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10,077,534
29,345,364
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Inderal / Minipress / Clonidine / Enalapril / Verapamil / Cozaar / Nifedipine / Norvasc / Bacitracin / Micardis / fluocinonide / Nizoral / n...
[ "I129", "N189", "N179", "J208", "E785", "M4806", "M21372", "E871", "D649", "Z86010", "M1990", "M810", "I7300", "G4762", "K219" ]
Allergies: Inderal / Minipress / Clonidine / Enalapril / Verapamil / Cozaar / Nifedipine / Norvasc / Bacitracin / Micardis / fluocinonide / Nizoral / nystatin / Atrovent / levofloxacin Chief Complaint: cough, transient left leg weakness/burning Major Surgical or Invasive Procedure: None History of Present Illness: [MAS...
[]
[ "I129", "N189", "N179", "E785", "E871", "D649", "K219" ]
[ "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "N179: Acute kidney failure, unspecified", "J208: Acute bronchitis due to other specified organisms", "E785: Hyperlipidemia, un...
10,077,619
22,073,305
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Bactrim / Pravachol / Ciprofloxacin / Zoloft / Lipitor / Macrobid / Statins-Hmg-Coa Reductase Inhibitors Attending: ___. Chief Complaint...
[ "S20211A", "W010XXA", "Y92009", "F419", "F329", "E039", "I110", "I509", "R4182", "H409", "M315", "E785", "M4800", "D649", "M1711", "K219", "M810", "K5790" ]
Allergies: Bactrim / Pravachol / Ciprofloxacin / Zoloft / Lipitor / Macrobid / Statins-Hmg-Coa Reductase Inhibitors Chief Complaint: s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] with a hx of GCA and PMR on pred, hypothyroidism, CHF [MASKED] EF: >55%), spinal stenosis, h/o fal...
[]
[ "F419", "F329", "E039", "I110", "E785", "D649", "K219" ]
[ "S20211A: Contusion of right front wall of thorax, initial encounter", "W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of ...
10,077,769
21,673,397
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: tramadol Attending: ___ Chief Complaint: Lower back pain, difficulty walking Major Surgical or Invasive Procedure: Interventional radiol...
[ "G061", "F1120", "B9689", "B182", "M4647", "K219", "D649" ]
Allergies: tramadol Chief Complaint: Lower back pain, difficulty walking Major Surgical or Invasive Procedure: Interventional radiology performed a CT- guided percutaneous bone biopsy on [MASKED]. History of Present Illness: [MASKED] yo male h/o IVDU (on suboxone, last heroin in [MASKED] and Hepatitis C with worsening ...
[]
[ "K219", "D649" ]
[ "G061: Intraspinal abscess and granuloma", "F1120: Opioid dependence, uncomplicated", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "B182: Chronic viral hepatitis C", "M4647: Discitis, unspecified, lumbosacral region", "K219: Gastro-esophageal reflux disease with...
10,077,769
23,862,813
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/leg pain Major Surgical or Invasive Procedure: ___: Le...
[ "M5116", "F1120", "K219", "B1920", "F17210", "M21372" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Back/leg pain Major Surgical or Invasive Procedure: [MASKED]: Left laminectomy and microdissectomy with ortho spine History of Present Illness: HISTORY OF THE PRESENTING ILLNESS: [MASKED] male with past medical history of epidural abscess in [MASKE...
[]
[ "K219", "F17210" ]
[ "M5116: Intervertebral disc disorders with radiculopathy, lumbar region", "F1120: Opioid dependence, uncomplicated", "K219: Gastro-esophageal reflux disease without esophagitis", "B1920: Unspecified viral hepatitis C without hepatic coma", "F17210: Nicotine dependence, cigarettes, uncomplicated", "M21372:...
10,078,162
21,066,656
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PLASTIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: L cheek Moh's defect Major Surgical or Invasive Procedur...
[ "Z481", "Z85820", "R51", "Z87891", "K219" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: L cheek Moh's defect Major Surgical or Invasive Procedure: Cervicofacial flap closure ([MASKED]) History of Present Illness: [MASKED] is a [MASKED] yo female w/ PMH notable for BCC, biopsy-proven melanoma in situ of L cheek s/p Moh's, who was admit...
[]
[ "Z87891", "K219" ]
[ "Z481: Encounter for planned postprocedural wound closure", "Z85820: Personal history of malignant melanoma of skin", "R51: Headache", "Z87891: Personal history of nicotine dependence", "K219: Gastro-esophageal reflux disease without esophagitis" ]
10,078,297
21,722,831
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: fatigue Major Surgical or Invasive Procedure: None H...
[ "M3214", "N179", "R34", "D619", "N390", "D696", "E875", "I10", "K219", "H5712", "B9620", "L259", "H109", "D320", "T420X5A" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: fatigue Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with history of meningioma s/p resection [MASKED] presents with subacute fatigue and dizziness of about 1month following presentation to her PCPs office. Pt's s...
[]
[ "N179", "N390", "D696", "I10", "K219" ]
[ "M3214: Glomerular disease in systemic lupus erythematosus", "N179: Acute kidney failure, unspecified", "R34: Anuria and oliguria", "D619: Aplastic anemia, unspecified", "N390: Urinary tract infection, site not specified", "D696: Thrombocytopenia, unspecified", "E875: Hyperkalemia", "I10: Essential (p...
10,078,297
27,114,285
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: anemia Major Surgical or Invasive Procedure: none Hi...
[ "D6481", "I129", "N184", "D631", "M329", "D569", "T451X5A", "Y929", "Z85841", "Z923", "R110" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: anemia Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] w/CKD4, SLE and anemia presents with worsening anemia. Pt was recently diagnosed with SLE and started on mycophenolate mofetil. She was also diagnosed with thala...
[]
[ "I129", "Y929" ]
[ "D6481: Anemia due to antineoplastic chemotherapy", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N184: Chronic kidney disease, stage 4 (severe)", "D631: Anemia in chronic kidney disease", "M329: Systemic lupus erythe...
10,078,309
22,388,171
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: left ophthalmic artery aneurysm Major Surgical or Invas...
[ "I671", "G935", "Z7902" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: left ophthalmic artery aneurysm Major Surgical or Invasive Procedure: [MASKED]: pipeline embolization of left ophthalmic artery aneurysm History of Present Illness: [MASKED] year old male electively admitted for planned pipeline embolization of lef...
[]
[ "Z7902" ]
[ "I671: Cerebral aneurysm, nonruptured", "G935: Compression of brain", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]
10,078,574
21,482,035
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: primary hyperparathyroidism, hypercalcemia, multinodular thyroid Maj...
[ "D34", "N390", "E0520", "N400", "E559", "D649", "E785", "Z808" ]
Allergies: Sulfa (Sulfonamide Antibiotics) Chief Complaint: primary hyperparathyroidism, hypercalcemia, multinodular thyroid Major Surgical or Invasive Procedure: thyroidectomy, parathyroidectomy History of Present Illness: [MASKED] with known multinodular goiter presents to the ED after labs drawn at thyroid clinic re...
[]
[ "N390", "N400", "D649", "E785" ]
[ "D34: Benign neoplasm of thyroid gland", "N390: Urinary tract infection, site not specified", "E0520: Thyrotoxicosis with toxic multinodular goiter without thyrotoxic crisis or storm", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "E559: Vitamin D deficiency, unspecified", "D6...
10,078,762
20,234,810
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Lipitor Attending: ___. Chief Complaint: Urinary Retention, Acute Renal Failure Major Surgical or Invasive Procedure: None ...
[ "N401", "N179", "E872", "E875", "N200", "R338", "H9193", "K219", "E785", "I10" ]
Allergies: Penicillins / Lipitor Chief Complaint: Urinary Retention, Acute Renal Failure Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] hx HTN admitted for urinary retention and [MASKED]. History taken from patient's family mostly as patient is very hard of hearing even with his hearing...
[]
[ "N179", "E872", "K219", "E785", "I10" ]
[ "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "N179: Acute kidney failure, unspecified", "E872: Acidosis", "E875: Hyperkalemia", "N200: Calculus of kidney", "R338: Other retention of urine", "H9193: Unspecified hearing loss, bilateral", "K219: Gastro-esophageal reflux disease...
10,078,762
22,681,724
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Lipitor Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness:...
[ "T85618A", "L03319", "D61818", "J90", "E785", "K219", "Z7982", "N289", "Z66", "G250", "I129", "N183" ]
Allergies: Penicillins / Lipitor Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] year old male with hypertension, hyperlipidemia, GERD and recurrent pleural effusion s/p left tunneled pleural catheter placed by IP on [MASKED] presents with worsening dyspnea. Pati...
[]
[ "E785", "K219", "Z66", "I129" ]
[ "T85618A: Breakdown (mechanical) of other specified internal prosthetic devices, implants and grafts, initial encounter", "L03319: Cellulitis of trunk, unspecified", "D61818: Other pancytopenia", "J90: Pleural effusion, not elsewhere classified", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophage...
10,078,805
20,434,240
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Ampicillin / indomethacin / lisinopril Attending: ___. Chief Complaint: Fall, Altered mental status Major Surgical or Invasive Proce...
[ "A4159", "J690", "J9601", "I2109", "R6521", "N170", "K7200", "I5021", "N390", "S22079A", "I130", "Z66", "Z781", "E1122", "N183", "R32", "N359", "G3184", "F329", "M4814", "E785", "M109", "W19XXXA", "Z9181", "Y92009", "I651", "Z8546", "Z9079", "Z923", "Z87891"...
Allergies: Ampicillin / indomethacin / lisinopril Chief Complaint: Fall, Altered mental status Major Surgical or Invasive Procedure: Intubation Suprapubic catheter insertion History of Present Illness: [MASKED] year old gentleman with history of CKD IIIb, type II diabetes, remote prostate cancer, hypertension, dyslipid...
[]
[ "J9601", "N390", "I130", "Z66", "E1122", "F329", "E785", "M109", "Z87891" ]
[ "A4159: Other Gram-negative sepsis", "J690: Pneumonitis due to inhalation of food and vomit", "J9601: Acute respiratory failure with hypoxia", "I2109: ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall", "R6521: Severe sepsis with septic shock", "N170: Acute kidney...
10,078,805
27,026,517
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Ampicillin / indomethacin / lisinopril Attending: ___ Chief Complaint: Presyncopal event Major Surgical or Invasive Procedure: None ...
[ "R55", "N183", "E119", "I129", "E785", "F329", "M109", "G3184", "I351", "R32", "I878", "Z87891", "Z8546", "Z923" ]
Allergies: Ampicillin / indomethacin / lisinopril Chief Complaint: Presyncopal event Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with CKD stage IIIB, DM2 diet controlled, remote prostate cancer, HTN, HLP, depression, presents with presyncope. He was in usual state of health until tod...
[]
[ "E119", "I129", "E785", "F329", "M109", "Z87891" ]
[ "R55: Syncope and collapse", "N183: Chronic kidney disease, stage 3 (moderate)", "E119: Type 2 diabetes mellitus without complications", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E785: Hyperlipidemia, unspecified"...
10,078,892
29,364,106
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Ceclor / Penicillins Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: none History of Prese...
[ "O8629", "B9620", "N12" ]
Allergies: Ceclor / Penicillins Chief Complaint: fever Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] G1P1 [MASKED] s/p pLTCS after IOL for cholestasis presents with fevers. Patient states she was feeling well until [MASKED] when she started having urinary frequency and dysuria. She spo...
[]
[]
[ "O8629: Other urinary tract infection following delivery", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "N12: Tubulo-interstitial nephritis, not specified as acute or chronic" ]
10,079,117
26,188,728
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PLASTIC Allergies: Tegretol / Enalapril / hydrochlorothiazide Attending: ___. Chief Complaint: right breast cancer Major Surgical or Invasive Procedure: right...
[ "C50111", "E1165", "I10", "Z171", "Z853", "Z86000", "N62", "E785", "G629" ]
Allergies: Tegretol / Enalapril / hydrochlorothiazide Chief Complaint: right breast cancer Major Surgical or Invasive Procedure: right mastectomy, right TRAM, left breast reduction for symmetry History of Present Illness: [MASKED] w/ carcinoma of the right breast diagnosed on [MASKED]. This is an invasive ductal carcin...
[]
[ "E1165", "I10", "E785" ]
[ "C50111: Malignant neoplasm of central portion of right female breast", "E1165: Type 2 diabetes mellitus with hyperglycemia", "I10: Essential (primary) hypertension", "Z171: Estrogen receptor negative status [ER-]", "Z853: Personal history of malignant neoplasm of breast", "Z86000: Personal history of in-...
10,079,290
22,706,512
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: None attach Pertinent Results: Admission...
[ "R1013", "G8929", "R079", "R110", "R630", "Z8619", "Z8719", "I10", "E785", "F419", "F329", "E1165", "G43909", "Z8673", "Z9114", "Z794", "R911" ]
Allergies: No Known Allergies / Adverse Drug Reactions Major Surgical or Invasive Procedure: None attach Pertinent Results: Admission/Discharge Labs: [MASKED] 07:39AM BLOOD WBC-5.3 RBC-5.00 Hgb-13.9 Hct-42.3 MCV-85 MCH-27.8 MCHC-32.9 RDW-12.1 RDWSD-37.1 Plt [MASKED] [MASKED] 07:39AM BLOOD Neuts-59.4 [MASKED] Monos-6.6 ...
[]
[ "G8929", "I10", "E785", "F419", "F329", "E1165", "Z8673", "Z794" ]
[ "R1013: Epigastric pain", "G8929: Other chronic pain", "R079: Chest pain, unspecified", "R110: Nausea", "R630: Anorexia", "Z8619: Personal history of other infectious and parasitic diseases", "Z8719: Personal history of other diseases of the digestive system", "I10: Essential (primary) hypertension", ...
10,079,466
26,124,920
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PSYCHIATRY Allergies: erythromycin base / haloperidol / Keflex Attending: ___. Chief Complaint: "It's a ___ year story." Major Surgical or Invasive Proced...
[ "F209", "Z9114", "R45851", "R419", "F1010", "F329", "F419", "F17210", "H5412", "K121", "S0031XA", "X58XXXA", "Y929" ]
Allergies: erythromycin base / haloperidol / Keflex Chief Complaint: "It's a [MASKED] year story." Major Surgical or Invasive Procedure: None History of Present Illness: For further details of the history and presentation, please see OMR including Dr. [MASKED] and Dr. [MASKED] initial consultation note dated [MASKED] a...
[]
[ "F329", "F419", "F17210", "Y929" ]
[ "F209: Schizophrenia, unspecified", "Z9114: Patient's other noncompliance with medication regimen", "R45851: Suicidal ideations", "R419: Unspecified symptoms and signs involving cognitive functions and awareness", "F1010: Alcohol abuse, uncomplicated", "F329: Major depressive disorder, single episode, uns...
10,079,545
26,201,323
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: Cardiac Arrest Major Surgical or Invasive Procedure: Endotracheal intubatio...
[ "I469", "J9690", "Z9911", "N390", "E871", "I130", "I472", "J449", "G629", "H409", "I10", "M1990", "Z515", "N189", "Z66", "I509", "R740" ]
Allergies: No Allergies/ADRs on File Chief Complaint: Cardiac Arrest Major Surgical or Invasive Procedure: Endotracheal intubation - [MASKED] Right femoral central line - [MASKED] History of Present Illness: Ms. [MASKED] is an [MASKED] year old F who was transferred from [MASKED] [MASKED] after a cardiac arrest. The pa...
[]
[ "N390", "E871", "I130", "J449", "I10", "Z515", "N189", "Z66" ]
[ "I469: Cardiac arrest, cause unspecified", "J9690: Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia", "Z9911: Dependence on respirator [ventilator] status", "N390: Urinary tract infection, site not specified", "E871: Hypo-osmolality and hyponatremia", "I130: Hypertensive h...
10,079,616
23,166,327
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: obstructed L PCN tube Major Surgical or Invasive Procedure: Le...
[ "N99522", "N1339", "N179", "R180", "C787", "C786", "N390", "B9689", "Z8546", "Z9079", "I10", "E785", "Z86718", "D638", "K5903", "T40605A", "Y92003", "Z66" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: obstructed L PCN tube Major Surgical or Invasive Procedure: Left percutaneous nephrostomy tube exchange - [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] male with history of advanced prostate cancer metastatic to the liver with per...
[]
[ "N179", "N390", "I10", "E785", "Z86718", "Z66" ]
[ "N99522: Malfunction of incontinent external stoma of urinary tract", "N1339: Other hydronephrosis", "N179: Acute kidney failure, unspecified", "R180: Malignant ascites", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C786: Secondary malignant neoplasm of retroperitoneum and pe...
10,079,616
27,864,171
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: leaking from previous L PCN site Major Surgical or Invasive Pr...
[ "N99528", "C787", "R180", "N179", "I82402", "C786", "R64", "N131", "Z8546", "R112", "Y838", "Y929", "I10", "Z66", "D473", "Z6823", "D649", "Z86718" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: leaking from previous L PCN site Major Surgical or Invasive Procedure: Paracentesis - [MASKED] Left percutaneous nephrostomy tract embolization and nephrostomy tube placement - [MASKED] History of Present Illness: Mr. [MASKED] is a pleasant [MASKED...
[]
[ "N179", "Y929", "I10", "Z66", "D649", "Z86718" ]
[ "N99528: Other complication of incontinent external stoma of urinary tract", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "R180: Malignant ascites", "N179: Acute kidney failure, unspecified", "I82402: Acute embolism and thrombosis of unspecified deep veins of left lower extremit...
10,079,632
26,559,290
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: vaginal bleeding Major Surgical or Invasive ...
[ "O031", "O030", "Z23", "O0333", "E876", "D649" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: vaginal bleeding Major Surgical or Invasive Procedure: D&C History of Present Illness: CC: bleeding, abdominal pain HPI: [MASKED] yo F G1P0010 presenting with vaginal bleeding, abdominal pain S/p med AB [MASKED] at PP, did well initially. Yesterday...
[]
[ "D649" ]
[ "O031: Delayed or excessive hemorrhage following incomplete spontaneous abortion", "O030: Genital tract and pelvic infection following incomplete spontaneous abortion", "Z23: Encounter for immunization", "O0333: Metabolic disorder following incomplete spontaneous abortion", "E876: Hypokalemia", "D649: Ane...
10,079,700
23,980,824
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: AMS, seizure Major Surgical or Invasive Procedure: Non...
[ "G40909", "J690", "K921", "F05", "E870", "E46", "Z681", "F17210", "Q100", "Z5329", "R471", "S0003XA", "W1839XA", "Y92091", "F209", "D649", "K649", "G2401", "R451", "F419", "I129", "N189", "F1011", "Z9181", "D352", "M1711", "R260" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: AMS, seizure Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] male with past medical history significant for schizophrenia, seizure disorder stable on lamictal/clonazepam, presenting for BRBPR after a fall at his grou...
[]
[ "F17210", "D649", "F419", "I129", "N189" ]
[ "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "J690: Pneumonitis due to inhalation of food and vomit", "K921: Melena", "F05: Delirium due to known physiological condition", "E870: Hyperosmolality and hypernatremia", "E46: Unspecified protein-calorie malnutrition", "Z681: ...
10,079,700
24,239,751
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Seizures Major Surgical or Invasive Procedure: Intubati...
[ "R569", "J690", "J9601", "A4102", "R6521", "G92", "D62", "K2210", "E870", "N179", "K920", "D689", "K921", "Z781", "F209", "K449", "I129", "D631", "K210", "K2270", "F17210", "R451", "G253", "D352", "R400", "F1011", "R471", "N183", "Q100", "S0191XA", "W1830X...
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Seizures Major Surgical or Invasive Procedure: Intubation and mechanical ventilation History of Present Illness: [MASKED] is a [MASKED] man with history of schizophrenia, and epilepsy on Lamictal who presented from his group home due to "jerking" m...
[]
[ "J9601", "D62", "N179", "I129", "F17210", "Y92230" ]
[ "R569: Unspecified convulsions", "J690: Pneumonitis due to inhalation of food and vomit", "J9601: Acute respiratory failure with hypoxia", "A4102: Sepsis due to Methicillin resistant Staphylococcus aureus", "R6521: Severe sepsis with septic shock", "G92: Toxic encephalopathy", "D62: Acute posthemorrhagi...
10,079,855
20,417,774
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Topamax / Lyrica Attending: ___. Chief Complaint: Lower back pain Major Surgical or Invasive Procedure: None History of Present Ill...
[ "M4806", "M5126", "F419", "K219", "G43909" ]
Allergies: Topamax / Lyrica Chief Complaint: Lower back pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with a history of herniated disc since [MASKED] who presents with worsening lower back pain with radiation down her legs and inability to ambulate for 1 week. Pt says 1 week ago s...
[]
[ "F419", "K219" ]
[ "M4806: Spinal stenosis, lumbar region", "M5126: Other intervertebral disc displacement, lumbar region", "F419: Anxiety disorder, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "G43909: Migraine, unspecified, not intractable, without status migrainosus" ]
10,080,219
27,017,950
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PLASTIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Right upper extremity lymphedema Major Surgical or Invasive ...
[ "I972", "Y838", "Y929", "Z853", "Z9011", "Z923", "Z23" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Right upper extremity lymphedema Major Surgical or Invasive Procedure: OMENTAL LYMPH NODE HARVEST FROM ABDOMEN; TRANSPLANT OMENTAL LYMPH NODE TO RIGHT FOREARM History of Present Illness: [MASKED] year old female w PMH of right breast cancer s/p par...
[]
[ "Y929" ]
[ "I972: Postmastectomy lymphedema syndrome", "Y838: Other surgical procedures 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 applicable", "Z853: Personal history of malignant neoplasm of ...
10,080,299
20,128,305
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Nickel / caffeine / lactose / gluten Attending: ___. Chief Complaint: Planned admission for chemotherapy Major Surgical or Invasive Proc...
[ "Z5111", "C8337", "E43", "I82412", "I82432", "E6601", "Z6841", "I2720", "D630", "I10", "M1990", "E785", "E559", "G4733", "K589", "K219", "R002", "R918", "Z87891", "Z800", "Z8052", "Z806" ]
Allergies: Nickel / caffeine / lactose / gluten Chief Complaint: Planned admission for chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: HISTORY OF PRESENT ILLNESS: Ms. [MASKED] is a [MASKED] year old female with PMHx of HTN, HLD, celiac disease, morbid obesity, OSA, pHTN and anxiety w...
[]
[ "I10", "E785", "G4733", "K219", "Z87891" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8337: Diffuse large B-cell lymphoma, spleen", "E43: Unspecified severe protein-calorie malnutrition", "I82412: Acute embolism and thrombosis of left femoral vein", "I82432: Acute embolism and thrombosis of left popliteal vein", "E6601: Morbid (severe) ...
10,080,299
22,093,219
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Nickel / caffeine / lactose / gluten Attending: ___ Chief Complaint: admitted for C2 EPOCH Major Surgical or Invasive Procedure: POC pla...
[ "Z5111", "C8339", "C8333", "D6481", "T451X5A", "D630", "D72828", "R002", "K219", "E785", "E559", "R0609" ]
Allergies: Nickel / caffeine / lactose / gluten Chief Complaint: admitted for C2 EPOCH Major Surgical or Invasive Procedure: POC placement [MASKED] History of Present Illness: Ms. [MASKED] is a [MASKED] year old female with PMHx of HTN, HLD, celiac disease, morbid obesity, OSA, pHTN and anxiety who initially presented ...
[]
[ "K219", "E785" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8339: Diffuse large B-cell lymphoma, extranodal and solid organ sites", "C8333: Diffuse large B-cell lymphoma, intra-abdominal lymph nodes", "D6481: Anemia due to antineoplastic chemotherapy", "T451X5A: Adverse effect of antineoplastic and immunosuppress...
10,080,299
22,257,365
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Nickel / caffeine / lactose / gluten Attending: ___. Chief Complaint: dyspnea, splenomegaly, thrombocytopenia Major Surgical or Invasive...
[ "C8337", "Z6842", "D684", "D599", "D696", "I10", "E785", "K900", "E6601", "G4733", "F419", "Z87891", "R161", "D735", "I2720", "K219", "E559", "R002", "E876" ]
Allergies: Nickel / caffeine / lactose / gluten Chief Complaint: dyspnea, splenomegaly, thrombocytopenia Major Surgical or Invasive Procedure: [MASKED] - Bedside bone marrow biopsy [MASKED] - [MASKED] bone marrow biopsy [MASKED] - [MASKED] splenic core biopsy [MASKED] - LP History of Present Illness: Ms. [MASKED] is a ...
[]
[ "D696", "I10", "E785", "G4733", "F419", "Z87891", "K219" ]
[ "C8337: Diffuse large B-cell lymphoma, spleen", "Z6842: Body mass index [BMI] 45.0-49.9, adult", "D684: Acquired coagulation factor deficiency", "D599: Acquired hemolytic anemia, unspecified", "D696: Thrombocytopenia, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecif...
10,080,299
23,457,426
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Nickel / caffeine / lactose / gluten Attending: ___. Chief Complaint: planned admission for cycle 5 of EPOCH chemotherapy Major Surgica...
[ "Z5111", "C8337", "Z6841", "D630", "E785", "K219", "E559", "I10", "G4733", "F419", "M1990", "K900", "E6601", "Z87891", "G620", "T451X5S", "I2720", "R740", "R0600", "Z86718", "Z7901" ]
Allergies: Nickel / caffeine / lactose / gluten Chief Complaint: planned admission for cycle 5 of EPOCH chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year-old female with PMHx of HTN, HLD, celiac disease, morbid obesity, OSA, pHTN and anxiety who initiall...
[]
[ "E785", "K219", "I10", "G4733", "F419", "Z87891", "Z86718", "Z7901" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8337: Diffuse large B-cell lymphoma, spleen", "Z6841: Body mass index [BMI]40.0-44.9, adult", "D630: Anemia in neoplastic disease", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "E559: Vitamin D de...
10,080,299
24,925,543
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Nickel / caffeine / lactose / gluten Attending: ___. Chief Complaint: admitted for C4 EPOCH Major Surgical or Invasive Procedure: None ...
[ "Z5112", "E43", "C8337", "K521", "Z6841", "I82412", "I82432", "T451X5A", "Z87891", "K219", "G620", "E6601", "D72829", "R945", "R509", "R918", "F419", "M1990", "G4733", "I2720", "E559", "K900", "E785", "I10", "D6481", "D630" ]
Allergies: Nickel / caffeine / lactose / gluten Chief Complaint: admitted for C4 EPOCH Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year old female with PMHx of HTN, HLD, celiac disease, morbid obesity, OSA, pHTN and anxiety who initially presented with [MASKED] week...
[]
[ "Z87891", "K219", "F419", "G4733", "E785", "I10" ]
[ "Z5112: Encounter for antineoplastic immunotherapy", "E43: Unspecified severe protein-calorie malnutrition", "C8337: Diffuse large B-cell lymphoma, spleen", "K521: Toxic gastroenteritis and colitis", "Z6841: Body mass index [BMI]40.0-44.9, adult", "I82412: Acute embolism and thrombosis of left femoral vei...
10,080,299
25,126,688
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Nickel / caffeine / lactose / gluten Attending: ___. Chief Complaint: C6 da-EPOCH Major Surgical or Invasive Procedure: none History ...
[ "Z5111", "C8337", "Z6841", "I82512", "I82532", "I82542", "I10", "E785", "E6601", "Z7902", "K900", "G4733", "I2720", "F419", "M1990", "K589", "R918", "E559", "M545", "L309", "Z8249", "Z8052", "Z800", "J449", "G620", "T451X5A", "Y92230", "D630", "D6481", "R002...
Allergies: Nickel / caffeine / lactose / gluten Chief Complaint: C6 da-EPOCH Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [MASKED] is a [MASKED] year-old female with PMHx of HTN, HLD, celiac disease, morbid obesity, OSA, pHTN and anxiety who initially presented with [MASKED] weeks of dyspn...
[]
[ "I10", "E785", "Z7902", "G4733", "F419", "J449", "Y92230", "K219" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8337: Diffuse large B-cell lymphoma, spleen", "Z6841: Body mass index [BMI]40.0-44.9, adult", "I82512: Chronic embolism and thrombosis of left femoral vein", "I82532: Chronic embolism and thrombosis of left popliteal vein", "I82542: Chronic embolism an...
10,080,421
27,045,826
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: aspirin / phenobarbital Attending: ___ Chief Complaint: Left intertrochanteric femur fracture Major Surgical or Invasive Procedure: ...
[ "S72142A", "R710", "G309", "F0280", "M435X2", "I10", "K219", "W1839XA", "Y92199" ]
Allergies: aspirin / phenobarbital Chief Complaint: Left intertrochanteric femur fracture Major Surgical or Invasive Procedure: [MASKED]: L TFN History of Present Illness: Mrs. [MASKED] is a [MASKED] with history of paroxysmal SVT, remote GI bleed [MASKED] peptic ulcer s/p surgical repair, an Alzheimer dementia who pre...
[]
[ "I10", "K219" ]
[ "S72142A: Displaced intertrochanteric fracture of left femur, initial encounter for closed fracture", "R710: Precipitous drop in hematocrit", "G309: Alzheimer's disease, unspecified", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "M435X2: Other recurrent vertebral ...
10,080,443
28,790,420
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: chills/nausea Major Surgical or Invasive Procedure: none History of Present Illness: Ms _...
[ "N390", "I10", "N200", "E119", "B9620", "F329", "Z87440", "E785", "M810", "Z85828", "R05" ]
Allergies: lisinopril Chief Complaint: chills/nausea Major Surgical or Invasive Procedure: none History of Present Illness: Ms [MASKED] is a pleasant [MASKED] with history of DM2, nephrolithiasis and urosepsis who presents today with chills/nausea/dysuria. The patient has undergone treatment for UTI twice in the last 1...
[]
[ "N390", "I10", "E119", "F329", "E785" ]
[ "N390: Urinary tract infection, site not specified", "I10: Essential (primary) hypertension", "N200: Calculus of kidney", "E119: Type 2 diabetes mellitus without complications", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "F329: Major depressive disorder,...
10,080,524
20,238,636
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Remicade Attending: ___. Chief Complaint: Abdominal pain, bloody diarrhea Major Surgical or Invasiv...
[ "K580", "K861", "E1065", "T380X5A", "K2960", "R0789", "Z7289", "Z794", "Z87891" ]
Allergies: Sulfa (Sulfonamide Antibiotics) / Remicade Chief Complaint: Abdominal pain, bloody diarrhea Major Surgical or Invasive Procedure: Flexible sigmoidoscopy [MASKED] History of Present Illness: [MASKED] male with type 1 diabetes, ulcerative colitis (diagnosed [MASKED] years prior, previously on Remicade, plan to...
[]
[ "Z794", "Z87891" ]
[ "K580: Irritable bowel syndrome with diarrhea", "K861: Other chronic pancreatitis", "E1065: Type 1 diabetes mellitus with hyperglycemia", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "K2960: Other gastritis without bleeding", "R0789: Other chest pain", "Z7289:...
10,080,524
22,261,379
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Remicade / Reglan Attending: ___. Chief Complaint: Ulcerative colitis Major Surgical or Invasive Pro...
[ "K5190", "E109", "Z87891", "K219" ]
Allergies: Sulfa (Sulfonamide Antibiotics) / Remicade / Reglan Chief Complaint: Ulcerative colitis Major Surgical or Invasive Procedure: Laparoscopic abdominal colectomy with end ileostomy History of Present Illness: Mr [MASKED] is a pleasant [MASKED] male with hx of DM1 ulcerative colitis, recently discharged followin...
[]
[ "Z87891", "K219" ]
[ "K5190: Ulcerative colitis, unspecified, without complications", "E109: Type 1 diabetes mellitus without complications", "Z87891: Personal history of nicotine dependence", "K219: Gastro-esophageal reflux disease without esophagitis" ]
10,080,635
22,917,185
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PSYCHIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: "I'm afraid I will lose control." Major Surgical or In...
[ "F332", "R51" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: "I'm afraid I will lose control." Major Surgical or Invasive Procedure: none History of Present Illness: Per Dr. [MASKED] [MASKED] ED Initial Psychiatry Consult note, summarized here and updated per admission interview: Mrs. [MASKED] recalls an unc...
[]
[]
[ "F332: Major depressive disorder, recurrent severe without psychotic features", "R51: Headache" ]
10,080,695
23,273,240
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: ___ placeme...
[ "K521", "N170", "R571", "J9601", "J849", "A419", "E440", "C187", "C779", "D688", "K567", "N390", "E871", "E872", "K9049", "E860", "D472", "E7800", "M353", "I2510", "Z955", "N400", "T451X5A", "Y92009", "Z515", "Z87891", "Z7289", "I129", "E876", "R159", "Z45...
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: [MASKED] placement History of Present Illness: [MASKED] yo male with a history of colon cancer who is admitted with nausea and diarrhea and found to have an [MASKED]. The patient states he has been hav...
[]
[ "J9601", "N390", "E871", "E872", "I2510", "Z955", "N400", "Z515", "Z87891", "I129", "D696", "Z66", "N189" ]
[ "K521: Toxic gastroenteritis and colitis", "N170: Acute kidney failure with tubular necrosis", "R571: Hypovolemic shock", "J9601: Acute respiratory failure with hypoxia", "J849: Interstitial pulmonary disease, unspecified", "A419: Sepsis, unspecified organism", "E440: Moderate protein-calorie malnutriti...
10,080,695
24,844,905
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ ___ Complaint: Sigmoid mass Major Surgical or Invasive Procedure: Laparoscopi...
[ "C187", "Z8674", "I10", "N478", "I2510", "M353", "Z95810", "Z9861", "E7800", "N400", "Z86010" ]
Allergies: No Known Allergies / Adverse Drug Reactions [MASKED] Complaint: Sigmoid mass Major Surgical or Invasive Procedure: Laparoscopic sigmoid resection History of Present Illness: Mr. [MASKED] is a [MASKED] year old patient with an sigmoid mass diagnosed on colonoscopy and Biopsies confirmed adenocarcinoma. He was...
[]
[ "I10", "I2510", "N400" ]
[ "C187: Malignant neoplasm of sigmoid colon", "Z8674: Personal history of sudden cardiac arrest", "I10: Essential (primary) hypertension", "N478: Other disorders of prepuce", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "M353: Polymyalgia rheumatica", "Z95810:...
10,080,880
21,535,991
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've been having a really hard time recently" Major Surgical ...
[ "F329", "R45851", "F419", "K5900", "F515", "Z7289" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: "I've been having a really hard time recently" Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] is a [MASKED] year old international student BIBA after presenting to his [MASKED] counselor voicing passive suicidal sta...
[]
[ "F329", "F419", "K5900" ]
[ "F329: Major depressive disorder, single episode, unspecified", "R45851: Suicidal ideations", "F419: Anxiety disorder, unspecified", "K5900: Constipation, unspecified", "F515: Nightmare disorder", "Z7289: Other problems related to lifestyle" ]
10,080,985
24,679,803
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PSYCHIATRY Allergies: amoxicillin Attending: ___. Chief Complaint: "I'm feeling suicidal and I don't know why" Major Surgical or Invasive Procedure: None...
[ "F332", "R569", "R45851", "F19939", "F410", "F909", "F419", "F1290", "T43226A", "T43296A", "T43626A", "Z91128", "Y929" ]
Allergies: amoxicillin Chief Complaint: "I'm feeling suicidal and I don't know why" Major Surgical or Invasive Procedure: None History of Present Illness: Ms [MASKED] is a [MASKED] yo F with a PMHx significant for ADHD, anxiety, depression, likely unspecified seizure disorder, +BRCA mutation and two prior high lethalit...
[]
[ "F419", "Y929" ]
[ "F332: Major depressive disorder, recurrent severe without psychotic features", "R569: Unspecified convulsions", "R45851: Suicidal ideations", "F19939: Other psychoactive substance use, unspecified with withdrawal, unspecified", "F410: Panic disorder [episodic paroxysmal anxiety]", "F909: Attention-defici...
10,080,985
26,523,165
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: EMERGENCY Allergies: amoxicillin Attending: ___. Chief Complaint: genetic predisposition to breast cancer Major Surgical or Invasive Procedure: bilateral...
[ "F329", "R45851", "T43226A", "T43296A", "Z91128", "F909", "F419", "Z915", "Y929" ]
Allergies: amoxicillin Chief Complaint: genetic predisposition to breast cancer Major Surgical or Invasive Procedure: bilateral nipple sparing mastectomies; bilateral breast reconstruction with implants, surgimend History of Present Illness: Ms. [MASKED] is a lovely [MASKED] with h/o anxiety/depression, ADHD. Briefly, ...
[]
[ "F329", "F419", "Y929" ]
[ "F329: Major depressive disorder, single episode, unspecified", "R45851: Suicidal ideations", "T43226A: Underdosing of selective serotonin reuptake inhibitors, initial encounter", "T43296A: Underdosing of other antidepressants, initial encounter", "Z91128: Patient's intentional underdosing of medication reg...
10,080,985
26,916,340
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PLASTIC Allergies: amoxicillin / Bactrim Attending: ___. Chief Complaint: Outpatient Providers: Ms. ___ is a lovely ___ with h/o anxiety/depression, ADHD,...
[ "Z4001", "F329", "Z1501", "Z803", "F419" ]
Allergies: amoxicillin / Bactrim Chief Complaint: Outpatient Providers: Ms. [MASKED] is a lovely [MASKED] with h/o anxiety/depression, ADHD, referred for bilateral nipple sparing mastectomies; bilateral breast reconstruction with implants. She tolerated the procedure well, and was discharged the same day. Ambulatory, t...
[]
[ "F329", "F419" ]
[ "Z4001: Encounter for prophylactic removal of breast", "F329: Major depressive disorder, single episode, unspecified", "Z1501: Genetic susceptibility to malignant neoplasm of breast", "Z803: Family history of malignant neoplasm of breast", "F419: Anxiety disorder, unspecified" ]
10,081,067
29,607,169
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: chronic hypertension with superimposed severe p...
[ "O114", "O1092", "O6014X0", "O4103X0", "O365930", "O6981X0", "Z3A31", "Z370" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: chronic hypertension with superimposed severe pre-eclampsia spontaneous vaginal delivery at 31 weeks 6 days Major Surgical or Invasive Procedure: spontaneous vaginal delivery placement of [MASKED] IUD History of Present Illness: [MASKED] yo G3P1 at...
[]
[]
[ "O114: Pre-existing hypertension with pre-eclampsia, complicating childbirth", "O1092: Unspecified pre-existing hypertension complicating childbirth", "O6014X0: Preterm labor third trimester with preterm delivery third trimester, not applicable or unspecified", "O4103X0: Oligohydramnios, third trimester, not ...
10,081,375
22,472,344
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending: ___ Chief Complaint: Upper GI Bleed Major Surgical or Invasive Procedure:...
[ "K31811", "I81", "D62", "K766", "Z7682", "F17210", "K7031", "E119", "G8929", "D6959", "K3189", "E669", "Z6831" ]
Allergies: NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Chief Complaint: Upper GI Bleed Major Surgical or Invasive Procedure: EGD [MASKED] with GAVE s/p Argon plasma coagulation History of Present Illness: Mr. [MASKED] is a [MASKED] with PMHx EtOH cirrhosis (Child's B, decompensated by ascites, SBP, esophageal varices...
[]
[ "D62", "F17210", "E119", "G8929", "E669" ]
[ "K31811: Angiodysplasia of stomach and duodenum with bleeding", "I81: Portal vein thrombosis", "D62: Acute posthemorrhagic anemia", "K766: Portal hypertension", "Z7682: Awaiting organ transplant status", "F17210: Nicotine dependence, cigarettes, uncomplicated", "K7031: Alcoholic cirrhosis of liver with ...
10,081,375
25,112,669
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Admitted for planned thrombectomy, TIPS Major Surgical...
[ "K7031", "K766", "I81", "I8510", "K652", "K7210", "R112", "R161", "F419", "E119", "F17210", "J90", "Z7682", "Z86010", "Z794", "M545" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Admitted for planned thrombectomy, TIPS Major Surgical or Invasive Procedure: [MASKED] thrombus lysis and mechanical thrombectomy, TIPS placement ([MASKED]) History of Present Illness: Mr. [MASKED] is a [MASKED] year old male with past medical hist...
[]
[ "F419", "E119", "F17210", "Z794" ]
[ "K7031: Alcoholic cirrhosis of liver with ascites", "K766: Portal hypertension", "I81: Portal vein thrombosis", "I8510: Secondary esophageal varices without bleeding", "K652: Spontaneous bacterial peritonitis", "K7210: Chronic hepatic failure without coma", "R112: Nausea with vomiting, unspecified", "...
10,081,375
26,017,796
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: coffee ground emesis, melena, RUQ pain Major Surgical ...
[ "K652", "K7031", "K3189", "K922", "I81", "J90", "D696", "I8510", "E871", "K766", "F17210", "D72819", "F419", "K209", "Z006" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: coffee ground emesis, melena, RUQ pain Major Surgical or Invasive Procedure: Endoscopy [MASKED] Diagnostic paracentesis [MASKED] and [MASKED] History of Present Illness: ============================================================ MEDICINE ADMISSIO...
[]
[ "D696", "E871", "F17210", "F419" ]
[ "K652: Spontaneous bacterial peritonitis", "K7031: Alcoholic cirrhosis of liver with ascites", "K3189: Other diseases of stomach and duodenum", "K922: Gastrointestinal hemorrhage, unspecified", "I81: Portal vein thrombosis", "J90: Pleural effusion, not elsewhere classified", "D696: Thrombocytopenia, uns...
10,081,375
28,411,973
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: NSAIDS ___ Drug) Attending: ___. Chief Complaint: anemia and melena Major Surgical or Invasive Procedure: Endoscopy History of P...
[ "K31811", "K766", "K7030", "K3189", "D500", "E119", "F419", "Z87891", "Z86718", "G4733" ]
Allergies: NSAIDS [MASKED] Drug) Chief Complaint: anemia and melena Major Surgical or Invasive Procedure: Endoscopy History of Present Illness: Mr. [MASKED] is a [MASKED] with PMHx EtOH cirrhosis (Child's B, decompensated by ascites, SBP, esophageal varices with prior bleeding, and hepatic encephalopathy; s/p TIPS; on ...
[]
[ "E119", "F419", "Z87891", "Z86718", "G4733" ]
[ "K31811: Angiodysplasia of stomach and duodenum with bleeding", "K766: Portal hypertension", "K7030: Alcoholic cirrhosis of liver without ascites", "K3189: Other diseases of stomach and duodenum", "D500: Iron deficiency anemia secondary to blood loss (chronic)", "E119: Type 2 diabetes mellitus without com...
10,081,573
24,955,885
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: ciprofloxacin / Penicillins / morphine Attending: ___ Chief Complaint: Abdominal Pain, nausea and vomiting Major Surgical or Invasive Pr...
[ "K460", "K9161", "E13649", "K660", "K6389", "J45909", "I10", "Z9884", "Z794", "Y832", "Y92234" ]
Allergies: ciprofloxacin / Penicillins / morphine Chief Complaint: Abdominal Pain, nausea and vomiting Major Surgical or Invasive Procedure: [MASKED]: Lap -> open reduction & closure of internal hernia, LOA History of Present Illness: [MASKED] hx asthma, HTN, IDDM, Roux-en-Y gastric bypass [MASKED], [MASKED]) c/b anast...
[]
[ "J45909", "I10", "Z794" ]
[ "K460: Unspecified abdominal hernia with obstruction, without gangrene", "K9161: Intraoperative hemorrhage and hematoma of a digestive system organ or structure complicating a digestive system procedure", "E13649: Other specified diabetes mellitus with hypoglycemia without coma", "K660: Peritoneal adhesions (...
10,081,636
28,854,523
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / vancomycin Attending: ___. Chief Complaint: Heartburn, morbid obesity Major Surgical or ...
[ "E6601", "D6851", "Z6842", "Z23", "K219", "Z87891", "M797", "E785", "M1710", "M341", "D563", "E559", "L4050", "Z7982", "I2510", "R7303", "Z8249", "M109" ]
Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / vancomycin Chief Complaint: Heartburn, morbid obesity Major Surgical or Invasive Procedure: [MASKED]: 1. Laparoscopic removal of lap band and port device. 2. Laparoscopic sleeve gastrectomy. History of Present Illness: Per Dr. [MASKED]: [MASKED] has class III m...
[]
[ "K219", "Z87891", "E785", "I2510", "M109" ]
[ "E6601: Morbid (severe) obesity due to excess calories", "D6851: Activated protein C resistance", "Z6842: Body mass index [BMI] 45.0-49.9, adult", "Z23: Encounter for immunization", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence", "M797: Fi...
10,081,670
29,620,670
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Chest pain Major Surgical or Invasive Procedure: ___ cardi...
[ "I25110", "I10", "E785", "E119", "I350", "K219", "N400", "J449", "Z7984", "Z87891", "Z7902", "E669", "Z6827" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [MASKED] cardiac catheterization with right radial access DES to pLAD History of Present Illness: HISTORY OF PRESENTING ILLNESS: Mr. [MASKED] is a [MASKED] with PMH HTN, HLD, DMII, recently diagnosed...
[]
[ "I10", "E785", "E119", "K219", "N400", "J449", "Z87891", "Z7902", "E669" ]
[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E119: Type 2 diabetes mellitus without complications", "I350: Nonrheumatic aortic (valve) stenosis", "K219: Gastro-esophageal refl...
10,081,869
24,176,922
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: Demerol Attending: ___. Chief Complaint: Recurrent Spontaneous Pneumothorax Major Surgical or Invasive Procedure: Right ches...
[ "J9383", "F329", "K219", "R079" ]
Allergies: Demerol Chief Complaint: Recurrent Spontaneous Pneumothorax Major Surgical or Invasive Procedure: Right chest pigtail placement by interventional pulmonology [MASKED] History of Present Illness: [MASKED] F transferred from [MASKED] for pneumothorax management. Patient has hx of 2 spontaneous R pneumothoraces...
[]
[ "F329", "K219" ]
[ "J9383: Other pneumothorax", "F329: Major depressive disorder, single episode, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "R079: Chest pain, unspecified" ]
10,081,883
27,069,468
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: Altered Mental Status/Transfer Major Surgical or Invasive Procedure: Attempte...
[ "T404X1A", "G92", "J9691", "I214", "J690", "N179", "K521", "M6282", "E874", "E870", "I671", "F1110", "E860", "Y92149", "K209", "Z781", "T3695XA", "Y92239" ]
Allergies: No Allergies/ADRs on File Chief Complaint: Altered Mental Status/Transfer Major Surgical or Invasive Procedure: Attempted Lumbar Puncture [MASKED] [MASKED] guided Lumbar Puncture [MASKED] Cerebral angiography with R groin access Intubation [MASKED] History of Present Illness: [MASKED] PMH of opiate abuse p/w...
[]
[ "N179" ]
[ "T404X1A: Poisoning by, adverse effect of and underdosing of other synthetic narcotics", "G92: Toxic encephalopathy", "J9691: Respiratory failure, unspecified with hypoxia", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "J690: Pneumonitis due to inhalation of food and vomit", "N179: Acute kidne...
10,082,090
21,995,625
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Reglan / morphine / ferrous gluconate / Zofran (as hydrochloride) Attending: ___. Chief Complaint: abd pain, hand pain Major Sur...
[ "R1031", "K5010", "L03113", "R112", "D509", "D473", "T402X5A", "Y92009", "K219" ]
Allergies: Reglan / morphine / ferrous gluconate / Zofran (as hydrochloride) Chief Complaint: abd pain, hand pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with PMH Crohn's disease, esophageal erosions, presenting with abdominal pain. Patient was recently discharged on [MASKED] aft...
[]
[ "D509", "K219" ]
[ "R1031: Right lower quadrant pain", "K5010: Crohn's disease of large intestine without complications", "L03113: Cellulitis of right upper limb", "R112: Nausea with vomiting, unspecified", "D509: Iron deficiency anemia, unspecified", "D473: Essential (hemorrhagic) thrombocythemia", "T402X5A: Adverse effe...
10,082,090
22,941,513
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Reglan / morphine / ferrous gluconate / Zofran (as hydrochloride) Attending: ___. Chief Complaint: nausea/vomiting Major Surgical...
[ "K5010", "L03113", "R55", "D509", "W1830XA", "Y92231" ]
Allergies: Reglan / morphine / ferrous gluconate / Zofran (as hydrochloride) Chief Complaint: nausea/vomiting Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] with PMH Crohn's disease, esophageal erosions, presenting with left arm pain/numbness, hematochezia, hematemesis, diarrhea, nausea...
[]
[ "D509" ]
[ "K5010: Crohn's disease of large intestine without complications", "L03113: Cellulitis of right upper limb", "R55: Syncope and collapse", "D509: Iron deficiency anemia, unspecified", "W1830XA: Fall on same level, unspecified, initial encounter", "Y92231: Patient bathroom in hospital as the place of occurr...
10,082,090
27,631,162
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Reglan / morphine / ferrous gluconate Attending: ___. Chief Complaint: rt forearm pain at area of IV infiltration Major Surgical o...
[ "T8029XA", "K5090", "L02413", "M60831", "G5621", "D508", "E876", "Y848", "Y92239" ]
Allergies: Reglan / morphine / ferrous gluconate Chief Complaint: rt forearm pain at area of IV infiltration Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] y/o with reported hx IBD (Crohn's) who reports recent hospitalization at [MASKED] for IBD 'flare' - she reports rx with solumedrol,...
[]
[]
[ "T8029XA: Infection following other infusion, transfusion and therapeutic injection, initial encounter", "K5090: Crohn's disease, unspecified, without complications", "L02413: Cutaneous abscess of right upper limb", "M60831: Other myositis, right forearm", "G5621: Lesion of ulnar nerve, right upper limb", ...
10,082,163
21,587,377
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Keppra / ciprofloxacin Attending: ___. Chief Complaint: Drainage from groin Major Surgical or Invasive Procedure: ___ ___ Drain placem...
[ "K50913", "G40909", "I10", "K50914" ]
Allergies: Keppra / ciprofloxacin Chief Complaint: Drainage from groin Major Surgical or Invasive Procedure: [MASKED] [MASKED] Drain placement History of Present Illness: [MASKED] w/ CD, [MASKED] transferred from OSH for pus draining from R inguinal region. Today she presented to [MASKED] w/ pus draining from her R ing...
[]
[ "I10" ]
[ "K50913: Crohn's disease, unspecified, with fistula", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "I10: Essential (primary) hypertension", "K50914: Crohn's disease, unspecified, with abscess" ]
10,082,163
25,702,453
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Keppra / ciprofloxacin / metronidazole Attending: ___. Chief Complaint: Chron's disease Major Surgical or Invasive Procedure: Right cyst...
[ "K50013", "K50014", "I10" ]
Allergies: Keppra / ciprofloxacin / metronidazole Chief Complaint: Chron's disease Major Surgical or Invasive Procedure: Right cystoscopy stent placement; Open ileocecetomy, takedown of enterocutaneous fistula History of Present Illness: [MASKED] with Crohn's disease presenting to the hospital for a planned open ileoce...
[]
[ "I10" ]
[ "K50013: Crohn's disease of small intestine with fistula", "K50014: Crohn's disease of small intestine with abscess", "I10: Essential (primary) hypertension" ]
10,082,163
26,875,625
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Keppra / ciprofloxacin / metronidazole Attending: ___. Chief Complaint: abscess Major Surgical or Invasive Procedure: ABSCESS DRAINAGE ...
[ "K50013", "G620", "L02214", "L03314", "G40909", "T378X5A", "I10" ]
Allergies: Keppra / ciprofloxacin / metronidazole Chief Complaint: abscess Major Surgical or Invasive Procedure: ABSCESS DRAINAGE History of Present Illness: Ms. [MASKED] is a [MASKED] with Crohn's disease (diagnosed in [MASKED] being managed solely with budesonide in the past but no longer taking) complicated by EC fi...
[]
[ "I10" ]
[ "K50013: Crohn's disease of small intestine with fistula", "G620: Drug-induced polyneuropathy", "L02214: Cutaneous abscess of groin", "L03314: Cellulitis of groin", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "T378X5A: Adverse effect of other specified systemic anti-infec...
10,082,640
20,566,971
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Anemia Splenomegaly Major Surgical or Invasive Procedure:...
[ "D561", "R161", "D638", "K5900" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Anemia Splenomegaly Major Surgical or Invasive Procedure: open splenectomy History of Present Illness: [MASKED] woman with history of beta thalassemia with significant symptomatic anemia She has been followed for a number of years and has a slowly ...
[]
[ "K5900" ]
[ "D561: Beta thalassemia", "R161: Splenomegaly, not elsewhere classified", "D638: Anemia in other chronic diseases classified elsewhere", "K5900: Constipation, unspecified" ]
10,082,640
22,930,426
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Back pain and anemia Major Surgical or Invasive Procedure...
[ "D561", "D696", "B349", "D72819", "N200", "E83111" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Back pain and anemia Major Surgical or Invasive Procedure: None History of Present Illness: Ms [MASKED] is a [MASKED] year old female with a history of beta thalassemia intermedia who initially presented to [MASKED] [MASKED] this morning [MASKED] i...
[]
[ "D696" ]
[ "D561: Beta thalassemia", "D696: Thrombocytopenia, unspecified", "B349: Viral infection, unspecified", "D72819: Decreased white blood cell count, unspecified", "N200: Calculus of kidney", "E83111: Hemochromatosis due to repeated red blood cell transfusions" ]
10,082,662
20,506,635
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin / Fosamax Attending: ___. Chief Complaint: Lower extremity edema, hyponatremia, acute kidney injury Major Surgical or Invasive P...
[ "N170", "E872", "C787", "C7800", "C7889", "E222", "R188", "C7951", "C7971", "N141", "T508X5A", "Y929", "T451X5A", "Z85820", "E785", "M810", "Z66", "D6489", "I4891" ]
Allergies: aspirin / Fosamax Chief Complaint: Lower extremity edema, hyponatremia, acute kidney injury Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year old woman with history of diffusely metastatic melanoma ([MASKED]+, involving liver, spleen and other sites) on [M...
[]
[ "E872", "Y929", "E785", "Z66", "I4891" ]
[ "N170: Acute kidney failure with tubular necrosis", "E872: Acidosis", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C7800: Secondary malignant neoplasm of unspecified lung", "C7889: Secondary malignant neoplasm of other digestive organs", "E222: Syndrome of inappropriate secre...
10,082,662
22,060,359
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin / Fosamax Attending: ___. Chief Complaint: PE Major Surgical or Invasive Procedure: None. History of Present Illness: ___ is ...
[ "I2699", "B441", "N184", "I5032", "D6481", "I82412", "C439", "E785", "M810", "T451X5A", "Y929" ]
Allergies: aspirin / Fosamax Chief Complaint: PE Major Surgical or Invasive Procedure: None. History of Present Illness: [MASKED] is a [MASKED] year old woman with metastatic melanoma who is admitted from the ED after routine staging CT incidentally noted new right sided PE. Patient has been feeling generally well, but...
[]
[ "I5032", "E785", "Y929" ]
[ "I2699: Other pulmonary embolism without acute cor pulmonale", "B441: Other pulmonary aspergillosis", "N184: Chronic kidney disease, stage 4 (severe)", "I5032: Chronic diastolic (congestive) heart failure", "D6481: Anemia due to antineoplastic chemotherapy", "I82412: Acute embolism and thrombosis of left ...
10,082,662
23,913,187
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin / Fosamax Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS ___ 04:03PM ___ ...
[ "A419", "R6521", "G92", "I5021", "C787", "C7970", "C773", "C7800", "C7951", "C7889", "N184", "N179", "E872", "B441", "I248", "I4892", "I130", "Z515", "E8352", "I255", "I4891", "I2510", "C439", "D630", "R570", "S32402D", "R34", "Z66", "Z86711", "Z7902" ]
Allergies: aspirin / Fosamax Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS [MASKED] 04:03PM [MASKED] PTT-24.8* [MASKED] [MASKED] 04:03PM PLT SMR-NORMAL-MOD PLT COUNT-242 [MASKED] 04:03PM ANISOCYT-1+* POIKILOCY-2+* MICROCYT-1+* POLYCHROM-1+* OVALOCYT-1+* ECHINO-1+* TEARDROP-1+* ACAN...
[]
[ "N179", "E872", "I130", "Z515", "I4891", "I2510", "Z66", "Z7902" ]
[ "A419: Sepsis, unspecified organism", "R6521: Severe sepsis with septic shock", "G92: Toxic encephalopathy", "I5021: Acute systolic (congestive) heart failure", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C7970: Secondary malignant neoplasm of unspecified adrenal gland", "...
10,082,662
28,631,269
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin / Fosamax Attending: ___ Chief Complaint: Hip pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ ...
[ "S32492A", "C7951", "C7800", "C787", "C7889", "C7989", "C7970", "I5030", "M8458XA", "Z85820", "N189", "Z86711", "Z7902", "I110", "W108XXA", "Y9289" ]
Allergies: aspirin / Fosamax Chief Complaint: Hip pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] is a pleasant [MASKED] years old Female who presents to [MASKED] ED for the further evaluation s/p mechanical fall and now c/o L hip pain. Pt states she was in her usual state of health...
[]
[ "N189", "Z7902", "I110" ]
[ "S32492A: Other specified fracture of left acetabulum, initial encounter for closed fracture", "C7951: Secondary malignant neoplasm of bone", "C7800: Secondary malignant neoplasm of unspecified lung", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C7889: Secondary malignant neopl...
10,082,701
20,717,652
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: left distal humerus fracture, left proximal humerus fr...
[ "S42412A", "S42202A", "W182XXA", "Y9289" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: left distal humerus fracture, left proximal humerus fracture Major Surgical or Invasive Procedure: left distal humerus open reduction internal fixation History of Present Illness: [MASKED] female with no significant past medical history presents wi...
[]
[]
[ "S42412A: Displaced simple supracondylar fracture without intercondylar fracture of left humerus, initial encounter for closed fracture", "S42202A: Unspecified fracture of upper end of left humerus, initial encounter for closed fracture", "W182XXA: Fall in (into) shower or empty bathtub, initial encounter", "...
10,082,965
25,214,863
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine Attending: ___. Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: ___ Flexible sigmoidoscopy ...
[ "C20", "I214", "I2699", "G92", "I82512", "N1330", "Z66", "I4891", "K219", "Z7901", "K6289", "K648", "R339" ]
Allergies: Codeine Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: [MASKED] Flexible sigmoidoscopy History of Present Illness: Ms. [MASKED] is an [MASKED] with a background history of dementia, recent left pelvic fracture ([MASKED]), left femoral DVT, and right upper and lower lobe PE...
[]
[ "Z66", "I4891", "K219", "Z7901" ]
[ "C20: Malignant neoplasm of rectum", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "I2699: Other pulmonary embolism without acute cor pulmonale", "G92: Toxic encephalopathy", "I82512: Chronic embolism and thrombosis of left femoral vein", "N1330: Unspecified hydronephrosis", "Z66: Do not resu...
10,083,019
26,019,883
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PSYCHIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: He had the thought to commit suicide, but did not after "weighing t...
[ "F329", "R45851", "F17210", "G4700", "F1219" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: He had the thought to commit suicide, but did not after "weighing the pros and cons". Major Surgical or Invasive Procedure: n/a History of Present Illness: [MASKED] is a [MASKED] year old freshman student at [MASKED] with no previously diagnosed pa...
[]
[ "F329", "F17210", "G4700" ]
[ "F329: Major depressive disorder, single episode, unspecified", "R45851: Suicidal ideations", "F17210: Nicotine dependence, cigarettes, uncomplicated", "G4700: Insomnia, unspecified", "F1219: Cannabis abuse with unspecified cannabis-induced disorder" ]
10,083,072
21,772,485
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Aortic occlusion with left leg rest pain Major Surgical ...
[ "I7409", "I745", "I700", "F17210", "R739" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Aortic occlusion with left leg rest pain Major Surgical or Invasive Procedure: AORTO BIFEMORAL BYPASS USING 16x8 GORTEX GRAFT History of Present Illness: Mr. [MASKED] is a [MASKED] year old male without established primary care provider for around ...
[]
[ "F17210" ]
[ "I7409: Other arterial embolism and thrombosis of abdominal aorta", "I745: Embolism and thrombosis of iliac artery", "I700: Atherosclerosis of aorta", "F17210: Nicotine dependence, cigarettes, uncomplicated", "R739: Hyperglycemia, unspecified" ]
10,083,072
24,654,354
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left foot numbness Major Surgical or Invasive Procedure:...
[ "I7419", "N280", "I10", "F17210", "F1290", "E669", "Z6828" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Left foot numbness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] year old male without established primary care provider for around [MASKED] years. He developed acute left thigh pain with ambulati...
[]
[ "I10", "F17210", "E669" ]
[ "I7419: Embolism and thrombosis of other parts of aorta", "N280: Ischemia and infarction of kidney", "I10: Essential (primary) hypertension", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F1290: Cannabis use, unspecified, uncomplicated", "E669: Obesity, unspecified", "Z6828: Body mass index...
10,083,072
25,995,540
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dizziness and lightheadedness Major Surgical or Invasive...
[ "R55", "I10", "K8020", "F17210", "Z95828" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Dizziness and lightheadedness Major Surgical or Invasive Procedure: None History of Present Illness: HPI: [MASKED] who initially presented with acute onset lower extremity numbness and pain and was found to have an aortic occlusion at the level of ...
[]
[ "I10", "F17210" ]
[ "R55: Syncope and collapse", "I10: Essential (primary) hypertension", "K8020: Calculus of gallbladder without cholecystitis without obstruction", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z95828: Presence of other vascular implants and grafts" ]
10,083,072
26,471,257
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Incisional hernia Major Surgical or Invasive Procedure: ...
[ "K432", "F17210", "Z98890", "G8918", "I10" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Incisional hernia Major Surgical or Invasive Procedure: [MASKED]: laparoscopic incisional hernia repair History of Present Illness: [MASKED] s/p aortobifemoral bypass graft ([MASKED]) & recent lap chole now with incisional hernia. Past Medical Hist...
[]
[ "F17210", "I10" ]
[ "K432: Incisional hernia without obstruction or gangrene", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z98890: Other specified postprocedural states", "G8918: Other acute postprocedural pain", "I10: Essential (primary) hypertension" ]
10,083,424
23,339,573
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending: ___ Chief Complaint: Dyspnea of exertion Major Surgical or Invasive Procedure: ___ Aortic valve replace...
[ "I083", "D62", "E119", "Z7984", "E785", "K219" ]
Allergies: Penicillins Chief Complaint: Dyspnea of exertion Major Surgical or Invasive Procedure: [MASKED] Aortic valve replacement with a 21 mm [MASKED] tissue valve. History of Present Illness: [MASKED] year old male with history of diaphoresis, dyspnea on exertion, chest pressure over the last few months. Echo showe...
[]
[ "D62", "E119", "E785", "K219" ]
[ "I083: Combined rheumatic disorders of mitral, aortic and tricuspid valves", "D62: Acute posthemorrhagic anemia", "E119: Type 2 diabetes mellitus without complications", "Z7984: Long term (current) use of oral hypoglycemic drugs", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux diseas...
10,083,678
21,930,692
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Lisinopril Attending: ___ ___ Complaint: Right knee instability Major Surgical or Invasive Procedure: Right revision total knee a...
[ "T84022A", "D62", "F05", "E119", "M21161", "I10", "E785", "F17210", "K5900", "K219", "M109", "M1711", "M25361", "Y834", "Y929", "Z96653", "E8342", "I9581" ]
Allergies: Lisinopril [MASKED] Complaint: Right knee instability Major Surgical or Invasive Procedure: Right revision total knee arthroplasty History of Present Illness: R TKA done many years ago with subsequent knee instability, presenting for revision of right TKA. Past Medical History: DM Type II Hypertension GERD G...
[]
[ "D62", "E119", "I10", "E785", "F17210", "K5900", "K219", "M109", "Y929" ]
[ "T84022A: Instability of internal right knee prosthesis, initial encounter", "D62: Acute posthemorrhagic anemia", "F05: Delirium due to known physiological condition", "E119: Type 2 diabetes mellitus without complications", "M21161: Varus deformity, not elsewhere classified, right knee", "I10: Essential (...
10,083,754
21,574,288
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Tetanus Vaccines & Toxoid / Velcade / lenalidomide / Bactrim / sulfamethoxazole Attending: ___. Chief Complaint: Bloating and RLQ abdominal...
[ "K3580", "C9001", "Z9484", "E039", "D6851" ]
Allergies: Tetanus Vaccines & Toxoid / Velcade / lenalidomide / Bactrim / sulfamethoxazole Chief Complaint: Bloating and RLQ abdominal pain Major Surgical or Invasive Procedure: [MASKED]: Laparoscopic appendectomy History of Present Illness: Ms. [MASKED] is a [MASKED] year old woman with a history of multiple myeloma (...
[]
[ "E039" ]
[ "K3580: Unspecified acute appendicitis", "C9001: Multiple myeloma in remission", "Z9484: Stem cells transplant status", "E039: Hypothyroidism, unspecified", "D6851: Activated protein C resistance" ]
10,083,754
23,220,768
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Tetanus Vaccines & Toxoid / Velcade / lenalidomide / Bactrim / sulfamethoxazole Attending: ___. Chief Complaint: HD Cytoxan Major Surgic...
[ "Z5111", "C9000", "R740", "E039", "D6851", "M3500" ]
Allergies: Tetanus Vaccines & Toxoid / Velcade / lenalidomide / Bactrim / sulfamethoxazole Chief Complaint: HD Cytoxan Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [MASKED] is a [MASKED] woman with a history of hypothyroidism, heterozygous factor V Leiden mutation, Sjogren syndrome and IgG...
[]
[ "E039" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C9000: Multiple myeloma not having achieved remission", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "E039: Hypothyroidism, unspecified", "D6851: Activated protein C resistance", "M3500: Sicca syndrome, un...
10,083,754
28,071,358
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Tetanus Vaccines & Toxoid / Velcade / lenalidomide / Bactrim / sulfamethoxazole Attending: ___. Chief Complaint: admission for autologous ...
[ "C9000", "D6851", "D701", "M3500", "R5081", "R112", "K1231", "R197", "R630", "E039", "F419", "M8580", "T451X5A", "Y92230", "Z006", "K5900", "R7989", "Z6821" ]
Allergies: Tetanus Vaccines & Toxoid / Velcade / lenalidomide / Bactrim / sulfamethoxazole Chief Complaint: admission for autologous transplant w/ melphalan prep Major Surgical or Invasive Procedure: CVC placement [MASKED] CVC removal [MASKED] History of Present Illness: Ms. [MASKED] is a [MASKED] woman with a history ...
[]
[ "E039", "F419", "Y92230", "K5900" ]
[ "C9000: Multiple myeloma not having achieved remission", "D6851: Activated protein C resistance", "D701: Agranulocytosis secondary to cancer chemotherapy", "M3500: Sicca syndrome, unspecified", "R5081: Fever presenting with conditions classified elsewhere", "R112: Nausea with vomiting, unspecified", "K1...
10,083,814
20,747,734
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Agitation Major Surgical or Invasive Procedure: ___ Lumbar punc...
[ "I6201", "G92", "F0281", "N390", "E870", "I6203", "R4189", "G309", "Z9183", "Z781", "B9620", "N39498", "G40909", "Z87440", "I10", "E861", "R945", "E7849", "I69320", "Z538" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Agitation Major Surgical or Invasive Procedure: [MASKED] Lumbar puncture with Anesthesia team and conscious sedation History of Present Illness: [MASKED] is a [MASKED] woman with a history of cognitive decline and reported Alzheimer's dementia, mul...
[]
[ "N390", "I10" ]
[ "I6201: Nontraumatic acute subdural hemorrhage", "G92: Toxic encephalopathy", "F0281: Dementia in other diseases classified elsewhere with behavioral disturbance", "N390: Urinary tract infection, site not specified", "E870: Hyperosmolality and hypernatremia", "I6203: Nontraumatic chronic subdural hemorrha...
10,083,814
22,702,660
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Behavior changes Major Surgical or Invasive Procedure: None ...
[ "G40909", "R4701", "F0281", "Z9183", "I10", "R32", "R1310", "G309", "E538", "R739", "T380X5A", "T434X5A", "Y92239" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Behavior changes Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] woman with history notable for Alzheimer's dementia and hypertension transferred from [MASKED] after initially presenting with worsen...
[]
[ "I10" ]
[ "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "R4701: Aphasia", "F0281: Dementia in other diseases classified elsewhere with behavioral disturbance", "Z9183: Wandering in diseases classified elsewhere", "I10: Essential (primary) hypertension", "R32: Unspecified urinary inco...
10,083,814
24,333,426
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Acute on chronic functional decline and failure to thrive Major ...
[ "G3109", "E43", "F0281", "E870", "R627", "Z66", "Z515", "Z781", "I10", "G40909", "I951", "E785", "K5900", "Z6823" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Acute on chronic functional decline and failure to thrive Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] woman with a history of dementia, progressive decline in functional status since [MASKED] of...
[]
[ "Z66", "Z515", "I10", "E785", "K5900" ]
[ "G3109: Other frontotemporal dementia", "E43: Unspecified severe protein-calorie malnutrition", "F0281: Dementia in other diseases classified elsewhere with behavioral disturbance", "E870: Hyperosmolality and hypernatremia", "R627: Adult failure to thrive", "Z66: Do not resuscitate", "Z515: Encounter fo...
10,083,851
27,093,749
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Bactrim / levofloxacin Attending: ___. Chief Complaint: BRBPR Major Surgical or Invasive Procedure: ...
[ "K91840", "D839", "Y838", "I2510", "K5730", "I10", "G8929", "J45909", "N400", "K219", "F419", "K644", "G4733", "Y9289", "Z981", "Z86010", "Z800", "Z809" ]
Allergies: Sulfa (Sulfonamide Antibiotics) / Bactrim / levofloxacin Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Colonoscopy with placement of 2 clips History of Present Illness: [MASKED] PMH HTN, CAD, GERD, OA, CVID, BPH, chronic pain, colonic adenoma, OSA, p/w bleeding following colonoscopy w/ polypec...
[]
[ "I2510", "I10", "G8929", "J45909", "N400", "K219", "F419", "G4733" ]
[ "K91840: Postprocedural hemorrhage of a digestive system organ or structure following a digestive system procedure", "D839: Common variable immunodeficiency, unspecified", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure...
10,084,262
26,913,631
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hyponatremia Major Surgical or Invasive Procedure: none ...
[ "E222", "G92", "F17210", "I10", "R7303", "T502X5A", "Y929", "R270", "R4781", "H9192", "K219", "F1020" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Hyponatremia Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] w/ PMHx of HTN and pre-diabetes presents as a transfer from [MASKED] for evaluation of hyponatremia. Per wife, 1 month ago, patient was switched from metop...
[]
[ "F17210", "I10", "Y929", "K219" ]
[ "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "G92: Toxic encephalopathy", "F17210: Nicotine dependence, cigarettes, uncomplicated", "I10: Essential (primary) hypertension", "R7303: Prediabetes", "T502X5A: Adverse effect of carbonic-anhydrase inhibitors, benzothiadiazides and other ...
10,084,702
27,163,908
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PSYCHIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: "I'm anxious" Major Surgical or Invasive Procedure: none...
[ "F3181" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: "I'm anxious" Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] is a [MASKED] female from home with a past psychiatric history of depression and anxiety (no previous admissions) who is medically healthy, who was sent t...
[]
[]
[ "F3181: Bipolar II disorder" ]
10,085,403
25,258,495
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: red dye Attending: ___. Chief Complaint: cervical radiculopathy Major Surgical or Invasive Procedure: ___ C6-7 ACDF History of P...
[ "M50023", "G9519", "M4722", "I10", "E119", "Z794", "E039", "E785", "R200" ]
Allergies: red dye Chief Complaint: cervical radiculopathy Major Surgical or Invasive Procedure: [MASKED] C6-7 ACDF History of Present Illness: [MASKED] with a history of HTN, DM, hypothyroidism who presents with [MASKED] months of neck pain and an abnormal MRI. The patient reports slow onset of lower neck pain that ra...
[]
[ "I10", "E119", "Z794", "E039", "E785" ]
[ "M50023: Cervical disc disorder at C6-C7 level with myelopathy", "G9519: Other vascular myelopathies", "M4722: Other spondylosis with radiculopathy, cervical region", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin"...
10,085,667
27,382,550
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: __...
[ "I25110", "J9691", "T82855A", "K9189", "K567", "Z7902", "Y711", "Y929", "I10", "I252", "Z87891", "Z8249", "K219", "G629", "Z006", "K2270", "E7800", "Y832", "R5082", "Y92239" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chest pain 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 left posterior descending artery Hist...
[]
[ "Z7902", "Y929", "I10", "I252", "Z87891", "K219" ]
[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "J9691: Respiratory failure, unspecified with hypoxia", "T82855A: Stenosis of coronary artery stent, initial encounter", "K9189: Other postprocedural complications and disorders of digestive system", "K567: Ileu...
10,085,725
26,264,561
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Right sided recurrent malignant pleural effusion Major Surgical or...
[ "C3490", "J910", "E222", "E1142", "Z87891", "R0902", "J439" ]
Allergies: Sulfa (Sulfonamide Antibiotics) Chief Complaint: Right sided recurrent malignant pleural effusion Major Surgical or Invasive Procedure: Pleurex placement [MASKED] History of Present Illness: [MASKED] with PMH notable for metastatic lung cancer cycle 4 of Keytruda (care at [MASKED] and known recurrent left si...
[]
[ "Z87891" ]
[ "C3490: Malignant neoplasm of unspecified part of unspecified bronchus or lung", "J910: Malignant pleural effusion", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "Z87891: Personal history of nicotine dependence", "R090...
10,085,948
28,355,680
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Penicillins / amoxicillin / tramadol Attending: ___ Chief Complaint: Gender dysphoria Major Surgical or Invasive Procedure:...
[ "F648", "K420", "Z6841", "D414", "K660", "J45909", "E669", "K219", "Z87891", "F419", "F319" ]
Allergies: Penicillins / amoxicillin / tramadol Chief Complaint: Gender dysphoria Major Surgical or Invasive Procedure: EXAM UNDER ANESTHESIA, TOTAL LAPAROSCOPIC HYSTERECTOMY, BILATERAL SALPINGOOPHORECTOMY, CYSTOSCOPY WITH REMOVAL OF BLADDER POLYP; REDUCTION AND OPEN REPAIR OF INCARCERATED UMBILICAL HERNIA History of P...
[]
[ "J45909", "E669", "K219", "Z87891", "F419" ]
[ "F648: Other gender identity disorders", "K420: Umbilical hernia with obstruction, without gangrene", "Z6841: Body mass index [BMI]40.0-44.9, adult", "D414: Neoplasm of uncertain behavior of bladder", "K660: Peritoneal adhesions (postprocedural) (postinfection)", "J45909: Unspecified asthma, uncomplicated...
10,086,022
24,567,350
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Bactrim / Ultram / Sulfa (Sulfonamide Antibiotics) / IV Dye, Iodine Containing / Nitrofurantoin / mirtazapine / Cipro / levofloxacin / Macrobi...
[ "L89154", "R6521", "M868X8", "I442", "E871", "N179", "D688", "K5790", "H905", "I10", "Z951", "Z954", "I77819", "Z87891", "R1310", "R627", "D638", "D509", "I2510", "K5900", "F329", "E7800", "E8339", "Z66", "R5382", "Z9181", "R296", "R339" ]
Allergies: Bactrim / Ultram / Sulfa (Sulfonamide Antibiotics) / IV Dye, Iodine Containing / Nitrofurantoin / mirtazapine / Cipro / levofloxacin / Macrobid / fentanyl Chief Complaint: Fevers Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year old woman with a history of...
[]
[ "E871", "N179", "I10", "Z951", "Z87891", "D509", "I2510", "K5900", "F329", "Z66" ]
[ "L89154: Pressure ulcer of sacral region, stage 4", "R6521: Severe sepsis with septic shock", "M868X8: Other osteomyelitis, other site", "I442: Atrioventricular block, complete", "E871: Hypo-osmolality and hyponatremia", "N179: Acute kidney failure, unspecified", "D688: Other specified coagulation defec...
10,086,182
29,596,075
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Blood per rectum Major Surgical or Invasive Procedure: Colo...
[ "K5731", "D6852", "K5521", "J439", "F209", "K641", "R791", "I10", "R000", "F4310", "F418", "F17210", "Z23", "Z7901", "Z86718" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Blood per rectum Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: [MASKED] male with history of prothrombin gene mutation on Coumadin, COPD, hypertension, anxiety, depression, PTSD, and diverticulosis who presented to O...
[]
[ "I10", "F17210", "Z7901", "Z86718" ]
[ "K5731: Diverticulosis of large intestine without perforation or abscess with bleeding", "D6852: Prothrombin gene mutation", "K5521: Angiodysplasia of colon with hemorrhage", "J439: Emphysema, unspecified", "F209: Schizophrenia, unspecified", "K641: Second degree hemorrhoids", "R791: Abnormal coagulatio...
10,086,334
22,131,122
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abnormal labs Major Surgical or Invasive Procedure: None...
[ "D72829", "N179", "K7460", "I8510", "K429", "B1910", "I959", "Z86718", "Z7901", "G8929", "M549", "I129", "F1010", "N189", "F17210", "M40204", "M810", "D802" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Abnormal labs Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] gentleman with a history of alcoholic cirrhosis [MASKED] Class B, c/b portal hypertension with ascites requiring multiple LVP most recen...
[]
[ "N179", "Z86718", "Z7901", "G8929", "I129", "N189", "F17210" ]
[ "D72829: Elevated white blood cell count, unspecified", "N179: Acute kidney failure, unspecified", "K7460: Unspecified cirrhosis of liver", "I8510: Secondary esophageal varices without bleeding", "K429: Umbilical hernia without obstruction or gangrene", "B1910: Unspecified viral hepatitis B without hepati...
10,086,710
28,382,103
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: syncope Major Surgical or Invasive Procedure: Dual Chamber...
[ "I442", "E785", "I495" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: syncope Major Surgical or Invasive Procedure: Dual Chamber Pacemaker Placement Date of Implant: [MASKED] Indication: SSS + high grade AV block Device brand/[MASKED]: [MASKED] [MASKED] A lead [MASKED] date: [MASKED] / [MASKED] / [MASKED] RV lead [MA...
[]
[ "E785" ]
[ "I442: Atrioventricular block, complete", "E785: Hyperlipidemia, unspecified", "I495: Sick sinus syndrome" ]
10,087,092
21,411,023
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Leukocytosis Major Surgical or Invasive Procedure: Bone M...
[ "C9210", "E883", "Z806", "Z803", "R6881" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Leukocytosis Major Surgical or Invasive Procedure: Bone Marrow Biopsy History of Present Illness: [MASKED] is a [MASKED] yo equine [MASKED] with no significant medical problems, who presents with 1 month of abdominal bloating, early satiety, and ne...
[]
[]
[ "C9210: Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission", "E883: Tumor lysis syndrome", "Z806: Family history of leukemia", "Z803: Family history of malignant neoplasm of breast", "R6881: Early satiety" ]
10,087,189
20,052,610
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: ...
[ "I161", "I5033", "E872", "S3739XA", "T8389XA", "N183", "R319", "I130", "D72829", "E785", "F329", "Z66", "Z87891", "R0902", "K5900", "N401", "R338", "Y92230", "Y846", "H409" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a [MASKED] with history of BPH, HTN, dyslipidemia, and depression who presents with shortness of breath. Patient describes noticing mild exertiona...
[]
[ "E872", "I130", "E785", "F329", "Z66", "Z87891", "K5900", "Y92230" ]
[ "I161: Hypertensive emergency", "I5033: Acute on chronic diastolic (congestive) heart failure", "E872: Acidosis", "S3739XA: Other injury of urethra, initial encounter", "T8389XA: Other specified complication of genitourinary prosthetic devices, implants and grafts, initial encounter", "N183: Chronic kidne...
10,087,348
22,419,405
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: patotitis Major Surgical or Invasive Procedure: None ...
[ "K1120", "K113", "E785", "K219", "D638", "E559", "Z8546" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: patotitis Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with a history of prostate cancer status post external beam radiotherapy, pre-diabetes, hyperlipidemia, and GERD, who presented from his PCP office with MRI f...
[]
[ "E785", "K219" ]
[ "K1120: Sialoadenitis, unspecified", "K113: Abscess of salivary gland", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "D638: Anemia in other chronic diseases classified elsewhere", "E559: Vitamin D deficiency, unspecified", "Z8546: Personal history of...
10,087,562
21,037,736
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Ibuprofen / latex / meloxicam / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending: ___. Chief Complaint: Right knee OA Major...
[ "M1711", "F329", "I959", "R001" ]
Allergies: Ibuprofen / latex / meloxicam / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Chief Complaint: Right knee OA Major Surgical or Invasive Procedure: right knee replacement [MASKED], [MASKED] History of Present Illness: [MASKED] year old male with right knee OA s/p R TKR. Past Medical History: BMI 30.45, varico...
[]
[ "F329" ]
[ "M1711: Unilateral primary osteoarthritis, right knee", "F329: Major depressive disorder, single episode, unspecified", "I959: Hypotension, unspecified", "R001: Bradycardia, unspecified" ]
10,087,922
20,681,088
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Cephalexin Attending: ___. Chief Complaint: influenza infection Major Surgical or Invasive Procedure: none History of Present I...
[ "J111", "I10", "G40909", "E780", "R32", "F79", "R269" ]
Allergies: Cephalexin Chief Complaint: influenza infection Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] yoM with mental retardation, seizure disorder, hypertension, group home resident, being admitted from ED for influenza. . Pt is limited historian due to MR. [MASKED] obtained by rev...
[]
[ "I10" ]
[ "J111: Influenza due to unidentified influenza virus with other respiratory manifestations", "I10: Essential (primary) hypertension", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "E780: Pure hypercholesterolemia", "R32: Unspecified urinary incontinence", "F79: Unspecified ...
10,087,922
29,689,139
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Cephalexin Attending: ___. Chief Complaint: staring spells Major Surgical or Invasive Procedure: None History of Present Illne...
[ "G40919", "E7220", "F79", "I10" ]
Allergies: Cephalexin Chief Complaint: staring spells Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] right-handed man with intellectual disability and epilepsy, hypertension, group home resident that presented to hospital for admission to Epilepsy service for LTM EEG. ...
[]
[ "I10" ]
[ "G40919: Epilepsy, unspecified, intractable, without status epilepticus", "E7220: Disorder of urea cycle metabolism, unspecified", "F79: Unspecified intellectual disabilities", "I10: Essential (primary) hypertension" ]
10,087,943
29,761,408
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Bactrim / Statins-Hmg-Coa Reductase Inhibitors Attending: ___. Chief Complaint: enlarging AAA Major Surgical or Invasive Procedure: 5 ...
[ "I714", "I10", "E8801", "J449", "Z87891", "Z853" ]
Allergies: Bactrim / Statins-Hmg-Coa Reductase Inhibitors Chief Complaint: enlarging AAA Major Surgical or Invasive Procedure: 5 vessel PMEG History of Present Illness: [MASKED] with known history of AAA who was managed by Dr. [MASKED] at [MASKED], who presents to [MASKED] with a AAA that has enlarged on surveillance i...
[]
[ "I10", "J449", "Z87891" ]
[ "I714: Abdominal aortic aneurysm, without rupture", "I10: Essential (primary) hypertension", "E8801: Alpha-1-antitrypsin deficiency", "J449: Chronic obstructive pulmonary disease, unspecified", "Z87891: Personal history of nicotine dependence", "Z853: Personal history of malignant neoplasm of breast" ]
10,087,981
22,166,638
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: cephalexin / doxycycline / Furazolidone / morphine / naproxen / Macrobid / Oxycodone / prednisone / prochlorperazine / Sulfasalazine / me...
[ "S72451A", "G92", "S32019A", "N390", "W1830XA", "Y92129", "B9620", "Z1623", "I10", "E039", "D539", "D72829", "M810" ]
Allergies: cephalexin / doxycycline / Furazolidone / morphine / naproxen / Macrobid / Oxycodone / prednisone / prochlorperazine / Sulfasalazine / mesalamine / nitrofuran / sulfur dioxide / Benadryl / tramadol Chief Complaint: R leg pain, altered mental status Major Surgical or Invasive Procedure: ORIF R femur [MASKED] ...
[]
[ "N390", "I10", "E039" ]
[ "S72451A: Displaced supracondylar fracture without intracondylar extension of lower end of right femur, initial encounter for closed fracture", "G92: Toxic encephalopathy", "S32019A: Unspecified fracture of first lumbar vertebra, initial encounter for closed fracture", "N390: Urinary tract infection, site not...
10,088,163
21,796,475
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right sided 2cm complex cystic renal mass; Conn syndrome Maj...
[ "D495", "E278", "I10", "D563", "E2601", "E876", "K660", "Z8673", "Z87891" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Right sided 2cm complex cystic renal mass; Conn syndrome Major Surgical or Invasive Procedure: Right robotic partial nephrectomy and adrenalectomy History of Present Illness: [MASKED] with right sided 2cm complex cystic renal mass and poorly contro...
[]
[ "I10", "Z8673", "Z87891" ]
[ "D495: Neoplasm of unspecified behavior of other genitourinary organs", "E278: Other specified disorders of adrenal gland", "I10: Essential (primary) hypertension", "D563: Thalassemia minor", "E2601: Conn's syndrome", "E876: Hypokalemia", "K660: Peritoneal adhesions (postprocedural) (postinfection)", ...
10,088,198
26,124,727
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Sulfa (Sulfonamide Antibiotics) / Kenalog / shrimp / mango (fresh) / shellfish derived Attending: ___ Chief Complaint: Dizziness Major ...
[ "R42", "R2681", "G902", "I480", "Z7902", "Z8673", "Z951", "Z85850", "Z87891", "E785", "I2510", "I110", "I5032", "I9589" ]
Allergies: Sulfa (Sulfonamide Antibiotics) / Kenalog / shrimp / mango (fresh) / shellfish derived Chief Complaint: Dizziness Major Surgical or Invasive Procedure: None. History of Present Illness: HPI: [MASKED] is a [MASKED] year-old right-handed woman who presents with dizziness and unsteady gait. Examination in the E...
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[ "I480", "Z7902", "Z8673", "Z951", "Z87891", "E785", "I2510", "I110", "I5032" ]
[ "R42: Dizziness and giddiness", "R2681: Unsteadiness on feet", "G902: Horner's syndrome", "I480: Paroxysmal atrial fibrillation", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficit...