complaint: referred from clinic for hypertensive urgency Major Surgical or Invasive Procedure: None ...
[ "I160", "N910", "Z9114", "I129", "N182", "I517", "J45909", "E559", "E211", "F17200" ]
Allergies: Multihance Chief Complaint: referred from clinic for hypertensive urgency Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] woman with long-standing history of hypertension currently non-compliant with home medications, hyperparathyroidism, and depression presenting from clinic ...
[]
[ "I129", "J45909" ]
[ "I160: Hypertensive urgency", "N910: Primary amenorrhea", "Z9114: Patient's other noncompliance with medication regimen", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N182: Chronic kidney disease, stage 2 (mild)", ...
10,030,937
29,265,770
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dyspnea on exertion Major Surgical or Invas...
[ "O135", "O9953", "J811", "O9279", "J45909", "O9089", "R51", "R319", "O9081", "D649" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] s/p pLTCS for arrest of dilation on [MASKED] presents with two days of worsening shortness of breath. She describes onset of symptoms two nights ago...
[]
[ "J45909", "D649" ]
[ "O135: Gestational [pregnancy-induced] hypertension without significant proteinuria, complicating the puerperium", "O9953: Diseases of the respiratory system complicating the puerperium", "J811: Chronic pulmonary edema", "O9279: Other disorders of lactation", "J45909: Unspecified asthma, uncomplicated", "...
10,031,308
20,329,709
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PSYCHIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: "I am scared of something" Major Surgical or Invasive ...
[ "F312", "F1210", "F4310", "X58XXXS", "F17210" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: "I am scared of something" Major Surgical or Invasive Procedure: none History of Present Illness: For further details of the history and presentation, please see OMR, including Dr. [MASKED] initial consultation note dated [MASKED] and Dr. [MASKED] ...
[]
[ "F17210" ]
[ "F312: Bipolar disorder, current episode manic severe with psychotic features", "F1210: Cannabis abuse, uncomplicated", "F4310: Post-traumatic stress disorder, unspecified", "X58XXXS: Exposure to other specified factors, sequela", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]
10,031,316
27,575,109
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: amitriptyline / hydrochlorothiazide / lisinopril Attending: ___. Chief Complaint: left arm discomfort and shortness of breath Maj...
[ "I25110", "E1165", "I10", "J95812", "D62", "E782", "K219", "G4733", "F419", "F329", "Y832", "Y92234", "I9581", "Z87891" ]
Allergies: amitriptyline / hydrochlorothiazide / lisinopril Chief Complaint: left arm discomfort and shortness of breath Major Surgical or Invasive Procedure: [MASKED] Coronary artery bypass grafting x2 with the left internal mammary artery to the left anterior descending artery, and reverse saphenous vein graft to the...
[]
[ "E1165", "I10", "D62", "K219", "G4733", "F419", "F329", "Z87891" ]
[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "E1165: Type 2 diabetes mellitus with hyperglycemia", "I10: Essential (primary) hypertension", "J95812: Postprocedural air leak", "D62: Acute posthemorrhagic anemia", "E782: Mixed hyperlipidemia", "K219: Gas...
10,031,358
28,474,294
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ACE Inhibitors / ___ Receptor Antagonist Attending: ___. Chief Complaint: Toe ulcer, fevers, chills Major Surgical or Invasive Procedu...
[ "E11621", "M86172", "N179", "E1121", "E1140", "F3181", "L97529", "Z794", "E1169", "E11319", "E11628", "L03032", "E1122", "T43595S", "N189", "I129", "I890", "E538", "R251", "K2270", "Z87891", "M205X2", "Z89411" ]
Allergies: ACE Inhibitors / [MASKED] Receptor Antagonist Chief Complaint: Toe ulcer, fevers, chills Major Surgical or Invasive Procedure: Left hallux debridement and biopsy on [MASKED] History of Present Illness: [MASKED] M with [MASKED] IDDM DM2 c/b retinopathy, nephropathy, and neuropathy, HTN, traumatic SAH c/b seiz...
[]
[ "N179", "Z794", "E1122", "N189", "I129", "Z87891" ]
[ "E11621: Type 2 diabetes mellitus with foot ulcer", "M86172: Other acute osteomyelitis, left ankle and foot", "N179: Acute kidney failure, unspecified", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "F3181: Bipolar II ...
10,031,358
29,498,981
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: ACE Inhibitors / ___ Receptor Antagonist Attending: ___. Chief Complaint: slurred speech, facial droop Major Surgical or Invasive Pro...
[ "I619", "G8191", "E1329", "E1140", "K2270", "Z6841", "E538", "R1310", "E11319", "R29810", "E119", "E785", "Z9114", "E039", "N189", "E669", "R471", "I129", "F319", "F329", "Z7982", "Z794", "Z89421", "Z87891" ]
Allergies: ACE Inhibitors / [MASKED] Receptor Antagonist Chief Complaint: slurred speech, facial droop Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [MASKED] is a [MASKED] year old male with history of DM, HTN, HLD, and noncompliance to meds for financial reasons, who developed right facial...
[]
[ "E119", "E785", "E039", "N189", "E669", "I129", "F329", "Z794", "Z87891" ]
[ "I619: Nontraumatic intracerebral hemorrhage, unspecified", "G8191: Hemiplegia, unspecified affecting right dominant side", "E1329: Other specified diabetes mellitus with other diabetic kidney complication", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "K2270: Barrett's esophagus...
10,031,358
29,887,601
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: ACE Inhibitors / ___ Receptor Antagonist Attending: ___ Chief Complaint: right sided weakness Major Surgical or Invasive Procedure: N...
[ "I6329", "G8191", "E1121", "E1140", "Z6841", "E1165", "E11319", "E1122", "I129", "N183", "Z794", "E538", "Z87820", "I69398", "R569", "E039", "F319", "E669", "K219", "R251", "K2270", "Z87891", "Z9114", "E785" ]
Allergies: ACE Inhibitors / [MASKED] Receptor Antagonist Chief Complaint: right sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a pleasant [MASKED] man with DM2 c/b retinopathy, nephropathy, and neuropathy, HTN, B12 deficiency, traumatic SAH c/b seizure, and L putam...
[]
[ "E1165", "E1122", "I129", "Z794", "E039", "E669", "K219", "Z87891", "E785" ]
[ "I6329: Cerebral infarction due to unspecified occlusion or stenosis of other precerebral arteries", "G8191: Hemiplegia, unspecified affecting right dominant side", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "Z6841: B...
10,031,396
22,921,074
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Acute ___ in Pain Headache Major Surgical or Invasive P...
[ "I618", "I161", "I10", "R402142", "R402252", "R402362", "Z87891", "Z853" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Acute [MASKED] in Pain Headache Major Surgical or Invasive Procedure: Conventional Angiography History of Present Illness: [MASKED] with PMH HTN, left breast ca s/p mastectomy who presents with headache with hypertensive emergency and found to have...
[]
[ "I10", "Z87891" ]
[ "I618: Other nontraumatic intracerebral hemorrhage", "I161: Hypertensive emergency", "I10: Essential (primary) hypertension", "R402142: Coma scale, eyes open, spontaneous, at arrival to emergency department", "R402252: Coma scale, best verbal response, oriented, at arrival to emergency department", "R4023...
10,031,404
21,606,243
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Pericardiocentesis ___ History...
[ "I308", "J90", "N179", "E871", "E860", "I9589", "J9811", "R000", "I10", "E785", "Z8781", "L930", "R002", "Z8639", "Z87891" ]
Allergies: lisinopril Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Pericardiocentesis [MASKED] History of Present Illness: Ms. [MASKED] is an [MASKED] year old woman with a hx of HTN, HLD, Grave's disease, discoid lupus (in remission x [MASKED] years) who presents with pericardial effusion...
[]
[ "N179", "E871", "I10", "E785", "Z87891" ]
[ "I308: Other forms of acute pericarditis", "J90: Pleural effusion, not elsewhere classified", "N179: Acute kidney failure, unspecified", "E871: Hypo-osmolality and hyponatremia", "E860: Dehydration", "I9589: Other hypotension", "J9811: Atelectasis", "R000: Tachycardia, unspecified", "I10: Essential ...
10,031,575
21,330,901
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: chest pain Major Surgical or Invasive Procedure: None Histo...
[ "A419", "I130", "I5032", "N179", "R079", "E1142", "E1122", "N183", "K046", "I951", "K029", "E785", "D509", "Z89421", "Z8673" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: chest pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] pmhx of HFpEF (EF 55% [MASKED], HTN, DMII c/b peripheral neuropathy, retinopathy, R toe osteo s/p amp, CKD (b/l 1.9-2.3), HLD presenting with chest pain. Pt ...
[]
[ "I130", "I5032", "N179", "E1122", "E785", "D509", "Z8673" ]
[ "A419: Sepsis, unspecified organism", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5032: Chronic diastolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "R079: C...
10,031,575
21,395,590
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: SOB, ___ edema Major Surgical or Invasive Procedure: none ...
[ "I130", "I5023", "E1122", "E1142", "I69354", "N183", "E11319", "E785", "Z89421", "D509", "Z794", "E1165", "R001", "I160" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: SOB, [MASKED] edema Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [MASKED] is a [MASKED] y/o woman with a PMH of HFpEF, HTN, T2DM s/p peripheral neuropathy, retinopathy, R toe osteomyelitis s/p amputation, CKDIII (basel...
[]
[ "I130", "E1122", "E785", "D509", "Z794", "E1165" ]
[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5023: Acute on chronic systolic (congestive) heart failure", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E1142: Typ...
10,031,575
23,640,913
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: diarrhea weakness Major Surgical or Invasive Procedure: None ...
[ "A0472", "N179", "I130", "I5032", "E1122", "N183", "Z794", "E1142", "E11319", "E861", "D509", "E875", "Z9114", "E785" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: diarrhea weakness Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] y/o woman with a PMH of HFpEF, HTN, T2DM s/p peripheral neuropathy, retinopathy, R toe osteomyelitis s/p amputation, CKDIII (baseline Cr 1.7-2.0), HLD...
[]
[ "N179", "I130", "I5032", "E1122", "Z794", "D509", "E785" ]
[ "A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent", "N179: Acute kidney failure, unspecified", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5032: Chronic diasto...
10,031,575
24,907,346
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Foot pain, swelling Major Surgical or Invasive Procedure: ___...
[ "E1169", "L03115", "E1122", "M86171", "N179", "I130", "N183", "I5032", "I272", "E11621", "L97514", "E11628", "E1140", "Z794", "D500", "E785", "I2510", "Z8673", "E1165", "I340", "E11319", "E669", "Z6837", "B9561", "B9689" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Foot pain, swelling Major Surgical or Invasive Procedure: [MASKED] Bedside I&D, right foot [MASKED] Open right [MASKED] toe amputation [MASKED] Right foot debridement with wound vac placement History of Present Illness: [MASKED] year old woman with...
[]
[ "E1122", "N179", "I130", "I5032", "Z794", "E785", "I2510", "Z8673", "E1165", "E669" ]
[ "E1169: Type 2 diabetes mellitus with other specified complication", "L03115: Cellulitis of right lower limb", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "M86171: Other acute osteomyelitis, right ankle and foot", "N179: Acute kidney failure, unspecified", "I130: Hypertensive h...
10,031,575
25,549,462
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Weight loss, fatigue, dizziness Major Surgical or Invasive Pr...
[ "N179", "I214", "I130", "I5032", "T501X5A", "E1122", "E875", "E11621", "E11319", "L97519", "E1140", "E785", "I951", "Z794", "E869", "N184", "Z8673", "Y929", "D509", "E069", "I2510", "R319", "Z9181", "E6601", "Z6835" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Weight loss, fatigue, dizziness Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [MASKED] is a [MASKED] year old woman with a [MASKED] diastolic CHF (likely related to HTN), HTN, HLD, T2DM, and recent [MASKED] admission fo...
[]
[ "N179", "I130", "I5032", "E1122", "E785", "Z794", "Z8673", "Y929", "D509", "I2510" ]
[ "N179: Acute kidney failure, unspecified", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5032: Chronic diastolic (congestive) heart f...
10,031,575
27,796,946
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: dyspnea, chest pain Major Surgical or Invasive Procedure: Non...
[ "I130", "I214", "N179", "I5033", "L97419", "Z6841", "E1122", "E785", "Z794", "E11319", "E1140", "N189", "E11621", "E611", "E049", "E6601" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: dyspnea, chest pain Major Surgical or Invasive Procedure: None. History of Present Illness: [MASKED] woman with HTN, IDDM, HLD with heart failure (unknown EF) diagnosed [MASKED] at [MASKED] here with worsening dyspnea on exertion, lower extremity e...
[]
[ "I130", "N179", "E1122", "E785", "Z794", "N189" ]
[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "N179: Acute kidney failure, unspecified", "I5033: Acute on chronic diastolic (congestive...
10,032,176
20,464,560
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Depakote / lisinopril / Topamax / Ultram / hydrochlorothiazide Attending: ___. Chief Complaint: Dyspnea, cough, headache, diarrhea Majo...
[ "I110", "I5031", "E871", "N390", "A09", "Z6842", "F05", "D509", "R1310", "B961", "B373", "R339", "T502X5A", "Y92099", "J449", "J029", "E8342", "G40909", "E785", "E039", "K635", "K5730", "Z86718", "E1165", "F17210", "E1140", "E669" ]
Allergies: Depakote / lisinopril / Topamax / Ultram / hydrochlorothiazide Chief Complaint: Dyspnea, cough, headache, diarrhea Major Surgical or Invasive Procedure: Colonoscopy and EGD History of Present Illness: [MASKED] year old lady with history of HTN, COPD, IDDM, hypothyroidism, DVT who presented with diarrhea, SOB...
[]
[ "I110", "E871", "N390", "D509", "J449", "E785", "E039", "Z86718", "E1165", "F17210", "E669" ]
[ "I110: Hypertensive heart disease with heart failure", "I5031: Acute diastolic (congestive) heart failure", "E871: Hypo-osmolality and hyponatremia", "N390: Urinary tract infection, site not specified", "A09: Infectious gastroenteritis and colitis, unspecified", "Z6842: Body mass index [BMI] 45.0-49.9, ad...
10,032,409
28,020,206
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Enalapril / Ace Inhibitors / Iodine / Codeine / Advair HFA / Losartan / Levofloxacin / hydrochlorothiazide Attending: ___...
[ "J9621", "J690", "N179", "E870", "I471", "E1165", "F0390", "F05", "I5030", "J441", "J9622", "E11319", "Z9981", "I10", "I2510", "F259", "E785", "Z66", "G2401", "T43595A", "Y92230", "R740" ]
Allergies: Penicillins / Enalapril / Ace Inhibitors / Iodine / Codeine / Advair HFA / Losartan / Levofloxacin / hydrochlorothiazide Chief Complaint: respiratory failure Major Surgical or Invasive Procedure: Intubation - [MASKED] History of Present Illness: [MASKED] with PMH COPD on 3L home O2, dCHF, CAD, EtOH abuse, an...
[]
[ "N179", "E1165", "I10", "I2510", "E785", "Z66", "Y92230" ]
[ "J9621: Acute and chronic respiratory failure with hypoxia", "J690: Pneumonitis due to inhalation of food and vomit", "N179: Acute kidney failure, unspecified", "E870: Hyperosmolality and hypernatremia", "I471: Supraventricular tachycardia", "E1165: Type 2 diabetes mellitus with hyperglycemia", "F0390: ...
10,033,085
23,404,293
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PODIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: R foot Osteomyelitis Major Surgical or Invasive Procedur...
[ "E1169", "M86171", "M86671", "Z794", "I10", "Z006" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: R foot Osteomyelitis Major Surgical or Invasive Procedure: [MASKED]: R [MASKED] MPJ debridement; abx spacer History of Present Illness: [MASKED] male patient presenting to the ED with concern for a right toe infection. Patient with PMH of DM with h...
[]
[ "Z794", "I10" ]
[ "E1169: Type 2 diabetes mellitus with other specified complication", "M86171: Other acute osteomyelitis, right ankle and foot", "M86671: Other chronic osteomyelitis, right ankle and foot", "Z794: Long term (current) use of insulin", "I10: Essential (primary) hypertension", "Z006: Encounter for examination...
10,033,290
22,588,582
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: RUE pain/weakness Major Surgical or Invasive Procedure...
[ "M19041", "I110", "I509", "I482", "Z7902", "I447" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: RUE pain/weakness Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [MASKED] is a [MASKED] man with afib on apixaban, CHF, and LBBB who presents from clinic for evaluation of left hand pain and right arm pain. History was o...
[]
[ "I110", "Z7902" ]
[ "M19041: Primary osteoarthritis, right hand", "I110: Hypertensive heart disease with heart failure", "I509: Heart failure, unspecified", "I482: Chronic atrial fibrillation", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "I447: Left bundle-branch block, unspecified" ]
10,033,290
27,373,164
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Major Surgical or Invasive Procedure: Cardiac Catheterization, ___: No an...
[ "I110", "I4821", "I472", "Z7902", "I420", "I5042", "G4733", "I872", "Z8249", "I2720", "E669", "Z6834", "I447" ]
Allergies: No Known Allergies / Adverse Drug Reactions Major Surgical or Invasive Procedure: Cardiac Catheterization, [MASKED]: No angiographically apparent CAD. Elevated filling pressures CRT-D placement, [MASKED] attach Pertinent Results: ADMISSION LABS: =============== [MASKED] 10:10AM BLOOD WBC-5.9 RBC-4.96 Hgb-15....
[]
[ "I110", "Z7902", "G4733", "E669" ]
[ "I110: Hypertensive heart disease with heart failure", "I4821: Permanent atrial fibrillation", "I472: Ventricular tachycardia", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "I420: Dilated cardiomyopathy", "I5042: Chronic combined systolic (congestive) and diastolic (congestive) heart...
10,033,409
21,370,169
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: shellfish derived Attending: ___. Chief Complaint: Cough, fever, lethargy Major Surgical or Invasive Procedure: None History of Present...
[ "J690", "G20", "F0280", "F0150", "I129", "E1122", "E1165", "N183", "E113299", "E785", "M109", "I69322", "E1151", "Z86718", "Z87440", "R400", "R1312" ]
Allergies: shellfish derived Chief Complaint: Cough, fever, lethargy Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] y/o woman with history of uncontrolled type 2 DM complicated by small vessel CVA [MASKED], vascular dementia, recent L5 nerve root injection, and frequent UTI presenting w...
[]
[ "I129", "E1122", "E1165", "E785", "M109", "Z86718" ]
[ "J690: Pneumonitis due to inhalation of food and vomit", "G20: Parkinson's disease", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "F0150: Vascular dementia without behavioral disturbance", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chr...
10,033,409
21,582,131
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: shellfish derived Attending: ___ Chief Complaint: AMS Major Surgical or Invasive Procedure: None History of Present Illness: ___ hx unc...
[ "F0151", "E1121", "G20", "Z87440", "K5909", "Z8673", "E113299", "M4806", "R339", "M4726", "R32", "M47892", "I129", "N183", "E039", "E785" ]
Allergies: shellfish derived Chief Complaint: AMS Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] hx uncontrolled DM2 c/b small vessel CVA [MASKED], vascular dementia, recent L5 nerve root injection, frequent UTI p/w one week AMS and nonfocal weakness, superimposed on months of chronic b...
[]
[ "Z8673", "I129", "E039", "E785" ]
[ "F0151: Vascular dementia with behavioral disturbance", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "G20: Parkinson's disease", "Z87440: Personal history of urinary (tract) infections", "K5909: Other constipation", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral ...
10,033,409
27,804,795
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: shellfish derived Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: LABORATORY RESULTS: ___ 10:30PM ...
[ "A4151", "N390", "N179", "F0150", "Z8673", "E039", "Z86718", "Z7984", "E1151", "I10", "Z87440", "G214", "E7800", "M5416", "E113299", "K5900", "M109", "F329", "E1165" ]
Allergies: shellfish derived Major Surgical or Invasive Procedure: None attach Pertinent Results: LABORATORY RESULTS: [MASKED] 10:30PM BLOOD WBC-10.7* RBC-4.08 Hgb-13.0 Hct-40.3 MCV-99* MCH-31.9 MCHC-32.3 RDW-12.4 RDWSD-45.1 Plt [MASKED] [MASKED] 04:45AM BLOOD WBC-8.7 RBC-3.67* Hgb-11.5 Hct-35.5 MCV-97 MCH-31.3 MCHC-32...
[]
[ "N390", "N179", "Z8673", "E039", "Z86718", "I10", "K5900", "M109", "F329", "E1165" ]
[ "A4151: Sepsis due to Escherichia coli [E. coli]", "N390: Urinary tract infection, site not specified", "N179: Acute kidney failure, unspecified", "F0150: Vascular dementia without behavioral disturbance", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual ...
10,033,552
26,487,381
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Atenolol / Amlodipine / Tekturna / felodipine / lisinopril / Diovan Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive...
[ "I213", "E1122", "E8881", "I2510", "I129", "N182", "K219", "Z8673", "E7800" ]
Allergies: Atenolol / Amlodipine / Tekturna / felodipine / lisinopril / Diovan Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac cath ([MASKED]) History of Present Illness: Ms. [MASKED] is a [MASKED] yoF w metabolic syndrome, hx of diverticulitis, tension headaches and CKD stage II who presents ...
[]
[ "E1122", "I2510", "I129", "K219", "Z8673" ]
[ "I213: ST elevation (STEMI) myocardial infarction of unspecified site", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E8881: Metabolic syndrome", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I129: Hypertensive chronic kidney disease wi...
10,033,552
28,741,297
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Atenolol / Amlodipine / Tekturna / felodipine Attending: ___. Chief Complaint: headache, chest pain, abdominal pain Major Surgical or Invas...
[ "K5732", "R079", "K219", "E1122", "I129", "N182", "E785", "E860", "G44209", "E8881", "R933", "E669", "Z6830", "Z8673" ]
Allergies: Atenolol / Amlodipine / Tekturna / felodipine Chief Complaint: headache, chest pain, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] female with history of hypertension, hyperlipidemia, and metabolic syndrome on metformin presenting with headache, chest pain and...
[]
[ "K219", "E1122", "I129", "E785", "E669", "Z8673" ]
[ "K5732: Diverticulitis of large intestine without perforation or abscess without bleeding", "R079: Chest pain, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I129: Hypertensive chronic kidney disease with s...
10,033,552
29,061,116
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Atenolol / Amlodipine / Tekturna / felodipine / lisinopril / Diovan Attending: ___. Chief Complaint: Chest Pain, L Shoulder Pain Major S...
[ "I25119", "I129", "E1122", "N182", "Z955", "I252", "Z7902", "M7542", "E785", "K219", "Z8673", "E669", "Z6829" ]
Allergies: Atenolol / Amlodipine / Tekturna / felodipine / lisinopril / Diovan Chief Complaint: Chest Pain, L Shoulder Pain Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] w/ PMHx CAD s/p STEMI w/ PCI to mid-LAD ([MASKED]), HTN, previous hx of diverticulitis, and CKD stage II presenting ...
[]
[ "I129", "E1122", "Z955", "I252", "Z7902", "E785", "K219", "Z8673", "E669" ]
[ "I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N...
10,033,661
23,080,369
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Celebrex / codeine / Demerol / epinephrine / epinephrine / Penicillins / scallops / shellfish derived Attending: ___. Chief Complaint: LC1 ...
[ "S32591A", "W06XXXA", "J449", "M810", "I10", "H409", "Z96641", "Z96651", "K449", "M1990" ]
Allergies: Celebrex / codeine / Demerol / epinephrine / epinephrine / Penicillins / scallops / shellfish derived Chief Complaint: LC1 pelvis fracture Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] female history arthritis, COPD, osteoporosis, skin cancer, glaucoma who presents with righ...
[]
[ "J449", "I10" ]
[ "S32591A: Other specified fracture of right pubis, initial encounter for closed fracture", "W06XXXA: Fall from bed, initial encounter", "J449: Chronic obstructive pulmonary disease, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "I10: Essential (primary) hypertension",...
10,033,710
25,343,985
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: codeine Attending: ___. Chief Complaint: Right intertrochanteric femur fracture Major Surgical or Invasive Procedure: ___: Right tro...
[ "S72141A", "S22088A", "D62", "S52021A", "S62366A", "W1830XA", "Y92122", "Z66", "I4891", "F0390", "H409", "H9190", "M810", "Z87310", "Z961", "I440" ]
Allergies: codeine Chief Complaint: Right intertrochanteric femur fracture Major Surgical or Invasive Procedure: [MASKED]: Right trochanteric femoral nail History of Present Illness: This is a [MASKED] female who presents to the emergency department at [MASKED] in transfer from [MASKED] with right intertrochanteric hip...
[]
[ "D62", "Z66", "I4891" ]
[ "S72141A: Displaced intertrochanteric fracture of right femur, initial encounter for closed fracture", "S22088A: Other fracture of T11-T12 vertebra, initial encounter for closed fracture", "D62: Acute posthemorrhagic anemia", "S52021A: Displaced fracture of olecranon process without intraarticular extension o...
10,033,887
25,791,193
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PSYCHIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Psychiatry consulted by ED team for pt who was referred by ...
[ "F209", "F17210", "F1210" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Psychiatry consulted by ED team for pt who was referred by therapist [MASKED] at [MASKED] following an incident last night in which he had his pants down and was yelling sexual obscenities. Major Surgical or Invasive Procedure: None History of Pres...
[]
[ "F17210" ]
[ "F209: Schizophrenia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F1210: Cannabis abuse, uncomplicated" ]
10,034,031
28,282,749
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: chest pain Major Surgical or Invasive Procedure: ___...
[ "I214", "J90", "I4891", "D62", "I9581", "I2510", "I700", "I10", "E785", "N400", "Z8719", "Z8711", "Z87891" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: chest pain Major Surgical or Invasive Procedure: [MASKED] CABG x 3 LIMA-> LAD, RSVG-> Ramus, PDA History of Present Illness: Mr. [MASKED] is a [MASKED] year old M w/ PMH HTN, HLD, BPH who presents with 1 week of chest pain. Pt has good [MASKED] com...
[]
[ "I4891", "D62", "I2510", "I10", "E785", "N400", "Z87891" ]
[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "J90: Pleural effusion, not elsewhere classified", "I4891: Unspecified atrial fibrillation", "D62: Acute posthemorrhagic anemia", "I9581: Postprocedural hypotension", "I2510: Atherosclerotic heart disease of native coronary artery without angina pec...
10,034,049
20,053,563
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Confusion Major Surgical or Invasive ...
[ "A419", "G92", "N12", "F05", "I69351", "M0520", "E119", "Z9181", "Z87440", "F0390", "Z7952", "D509", "Z66", "N289", "E039", "K5903", "T402X5A", "I878", "J45909", "R339", "M549", "M79605" ]
Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Chief Complaint: Confusion Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] yo F w/ severe RA w/ leukocytoclastic vasculitis, venous insufficiency, hypothyroid, DM, presenting with abdominal pain and AMS. Per ...
[]
[ "E119", "D509", "Z66", "E039", "J45909" ]
[ "A419: Sepsis, unspecified organism", "G92: Toxic encephalopathy", "N12: Tubulo-interstitial nephritis, not specified as acute or chronic", "F05: Delirium due to known physiological condition", "I69351: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side", "M0520: Rheuma...
10,034,049
20,693,789
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: abdominal pain, AMS Major Surgical or...
[ "N390", "G92", "J449", "F05", "B9562", "I10", "E119", "F329", "E785", "G8929", "Z79899", "E039", "J45998", "Z7952", "K219", "R339", "I872", "M069", "E876" ]
Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Chief Complaint: abdominal pain, AMS Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] PMHx chronic pain on methadone, chronic BLE venous stasis ulcers and recurrent UTIs who presents with AMS...
[]
[ "N390", "J449", "I10", "E119", "F329", "E785", "G8929", "E039", "K219" ]
[ "N390: Urinary tract infection, site not specified", "G92: Toxic encephalopathy", "J449: Chronic obstructive pulmonary disease, unspecified", "F05: Delirium due to known physiological condition", "B9562: Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere", ...
10,034,049
22,185,456
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Inv...
[ "M47816", "G9340", "L97919", "D696", "I83009", "M069", "D649", "R109", "L739", "Z66", "Z5329", "R7303", "K5900", "F419", "F329", "E039", "E785", "F17210", "Z9114", "Z8673", "Z8542" ]
Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [MASKED] CT-guided L4-L5 spine biopsy History of Present Illness: Ms. [MASKED] is a [MASKED] year-old female with medical history notable for stroke (right sided weakness...
[]
[ "D696", "D649", "Z66", "K5900", "F419", "F329", "E039", "E785", "F17210", "Z8673" ]
[ "M47816: Spondylosis without myelopathy or radiculopathy, lumbar region", "G9340: Encephalopathy, unspecified", "L97919: Non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity", "D696: Thrombocytopenia, unspecified", "I83009: Varicose veins of unspecified lower extremity...
10,034,049
24,278,210
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: AMS Major Surgical or Invasive Proced...
[ "N390", "G9341", "K5901", "M069", "I10", "B9620", "E876", "E8342", "E785", "J449", "E039", "E119", "F419", "F329", "T402X5A", "Y92009", "F17210" ]
Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Chief Complaint: AMS Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] female with history of rheumatoid arthritis on daily prednisone, HTN, HLD, hypothyroidism, DM2, asthma, depression, anxie...
[]
[ "N390", "I10", "E785", "J449", "E039", "E119", "F419", "F329", "F17210" ]
[ "N390: Urinary tract infection, site not specified", "G9341: Metabolic encephalopathy", "K5901: Slow transit constipation", "M069: Rheumatoid arthritis, unspecified", "I10: Essential (primary) hypertension", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "...
10,034,049
28,052,811
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Leg lesions Major Surgical or Invasiv...
[ "N390", "G9341", "L97819", "D649", "J449", "B952", "E119", "E039", "L97829", "I872", "M545", "G8929", "I10", "E785", "J45909", "M069", "F329", "F419", "S80812A", "S80811A", "W010XXA", "Z9181", "Y92008", "F17210" ]
Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Chief Complaint: Leg lesions Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] PMH chronic low back pain (on narcotics agreement) who presents with CC of bilateral lower extremity pain after a fall one week ago...
[]
[ "N390", "D649", "J449", "E119", "E039", "G8929", "I10", "E785", "J45909", "F329", "F419", "F17210" ]
[ "N390: Urinary tract infection, site not specified", "G9341: Metabolic encephalopathy", "L97819: Non-pressure chronic ulcer of other part of right lower leg with unspecified severity", "D649: Anemia, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "B952: Enterococcus as the cause...
10,034,049
28,952,773
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Bilateral leg pain Major Surgical or ...
[ "I890", "J449", "E119", "G8929", "I10", "E039", "M069", "Z87891", "J45909", "I872", "Z7952", "E785", "F329", "K219", "R339" ]
Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Chief Complaint: Bilateral leg pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year old woman with a history of hypothyroidism, rheumatoid arthritis, chronic pain, DM II, hypertension w...
[]
[ "J449", "E119", "G8929", "I10", "E039", "Z87891", "J45909", "E785", "F329", "K219" ]
[ "I890: Lymphedema, not elsewhere classified", "J449: Chronic obstructive pulmonary disease, unspecified", "E119: Type 2 diabetes mellitus without complications", "G8929: Other chronic pain", "I10: Essential (primary) hypertension", "E039: Hypothyroidism, unspecified", "M069: Rheumatoid arthritis, unspec...
10,034,317
20,827,960
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: morphine / hydrochlorothiazide / amiodarone Attending: ___. Chief Complaint: HCV, HCC Major Surgical or Invasive Procedure: ___ 1. Explora...
[ "C220", "R571", "D693", "D62", "N179", "J90", "B182", "I2510", "I252", "I480", "Z7901", "Z87891", "Z8673", "E119", "Z794", "M47896", "G4733", "G8918", "E875", "K219" ]
Allergies: morphine / hydrochlorothiazide / amiodarone Chief Complaint: HCV, HCC Major Surgical or Invasive Procedure: [MASKED] 1. Exploratory laparotomy and resection of Liver segment VIII 2. Intraoperative ultrasound. History of Present Illness: [MASKED] man with HCC and fibrosis related to chronic HCV infection. Thi...
[]
[ "D62", "N179", "I2510", "I252", "I480", "Z7901", "Z87891", "Z8673", "E119", "Z794", "G4733", "K219" ]
[ "C220: Liver cell carcinoma", "R571: Hypovolemic shock", "D693: Immune thrombocytopenic purpura", "D62: Acute posthemorrhagic anemia", "N179: Acute kidney failure, unspecified", "J90: Pleural effusion, not elsewhere classified", "B182: Chronic viral hepatitis C", "I2510: Atherosclerotic heart disease ...
10,034,742
26,829,411
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: quinine Attending: ___ Chief Complaint: Lumbar stenosis Major Surgical or Invasive Procedure: ___: L2-3 laminectomy History o...
[ "M4806", "G8929", "M549", "E039", "J45909", "E669", "Z6834", "Z85828" ]
Allergies: quinine Chief Complaint: Lumbar stenosis Major Surgical or Invasive Procedure: [MASKED]: L2-3 laminectomy History of Present Illness: Ms. [MASKED] is a [MASKED] female who has a longstanding history of back pain. The back pain is [MASKED]. She is taking pain medication for the back pain. She applies ice, tri...
[]
[ "G8929", "E039", "J45909", "E669" ]
[ "M4806: Spinal stenosis, lumbar region", "G8929: Other chronic pain", "M549: Dorsalgia, unspecified", "E039: Hypothyroidism, unspecified", "J45909: Unspecified asthma, uncomplicated", "E669: Obesity, unspecified", "Z6834: Body mass index [BMI] 34.0-34.9, adult", "Z85828: Personal history of other mali...
10,034,933
28,591,708
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fatigue, New Effusion Major Surgical or Invasive Proced...
[ "C220", "D61810", "D609", "C7951", "C7970", "J90", "E440", "Z681", "E871", "T451X5A", "I671", "Z8673", "F319", "I10", "K219", "R7303", "Z96641", "F17210", "E806", "E860", "D6959", "G893", "E8339" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Fatigue, New Effusion Major Surgical or Invasive Procedure: Bone marrow biopsy [MASKED] History of Present Illness: [MASKED] PMH Bipolar Disorder, HTN, Metastatic HCC (on nivolumab, s/p recent XRT to skull bony mets), CVA, MCA Aneurysm, presented t...
[]
[ "E871", "Z8673", "I10", "K219", "F17210" ]
[ "C220: Liver cell carcinoma", "D61810: Antineoplastic chemotherapy induced pancytopenia", "D609: Acquired pure red cell aplasia, unspecified", "C7951: Secondary malignant neoplasm of bone", "C7970: Secondary malignant neoplasm of unspecified adrenal gland", "J90: Pleural effusion, not elsewhere classified...
10,034,933
29,594,531
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Back Pain Major Surgical or Invasive Procedure: RTx tre...
[ "C7951", "G9519", "I639", "C228", "C792", "E871", "R29702", "E876", "I671", "G8321", "K219", "D509", "E039", "F17200", "Z96643", "F319", "E83110", "E785", "D638", "E861" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Back Pain Major Surgical or Invasive Procedure: RTx treatment plan to deliver 20 Gy in 5 fractions total, D1 = [MASKED], completed [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] man s/p L3-S1 lumbar decompression with duraplasty in...
[]
[ "E871", "K219", "D509", "E039", "E785" ]
[ "C7951: Secondary malignant neoplasm of bone", "G9519: Other vascular myelopathies", "I639: Cerebral infarction, unspecified", "C228: Malignant neoplasm of liver, primary, unspecified as to type", "C792: Secondary malignant neoplasm of skin", "E871: Hypo-osmolality and hyponatremia", "R29702: NIHSS scor...
10,035,301
23,974,616
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Nausea/Vomiting Major Surgical or Invasive Procedure: ...
[ "C9030", "K311", "E46", "Z681", "D509", "E8339", "I10", "E785", "F329", "Z87891", "R918" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Nausea/Vomiting Major Surgical or Invasive Procedure: Endoscopic Ultrasound with Biopsy [MASKED] History of Present Illness: CC: abdominal pain, nausea, vomiting, anorexia, pancreatic mass. HISTORY OF PRESENT ILLNESS: Ms [MASKED] is a [MASKED] year...
[]
[ "D509", "I10", "E785", "F329", "Z87891" ]
[ "C9030: Solitary plasmacytoma not having achieved remission", "K311: Adult hypertrophic pyloric stenosis", "E46: Unspecified protein-calorie malnutrition", "Z681: Body mass index [BMI] 19.9 or less, adult", "D509: Iron deficiency anemia, unspecified", "E8339: Other disorders of phosphorus metabolism", "...
10,035,631
21,476,294
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fevers, chills and fatigue; concern for acute leukemia ...
[ "C92Z2", "J810", "Z9484", "D709", "K521", "D696", "E871", "I951", "R5081", "R0789", "G893", "Z853", "Z79810", "Z9012", "Z87891", "G44209", "R740", "T361X5A", "Y92230", "Z792", "Z20828", "R634", "Z6826", "M545" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Fevers, chills and fatigue; concern for acute leukemia Major Surgical or Invasive Procedure: [MASKED] placement [MASKED] Bone Marrow Biopsy [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] y/o male with a history of stage IIA breast ...
[]
[ "D696", "E871", "Z87891", "Y92230" ]
[ "C92Z2: Other myeloid leukemia, in relapse", "J810: Acute pulmonary edema", "Z9484: Stem cells transplant status", "D709: Neutropenia, unspecified", "K521: Toxic gastroenteritis and colitis", "D696: Thrombocytopenia, unspecified", "E871: Hypo-osmolality and hyponatremia", "I951: Orthostatic hypotensio...
10,035,631
21,599,196
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: admission for cycle 1 of dacogen Major Surgical or Inv...
[ "Z5111", "C9202", "Z9484", "Z853", "Z87891" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: admission for cycle 1 of dacogen Major Surgical or Invasive Procedure: [MASKED] placement [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] gentleman with a history of stage IIA breast cancer [MASKED] left mastectomy and currently on ...
[]
[ "Z87891" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C9202: Acute myeloblastic leukemia, in relapse", "Z9484: Stem cells transplant status", "Z853: Personal history of malignant neoplasm of breast", "Z87891: Personal history of nicotine dependence" ]
10,035,631
29,276,678
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hypoxia, AMS Major Surgical or Invasive Procedure: Int...
[ "J9601", "E883", "R6520", "A419", "B441", "J90", "B59", "E872", "J159", "D89813", "Z9484", "C92Z0", "J9811", "N179", "E871", "I248", "R042", "D689", "D709", "R5081", "E860", "E875", "G893", "I4891", "D6959", "D630", "H1133", "T451X5A", "Z66", "Z515", "Z781...
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Hypoxia, AMS Major Surgical or Invasive Procedure: Intubated [MASKED] R pheresis line [MASKED] Pheresis [MASKED] History of Present Illness: [MASKED] male with history of stage IIA breast cancer [MASKED] left mastectomy and currently on Tamoxifen a...
[]
[ "J9601", "E872", "N179", "E871", "I4891", "Z66", "Z515", "Z87891", "Y92230" ]
[ "J9601: Acute respiratory failure with hypoxia", "E883: Tumor lysis syndrome", "R6520: Severe sepsis without septic shock", "A419: Sepsis, unspecified organism", "B441: Other pulmonary aspergillosis", "J90: Pleural effusion, not elsewhere classified", "B59: Pneumocystosis", "E872: Acidosis", "J159: ...
10,035,780
21,074,018
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / lisinopril / metformin / amlodipine Attending: ___. Chief Complaint: Fever/Lethargy/Confusion Major Surgical or Invasive ...
[ "A419", "G9341", "E1122", "I120", "N186", "N390", "R6520", "A498", "Z1624", "Z992", "Z794", "I2510", "Z8619", "Z87440", "M1990", "M810", "E785", "J45909", "D649", "M109", "K219", "Z7982" ]
Allergies: Motrin / lisinopril / metformin / amlodipine Chief Complaint: Fever/Lethargy/Confusion Major Surgical or Invasive Procedure: Hemodialysis [MASKED] History of Present Illness: This patient is a [MASKED] yo F with a hx of ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV presenting with lethargy and fever following di...
[]
[ "E1122", "N390", "Z794", "I2510", "E785", "J45909", "D649", "M109", "K219" ]
[ "A419: Sepsis, unspecified organism", "G9341: Metabolic encephalopathy", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N186: End stage renal disease", "N390: Urinary tract...
10,035,780
23,172,477
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / lisinopril / metformin / amlodipine Attending: ___. Chief Complaint: Altered Mental Status Major Surgical or Invasive Pro...
[ "T82868A", "N186", "I120", "D61818", "B1910", "Y832", "Y92129", "G309", "F0280", "E1122", "D696", "J449", "K219", "Z66", "M1990", "M810", "D631", "E11649", "E1165", "E8339", "E875", "M109", "Z992", "Z7984", "Z8619", "Z7982", "Z8611" ]
Allergies: Motrin / lisinopril / metformin / amlodipine Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: AV fistula thrombectomy History of Present Illness: Ms [MASKED] is a [MASKED] y/o [MASKED] speaking patient with PMH significant for Alzheimer's dementia, HTN, HLD, ESRD (on [MASKED] HD),...
[]
[ "E1122", "D696", "J449", "K219", "Z66", "E1165", "M109" ]
[ "T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter", "N186: End stage renal disease", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "D61818: Other pancytopenia", "B1910: Unspecified viral hepatitis B w...
10,035,780
25,186,901
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / lisinopril / metformin / amlodipine Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: none ...
[ "N390", "N186", "I120", "I4891", "K521", "N2581", "E871", "B9620", "E119", "I2510", "K219", "B1920", "R740", "E876", "M109", "M810", "J45909", "E785", "Z9049", "R079", "D649", "Y92239", "T361X5A", "Z7982", "Z23", "Z992", "Z794" ]
Allergies: Motrin / lisinopril / metformin / amlodipine Chief Complaint: fever Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [MASKED] is a [MASKED] y/o female with a past medical history of ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV, GERD, Gout and osteoporosis who present with fever, cough ...
[]
[ "N390", "I4891", "E871", "E119", "I2510", "K219", "M109", "J45909", "E785", "D649", "Z794" ]
[ "N390: Urinary tract infection, site not specified", "N186: End stage renal disease", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "I4891: Unspecified atrial fibrillation", "K521: Toxic gastroenteritis and colitis", "N2581: Secondary hyperpara...
10,035,780
27,291,894
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / lisinopril / metformin / amlodipine Attending: ___ ___ Complaint: Hypotension and ?Altered Mental Status during dialysis ...
[ "I953", "I248", "E1122", "I120", "N186", "J45909", "B181", "B182", "A182", "R4182", "M810", "K219", "M109" ]
Allergies: Motrin / lisinopril / metformin / amlodipine [MASKED] Complaint: Hypotension and ?Altered Mental Status during dialysis Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] only; History obtained from chart, nephew/niece over phone call, and with the assistance of language line int...
[]
[ "E1122", "J45909", "K219", "M109" ]
[ "I953: Hypotension of hemodialysis", "I248: Other forms of acute ischemic heart disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N186: End stage renal disease", "J4...
10,035,780
28,030,709
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / lisinopril / metformin / amlodipine Attending: ___ Chief Complaint: Head Injury, s/p Fall Major Surgical or Invasive Pro...
[ "R591", "N186", "I120", "D62", "F0390", "B1910", "N390", "E871", "K922", "E1122", "Z992", "I2510", "S0102XA", "I4891", "E876", "M542", "D631", "K6389", "W01190A", "R7611", "R61", "R634", "Y92003", "E785", "J45909", "Z87440", "B1920", "K219", "M109", "Z794", ...
Allergies: Motrin / lisinopril / metformin / amlodipine Chief Complaint: Head Injury, s/p Fall Major Surgical or Invasive Procedure: EUS with biopsy [MASKED] Mediastinoscopy with biopsy [MASKED] History of Present Illness: Ms. [MASKED] is a [MASKED] yo woman with PMH of ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV co-infe...
[]
[ "D62", "N390", "E871", "E1122", "I2510", "I4891", "E785", "J45909", "K219", "M109", "Z794" ]
[ "R591: Generalized enlarged lymph nodes", "N186: End stage renal disease", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "D62: Acute posthemorrhagic anemia", "F0390: Unspecified dementia without behavioral disturbance", "B1910: Unspecified vira...
10,035,780
29,685,392
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / lisinopril / metformin / amlodipine Attending: ___. Chief Complaint: Fever and confusion Major Surgical or Invasive Proce...
[ "R509", "E119", "N2581", "I120", "N186", "B181", "D649", "D72829", "R4182", "R05", "R740", "Z87440", "Z992", "B182", "I2510", "J45909", "M810", "M109", "K219" ]
Allergies: Motrin / lisinopril / metformin / amlodipine Chief Complaint: Fever and confusion Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year-old [MASKED] woman with PMH significant for ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV co-infection, and recent admission for...
[]
[ "E119", "D649", "I2510", "J45909", "M109", "K219" ]
[ "R509: Fever, unspecified", "E119: Type 2 diabetes mellitus without complications", "N2581: Secondary hyperparathyroidism of renal origin", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N186: End stage renal disease", "B181: Chronic viral hepa...
10,035,787
29,728,342
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Proce...
[ "I350", "G9340", "I4891", "D696", "K5190", "E861", "D62", "I10", "E785", "T8383XA", "I9789", "J95811", "I2510", "J029", "K5900", "R319", "I9581", "Y846", "Y92234", "Y832", "Y92230", "Z87891", "R410", "K219" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [MASKED] Aortic valve replacement with 21mm Magna Ease tissue valve, Coronary artery bypass graft x1 (Saphenous vein >Acute Marginal) History of Present Illness: [MASKED] year old male with ...
[]
[ "I4891", "D696", "D62", "I10", "E785", "I2510", "K5900", "Y92230", "Z87891", "K219" ]
[ "I350: Nonrheumatic aortic (valve) stenosis", "G9340: Encephalopathy, unspecified", "I4891: Unspecified atrial fibrillation", "D696: Thrombocytopenia, unspecified", "K5190: Ulcerative colitis, unspecified, without complications", "E861: Hypovolemia", "D62: Acute posthemorrhagic anemia", "I10: Essentia...
10,035,791
20,113,280
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Compazine / doxycycline / Phenergan Attending: ___ Chief Complaint: n/v, eval cholelithiasis Major Surgical or Invasive Procedure: EGD...
[ "K831", "K838", "R932", "E871", "R9431", "D72829", "I10", "E785", "E039" ]
Allergies: Compazine / doxycycline / Phenergan Chief Complaint: n/v, eval cholelithiasis Major Surgical or Invasive Procedure: EGD History of Present Illness: Ms [MASKED] is a pleasant [MASKED] yo F with HLD, hypothyroidism, HTN, n/v/abd pain since [MASKED], found to have biliary dilation and CBD stone, admitted for ER...
[]
[ "E871", "I10", "E785", "E039" ]
[ "K831: Obstruction of bile duct", "K838: Other specified diseases of biliary tract", "R932: Abnormal findings on diagnostic imaging of liver and biliary tract", "E871: Hypo-osmolality and hyponatremia", "R9431: Abnormal electrocardiogram [ECG] [EKG]", "D72829: Elevated white blood cell count, unspecified"...
10,035,844
27,129,365
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: oxycodone Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: Admission Labs ------------------ ___...
[ "E11649", "E039", "G8384", "R569", "E785", "I6522", "I2510", "F329", "F1290", "Z794", "Z885", "Z882" ]
Allergies: oxycodone Major Surgical or Invasive Procedure: None attach Pertinent Results: Admission Labs ------------------ [MASKED] 01:22PM BLOOD WBC-11.5* RBC-4.96 Hgb-15.1 Hct-47.0* MCV-95 MCH-30.4 MCHC-32.1 RDW-13.4 RDWSD-47.3* Plt [MASKED] [MASKED] 01:22PM BLOOD Neuts-84.1* Lymphs-10.4* Monos-4.3* Eos-0.1* Baso-0....
[]
[ "E039", "E785", "I2510", "F329", "Z794" ]
[ "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "E039: Hypothyroidism, unspecified", "G8384: Todd's paralysis (postepileptic)", "R569: Unspecified convulsions", "E785: Hyperlipidemia, unspecified", "I6522: Occlusion and stenosis of left carotid artery", "I2510: Atherosclerotic heart d...
10,036,086
22,023,413
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Erythromycin Base / Biaxin / Ciprofloxacin Attending: ___ Chief Complaint: Left arm pain Major Surgical or Invasive Procedure: Coronary A...
[ "I25110", "B20", "I1310", "B181", "Z6842", "Z862", "E119", "Z794", "N183", "R9439", "Z8619", "Z9081", "E6601", "E785", "J45909", "M23203", "Z22322", "Q248", "G4733", "Z8546", "Z923", "Z87442", "Z96652" ]
Allergies: Erythromycin Base / Biaxin / Ciprofloxacin Chief Complaint: Left arm pain Major Surgical or Invasive Procedure: Coronary Anatomy Right dominant, heart rotated to the left. LM: No significant disease. LAD: Proximal 40% smooth disease. Mid vessel 90% stenosis after large diag. LCx: Luminal irregularities. RCA:...
[]
[ "E119", "Z794", "E785", "J45909", "G4733" ]
[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "B20: Human immunodeficiency virus [HIV] disease", "I1310: Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney dise...
10,036,086
24,186,608
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Erythromycin Base / Biaxin / Ciprofloxacin Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: ___ catheter i...
[ "I2692", "J9621", "I5033", "K264", "I130", "D62", "Z6842", "E1122", "N183", "I480", "I2720", "E6601", "I2510", "E785", "Z21", "G4733", "R932", "Z955", "Z86711", "Z86718", "Z7901", "Z794", "Z8546" ]
Allergies: Erythromycin Base / Biaxin / Ciprofloxacin Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [MASKED] catheter insertion [MASKED] filter placement [MASKED] with duodenal ulcer clipping History of Present Illness: Mr. [MASKED] is a [MASKED] man with a history of CAD s/p DES to LAD ([MASKED]), HIV...
[]
[ "I130", "D62", "E1122", "I480", "I2510", "E785", "G4733", "Z955", "Z86718", "Z7901", "Z794" ]
[ "I2692: Saddle embolus of pulmonary artery without acute cor pulmonale", "J9621: Acute and chronic respiratory failure with hypoxia", "I5033: Acute on chronic diastolic (congestive) heart failure", "K264: Chronic or unspecified duodenal ulcer with hemorrhage", "I130: Hypertensive heart and chronic kidney di...
10,036,086
25,086,233
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Erythromycin Base / Biaxin / Ciprofloxacin Attending: ___ Chief Complaint: PE Major Surgical or Invasive Procedure: TEE/DCCV ___ Histo...
[ "I2699", "I5033", "I82441", "E872", "I4892", "L03115", "I2510", "Z955", "Z21", "E6601", "I4891", "G4733", "Z96652", "E8881", "Z8546", "N183", "E785", "J45909", "E1121" ]
Allergies: Erythromycin Base / Biaxin / Ciprofloxacin Chief Complaint: PE Major Surgical or Invasive Procedure: TEE/DCCV [MASKED] History of Present Illness: [MASKED] y/o male with hx of HIV on HAART therapy, prostate cancer s/p brachytherapy, T2IDDM, HTN, HLD, obesity, CKD, presents w tachycardia and dyspnea on exerti...
[]
[ "E872", "I2510", "Z955", "I4891", "G4733", "E785", "J45909" ]
[ "I2699: Other pulmonary embolism without acute cor pulmonale", "I5033: Acute on chronic diastolic (congestive) heart failure", "I82441: Acute embolism and thrombosis of right tibial vein", "E872: Acidosis", "I4892: Unspecified atrial flutter", "L03115: Cellulitis of right lower limb", "I2510: Atheroscle...
10,036,821
20,948,493
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Percocet / Ativan / latex Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present...
[ "R109", "C169", "Z8571", "C772", "G629", "N400", "Z86718", "M545", "G8929", "Z801", "Z8042" ]
Allergies: Percocet / Ativan / latex Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with h/o Hodgkin disease (Dx [MASKED], s/p ABVD x6), newly diagnosed gastric cancer (cT3N2M0 Stage III, Her-2 neg) currently C1D7 [MASKED] chemotherapy. He was referred in...
[]
[ "N400", "Z86718", "G8929" ]
[ "R109: Unspecified abdominal pain", "C169: Malignant neoplasm of stomach, unspecified", "Z8571: Personal history of Hodgkin lymphoma", "C772: Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes", "G629: Polyneuropathy, unspecified", "N400: Benign prostatic hyperplasia without lower...
10,036,821
26,036,824
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Percocet / Ativan / latex Attending: ___. Chief Complaint: gastric cancer Major Surgical or Invasive Procedure: robotic gastrectomy with es...
[ "C162", "E46", "L02211", "K9413", "I824Z2", "C161", "G629", "N400", "G8929", "M545", "M11261", "R1013", "R1031", "Z8571", "Z86718" ]
Allergies: Percocet / Ativan / latex Chief Complaint: gastric cancer Major Surgical or Invasive Procedure: robotic gastrectomy with esopho-jejunostomy History of Present Illness: [MASKED] with Hx Hodgkins disease s/p ABVD x 6 and interstitial lung disease, presenting for surgical follow-up s/p neoadjuvant therapy for g...
[]
[ "N400", "G8929", "Z86718" ]
[ "C162: Malignant neoplasm of body of stomach", "E46: Unspecified protein-calorie malnutrition", "L02211: Cutaneous abscess of abdominal wall", "K9413: Enterostomy malfunction", "I824Z2: Acute embolism and thrombosis of unspecified deep veins of left distal lower extremity", "C161: Malignant neoplasm of fu...
10,036,821
26,439,594
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Percocet / Ativan / latex Attending: ___. Chief Complaint: Abdominal pain following total gastrectomy with roux-en-y esophagojejunostomy (__...
[ "T8143XA", "Y836", "Y929", "K651", "Z903", "Z9049", "R197", "C8192", "C168", "Z934", "G629", "N400", "Z86718", "G8929", "M545", "Z801", "Z8042", "Z7902" ]
Allergies: Percocet / Ativan / latex Chief Complaint: Abdominal pain following total gastrectomy with roux-en-y esophagojejunostomy ([MASKED]). Major Surgical or Invasive Procedure: Underwent drain repositioning with Interventional Radiology on [MASKED]. History of Present Illness: [MASKED] history of recurrent DVT on ...
[]
[ "Y929", "N400", "Z86718", "G8929", "Z7902" ]
[ "T8143XA: Infection following a procedure, organ and space surgical site, initial encounter", "Y836: Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not...
10,036,821
28,791,904
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Percocet / Ativan / latex Attending: ___ Chief Complaint: Esophageal perforation Major Surgical or Invasive Procedure: None History of ...
[ "K9171", "K222", "T8182XA", "K449", "G620", "M25861", "N400", "D509", "R197", "T451X5S", "Y92238", "Z86718", "Z85028", "Z7902", "Z8571" ]
Allergies: Percocet / Ativan / latex Chief Complaint: Esophageal perforation Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] with h/o Hodgkin disease (Dx [MASKED], s/p ABVD x6), Stage III gastric adenocarcinoma (signet ring, cT3N2M0, ypT3N2a, Her-2 neg) s/p 4 cycles neo...
[]
[ "N400", "D509", "Z86718", "Z7902" ]
[ "K9171: Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure", "K222: Esophageal obstruction", "T8182XA: Emphysema (subcutaneous) resulting from a procedure, initial encounter", "K449: Diaphragmatic hernia without obstruction or gangrene", "G620: Dr...
10,036,942
23,803,237
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Major Surgical or Invasive Procedure: TEE on ___ Midline placement ___ atta...
[ "R7881", "F1123", "B9561", "R0789", "F329", "F4310", "F909", "F17200", "Z23", "Z915", "Z813", "M62830" ]
Allergies: No Known Allergies / Adverse Drug Reactions Major Surgical or Invasive Procedure: TEE on [MASKED] Midline placement [MASKED] attach Pertinent Results: ADMISSION LABS: ================ [MASKED] 04:10PM BLOOD WBC-10.1* RBC-4.22* Hgb-12.7* Hct-38.3* MCV-91 MCH-30.1 MCHC-33.2 RDW-12.7 RDWSD-41.7 Plt [MASKED] [MA...
[]
[ "F329" ]
[ "R7881: Bacteremia", "F1123: Opioid dependence with withdrawal", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "R0789: Other chest pain", "F329: Major depressive disorder, single episode, unspecified", "F4310: Post-traumatic stress disorder...
10,037,313
22,489,707
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: fibroid uterus Major Surgical or Invasive Proc...
[ "D251", "D252" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: fibroid uterus Major Surgical or Invasive Procedure: Abdominal multiple myomectomy Physical Exam: Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no...
[]
[]
[ "D251: Intramural leiomyoma of uterus", "D252: Subserosal leiomyoma of uterus" ]
10,037,602
26,699,121
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: quaternium 15 / potassium dichronate / balsam of ___ / nickel / paraben / fragrances / glycerol monothiogylconate / tea tree oil / benzo...
[ "M1711", "I10", "E785", "E041", "K219", "F329", "E669", "Z6839" ]
Allergies: quaternium 15 / potassium dichronate / balsam of [MASKED] / nickel / paraben / fragrances / glycerol monothiogylconate / tea tree oil / benzoyl peroxide [MASKED] Complaint: Right knee osteoarthritis Major Surgical or Invasive Procedure: [MASKED]: R TKR History of Present Illness: [MASKED] year old female wit...
[]
[ "I10", "E785", "K219", "F329", "E669" ]
[ "M1711: Unilateral primary osteoarthritis, right knee", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E041: Nontoxic single thyroid nodule", "K219: Gastro-esophageal reflux disease without esophagitis", "F329: Major depressive disorder, single episode, unspecified", "E66...
10,037,861
24,540,843
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: metformin Attending: ___. Chief Complaint: Right Subdural Hematoma. Major Surgical or Invasive Procedure: ___ - Right craniotomy...
[ "S065X7A", "G935", "J9600", "R6521", "A419", "I5023", "I130", "N390", "Z9911", "N179", "J95851", "E870", "I82612", "W19XXXA", "Y92009", "Z66", "Z515", "Z95810", "I4891", "Z7901", "E785", "E1122", "N183", "I2510", "Z955", "I252", "I255", "Z9282", "Z87891", "G...
Allergies: metformin Chief Complaint: Right Subdural Hematoma. Major Surgical or Invasive Procedure: [MASKED] - Right craniotomy for evacuation of subdural hematoma. History of Present Illness: Mr. [MASKED] is a [MASKED] M with significant cardiac history including ICD placement, EF 25%, afib on Coumadin. He complained...
[]
[ "I130", "N390", "N179", "Z66", "Z515", "I4891", "Z7901", "E785", "E1122", "I2510", "Z955", "I252", "Z87891", "Y92230" ]
[ "S065X7A: Traumatic subdural hemorrhage with loss of consciousness of any duration with death due to brain injury before regaining consciousness, initial encounter", "G935: Compression of brain", "J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia", "R6521: Severe sepsis with se...
10,037,928
24,885,579
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Aspirin / Sulfasalazine / Lisinopril / Codeine / nitrofurantoin / Sulfa (Sulfonamide Antibiotics) Attending: ___ Chief Complaint: abdo...
[ "K3580", "E1165", "C029", "I10", "Z794", "E785", "F329", "F419", "D509", "K219", "G8929", "M545", "G4700", "Z8711", "Z801", "Z8049" ]
Allergies: Aspirin / Sulfasalazine / Lisinopril / Codeine / nitrofurantoin / Sulfa (Sulfonamide Antibiotics) Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] is a [MASKED] w/ hx of HTN and IDDM who is presenting here to the ED for a 1 day hx of RLQ abd pain...
[]
[ "E1165", "I10", "Z794", "E785", "F329", "F419", "D509", "K219", "G8929", "G4700" ]
[ "K3580: Unspecified acute appendicitis", "E1165: Type 2 diabetes mellitus with hyperglycemia", "C029: Malignant neoplasm of tongue, unspecified", "I10: Essential (primary) hypertension", "Z794: Long term (current) use of insulin", "E785: Hyperlipidemia, unspecified", "F329: Major depressive disorder, si...
10,038,141
21,658,233
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: alendronate sodium Attending: ___. Chief Complaint: Disinhibited conduct, progressively worsening gait, and large volume urinary incont...
[ "G3109", "F0281", "E512", "F070", "Z781", "I10", "K219", "F603", "F6089", "Z853", "R3981" ]
Allergies: alendronate sodium Chief Complaint: Disinhibited conduct, progressively worsening gait, and large volume urinary incontinence. Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a [MASKED] yo woman with medical history of HTN, GERD, and recent personality changes presenting...
[]
[ "I10", "K219" ]
[ "G3109: Other frontotemporal dementia", "F0281: Dementia in other diseases classified elsewhere with behavioral disturbance", "E512: Wernicke's encephalopathy", "F070: Personality change due to known physiological condition", "Z781: Physical restraint status", "I10: Essential (primary) hypertension", "K...
10,038,332
21,419,608
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin / lima beans Attending: ___. Chief Complaint: buttock pain Major Surgical or Invasive Procedure: None History of Present Ill...
[ "K5903", "G8220", "F1120", "R933", "T507X5A", "Y92019", "S24103S", "W3400XS", "F29", "F909", "Z8614", "G8929", "Z902", "D550", "N319", "N39498", "Z87440" ]
Allergies: aspirin / lima beans Chief Complaint: buttock pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] year old with PMH of paraplegia below T10 since age [MASKED] due to a gunshot wound, recurrent UTIs (self-caths due to neurogenic bladder), hx of prostatic absc...
[]
[ "G8929" ]
[ "K5903: Drug induced constipation", "G8220: Paraplegia, unspecified", "F1120: Opioid dependence, uncomplicated", "R933: Abnormal findings on diagnostic imaging of other parts of digestive tract", "T507X5A: Adverse effect of analeptics and opioid receptor antagonists, initial encounter", "Y92019: Unspecifi...
10,038,332
22,514,900
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin Attending: ___. Chief Complaint: CC: ___, Wound Eval Major Surgical or Invasive Procedure: None History of Present Illness: ...
[ "N390", "E7401", "L89321", "L89312", "F1420", "G8220", "N318", "F209", "R45851", "F1123", "B9689", "N39498", "M545", "G8929", "F319", "K5909", "N411", "Z9114", "Z9119", "Z87440", "Z8614", "Z993", "Z590", "S24103S", "X959XXS", "R419" ]
Allergies: aspirin Chief Complaint: CC: [MASKED], Wound Eval Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] yo man with h/o T10 paraplegia and recurrent UTIs, who presents via own wheelchair to the [MASKED] ED with multiple concerns including "bed sores", new UTI and f...
[]
[ "N390", "G8929" ]
[ "N390: Urinary tract infection, site not specified", "E7401: von Gierke disease", "L89321: Pressure ulcer of left buttock, stage 1", "L89312: Pressure ulcer of right buttock, stage 2", "F1420: Cocaine dependence, uncomplicated", "G8220: Paraplegia, unspecified", "N318: Other neuromuscular dysfunction of...
10,038,332
22,517,908
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin / lima beans Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: Admission Labs ==============...
[ "F1123", "G92", "G8220", "F1423", "R8281", "F319", "G629", "F909", "L89321", "Z902", "S24153S", "S21209S", "W3400XS", "Z87440", "Z8614", "D75A", "N319", "N39498", "Z590", "Z818", "B9620" ]
Allergies: aspirin / lima beans Major Surgical or Invasive Procedure: None attach Pertinent Results: Admission Labs ============== [MASKED] 02:25AM BLOOD WBC-8.4 RBC-3.92* Hgb-11.1* Hct-36.5* MCV-93 MCH-28.3 MCHC-30.4* RDW-13.3 RDWSD-45.4 Plt [MASKED] [MASKED] 02:25AM BLOOD Neuts-54.8 [MASKED] Monos-18.7* Eos-4.1 Baso-...
[]
[]
[ "F1123: Opioid dependence with withdrawal", "G92: Toxic encephalopathy", "G8220: Paraplegia, unspecified", "F1423: Cocaine dependence with withdrawal", "R8281: Pyuria", "F319: Bipolar disorder, unspecified", "G629: Polyneuropathy, unspecified", "F909: Attention-deficit hyperactivity disorder, unspecif...
10,038,332
22,921,487
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Decubitus pressure ulcer Major Surgical or Invasive Proced...
[ "N390", "L89323", "G8220", "B952", "R32", "R112", "R61", "K5900", "F329", "F17210", "Z87440" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Decubitus pressure ulcer Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with a PMH of T10 paraplegia [MASKED] GSW with chronic decubitus ulcers and history MRSA abscesses, recently seen for perirectal abscess with I...
[]
[ "N390", "K5900", "F329", "F17210" ]
[ "N390: Urinary tract infection, site not specified", "L89323: Pressure ulcer of left buttock, stage 3", "G8220: Paraplegia, unspecified", "B952: Enterococcus as the cause of diseases classified elsewhere", "R32: Unspecified urinary incontinence", "R112: Nausea with vomiting, unspecified", "R61: Generali...
10,038,332
23,073,151
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin Attending: ___. Chief Complaint: Acute Pyelonephritis Major Surgical or Invasive Procedure: None History of Present Illness: ...
[ "A4151", "G8220", "N410", "Z1623", "Z1639", "S24103D", "N319", "N39498", "N3289", "G8929", "N3020", "M549", "K5909", "F329", "F909", "F1421", "F29", "X959XXD" ]
Allergies: aspirin Chief Complaint: Acute Pyelonephritis Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with paraplegia as a result of a GSW, neurogenic bladder with chronic intermittent straight caths, with recurrent UTIs with various organisms, now on chronic suppressive methenamine, ...
[]
[ "G8929", "F329" ]
[ "A4151: Sepsis due to Escherichia coli [E. coli]", "G8220: Paraplegia, unspecified", "N410: Acute prostatitis", "Z1623: Resistance to quinolones and fluoroquinolones", "Z1639: Resistance to other specified antimicrobial drug", "S24103D: Unspecified injury at T7-T10 level of thoracic spinal cord, subsequen...
10,038,332
23,488,593
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin / lima beans Attending: ___. Chief Complaint: AMS/agitation requiring sedation/intubation Major Surgical or Invasive Procedure:...
[ "T403X1A", "G92", "J9600", "F11221", "N390", "G8220", "F19121", "T401X1A", "T405X1A", "N319", "D649", "F909", "F319", "G629", "Z781", "Z87440", "S24103S", "W3400XS", "R791", "Z23", "Z993" ]
Allergies: aspirin / lima beans Chief Complaint: AMS/agitation requiring sedation/intubation Major Surgical or Invasive Procedure: Intubation Extubation History of Present Illness: [MASKED] male with PMH of T10 paraplegia secondary to gunshot wound in [MASKED], psychiatric history (?bipolar disorder, ?ADHD), neurogenic...
[]
[ "N390", "D649" ]
[ "T403X1A: Poisoning by methadone, accidental (unintentional), initial encounter", "G92: Toxic encephalopathy", "J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia", "F11221: Opioid dependence with intoxication delirium", "N390: Urinary tract infection, site not specified", "...
10,038,332
23,550,887
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin Attending: ___ Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old g...
[ "N3090", "G92", "L89159", "G8220", "L89319", "F1120", "N319", "N410", "F1420", "F29", "R55", "T43615A", "T43635A", "F209", "N39498", "G4700", "F329", "F909", "F17210", "F22", "M479", "B952", "B9689", "S91109A", "W228XXA", "Y929" ]
Allergies: aspirin Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] year old gentleman with history of paraplegia from gun shot wound ([MASKED]), neurogenic bladder, recurrent UTIs, chronic pain, hx of cocaine abuse, hx of psychosis, transferred from [MASKED] for ...
[]
[ "G4700", "F329", "F17210", "Y929" ]
[ "N3090: Cystitis, unspecified without hematuria", "G92: Toxic encephalopathy", "L89159: Pressure ulcer of sacral region, unspecified stage", "G8220: Paraplegia, unspecified", "L89319: Pressure ulcer of right buttock, unspecified stage", "F1120: Opioid dependence, uncomplicated", "N319: Neuromuscular dys...
10,038,332
27,818,008
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin Attending: ___. Chief Complaint: Pyelonephritis Major Surgical or Invasive Procedure: None History of Present Illness: Mr. _...
[ "N10", "B9620", "Z1624", "T368X6A", "Z91138", "Y9289", "F1120", "G8220", "N319", "R338", "S24103S", "W3400XS", "F29", "K5900", "M47812", "M792", "F1421", "F17290", "Z993" ]
Allergies: aspirin Chief Complaint: Pyelonephritis Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] with PMH of history of unspecified psychotic disorder (bipolar vs schizophrenia) and significant cocaine and opioid use disorders (sober >9 mo), prostatic abscess, and T10...
[]
[ "K5900" ]
[ "N10: Acute pyelonephritis", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "Z1624: Resistance to multiple antibiotics", "T368X6A: Underdosing of other systemic antibiotics, initial encounter", "Z91138: Patient's unintentional underdosing of medication regimen...
10,038,688
25,926,997
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Post cardiac arrest Major Surgical or Invasive Procedure: Intub...
[ "J9601", "G936", "R579", "K7200", "G9340", "J189", "G931", "D689", "N179", "J95851", "K766", "E870", "E872", "B1910", "F3181", "F1920", "K7460", "B1920", "D539", "D696", "F1010", "F17210", "B356", "Z8614", "Z781", "Z89511", "Z66", "Z515", "Z590", "Y848", "...
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Post cardiac arrest Major Surgical or Invasive Procedure: Intubation History of Present Illness: [MASKED] hepatitis B and C, cirrhosis w/ portal HTN, bipolar 2, depression, osteo, BKA right, craniectomy, who was found down in a public restroom with...
[]
[ "J9601", "N179", "E872", "D696", "F17210", "Z66", "Z515", "Y92230" ]
[ "J9601: Acute respiratory failure with hypoxia", "G936: Cerebral edema", "R579: Shock, unspecified", "K7200: Acute and subacute hepatic failure without coma", "G9340: Encephalopathy, unspecified", "J189: Pneumonia, unspecified organism", "G931: Anoxic brain damage, not elsewhere classified", "D689: Co...
10,038,992
24,745,425
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: lisinopril / shellfish derived Attending: ___. Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: ___ ...
[ "I082", "I428", "D696", "I272", "I130", "N183", "I5022", "I471", "D62", "J449", "E785", "G4733", "M109", "E039", "E669", "Z87891", "Z6829" ]
Allergies: lisinopril / shellfish derived Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [MASKED] Aortic valve replacement with a 25 mm [MASKED] Biocor Epic tissue valve. History of Present Illness: Mr. [MASKED] is a [MASKED] year old man with a history of aortic insufficiency, chronic kidne...
[]
[ "D696", "I130", "D62", "J449", "E785", "G4733", "M109", "E039", "E669", "Z87891" ]
[ "I082: Rheumatic disorders of both aortic and tricuspid valves", "I428: Other cardiomyopathies", "D696: Thrombocytopenia, unspecified", "I272: Other secondary pulmonary hypertension", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, ...
10,038,999
27,189,241
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: abdominal pain, found to have pericardial effusion Major Surgical or Inva...
[ "J189", "R570", "I314", "J918", "D688", "E46", "J9691", "I313", "J9811", "I319", "G40909", "H540", "R21", "I509", "D649", "E875", "R001" ]
Allergies: No Allergies/ADRs on File Chief Complaint: abdominal pain, found to have pericardial effusion Major Surgical or Invasive Procedure: pericardiocentesis intubation bronchoscopy History of Present Illness: This is a [MASKED] yoM with a PMH significant for developmental mental delay, seizure disorder, and blindn...
[]
[ "D649" ]
[ "J189: Pneumonia, unspecified organism", "R570: Cardiogenic shock", "I314: Cardiac tamponade", "J918: Pleural effusion in other conditions classified elsewhere", "D688: Other specified coagulation defects", "E46: Unspecified protein-calorie malnutrition", "J9691: Respiratory failure, unspecified with hy...
10,038,999
29,026,789
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Valium Attending: ___. Chief Complaint: right ankle pain Major Surgical or Invasive Procedure: right tibial intramedullary nail ...
[ "S82251A", "F09", "G40909", "H548", "W1830XA", "Y92199" ]
Allergies: Valium Chief Complaint: right ankle pain Major Surgical or Invasive Procedure: right tibial intramedullary nail History of Present Illness: [MASKED] hx of developmental mental delay, seizure disorder, and blindness resides at a group home and while at day care had a witnessed fall. No head strike per staff. ...
[]
[]
[ "S82251A: Displaced comminuted fracture of shaft of right tibia, initial encounter for closed fracture", "F09: Unspecified mental disorder due to known physiological condition", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "H548: Legal blindness, as defined in USA", "W1830XA...
10,039,110
20,528,136
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Diflucan Attending: ___ Chief Complaint: Vaginal bleeding Major Surgical or Invasive Procedure: none History of Prese...
[ "N938", "D259", "D649", "Z86711", "Z7902" ]
Allergies: Diflucan Chief Complaint: Vaginal bleeding Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a [MASKED] y/o G6P2 with a history of known fibroid uterus, history of anemia, history of PE on Eliquis ([MASKED]), who presents with vaginal bleeding. LMP started [MASKED] - has been ...
[]
[ "D649", "Z7902" ]
[ "N938: Other specified abnormal uterine and vaginal bleeding", "D259: Leiomyoma of uterus, unspecified", "D649: Anemia, unspecified", "Z86711: Personal history of pulmonary embolism", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]
10,039,110
25,345,103
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Diflucan Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None. History of Present Illness: HISTORY ...
[ "I2699", "R042", "D509", "F17210", "F1490", "N938" ]
Allergies: Diflucan Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None. History of Present Illness: HISTORY OF PRESENT ILLNESS: Ms. [MASKED] is a [MASKED] year old woman with history of dysfunctional uterine bleeding, iron deficiency anemia, and polysubstance abuse including crack cocaine presenting wi...
[]
[ "D509", "F17210" ]
[ "I2699: Other pulmonary embolism without acute cor pulmonale", "R042: Hemoptysis", "D509: Iron deficiency anemia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F1490: Cocaine use, unspecified, uncomplicated", "N938: Other specified abnormal uterine and vaginal bleeding" ]
10,039,110
25,441,215
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Symptomatic fibroid uterus Major Surgical or...
[ "D259", "Z86718", "Z86711", "Z7902" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Symptomatic fibroid uterus Major Surgical or Invasive Procedure: Total abdominal hysterectomy, Bilateral salpingectomy History of Present Illness: [MASKED] is a [MASKED] gravida 7 [MASKED] who returns to discuss further future hysterectomy and bila...
[]
[ "Z86718", "Z7902" ]
[ "D259: Leiomyoma of uterus, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "Z86711: Personal history of pulmonary embolism", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]
10,039,272
23,744,596
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / amiodarone Attending: ___. Chief Complaint: neutropenic fever Major Surgical or Invasive Procedure: None History of...
[ "J189", "I482", "D709", "C457", "H905", "R5081", "I2510", "Z7901", "K219", "J3489", "R0781", "F419", "N401", "K5900", "I10", "E039", "R600", "Z8781", "L821", "Z85828", "Z87891" ]
Allergies: Penicillins / amiodarone Chief Complaint: neutropenic fever Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] w/ CAD, Afib (Coumadin), GERD, and dx of pleural mesothelioma ([MASKED]) s/p cycle two of pemetrexed at [MASKED] [MASKED] (primary oncologist Dr. [MASKED] who presents w...
[]
[ "I2510", "Z7901", "K219", "F419", "K5900", "I10", "E039", "Z87891" ]
[ "J189: Pneumonia, unspecified organism", "I482: Chronic atrial fibrillation", "D709: Neutropenia, unspecified", "C457: Mesothelioma of other sites", "H905: Unspecified sensorineural hearing loss", "R5081: Fever presenting with conditions classified elsewhere", "I2510: Atherosclerotic heart disease of na...
10,039,302
20,263,091
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Lipitor / Prempro / Fosamax / Aspirin / Tamoxifen / Zetia / Naproxen / Rofecoxib / Celebrex / Atenolol / Metoprolol / Glucophage / Lotrel...
[ "I70244", "E1151", "L97429", "Z89511", "I2510", "I252", "Z951", "Z794", "I10", "E039", "Z853", "Z006" ]
Allergies: Lipitor / Prempro / Fosamax / Aspirin / Tamoxifen / Zetia / Naproxen / Rofecoxib / Celebrex / Atenolol / Metoprolol / Glucophage / Lotrel / Sulfur / Nsaids / Ace Inhibitors / Statins-Hmg-Coa Reductase Inhibitors / Niacin Chief Complaint: Left heel ulcer secondary to peripheral vascular disease Major Surgical...
[]
[ "I2510", "I252", "Z951", "Z794", "I10", "E039" ]
[ "I70244: Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot", "E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene", "L97429: Non-pressure chronic ulcer of left heel and midfoot with unspecified severity", "Z89511: Acquired absence of right leg ...
10,039,302
21,345,637
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Lipitor / Prempro / Fosamax / Aspirin / Tamoxifen / Zetia / Naproxen / Rofecoxib / Celebrex / Atenolol / Metoprolol / Glucophage / Lotrel...
[ "I70244", "I7092", "E1140", "N390", "L97429", "I10", "Z89511", "I2510", "I252", "Z951", "Z955", "E039", "R9431", "Z853", "Z8673" ]
Allergies: Lipitor / Prempro / Fosamax / Aspirin / Tamoxifen / Zetia / Naproxen / Rofecoxib / Celebrex / Atenolol / Metoprolol / Glucophage / Lotrel / Sulfur / Nsaids / Ace Inhibitors / Statins-Hmg-Coa Reductase Inhibitors / Niacin Chief Complaint: Non healing left heel wound. Major Surgical or Invasive Procedure: [MAS...
[]
[ "N390", "I10", "I2510", "I252", "Z951", "Z955", "E039", "Z8673" ]
[ "I70244: Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot", "I7092: Chronic total occlusion of artery of the extremities", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "N390: Urinary tract infection, site not specified", "L97429: Non-pressure chr...
10,039,302
28,794,550
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Lipitor / Prempro / Fosamax / Aspirin / Tamoxifen / Zetia / Naproxen / Rofecoxib / Celebrex / Atenolol / Metoprolol / Glucophage / Lotrel...
[ "T8131XA", "L97429", "E118", "L03116", "I2510", "Z951", "I252", "I10", "E039", "Z853", "Z89511", "Z87891", "B9562", "R4182", "T450X5A", "L298", "M7989", "Y839", "Y929" ]
Allergies: Lipitor / Prempro / Fosamax / Aspirin / Tamoxifen / Zetia / Naproxen / Rofecoxib / Celebrex / Atenolol / Metoprolol / Glucophage / Lotrel / Sulfur / Nsaids / Ace Inhibitors / Statins-Hmg-Coa Reductase Inhibitors / Niacin / minocycline Chief Complaint: LLE wound dehiscence, right arm edema and pain. Major Sur...
[]
[ "I2510", "Z951", "I252", "I10", "E039", "Z87891", "Y929" ]
[ "T8131XA: Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter", "L97429: Non-pressure chronic ulcer of left heel and midfoot with unspecified severity", "E118: Type 2 diabetes mellitus with unspecified complications", "L03116: Cellulitis of left lower limb", "I2510...
10,039,393
20,123,798
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Percocet / Motrin / crab and lobster / shellfish derived Attending: ___. Chief Complaint: back pain Major Surgical or Invasive Proce...
[ "M4807", "M5117", "M4317", "I10", "J45909", "F329", "Z96651", "Z8711", "Z961" ]
Allergies: Percocet / Motrin / crab and lobster / shellfish derived Chief Complaint: back pain Major Surgical or Invasive Procedure: [MASKED] L5-S1 ALIF [MASKED] L4-S1 PLF History of Present Illness: Patient returns to the office for follow-up. Since his last visit, he states his back pain has gotten worse. He has a kn...
[]
[ "I10", "J45909", "F329" ]
[ "M4807: Spinal stenosis, lumbosacral region", "M5117: Intervertebral disc disorders with radiculopathy, lumbosacral region", "M4317: Spondylolisthesis, lumbosacral region", "I10: Essential (primary) hypertension", "J45909: Unspecified asthma, uncomplicated", "F329: Major depressive disorder, single episod...
10,039,396
27,932,215
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Aphasia, weakness Major Surgical or Invasive Procedure: Ab...
[ "I63412", "G8191", "R1310", "R4701", "R4189", "I10", "E785", "R29717", "I2510", "G510", "Z66", "R21" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Aphasia, weakness Major Surgical or Invasive Procedure: Aborted thrombectomy [MASKED] History of Present Illness: NEUROLOGY STROKE ADMISSION/CONSULT NOTE Neurology at bedside after Code Stroke activation within: 3 mins Time/Date the patient was las...
[]
[ "I10", "E785", "I2510", "Z66" ]
[ "I63412: Cerebral infarction due to embolism of left middle cerebral artery", "G8191: Hemiplegia, unspecified affecting right dominant side", "R1310: Dysphagia, unspecified", "R4701: Aphasia", "R4189: Other symptoms and signs involving cognitive functions and awareness", "I10: Essential (primary) hyperten...
10,039,708
20,093,566
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: cats, dogs, dust, pollen Attending: ___. Chief Complaint: Lethargy Major Surgical or Invasive Procedure: None History of Present Ill...
[ "K7040", "N186", "F10251", "F10239", "I8510", "I120", "D62", "K921", "E872", "K7030", "Z8711", "Z992", "D638", "F17210", "J45909", "E039", "Z86718", "Z9884", "M109", "S40022A", "S40021A", "S8012XA", "S8011XA", "S0003XA", "S20222A", "S20221A", "W108XXA", "Y92018"...
Allergies: cats, dogs, dust, pollen Chief Complaint: Lethargy Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] yo F with hx of EtOH cirrhosis c/b esophageal varices s/p recent banding ([MASKED]), stomach ulcer, ESRD (HD TTS, last session [MASKED], HTN, asthma who present...
[]
[ "D62", "E872", "F17210", "J45909", "E039", "Z86718", "M109", "D696" ]
[ "K7040: Alcoholic hepatic failure without coma", "N186: End stage renal disease", "F10251: Alcohol dependence with alcohol-induced psychotic disorder with hallucinations", "F10239: Alcohol dependence with withdrawal, unspecified", "I8510: Secondary esophageal varices without bleeding", "I120: Hypertensive...
10,039,708
23,819,016
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hypotension, Abdominal Pain Major Surgical or Invasive Pro...
[ "A4189", "K859", "R6521", "N179", "R64", "E46", "E872", "E5112", "G629", "F1020", "K7010", "E039", "I129", "N189", "Z720", "J45909", "M109", "D649", "R410", "Z86718", "Z9884" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Hypotension, Abdominal Pain Major Surgical or Invasive Procedure: Right internal jugular line placement History of Present Illness: Ms. [MASKED] is a [MASKED] w/ PMH of EtOH abuse (currently still drinking) c/b EtOH hepatitis, Wernicke's encephalop...
[]
[ "N179", "E872", "E039", "I129", "N189", "J45909", "M109", "D649", "Z86718" ]
[ "A4189: Other specified sepsis", "K859: Acute pancreatitis, unspecified", "R6521: Severe sepsis with septic shock", "N179: Acute kidney failure, unspecified", "R64: Cachexia", "E46: Unspecified protein-calorie malnutrition", "E872: Acidosis", "E5112: Wet beriberi", "G629: Polyneuropathy, unspecified...
10,039,708
24,928,679
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: cats, dogs, dust, pollen Attending: ___ Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: ___: EGD w/ banding ...
[ "K7031", "I8511", "K767", "N186", "K284", "D62", "K861", "E872", "K7040", "R600", "D539", "D6959", "E039", "M109", "R300", "R7989", "E875", "R2232", "N281", "F1010", "F17210", "Z992", "Z86718", "Z9884", "Z980" ]
Allergies: cats, dogs, dust, pollen Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [MASKED]: EGD w/ banding History of Present Illness: Ms. [MASKED] is a [MASKED] yo F with PMH EtOH cirrhosis c/b renal failure (HD [MASKED], continued EtOH abuse (1 pint/day), and prior RLE DVT [MASKED] ago) w...
[]
[ "D62", "E872", "E039", "M109", "F17210", "Z86718" ]
[ "K7031: Alcoholic cirrhosis of liver with ascites", "I8511: Secondary esophageal varices with bleeding", "K767: Hepatorenal syndrome", "N186: End stage renal disease", "K284: Chronic or unspecified gastrojejunal ulcer with hemorrhage", "D62: Acute posthemorrhagic anemia", "K861: Other chronic pancreatit...
10,039,708
25,864,431
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: EGD (...
[ "K7290", "K8520", "K767", "E43", "J189", "K7681", "D689", "N184", "N179", "D62", "I8510", "K860", "D6959", "K7011", "K7031", "F1020", "M109", "E039", "D539", "I129", "F17210", "R0902", "Z66", "Z9884", "Z86718", "Z6830" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: EGD ([MASKED]) Paracentesis x3 ([MASKED]) HD line placement ([MASKED]) History of Present Illness: [MASKED] with history of active alcohol abuse with cirrhosis, Wernicke encephalopathy, gastric b...
[]
[ "N179", "D62", "M109", "E039", "I129", "F17210", "Z66", "Z86718" ]
[ "K7290: Hepatic failure, unspecified without coma", "K8520: Alcohol induced acute pancreatitis without necrosis or infection", "K767: Hepatorenal syndrome", "E43: Unspecified severe protein-calorie malnutrition", "J189: Pneumonia, unspecified organism", "K7681: Hepatopulmonary syndrome", "D689: Coagulat...
10,039,708
26,793,610
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Elevated Creatinine Major Surgical or Invasive Procedure:...
[ "N179", "E872", "I959", "N183", "I129", "F1020", "E039", "D539", "F17210", "R740" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Elevated Creatinine Major Surgical or Invasive Procedure: None History of Present Illness: is a [MASKED] woman with a history of ETOH abuse, hypotension likely [MASKED] autonomic instability, and recent ATN requiring temporary HD who was admitted f...
[]
[ "N179", "E872", "I129", "E039", "F17210" ]
[ "N179: Acute kidney failure, unspecified", "E872: Acidosis", "I959: Hypotension, unspecified", "N183: Chronic kidney disease, stage 3 (moderate)", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "F1020: Alcohol depende...
10,039,708
28,258,130
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chief Complaint: Hypotension Reason for MICU transfer: Refr...
[ "D649", "N170", "J9691", "I214", "J690", "G9340", "I5021", "J95851", "E43", "R64", "E872", "E5112", "I82401", "Z681", "E873", "I5181", "E870", "R34", "D61818", "D696", "R680", "F1020", "F17210", "E039", "I10", "I340", "K7030", "K7010", "E59", "E60", "D124"...
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chief Complaint: Hypotension Reason for MICU transfer: Refractory hypotension, severe anemia Major Surgical or Invasive Procedure: Intubation: [MASKED] Sigmoidoscopy [MASKED] EGD [MASKED] Tunneled hemodialysis line placement [MASKED] Colonoscopy [M...
[]
[ "D649", "E872", "D696", "F17210", "E039", "I10", "J45909", "Y92230" ]
[ "D649: Anemia, unspecified", "N170: Acute kidney failure with tubular necrosis", "J9691: Respiratory failure, unspecified with hypoxia", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "J690: Pneumonitis due to inhalation of food and vomit", "G9340: Encephalopathy, unspecified", "I5021: Acute s...
10,039,708
29,488,258
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: cats, dogs, dust, pollen Attending: ___. Chief Complaint: confusion Major Surgical or Invasive Procedure: None History of Present Il...
[ "K7290", "N186", "F1019", "I8510", "K7030", "J45909", "T473X6A", "E039", "F17210", "D649", "Z992", "Z86718", "Z91128" ]
Allergies: cats, dogs, dust, pollen Chief Complaint: confusion Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] yo F with hx of EtOH cirrhosis c/b esophageal varices s/p recent banding ([MASKED]), stomach ulcer, ESRD on HD, HTN, asthma who presents with altered mental st...
[]
[ "J45909", "E039", "F17210", "D649", "Z86718" ]
[ "K7290: Hepatic failure, unspecified without coma", "N186: End stage renal disease", "F1019: Alcohol abuse with unspecified alcohol-induced disorder", "I8510: Secondary esophageal varices without bleeding", "K7030: Alcoholic cirrhosis of liver without ascites", "J45909: Unspecified asthma, uncomplicated",...
10,039,709
21,965,984
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Pneumococcal Vaccine / nuts / treenuts Attending: ___. Chief Complaint: severe left thoracic pain Major Surgical or Invasive Pr...
[ "M5114", "M4804", "I10", "Z86718", "Z86711" ]
Allergies: Pneumococcal Vaccine / nuts / treenuts Chief Complaint: severe left thoracic pain Major Surgical or Invasive Procedure: T5-6 DISCECTOMY AND T5-7 POSTERIOR INSTRUMENTED ARTHRODESIS History of Present Illness: Mr. [MASKED] is a pleasant gentleman who presented with severe left thoracic radiculopathy.He did not...
[]
[ "I10", "Z86718" ]
[ "M5114: Intervertebral disc disorders with radiculopathy, thoracic region", "M4804: Spinal stenosis, thoracic region", "I10: Essential (primary) hypertension", "Z86718: Personal history of other venous thrombosis and embolism", "Z86711: Personal history of pulmonary embolism" ]
10,039,870
22,600,344
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Attending: ___ Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Diag...
[ "K353", "K660", "R338", "R400", "T402X5A", "Y92230" ]
Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Diagnostic laparoscopy and open appendectomy History of Present Illness: [MASKED] woman with 3-day history of abdominal pain which was generalized, and ultimately today had started to localize ...
[]
[ "Y92230" ]
[ "K353: Acute appendicitis with localized peritonitis", "K660: Peritoneal adhesions (postprocedural) (postinfection)", "R338: Other retention of urine", "R400: Somnolence", "T402X5A: Adverse effect of other opioids, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the ext...
10,039,913
24,711,716
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: shortness of breath and cough Major Surgical or Invasive Procedure: None History of ...
[ "A481", "B20", "E871", "N179", "D649", "Z8619", "F1911", "Z87891", "R0902" ]
Allergies: Penicillins Chief Complaint: shortness of breath and cough Major Surgical or Invasive Procedure: None History of Present Illness: CC: cough HISTORY OF THE PRESENTING ILLNESS: This is a [MASKED] gentleman with a history of HIV currently on active retroviral therapy, hepatitis C who was recently completed trea...
[]
[ "E871", "N179", "D649", "Z87891" ]
[ "A481: Legionnaires' disease", "B20: Human immunodeficiency virus [HIV] disease", "E871: Hypo-osmolality and hyponatremia", "N179: Acute kidney failure, unspecified", "D649: Anemia, unspecified", "Z8619: Personal history of other infectious and parasitic diseases", "F1911: Other psychoactive substance a...